高龄患者胰十二指肠切除术分析

目的分析70岁以上老年人胰十二指肠切除术（PD）临床资料并探讨其安全性。方法回顾性分析老年人行PD的临床资料,将90例50岁以上PD手术病例分成≥70岁（高龄组,n＝27）和＜70岁（低龄组,n＝63）两组,分析两组术前Karnofsky功能状态（KPS）评分、入院时血红蛋白（Hb）、血细胞比容（Hct）、血浆白蛋白（ALB）、血清总胆红素（TBIL）、血浆前白蛋白（PALB）、血糖、血钾、手术时间、术中失血量、术后重症监护病房（ICU）入住率、术后住院日、术后并发症发生率及术后死亡率。结果高龄组与低龄组比较,术前KPS评分低[（71.11±6.98） vs （85.40±6.43）,P＜0.01]、血浆ALB低[（34.86±4.54） vs （37.02±4.13）g/L,P＜0.05]、PALB低（127.36±41.19） vs （160.27±57.11）g/L,P＜0.05）、血糖高[（8.47±3.68） vs （6.41±2.12）mmol/L,P＜0.05]、血钾低[（3.38±0.48） vs （3.81±0.45）mmol/L,P＜0.01]、术后ICU入住率高（81.48%vs 39.68%,P＜0.01）,两组间的差异均有统计学意义。两组并发症发生率差异无统计学意义（48.15% vs 39.42%,P＞0.05）。高龄组无住院期间手术死亡,低龄组有2例术后30d内死于并发症。结论严格掌握适应证,重视术前内环境调整,术后积极ICU治疗,≥70岁高龄患者行PD是安全可行的。     

A comparison of pancreaticoduodenectomy and duodenum-preserving head resection for the treatment of chronic pancreatitis

Background:

For chronic pancreatitis, European prospective trials have concluded that duodenum-preserving head resections (DPHR) are associated with less morbidity and similar pain relief and quality of life (QoL) outcomes compared with pancreaticoduodenectomy (PD). However, DPHR procedures are seldom performed in North America.

Methods:

Patients undergoing PD or DPHR for unremitting pain secondary to chronic pancreatitis were retrospectively identified. Quality of life was assessed cross-sectionally using the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30) and pancreatic cancer-specific supplemental module (QLQ-PAN26).

Results:

Eighty-one patients underwent either a Whipple PD (n= 59) or a DPHR (Bern, Beger or Frey procedure, n= 22) for the treatment of pain caused by chronic pancreatitis over a 5-year period. The characteristics of patients undergoing DPHR and PD procedures were similar. Duration of procedure (360 min vs. 245 min), duration of hospital stay (12.0 days vs. 9.5 days) and estimated blood loss (535 ml vs. 214 ml) were all significantly less for DPHR patients (P < 0.05). Thirty-day morbidity and mortality, postoperative pain relief and QoL scores did not differ significantly between groups.

Conclusions:

Duodenum-preserving head resection is equally as effective as PD in relieving pain and improving QoL in chronic pancreatitis patients, and involves a shorter hospital stay and less blood loss.     

Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduode-nectomies in the setting of chronic pancreatitis

BACKGROUND: The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients under-going pancreaticoduodenectomy (PD) for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease.METHODS: Eighty-eight patients (85.4%) with a clinicoradio-logical picture highly suggestive for malignancy received for-mal PD (group 1). Fifteen patients (14.6%) in whom preopera-tive diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation (PHEX) for intraoperative tissue diagnosis (group 2): those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy (PJ).RESULTS: No patient received PD for benign disease. All pa-tients in group 1 had adenocarcinoma on final histology. Eight patients of group 2 (53.3%) received PD after intraoperative diagnosis of cancer, whereas 7 (46.7%) received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall sur-vival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 (P=0.509).CONCLUSION: Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unneces-sary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.     

