十二指肠间质瘤16例临床分析

目的 探讨十二指肠间质瘤的诊断和治疗.方法 回顾性分析了16例十二指肠间质瘤治疗的临床资料.结果 十二指肠间质瘤发病部位主要集中在降部和水平部;出血是最常见的临床症状,其次为上腹部疼痛不适,内镜和CT为最常用的辅助检查手段,16例中行胰十二指肠切除2例,十二指肠节段切除9例,肿瘤局部切除5例,术后随访6～42个月,1例复发并出现肝脏转移存活22个月,其余均未发现复发.结论 根据十二指肠间质瘤大小和确切位置应采取不同的手术方式,大部分患者可通过十二指肠节段切除或局部切除达到根治目的,对于病理分级呈高度危险患者术后应给予伊马替尼辅助治疗.     

Use of a stent graft for bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy

Although uncommon, bleeding following pancreaticoduodenectomy is associated with high mortality. Management generally includes surgical reexploration or, alternatively, transarterial embolization. We report the case of a 62-year-old man who presented with massive upper gastrointestinal bleeding 3 weeks after pancreaticoduodenectomy. Selective coeliac angiography revealed a large pseudoaneurysm involving the proper hepatic artery. This was treated successfully with a stent graft. There was no recurrence of bleeding at the 6-month follow-up. To our knowledge, this is the first report of stent graft repair of bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy.     

Presentation and management of gastrointestinal stromal tumors of the duodenum

Duodenal gastrointestinal stromal tumors (GIST) have been described primarily in isolated case reports. In order to learn more about duodenal GIST, a retrospective review of patients with GIST managed at a single institution between 2000 and 2005 was conducted. Thirty-eight GIST of the stomach and small bowel were analyzed. Eight (21%) were duodenal GIST. The median size of duodenal GIST (6.0 cm) and small bowel GIST (6.3 cm) was larger than the median size of gastric GIST (3.0 cm). The most common presentation of duodenal GIST was bleeding (50%) which was similar to other small bowel GIST (49%) but different from gastric GIST which were most commonly an incidental finding (62%). Two patients (25%) with duodenal GIST had a history of neurofibromatosis. The duodenal GIST were located in the 2nd (n = 5, 63%) and 3rd portion of duodenum (n = 3, 37%). Seven of 8 patients underwent complete resection of duodenal GIST. Pancreaticoduodenectomy was the most common operation performed (n = 5); 2 patients were treated with partial duodenal resection. No patients undergoing pancreaticoduodenectomy (n = 5) were found to have lymph node metastases. No patients received neo-adjuvant or adjuvant therapy with Imatinib. Following resection, 2 patients have recurred (12 and 48 mo.), 4 patients are without disease (1, 6, 6, and 24 mo.), 1 patient died postoperatively. Duodenal GIST are relatively rare tumors that present most commonly with gastrointestinal bleeding. Duodenal GIST are associated with neurofibromatosis. Many duodenal GIST require pancreaticoduodenectomy for complete removal.     

八例十二指肠良性肿瘤的诊治体会

目的 探讨十二指肠良性肿瘤的诊断及治疗方法。方法 回顾性分析１９８９年２月～２０００年３月和术切除,并经病理证实的８例十二指肠良性肿瘤。结果 Ｂｒｕｎｎｅｒ腺瘤３例,平滑肌瘤２例,间质瘤２例,脂肪瘤１例。十二指肠良性肿瘤的临床状态多不典型,早期诊断困难。患者均表现为上消化道出血,不同程度的贫血,这对进一步检查有提示意义。上消化道造影及胃十二指肠镜检查是主要的辅助诊断方法。本组患者均行外科手术切除肿     

Acute gastrointestinal bleeding caused by a rare, benign tumor of the duodenum (gangliocytic paraganglioma)

Diagnosis and treatment of massive gastrointestinal bleeding is sometimes very difficult problem in a surgical unit. Authors present a case of a 40 years old female with an atypical source of upper gastrointestinal bleeding. The origin of the bleeding was detected only by intraoperative enteroscopy. The source of the bleeding was a very rare benign tumour of the duodenum (Gangliocytic paraganglioma) which involved the papilla of Vater. During the operation resection of the pedunculated tumour was carried out, with choledochal--and Wirsungoplastyc, associated with external drainage of these ducts. According to the literature in preoperative diagnosis of this rare tumour endoscopy, angiography, and EUS are very useful. In case of malignancy, metastases radical operation-pancreatoduodenectomy--is indicated.     

Angiodysplasia of upper gastrointestinal tract with coagulopathy

A combination of duodenal telangiectasia with factor X deficiency presenting as recurrent malaena is rarely reported. Pylorus preserving pancreaticoduodenectomy done under cover of prothrombin complex resulted in complete recovery. Histopathology was consistent with angiomatosis. It is suggested that in managing a case of upper gastrointestinal bleeding, besides establishing the source of bleeding, it is important to detect underlying coagulopathy.     

