胰头肿块型慢性胰腺炎的治疗

胰头肿块型慢性胰腺炎已被视为胰腺癌的癌前病变,并且可以导致胰管、胆管及十二指肠梗阻,其与胰头癌的鉴别诊断困难,然而二者的预后截然不同。因此,胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,以切除病变,缓解疼痛症状,改善病人的生活质量。胰头部肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括胰十二指肠切除术（保留或不保留幽门的Whipple 手术）和保留十二指肠的胰头切除术（Beger手术及其改良术式）。手术方式尽可能采用胰十二指肠切除术,不仅切除了胰头部肿块、解除了胆道、胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;如胰头肿块巨大,行胰十二指肠切除术有极大风险,可考虑行保留十二指肠的胰头切除术。     

胰头部肿块型慢性胰腺炎诊断与治疗

胰头部肿块型慢性胰腺炎从临床表现上很难与胰头癌相鉴别,目前已将发生于胰头部的肿块型慢性胰腺炎视为胰腺癌发生的癌前病变。影像学检查在肿块型慢性胰腺炎诊断中起着重要作用,对于手术指征的掌握、胰头部肿块的可切除性、手术方式的选择以及手术困难程度的估计很有帮助。胰头部肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括胰十二指肠切除术（保留或不保留幽门的Whipple手术）和胰头部分切除加胰管引流术（Frey 手术,Beger 手术）。胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,手术方式尽可能采用胰十二指肠切除术,因为它不仅切除了胰头部肿块、解除了胆道和胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;如胰头肿块巨大,行胰十二指肠切除有极大风险,可考虑行保留十二指肠的胰头切除术。     

胰头肿块型胰腺炎的诊断与治疗

胰头肿块型慢性胰腺炎从临床表现上很难与胰头癌相鉴别,影像学检查在肿块型慢性胰腺炎诊断中起重要作用,对于手术指征的掌握、胰头部肿块的可切除性、手术方式的选择以及手术困难程度的估计很有帮助.目前已将发生于胰头的肿块型慢性胰腺炎视为胰腺癌发生的癌前病变.胰头肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括:胰十二指肠切除术(保留或不保留幽门)和胰头部分切除(Beger手术)加胰管引流术(Frey手术).胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,手术方式尽可能采用胰十二指肠切除术,因为它不仅切除了胰头肿块、解除了胆道和胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;若胰头肿块巨大胰十二指肠切除有极大风险,可考虑保留十二指肠的胰头切除术.     

保留十二指肠胰头切除术治疗胰头良性肿瘤1例

<正>保留十二指肠胰头切除术(duodenum preserving resection of head of pancreas,DPRHP)由Beger 1972年首先提出并应用于临床,该术主要用以治疗胰头部良性肿瘤及慢性胰腺炎。近期我院行本手术1例,为胰头良性肿瘤,现报告如下。     

保留十二指肠胰头切除术

保留十二指肠胰头切除术主要运用于慢性胰头肿块性胰腺炎和胰头部良性肿瘤及低度恶性肿瘤,主要包括Beger、Frey、Bern和保留十二指肠胰头全切术4种术式,对比传统的Whipple术与保留幽门胰头十二指肠切除术创伤小、并发症少。现就保留十二指肠胰头切除术本身作一系统综述。     

联合肠系膜门静脉切除的胰十二指肠切除术治疗胰头腺癌

胰腺癌侵犯门静脉被视为切除手术的禁忌证，一般认为门静脉系统孤立的肿瘤侵犯是根治性切除的最大障碍。而胰十二指肠切除术中联合肠系膜门静脉切除的价值一直存有争议。本文的主要目的是比较胰头癌病人接受单纯或联合胰十二指肠切除术两组的死亡率、发病率、长期生存率以及术后预后参数。自1989年至2003年，共45例相连续的胰头癌病人接受胰十二指肠切除术，术中发现肠系膜上静脉或（和）门静脉被肿瘤侵犯而联合施行肠系膜门静脉切除（VR＋组）。同期88例胰头部腺癌病人接受了胰十二指肠切除而未联合肠系膜门静脉联合切除术（VR-组）。     