Preservation of the pylorus during pancreaticoduodenectomy —Evolution and current indications

The Whipple procedure has been improved by preservation of afunctioning pylorus. A functioning pylorus is important because marginal ulceration is avoided and, compared to the standard Whipple procedure with hemigastrectomy, more patients can gain weight postoperatively. The most common indications for this procedure are severe complication of chronic pancreatitis and periampullary tumors. In patients with pancreatic adenocarcinoma, the pylorus-preserving variety results in equal or better survival rates than those of the standard Whipple procedure with hemigastrectomy. Surgery alone is not sufficient to improve survival rates in patients with adenocarcinoma of the pancreas. Improved imaging modalities are required to diagnose the disease earlier. The most likely combination of treatment to prolong survival time is a combination of resection for cure in a patient with an early diagnosis plus an aggressive adjuvant chemoradiotherapy protocol. This protocol is most likely to be completed if a patient has preserved endocrine, exocrine, and digestive ability. A radical (R1) pylorus-preserving Whipple procedure would have the following advantages to result in the best survival rates — the patients can gain weight and thereby withstand the chemoradiotherapy protocol while, at the same time, the weakest aspect of the radical resection is addressed, i.e., the retroperitoneal margin of the pancreatic head.     

Pancreaticoduodenectomy in the elderly over 80 years:a case report

Introduction A ge limits for radical surgery have become a matter of interest because of aging of the population. There are a large series of very elderly patients undergoing cardiothoracic and vascular procedures, but few studies have been undertaken on the outcomes of these patients following major intra-abdominal surgery.[1] Among digestive tumors, the incidences of periampullary malignant tumor and pancreatic ductal adenocarc- inoma are one of the highest. Before the early 1990s, there was…     

Appraisal of the Imaizumi modification of the Beger procedure: the TWMU experience

Background/purpose

We developed the Imaizumi modification of the Beger procedure, a duodenum-preserving pancreatic head resection. The Imaizumi modification allows for removal of more of the subtotal pancreatic head than in the conventional Beger procedure, including the intrapancreatic bile duct, for chronic pancreatitis with common bile duct stenosis. A retrospective study was performed to evaluate the efficacy of the Imaizumi modification compared to a pylorus-preserving pancreaticoduodenectomy (PPPD), based on the early and late postoperative results.

Methods

A group of 14 patients who underwent the Beger procedure with the Imaizumi modification to treat chronic pancreatitis from November 1997 to December 2005 was investigated retrospectively. This group was compared to a group of 21 patients who underwent PPPD from November 1997 to December 2003. The median follow-up period was 3.6 years (range 3.1–5.7 years) for the Imaizumi modification group and 4.0 years (range 3.0–8.3 years) for the PPPD group.

Results

A pancreatic fistula formed in 7% of the Imaizumi modification patients (PPPD 5%), pain relief was achieved in 92% (PPPD 94%), complete professional rehabilitation was achieved in 71% (PPPD 67%), insulin-dependent diabetes mellitus was present in 43 versus 36% before the procedure (PPPD 62 versus 38% before the procedure), and body weight improved in 79% (PPPD 48%). No significant differences were found between the two groups for the early postoperative complications and the late postoperative outcome 3 years after the procedure. However, the Imaizumi modification group exhibited an encouraging tendency to have a lower rate of new-onset exocrine and endocrine insufficiency than the PPPD group.

Conclusions

Our Imaizumi modification of the Beger procedure, including intrapancreatic bile duct resection, represents a useful alternative for the treatment of chronic pancreatitis with an inflammatory mass and bile duct stenosis in the pancreatic head.     

Pancreaticoduodenectomy for borderline resect-able pancreatic head cancer with a modified artery-first approach technique

BACKGROUND: The treatment of borderline resectable pan-creatic head cancer (BRPHC) is still controversial and chal-lenging. The artery-first approaches are described to be the important options for the early determination. Whether these approaches can achieve an increase R0 rate, better bleeding control and increasing long-term survival for BRPHC are still controversial. We compared a previously reported technique, a modified artery-first approach (MAFA), with conventional techniques for the surgical treatment of BRPHC.METHODS: A total of 117 patients with BRPHC undergone pancreaticoduodenectomy (PD) from January 2013 to June 2015 were included. They were divided into an MAFA group (n=78) and a conventional-technique group (n=39). Back-ground characteristics, operative data and complications were compared between the two groups.RESULTS: Mean operation time was significantly shorter in the MAFA group than that in the conventional-technique group (313 vs 384 min; P=0.014); mean volume of intraop-erative blood loss was significantly lower in the MAFA group than that in the conventional-technique group (534 vs 756 mL;P=0.043); and mean rate of venous resection was significantly higher in the conventional-technique group than that in the MAFA group (61.5% vs 35.9%; P=0.014). Pathologic data, early mortality and morbidity were not different significantly between the two groups.CONCLUSIONS: MAFA is safe, simple, less time-consuming, less intraoperative blood loss and less venous resection, and therefore, may become a standard surgical approach to PD for BRPHC with the superior mesenteric vein-portal vein involve-ment but without superior mesenteric artery invasion.     