Emergency Pancreatoduodenectomy (Whipple Procedure) for Massive Upper Gastrointestinal Bleeding Caused by a Diffuse B-Cell Lymphoma of the Duodenum: Report of a Case

We herein report a rare case of a massive upper gastrointestinal (GI) bleeding, caused by high-grade diffuse B-cell lymphoma of the duodenum, secondary to immunoproliferative small intestinal disease (IPSID) and treated with an emergency partial pancreatoduodenectomy. A 42-year-old man was admitted to our hospital because of hematemesis. Upper GI endoscopy was unrevealing because of the copious bleeding. Initially, the patient underwent conservative treatment, thus resulting in the temporary cessation of the bleeding. Later, the hemorrhage massively relapsed. An urgent abdominal ultrasound raised the suspicion of a large, possibly bleeding, neoplasm of the duodenum, which was finally confirmed by abdominal computed tomography. The patient underwent an emergency laparotomy, during which a partial pancreatoduodenectomy was performed (Whipple procedure). Histologically, the tumor was a high-grade B-cell lymphoma of the duodenum. The nearby small intestinal mucosa was suggestive of IPSID. A massive upper GI hemorrhage from a high-grade B-cell non-Hodgkin lymphoma of the duodenum, which develops secondary to IPSID, is a very rare clinical demonstration of this disease. Our case is one of the few reports in the English literature, for which the Whipple procedure has been performed as a curative treatment.     

Duodenal stenosis caused by cystic dystrophy in heterotopic pancreas: Report of a case

We herein describe the first reported case of duodenal stenosis caused by cystic dystrophy in heterotopic pancreas (CDHP) in Asia. A 63-year-old man was admitted to the hospital presenting with nausea and vomiting of 2 days’ duration. Laboratory examinations showed an elevation in both the serum amylase level (275 IU/l) and white blood cell count (13 600/μl). A 3-cm-diameter tumor close against the duodenum was pointed out from the results of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP); the tumor contained a cystic and solid component. Endoscopic examinations and an upper gastrointestinal series showed stenosis of the second portion of the duodenum without any mucosal change. The tumor was considered to be located at the submucosal layer of the second duodenum. The biopsy specimen of the duodenum revealed no malignancy. We strongly doubted the presence of a malignant submucosal tumor in the duodenum based on the findings of diagnostic imaging, and a pancreaticoduodenectomy was thus performed. Histopathologically, the lesion was diagnosed to be CDHP. The postoperative course was uneventful. The patient was symptomatic but was free of any symptoms after surgery. He continues to be regularly followed up on an outpatient basis and has had no recurrence of symptoms. This case demonstrates the need to consider CDHP in the differential diagnosis as a rare cause of duodenal stenosis.     

Duodenal Stromal Tumor: Report of a Case

Gastrointestinal stromal tumors are rare tumors of the gastrointestinal (GI) tract that arise from primitive mesenchymal cells. Gastrointestinal stromal tumors account for approximately 80% all of gastrointestinal mesenchymal tumors. Duodenal stromal tumors (DSTs) manifest with unexplained melena, pain, bleeding, anemia, sometimes a partial duodenal obstruction and, rarely, with obstructive jaundice. If the tumor is successfully treated, its prognosis is usually good because of its non-aggressive nature. If resected, the prognosis is favorable in a majority of cases, and it is much better than in carcinomas of the duodenum. In this article, we report a case of DST originating from the first and second portion of the duodenum. Our patient did not have any problems postoperatively and remained symptom-free at 18 months after surgery.     

An unusual case of duodenal obstruction-gangliocytic paraganglioma

Gangliocytic paragangliomas are rare tumors located in the gastrointestinal tract that are considered to be benign. They are composed of spindle-shaped cells, epithelioid cells, and ganglion-like cells. They usually present with abdominal pain, and/or gastrointestinal bleeding, and occasionally with obstructive jaundice. We report a case of obstruction in a 17-year-old female, which on histology was found to be a gangliocytic paraganglioma, with an extremely unusual presentation. Intraoperatively, the patient was found to have local tumor extension and regional lymph node invasion, and so she underwent a pylorus-preserving pancreaticoduodenectomy, with local lymph node clearance. We discuss the management of this unusual case and review the literature.     

Jejunal varices with extra hepatic portal vein obstruction: A case report

Introduction and importanceExtrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare.Presentation of caseWe report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices.DiscussionPortal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices.ConclusionJejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy.     

Upper gastrointestinal bleeding due to primary aortoenteric fistula

Primary aortoenteric fistula (PAEF) is a rare but clinically important cause of catastrophic gastrointestinal bleeding. "Herald bleeding" is a characteristic symptom which refers to specific case of upper gastrointestinal bleeding that stop temporarily spontaneously and then proceeds to massive bleeding. We present the case report of a 55-year-old male with PAEF who was admitted due to upper gastrointestinal bleeding. Endoscopic studies were unremarkable and patient underwent exploratory laparotomy. The postoperative course was uneventful. A high index of suspicion, early diagnosis and prompt appropriate surgical intervention are crucial for survival of patient with PAEF. Gastrointestinal bleeding combined with a negative endoscopy suggests PAEF. Endovascular operation is an attractive treatment option.     