胰头部肿块手术方式选择及评价

胰头部肿块解剖位置特殊,病理类型多样,治疗应采取个体化原则,对于胰头部实性包块,术前应重视肿块型胰腺炎和胰腺癌的鉴别,胰十二指肠切除术是胰头癌的经典术式,关于保留幽门的胰十二指肠切除,扩大淋巴结清扫范围及联合血管切除目前仍无共识,可酌情选用。近年来保留十二指肠的胰头切除术在治疗胰头肿块型胰腺炎中体现出一定优越性。对于术中仍无法区别良恶性者,不必过分强调病理结果,选择胰十二指肠切除术是可以接受,也是值得的。对于胰头部囊性及囊实性肿块,应根据肿瘤大小、位置、病理类型选用假性囊肿内、外引流、单纯摘除、保留十二指肠的胰头切除、胰腺节段切除及胰十二指肠切除术等,注意囊性肿块鉴别诊断,避免误将囊性肿瘤按假性囊肿行内引流术。     

保留十二指肠胰头勺式切除与Whipple术治疗慢性胰腺炎并胰头结石的对比研究

目的探讨保留十二指肠胰头勺式切除术在慢性胰腺炎并胰头结石治疗的价值。方法胰头部结石患者64例,行保留十二指肠胰头勺式切除24例(Ⅰ组)和Whipple术40例(Ⅱ组)。比较两种方法在手术时间、术中出血量、术后血糖及胆红素水平、疼痛缓解、住院时间及并发症等指标的差异。结果两组手术时间、术中出血量均有统计学差异(P<0.05);术后血糖、胆红素变化及腹痛缓解率比较无统计学差异(P>0.05);而住院时间、并发症发生率两组比较有统计学差异(P<0.05)。结论保留十二指肠胰头勺式切除在慢性胰腺炎并胰头部结石术中是安全可行的,相对胰十二指肠切除术,其创伤相对小,术后恢复快,住院时间短,并发症发生率低。     

胰头部动脉优先离断在根治性胰十二指肠切除术中的运用

目的探讨胰头部动脉优先离断在肠系膜上静脉或门静脉受侵犯的胰头部恶性肿瘤行根治性胰十二指肠切除术中的运用价值。方法回顾性分析2012年1月至2013年5月华中科技大学同济医学院附属同济医院完成的58例胰头部恶性肿瘤行根治性胰十二指肠切除术患者的临床资料。58例患者术前薄层CT检查均显示肠系膜上静脉或门静脉受侵犯或受压,均行胰头部动脉优先离断的根治性胰十二指肠切除术,即在处理胰头部静脉血管之前优先离断胰头部的所有动脉供血,即三大动脉血管的分支,主要步骤包括：在十二指肠水平部或横结肠系膜根部暴露和悬吊肠系膜上动、静脉;解剖肝总动脉从而离断胃十二指肠动脉和胃右动脉,同时沿肝总动脉根部解剖腹腔动脉干上方;离断胰腺和脾动脉的胰头分支;沿暴露的肠系膜上动脉前方、右侧和后方解剖,完全离断胰头钩突部与肠系膜上动脉和腹腔动脉干间的神经结缔组织,与腹腔动脉干的上方贯通,此时可清楚地显示腹主动脉前方;最后通过预置的静脉血管阻断带安全剥离、切除或重建肠系膜上静脉或门静脉,完整切除肿瘤。结果术前影像学检查判断局部肿瘤可切除患者37例,可能切除患者21例。58例患者均顺利施行胰头部动脉优先离断的根治性胰十二指肠切除术,手术时间为4．5～8．1h,术中出血量为200—900mL,术中及术后胰腺钩突部无出血。行肠系膜上静脉侧壁部分切除修补术21例,肠系膜上静脉受累段切除端端吻合术10例,血管受压迫成功将肿瘤从血管上剥离行标准的胰十二指肠切除术27例。术后患者出血、胰液漏和胆汁漏的发生率分别为5．2％（3／58）、6．9％（4／58）和1．7％（1／58）。围手术期无患者死亡。结论胰头部动脉优先离断方式能保障肠系膜上静脉或门静脉受侵犯或受压的胰头部恶性肿瘤行根治性胰十二指肠切除术的安全性,减少术中出血。     