Pancreaticoduodenectomy following total gastrectomy:A case report and literature review

We present a case of afferent loop syndrome(ALS)occurring after pancreaticoduodenectomy(PD)in a patient who had previously undergone total gastrectomy(TG),and review the English-language literature concerning reconstruction procedures following PD in patients who had undergone TG.The patient was a69-year-old man who had undergone TG reconstruction by a Roux-en-Y method at age 58 years.The patient underwent PD for pancreas head adenocarcinoma.A jejunal limb previously made at the prior TG was used for pancreaticojejunostomy and hepaticojejunostomy.Despite normal patency of the hepaticojejunostomy,he suffered from repeated postoperative cholangitis which was brought on by ALS due to shortness of the jejunal limb(15 cm in length).We therefore performed receliotomy in which the hepaticojejunostomy was disconnected and reconstructed using a new Y limb 40-cm in length constructed in a double Roux-en-Y fashion.The refractory cholangitis resolved immediately after the receliotomy and did not recur.Review of the literature revealed the lack of any current consensus for a standard procedure for reconstruction following PD in patients who had previously undergone TG.This issue warrants further attention,particularly given the expected future increase in the number of PDs in patients with a history of gastric cancer.     

Groove pancreatitis with recurrent duodenal obstruction

Summary Groove pancreatitis is a rare subtype of chronic pancreatitis that is difficult to distinguish from pancreatic carcinoma. Most reported patients have undergone a Whipple procedure because pancreatic cancer was not ruled out. We report a case of groove pancreatitis in a patient who presented with recurrent duodenal obstruction without biliary stricture. The diagnosis of groove pancreatitis was based on characteristic episodes of repeated duodenal obstruction and the absence of radiographic evidence of cancer. Subsequently, our patient underwent a successful pylorus-reserving pancreaticoduodenectomy (PPPD). PPPD is a favorable alternative to the Whipple operation for duodenal obstruction resulting from this disease.     

Pancreaticoduodenectomy for periampullary cancer in patients more than 70 years of age

BACKGROUND/AIMS: To assess the indications for and results of pancreaticoduodenectomy in patients more than 70 years old with periampullary cancer. METHODOLOGY: Thirty-four consecutive patients older than 70 years with periampullary cancer. The surgical procedure was pancreaticoduodectomy (Whipple's operation) with an extensive dissection of lymph nodes and the connective tissue in the peripancreatic region. Main outcome measures were postoperative morbidity and mortality, median and 5-year survival rates. RESULTS: Postoperative medical complications occurred in 24% and surgical complications in 53% of the patients. Four patients (12%) died in the postoperative period (within 30 days), and 3 patients (9%) died later in the postoperative course. The cumulative and age corrected 5-year survival rate for the remaining patients was 26%. Fifteen patients died of recurrence, and 7 patients of other causes. Five patients are still alive more than 5 years after surgery. In patients with noncurative operation the median survival time was 1 1/2 years, which is longer than would be expected from other palliative procedures. Apart from a moderately increased postoperative mortality the results were similar to those reported for younger patients. CONCLUSIONS: Pancreaticoduodenectomy should be considered in patients older than 70 years with resectable periampullary cancer. A 5-year survival rate of 20-35% can be obtained. Palliative resection may be indicated in patients in good general condition, as resection gives the best palliation and longer survival than other palliative methods.     

Biliary stenting versus surgical bypass for palliation of periampullary malignancy

Background

Patients with periampullary cancers may not be suitable for curative resection due to locally advanced disease, metastases, or poor health. Biliary stenting and surgical bypass are utilized for symptom control, but the true benefit of one technique over the other is not clear.

Methods

A retrospective analysis of case records was undertaken of patients with periampullary (pancreatic head/uncinate process, distal bile duct, and ampulla of Vater and surrounding duodenum) malignancy treated between June 2004 and June 2010 in a tertiary center by palliative biliary stenting or palliative surgical bypass.