Gardner's syndrome. Unusual presentation of abdominal pain

Two sisters with Gardner's syndrome and abdominal pain are described. One had a complicated clinical course manifested by severe pain in the right upper quadrant, tenderness, fever, and leukocytosis. Exploratory laparotomy failed to reveal the cause of her illness and was complicated by postoperative pancreatitis and upper gastrointestinal bleeding, the latter from severe gastritis. A second abdominal exploration demonstrated necrotic desmoid tumor behind the second portion of the duodenum. It is postulated that necrosis of the tumor produced the clinical picture of an acute surgical abdomen.     

Solitary cavernous hemangioma of the duodenum: Report of a case

Vascular lesions of the duodenum, including hemangioma, are rare causes of gastrointestinal bleeding. We herein describe a 52-year-old woman with a solitary cavernous hemangioma of the duodenum that caused chronic gastrointestinal bleeding. Repeated upper gastrointestinal endoscopy and a barium meal study revealed a solitary vascular tumor in the fourth portion of the duodenum, although the initial investigations including selective angiography were unsuccessful. A wedge resection of the duodenum was performed and microscopical examination showed a cavernous hemangioma. Vascular lesions should therefore also be considered in the differential diagnosis of patients with gastrointestinal bleeding of unknown origin.     

Intraoperative Doppler localization of intestinal arteriovenous malformation.

Arteriovenous malformations of the gastrointestinal tract have been identified as the cause of significant bleeding when other causes are obscure. A method of precise intraoperative localization using Doppler ultrasound technique is presented. The value of this method is shown in the management of an illustrative case of a rare arteriovenous malformation of the duodenum.     

Exceptional etiologies in upper digestive tract bleeding

7 cases, considered as being true etiological exceptions selected from 756 upper gastrointestinal bleeding, are presented. The causes of bleeding were: pancreatic pseudocyst with intracystic hemorrhage broken into duodenum (2 cases), the nonepithelial gastroduodenal tumor (3 cases), the aneurysm of gastroduodenal artery broken into duodenum (1 case) and the aortoduodenal fistula in one patient with a bilateral aorto-iliac by-pass (1 case). The etiological diagnosis could not be established in any cases before the operations. All the cases were operated on, the operation being imposed by the severity of bleeding and having the haemostasis as a main purpose.     

Massive upper gastrointestinal bleeding originating from a fourth-stage duodenal diverticulum: a case report and review of the literature

Duodenal diverticulum is well-known pathologic entity. Most such diverticula are asymptomatic and located on the second stage of the duodenum. The diagnosis is most often established by endoscopy or upper gastrointestinal radiography. Hemorrhage has been described but is an infrequent complication. We report on a patient who presented with massive upper gastrointestinal bleeding, originating from a fourth-stage duodenal diverticulum. The diagnosis was made with a combination of arteriography and scanning with technetium 99-labelled red cells. Diverticulectomy was performed with a successful outcome. This report underlines the diagnostic limits of fiberoptic endoscopy for hemorrhagic lesions located past the third stage of the duodenum.     

Features of the diagnosis of tumors of the small intestine complicated by hemorrhage

Among 5,190 patients with gastrointestinal hemorrhage in 14 (0.27%) the bleeding was caused by tumor of the small intestine. The success of recognition of tumors of the small intestine complicated by bleeding is determined to a great measure by the sequence of the diagnostic procedures. It is most rational to begin the examination with endoscopy of the stomach and duodenum. In the absence of abnormalities in these organs rectosigmoidoscopy or colonoscopy is undertaken next. If the source of the bleeding is not detected in this case, then the small intestine is examined by means of probe radioenterography. During the operation, at the peak of bleeding, the authors search for its source along the "track" of blood by palpating the small intestine.     

原发性十二指肠癌101例的诊断与治疗

目的 提高原发性十二指肠癌的早期诊断及治疗水平。方法 回顾性分析1990～2002年间经手术及病理证实的原发性十二指肠癌患101例的临床资料。结果 肿瘤位于十二指肠乳头上区9例，乳头下区15例，乳头区77例。主要临床表现为上腹隐痛、上消化道梗阻和出血及黄疸症状。术前纤维十二指肠镜确诊率为97．7％，低张十二指肠造影为91．2％，B超及CT检查阳性率为80．0％。59例行胰十二指肠切除术，24例行十二指肠乳头癌局部切除术，5例行十二指肠部分切除术，4例行远端胃大部切除术，9例行姑息性探查及胆肠或胃肠吻合术。结论 纤维十二指肠镜、低张十二指肠造影及CT是诊断十二指肠癌的主要手段，早期诊断有赖于提高对本病的认识，一旦确诊则手术彻底切除肿瘤是首选的治疗方法。     

困难胰腺切除术中肠系膜上静脉的处理(附12例报告)

目的 探讨12例运用肠系膜上静脉解剖技术于胰腺切除病例中的经验和结果.方法 回顾性分析2008年1月至2010年12月采取经横结肠系膜下途径解剖肠系膜上静脉,再完成胰腺切除的方法,行困难胰腺切除12例的临床资料,总结病人的围手术情况和并发症发生率.结果 本组12例中,胰头癌8例,十二指肠乳头癌2例,胰体尾癌2例.行胰十...