胰十二指肠切除术在胰头部慢性胰腺炎治疗中的应用和选择

目的 探讨胰十二指肠切除术在胰头部慢性胰腺炎治疗中的应用和选择。方法 回顾性分析我院1988年7月至1999年11月经胰十二指肠切除术和病理证实的10例胰头部慢性胰腺炎临床资料。结果 本组病人男性7例，妇性3例，年龄41－75岁，平均57.2岁。主要临床表现为腹痛、黄疸。影像学检查（B超、CT和ERCP）发现胰头部局限性肿大。9例行典型的Whipple手术，1例行保留幽门的胰十二指肠切除术。7例随访均无腹痛、糖尿病。结论 胰头部慢性胰腺炎早期诊断困难，重要的是与胰头癌相鉴别。胰十二指肠切除术治疗胰头部慢性胰腺炎的手术效果良好，其手术适应证的选择和手术时机的掌握至关重要。     

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??Applied value of duodenum-preserving pancreatic head resection (DPPHR) in treating tumor of pancreatic head Department of General Surgery, the First Affiliated Hospital of China Medical University, Shenyang 110001, China Abstract There is a close relationship anatomically between pancreatic head and duodenum. It was known previously that it was inevitable to resect pancreatic head together with duodenum. Beger firstly reported duodenum-preserving pancreatic head resection (DPPHR) for the patient with chronic pancreatitis in 1972. Imaizimi reported modified Beger’s operation, duodenum-preserving total pancreatic head resection (DPTPHR) for the patient with low-degree malignant tumor of pancreatic head without lymph nodes clearance in 1990. DPPHR resect only focus of pancreatic head, do not destroy continuous instruction of digest tract, and improve postoperative life quality. Recently, DPPHR has been extensively used in surgical clinics.     

Duodenum-preserving pancreatic head resection for pancreatic metastasis from renal cell carcinoma: a case report

Introduction We report a case of duodenum-preserving pancreatic head resection (DPPHR) for the treatment of pancreatic head metastasis from renal cell carcinoma (RCC). Case report The patient was a 59-year-old male with a medical history of RCC 18 years ago. Abdominal imaging studies revealed a hypervascular mass localized in the pancreatic head without distant metastasis or tumor invasion into the adjacent organs including the common bile duct and duodenum. Under the preoperative diagnosis of pancreatic metastasis from RCC, the tumor was completely resected by DPPHR. The pathological examination of the resected specimen confirmed the preoperative diagnosis. Conclusion As lymph node metastasis has been rarely reported in previous cases of pancreatic metastasis from RCC, DPPHR should be considered as a less invasive surgical option to provide a favorable postoperative quality of life (QOL).     

Duodenum-preserving total pancreatic head resection and pancreatic head resection with segmental duodenostomy

A duodenum-preserving pancreatic head resection (DPPHR) was first reported by Beger et al. in 1980. However, its application has been limited to chronic pancreatitis because of it is a subtotal pancreatic head resection. In 1990, we reported duodenum-preserving total pancreatic head resection (DPTPHR) in 26 cases. This opened the way for total pancreatic head resection, expanding the application of this approach to tumorigenic morbidities such as intraductal papillary mucinous tumor (IMPT), other benign tumors, and small pancreatic cancers. On the other hand, Nakao et al. reported pancreatic head resection with segmental duodenectomy (PHRSD) as an alternative pylorus-preserving pancreatoduodenectomy technique in 24 cases. Hirata et al. also reported this technique as a new pylorus-preserving pancreatoduodenostomy with increased vessel preservation. When performing DPTPHR, the surgeon should ensure adequate duodenal blood supply. Avoidance of duodenal ischemia is very important in this operation, and thus it is necessary to maintain blood flow in the posterior pancreatoduodenal artery and to preserve the mesoduodenal vessels. Postoperative pancreatic functional tests reveal that DPTPHR is superior to PPPD, including PHSRD, because the entire duodenum and duodenal integrity is very important for postoperative pancreatic function.     

