胰头癌姑息性手术的手术方式选择

目的探讨中晚期胰头癌姑息性手术的术式选择。方法对1995年1月-2003年6月期间收治的142例中晚期胰头癌患者的临床资料进行回顾性分析。结果单纯胆囊空肠吻合术30天内死亡率为14．2％，术后黄疸或胆管炎复发率为61．9％，生存期为7．1个月；肝(胆)总管空肠吻合术死亡率为5．7％，黄疸和胆管炎复发率仅为6．8％，生存期10．3个月，但31．8％的病人术后半年内出现十二指肠梗阻；胆肠吻合加胃空肠吻合术生存期比前两组均高(13．9个月)，术后未出现十二指肠梗阻。结论胰头癌姑息性手术术式应尽量选择Roux-en-Y式的HDJS，同时应作预防性胃空肠吻合术。     

胰头癌早期诊断和治疗分析（附254例报告）

目的 探讨胰头癌的早期诊断、并发症防治和姑息性手术术式选择。方法 回顾分析了自１９７８年１月至１９９８年４月２５４例胰头癌手术治疗情况。结果 胰头癌首发症状多为无明显诱因的上腹痛、上腹不适、纳差（７２．８％）。ＥＲＣＰ敏感性最高（９２．９％）。行根治术６７例,姑息性手术１８７例。在姑息性手术中;肝（胆）总管空肠吻合＋胃空肠吻合术生存工于胆囊空肠吻合＋胃空肠吻合（ｔ＝２．６７,Ｐ〈０．０２）,ｅｊｇ     

胰头癌姑息性手术加作胃空肠吻合必要性探讨

目的：探讨更好地解决胰头癌姑息性手术的问题。方法：对近12年收治的73例胰头癌患者，在不同时期，采取不同手术方式实施姑息性手术治疗进行回顾分析。结果：单纯胆囊空肠吻合术引流减黄效果不佳；肝（胆）总管空肠Roux-Y吻合减黄效果肯定，但缓解不了十二指肠梗阻；肝（胆）总管空肠Roux-Y吻合加作胃空肠吻合，减黄效果好，肝功能恢复快，且中位生存期明显较前两种术式组长（P＜0．01）。结论：在胰头癌姑息性手术治疗方法的选择上，应考虑到双重梗阻因素，即便尚未明确伴有十二指肠梗阻，预防性加作胃空肠吻合也是必要的。     

胰头癌姑息性手术术式选择探讨

目的　探讨胰头癌姑息性手术的术式选择。方法　对近 2 0年来 187例姑息性手术治疗的胰头癌患者临床资料进行回顾性分析。结果　手术死亡率 8 6 % ;肝 (胆 )总管空肠吻合术 (HDJS)手术死亡率并不高于胆囊空肠吻合术 (CJS) (P >0 .0 5 ) ,HDJS术后复发性黄疸和胆管炎发生率显著低于CJS(P <0 .0 2 5 ) ,术后生存期显著长于CJS(P <0 .0 1) ;胆肠吻合加胃空肠吻合术 (GJS)手术死亡率并不显著高于单纯胆肠吻合术 (P >0 .0 5 ) ,术后生存期却显著长于胆肠吻合术 (P <0 .0 1)。单纯胆肠吻合术十二指肠梗阻发生率为2 9 3%。结论　胰头癌姑息性手术术式应尽量选择Roux en Y式HDJS ,同时作预防性胃空肠吻合术。     

成人胆总管囊肿的诊治

目的 进一步探讨成人胆总管囊肿的诊断和治疗。方法 回顾性分析１９９５年１月至１９９９年１月手术室治疗成人胆总管囊肿４２例资料,术后随访平均为３５个月,随访率为８０％。结果 行囊肿十二指肠吻合术２例,囊肿空肠Ｒｏ７ｕｘ－Ｙ吻合术１０例,行囊肿切除加肝总管空肠Ｒｏｕｘ－Ｙ吻合术３０例;术后胆瘘２例,腹腔出血、胰瘘各１例,无手术死亡。结论 囊肿切除加肝总管空肠Ｒｏｕｘ－Ｙ吻合术应为肝外胆管囊肿治疗的首选     

胃、空肠Roux-Y吻合在胰十二指肠切除术中的应用

我们应用一种改革的Ｗｈｉｐｐｌｅ手术 ,即胰十二指肠切除后 ,采用胰、胆、胃、空肠Ｒｏｕｘ Ｙ型吻合重建消化道 ,共 2 6例。现介绍如下。1 一般资料 :1 998年 3月～ 2 0 0 1年3月 ,共施行胃、空肠Ｒｏｕｘ Ｙ吻合型胰十二指肠切除术 2 6例。其中 ,男 1 9例 ,女7例。年龄 :37～ 76岁 ,平均 57 6岁。全部病例均经病理组织学证实为恶性肿瘤 ,它们分别为胰头癌 6例、胆总管下段癌 8例、壶腹部腺癌 5例、十二指肠癌 6例和十二指肠恶性淋巴瘤 1例。2 手术方法 :2 6例均行胆囊、部分肝总管、胆总管、胃窦部、全十二指肠、胰头及其钩突部和部分…     