Results

Of the 69 patients included in the analysis, combined biliary and gastric bypass was performed on 28, while 41 underwent biliary stent (metallic, n?=?39) insertion. Patients undergoing stenting were significantly older and less likely to be offered chemotherapy than those from the surgical bypass group. Overall, there were significantly more complications in the stent insertion group (85 %) than the surgical bypass group (36 %) (p?=?0.003). The stent group required significantly more subsequent procedures than the surgical bypass group. Metal stent obstruction occurred in 16 of 39 (41 %) patients, with a median stent patency of 224 days. The overall median survival of patients in this study was 7 months with no significant difference between the groups (p?=?0.992). The presence of metastases at presentation was the only independent factor associated with decreased survival.

Conclusion

There was no survival difference between stenting vs. surgical bypass for palliation of periampullary cancer. There was, however, a high rate of stent occlusion and need for repeat procedures in patients treated by metal stenting, suggesting that stenting may be best suited to patients predicted as having the shortest survival.     

Survival analysis of pancreatic and periampullary collision cancers

OBJECTIVE: Collision cancers are malignancies in the same organ or anatomical site that comprises at least two different tumor components, with no mixed or transitional area between two components. Collision cancers are very rare in the pancreas and periampullary region. The aim of this study was to analyze the clinical and pathological features and prognosis of collision cancer in the pancreas and periampullary region. METHODS: Patients with collision cancers of the pancreas and periampullary region (n= 10) who had undergone radical surgery were retrospectively studied. Their clinical and pathological features were summarized and the prognostic data were compared with patients with pancreatic adenocarcinomas who underwent radical surgery (n= 87) and with patients with pancreatic or periampullary malignancies who underwent palliative surgery (n= 89). RESULTS: Compared with other cancers at these sites, collision cancer presents no specific clinical features. However, the median survival period of patients with such malignancies was only 10.0 months, which was much less than those with pancreatic adenocarcinomas who underwent radical surgery (27.0 months) and those who received a palliative operation (20.9 months) only. CONCLUSION: Collision cancers of the pancreas and periampullary region are difficult to diagnose preoperatively. Their prognosis is poor even after radical resection and adjuvant chemotherapy were given.     

A pancreaticoduodenectomy is acceptable for periampullary tumors in the elderly,even in patients over 80 years of age

Background

Although the mortality rates for pancreaticoduodenectomy have been reported to be low for periampullary tumors at high-volume centers, postoperative results still remain unclear for elderly patients over 80 years of age.

Methods

This was a retrospective study of patients who underwent a pancreaticoduodenectomy and consisted of 335 patients who were treated for periampullary tumors between January 1994 and August 2008. The main outcomes were postoperative complications, mortality, and the length of hospital stay among the elderly patients, and they were analyzed in three groups: elderly patients over 80 years old, septuagenarians, and those under 70 years of age.

Results

The performance status of elderly patients was lower than that of the patients under 70 (P < 0.05), and the elderly had a higher American Society of Anesthesiologists physical status classification score (P < 0.001) as well as low hemoglobin and serum albumin levels (P < 0.01 and P < 0.001, respectively). The incidence of delayed gastric emptying in the elderly was higher; however, there was no significant difference. The other outcomes in the elderly group were similar to those of the other groups.

Conclusions

Pancreaticoduodenectomy was considered to be a feasible surgical procedure for elderly patients who had a good performance status.     

Surgical treatment of chronic pancreatitis

Debilitating abdominal or back pain remains the most common indication for surgery in patients with chronic pancreatitis. The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co‐morbidity. No single approach is ideal for all patients with chronic pancreatitis. Pancreatic ductal drainage with pancreaticojejunostomy targets patients with a dilated pancreatic duct and produces good early postoperative pain relief; however, 30%–50% of patients experience recurrent symptoms at 5 years. Resection for chronic pancreatitis should be considered (1) when the main pancreatic duct is not dilated, (2) when the pancreatic head is enlarged, (3) when there is suspicion of a malignancy, or (4) when previous pancreaticojejunostomy has failed. Re‐sectional strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum‐preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure). Superior results are obtained when the pancreatic head is resected, either completely (pancreaticoduodenectomy) or partially (Beger or Frey procedure). Although pylorus‐preserving pancreaticoduodenectomy remains the gold standard resection procedure, there is evidence that newer operations, such as the Beger resection, may be as effective in regard to pain relief and better in respect to nutritional repletion and preservation of endocrine and exocrine function.