医源性胆管损伤并狭窄（附18例分析）

本文报告１８例医源性胆管损伤，１４例发生于胆囊切除，４例发生于胃大部切除。４例经总胆管十二指肠吻合，７例经胆管修补Ｔ管支撑，２例胆管端端吻合Ｔ管支撑，５例经肝总管空肠Ｒｏｕｘ一ｅｎ一Ｙ吻合，１７例治愈，１例死于心脏病。作者认为Ｒｏｕｘ一ｅｎ一Ｙ吻合术疗效最可靠。     

多发性肝胆管结石的手术治疗

２１例多发性复杂胆管结石在采用肝门部胆管切开取石胆肠Ｒｏｕｘ－Ｙ吻合术的基础上，对局限于肝段的肝内胆管结石行肝总结切除术。其中行ⅡⅢ肝段切除１８例，行Ⅵ肝段切除３例，行胆管总管空肠Ｒｏｕｘ－Ｙ吻合术１１例，行左右肝管汇合部切开＋原位整形盆状胆肠吻合术８例，左／右肝管残端及肝总管与空肠行双口Ｒｏｕｘ＝Ｙ吻合术２例。结果：２１例均痊愈，无死亡，随访１年以上１６例，疗效优良率１５／１６例。     

改良空肠ρ袢代胃Roux-en-Y食管空肠吻合术──全胃切除后消化道重建术式

改良空肠ρ袢代胃Ｒｏｕｘ－ｅｎ－Ｙ食管空肠吻合术──全胃切除后消化道重建术式彭德恕七十年代前，全胃切除术手术死亡率长期徘徊于８％～１２％。近十多年来由于手术技术的进步，特别是对全胃切除术后消化道连续性重建术式进行了各种研究和改良，使术后吻合口漏、碱性...     

胰头癌姑息性手术——胆道改道加胃空肠吻合术

胰头癌发生率逐日增多,约90％的病例只能作姑息手术——胆道改道术。我院自1987年10月至1992年3月共收治胰头癌病人80例,手术时已不能行根治性切除手术的67例,其中30例在胆道改道同时加做胃空肠吻合术,与同期37例单一胆道改道手术相比,住院天数相似,无并发症和死亡率。在37例单一胆道改道术患者中,4例(10.8％)术后3～12个月因十二指肠梗阻而再次行胃空肠吻合术。故作者推荐胰头癌行姑息性手术时应选用胆道改道加胃空肠吻合术。     

腹腔镜、内镜联合治疗晚期胰头癌的临床研究(附193例报告)

目的:探讨腹腔镜、内镜联合治疗晚期胰头癌,延长患者生存期并改善生活质量的方法与效果。方法:2000年12月至2008年12月我院为193例不能根治性切除的晚期胰头癌患者施行内镜金属支架和腹腔镜胆囊空肠、胃空肠内引流手术。结果:内镜治疗成功率达84.5%(163/193),内镜治疗失败或伴有十二指肠排空障碍者行腹腔镜内引流术成功率达100%(52/52)。术后患者黄疸消退,肝功能好转,能经口进食,提高了生活质量。内镜术后8例(4.9%)发生相关并发症,其中胆道感染5例(3.1%),急性水肿性胰腺炎3例(1.8%)。内镜治疗术后生存期最短3个月,最长37个月,平均(13.1±2.7)个月。腹腔镜内引流术后5例(9.6%)发生相关并发症,其中切口感染3例(5.8%),胃肠排空障碍2例(3.8%)。术后生存期最短2个月,最长21个月,平均(12.3±2.2)个月。结论:对于失去根治切除机会的晚期胰头癌患者,有针对性地选择内镜金属支架和腹腔镜胆肠、胃空肠吻合术,可达到微创、有效的姑息治疗效果,能较好地提高患者的生活质量,延长生存时间。     

The results of surgery for carcinoma of the pancreas

A retrospective analysis was performed on 104 consecutive patients with carcinoma of the pancreas treated between 1970 and 1974 inclusive. Fifty-three per cent underwent palliative bypass, 13% laparotomy only, 6% had a Whipple operation, 7% various miscellaneous operations, and 21% did not undergo operation. The operative mortality of palliative bypass and diagnostic laparotomy was 13% and 71% respectively. The mean survival of patients after biliary bypass was 6.7 months. Seven patients undergoing bypass had tumours of the pancreatic head, five centimetres or less in diameter, and apparently localized disease, and their means survival was 15.9 months. The mean survival of the four patients surviving radical surgery was 15.5 months. There were no cures. It was concluded that cholecystojejunostomy without enteroenterostomy was an appropriate biliary bypass operation and that diagnostic laparotomy should be avoided in patients without obstructive jaundice and with disseminated disease.     

Carcinoma of the head of the pancreas. Morbidity and mortality of surgical procedures

This retrospective study analyses the peri-operative morbidity and mortality of 165 patients presenting with carcinoma of the head of the pancreas over a 5-year period. Patients clinically fit for surgery (84%) were subdivided into three main groups, namely: group I (6%) underwent pancreaticoduodenal resection; group II (42%) had locoregionally advanced disease; and group III (36%) with metastatic disease. The latter group was subdivided into groups IIIa (22%) without ascites and IIIb (14%) with ascites. In the palliative groups (II and III), 61% underwent operative biliary drainage procedures, 33% a combined biliary drainage and a duodenal bypass procedure and 5% a duodenal bypass only. Obstructive jaundice recurred in 3% of cases after operative biliary drainage. Only 7% of patients required a duodenal bypass during follow-up. The mortality rates after surgery were 22% following pancreaticoduodenectomy (group I), 1.5% for the palliative procedures in group II, but 17% in group IIIa patients with metastatic disease without ascites and 83% when ascites was present (group IIIb). This study demonstrates that patients with ascites, although clinically fit for surgery, had a prohibitively high operative mortality rate and represented a subgroup of patients better treated by non-operative methods. Surgical drainage of the biliary system in all other cases had acceptably low morbidity and mortality rates. A prophylactic duodenal bypass is not mandatory.     

Palliative biliodigestive anastomosis in non-resectable cancer of the head of the pancreas--with or without preventive gastroenterostomy?

In 226 patients with malignant obstructive jaundice over a 10-year period (1975-1984) 92 presented with an unresectable carcinoma of the head of the pancreas and were treated with a palliative bilioenteric diversion: in 52 cases alone, in 20 cases with a therapeutic gastroenterostomy because of early duodenal obstruction, and in 20 cases with a simultaneous prophylactic gastroenterostomy. The latter did not increase perioperative morbidity (25% vs. 50% in bilioenteric diversion alone), mortality (5% vs. 19%) nor length of hospital stay (19.9 vs. 20.6 days). Later on patients with a prophylactic gastroenterostomy showed a decreased incidence of chronic vomiting (15% vs. 42%). No secondary gastroenterostomy was performed in this group, vs. 14% (6 patients) in cases with bilioenteric diversion alone (mortality 33%). We recommend the simultaneous prophylactic gastroenterostomy which does not increase morbidity, mortality and length of hospital stay and helps avoiding a risky secondary gastroenterostomy.     

手术治疗胰体尾癌26例临床分析

目的探讨胰体尾癌外科治疗方法和根治性切除的影响因素。方法回顾性分析手术治疗26例胰体尾癌病例的临床病理资料。结果肿瘤侵犯横结肠者2例,脾脏者2例;侵犯脾动静脉14例,门静脉、肠系膜上静脉2例,肠系膜上动脉、腹腔干8例。肿瘤直径小于4cm11例,4—8cm13例,大于10cm2例,根治性切除组肿瘤直径平均为3．8cm（2例胰腺囊腺癌除外）,姑息性切除组肿瘤直径平均为5．4cm。根治性切除18例,姑息性切除8例,胰体尾切除加脾切除24例,门静脉、肠系膜上静脉局部楔行切除修补2例,胰体尾切除加脾切除加横结肠切除2例。根治性切除组与姑息性切除组中位生存时间分别为18．6个月和10．3个月。结论积极行手术切除肿瘤是胰体尾癌患者获得长期生存的唯一途径,而肿瘤的大小、对重要血管和邻近脏器的侵犯程度是影响肿瘤能否根治性切除的重要因素。     

Effect of tumor size and lymph node status on the prognosis of pancreatic cancer

Between 1982 and 1987 186 patients with a carcinoma of the pancreas underwent surgery. In 69 patients (37%) a resective surgical procedure was performed. In these patients, lymph node staging was conducted intraoperatively. The operative mortality of the resection was 4.3%. The median survival of the resected patients with papillary carcinoma was 21 months and of the patients with ductal pancreatic carcinoma 7 months. A correlation between survival time and frequency as well as localization of the lymph node attack could be established. Only patients in the TNM stage I of a ductal carcinoma appeared to have profited significantly from the resection compared to the palliative procedure.     

Palliative gastroenteroanastomosis in pancreatic carcinoma]

The surgical treatment of pancreatic carcinoma is palliative in 90% of cases. The authors report their experience with 25 patients with unresectable pancreatic exocrine cancer, 23 of whom underwent palliative surgery. Sixteen patients had a bilioenteric by-pass and in 7 cases a gastroenterostomy was associated. The postoperative mortality rate was 8.7% and morbidity 28.6%. Eight patients with bilioenteric bypass only survived and only two of these required gastroenterostomy later on because of neoplastic duodenal obstruction. The shorter hospital stay and the longer survival of patients treated by bilioenteric by-pass only suggest that prophylactic gastroenterostomy is unnecessary and should be associated in selected patients only.     

原发性十二指肠恶性肿瘤的外科治疗

目的探讨原发性十二指肠恶性肿瘤的外科治疗策略。方法回顾性分析1997~2004年我院收治的72例原发性十二指肠恶性肿瘤病人的临床资料。52例行胰十二指肠切除术,8例行肿瘤局部切除术,5例行胆肠和/或胃肠吻合术解除梗阻,4例行肿瘤活检术以明确诊断,3例确诊后拒绝手术治疗。结果随访62例。46例行胰十二指肠切除术病人术后1年、3年和5年的生存率分别为76.1%,54.3%和28.3%。3例放弃手术治疗者及3例行肿瘤活检术者均于1年内死亡。4例仅行胆肠和/或胃肠吻合术者术后1年生存率为25%。6例行肿瘤局部切除术者均于术后短期内复发,仅2例存活1年。52例行胰十二指肠切除术病例中出现并发症的有8例。应用单层褥式交锁缝合进行胰肠重建的20例及保留幽门的8例术后经过均良好,无1例出现严重并发症。结论胰十二指肠切除术系原发性十二指肠恶性肿瘤的首选治疗方法,应严格掌握肿瘤局部切除术的适应证。     

OESOPHAGEAL PERFORATION—A REVIEW OF 37 CASES

We have reviewed 37 cases of ruptured oesophagus treated at st vincent's hospital from 1976 to 1986. Their age ranged from 20 to 89 years (mean 64 years) and 59% were female. The cause of rupture were spontaneous (9), foreign body (5), diagnostic oesophagoscopy (8), oesophagoscopy and dilatation (5), balloon dilatation (3), palliative intubation (6) and patient self dilatation (1). Eighty-six per cent of perforations occurred in the lower third of the oesophagus. The most common means of diagnosis was a positive contrast swallow (90%) and/or the presence of cervical or mediastinal air (4970). Eighteen patients underwent surgical treatment which consisted of a combination of thoracotomy, drainage and repair, or laparotomy and celestin tube insertion, with or without chest drainage. Two patients underwent oesophageal diversion. The overall mortality in all patients was 30% (37% non-operative and 22% operative group). We conclude that the management of ruptured oesophagus demands an individual approach depending upon the site and aetiology of perforation and the underlying disease. The condition is a disease of the elderly and continues to have a high morbidity and mortality.     

Surgical Treatment of Metastatic Tumors to the Pancreas: A Single Center Experience and Review of the Literature

Background Unlike primary pancreatic carcinoma, metastases to the pancreas are rare, and their resection may be performed as palliative treatment. The aim of this study was to review our experience with the operative management of pancreatic metastases. Materials and Methods Between January 1994 and December 2004 13 patients (nine women and four men; median age: 59 years; range: 36–79 years) were admitted to our institution with metastatic lesion to the pancreas. The clinical features of the treatment and results were examined. Results Primary tumors were renal cell carcinoma (n = 5), lobular carcinoma of the breast (n = 3), endometrioid carcinoma of the ovary (n = 1), colonic adenocarcinoma (n = 1), jejunal leiomyosarcoma (n = 1), melanoma (n = 1), and non-small-cell lung cancer (n = 1). The median interval between primary tumor and pancreatic metastases was 36 months (range: 5–192 months). Six patients (46%) were asymptomatic, while the other seven patients presented with jaundice, pain, and duodenal obstruction. Two patients with extrapancreatic disease underwent palliative surgery, and the remaining 11 patients underwent operative procedures that included seven pancreaticoduodenectomy and four distal pancreatectomies with splenectomy. Postoperative mortality was nil, and the morbidity rate was 30%. The two patients who underwent palliative surgery died after 7 and 9 months, respectively. The median survival of the resected patients was 26 months (range: 13–95 months). Five patients died of disease, eight are alive at the time of this report. Conclusion A trend towards improved survival, even if not statistically significant, was observed in the renal carcinoma patients reported here. Surgical resection can be performed safely in selected patients with isolated metastases to the pancreas, achieving long-term survival as well as good palliation.