保留十二指肠胰头切除术的适应证及术式选择:附22例报告

目的探讨保留十二指肠胰头切除术（DPPHR）的适应证及具体术式的选择指征。方法回顾性分析我中心2001年1月至2006年1月实施的22例DPPHR术患者的临床资料,其中黏液性囊腺瘤8例,黏液性囊腺癌2例,实性-假乳头状瘤4例,神经内分泌肿瘤2例,慢性胰腺炎4例（伴胰头肿块2例,伴多发结石2例）,淋巴上皮囊肿1例,浆液性囊腺瘤1例。探讨DPPHR术式的适应证、手术方式的选择及术后并发症的防治。结果患者手术死亡0例,术后发生胰瘘3例,胆瘘1例,腹腔感染1例,十二指肠瘘2例。结论DPPHR术保留了胃、十二指肠及胆道的连续性,手术安全性好,降低了手术创伤和切除范围,可作为胰头颈部良性和低度恶性肿块局限性切除的术式。     

Duodenum preservation in pancreatic head resection to maintain pancreatic exocrine function (determined by pancreatic function diagnostant test and cholecystokinin secretion)

Background/Purpose Organ-preserving surgery, such as pylorus-preserving pancreatoduodenectomy (PPPD), duodenum-preserving pancreatic head resection (DPPHR), or medial pancreatectomy (MP), is one of the recent advances in pancreatic surgery. There was a previous report that preservation of the duodenum maintained pancreatic function. However, concerning the resected pancreas, patients were divided into two groups; one group included pancreatic head resections such as Whipple, PPPD, and complete DPPHR, and the other group included MP that removed only the pancreatic neck and preserved the pancreatic head and distal pancreas. The present study was designed to clarify the significance of duodenum preservation, in comparison with duodenum removal, in patients with pancreatic head resection, in terms of pancreatic function, determined by a pancreatic function diagnostant (PFD) test and cholecystokinin (CCK) secretion.Methods The subjects were 61 patients (10 with Whipple, 41 with PPPD, and 10 with complete DPPHR). PFD tests and postprandial plasma CCK secretion were used for evaluation.Results There was a significant difference between pre- and postoperative PFD values in the patients who received Whipple or PPPD; however, there was no difference in those who had complete DPPHR. Concerning the postoperative PFD value, complete DPPHR was superior to Whipple and PPPD. Regarding postprandial CCK secretion, the pre- and postoperative values were significantly different in the patients with Whipple or PPPD, but there was no difference in those with complete DPPHR. Comparing the three kinds of operations, complete DPPHR was superior to the other two procedures in its maintenance of pancreatic function. There was the significant correlation between CCK and PFD in our patients in the Spearman Rank Correlation (P < 0.0029) and Fishers r to z (P < 0.0058).Conclusions When pre- and postoperative pancreatic exocrine function and postprandial CCK secretion were measured in patients with pancreatic head resection, it was found that preservation of the entire duodenum was an important factor for maintaining pancreatic function.     

Pancreatic fistula after pancreatic head resection

BACKGROUND: Pancreatic resections can be performed with great safety. However, the morbidity rate is reported to be 40-60 per cent with a high prevalence of pancreatic complications. The aim of this study was to analyse complications after pancreatic head resection, with particular attention to morbidity and pancreatic fistula. METHODS: From November 1993 to May 1999, perioperative and postoperative data from 331 consecutive patients undergoing pancreatic head resection were recorded prospectively. Data were analysed and grouped according to the procedure performed: classic Whipple resection, pylorus-preserving pancreatoduodenectomy (PPPD) or duodenum-preserving pancreatic head resection (DPPHR). RESULTS: Pancreatic head resection had a mortality rate of 2.1 per cent; the difference in mortality rate between the three groups (0.9-3.0 per cent) was not significant. Total and local morbidity rates were 38.4 and 28 per cent respectively. DPPHR had a lower morbidity, both local and systemic, than pancreatoduodenectomy. The prevalence of pancreatic fistula was 2.1 per cent in 331 patients, and was not dependent on the procedure or the aetiology of the disease. Reoperations were performed in 3.9 per cent of patients, predominantly for bleeding and non-pancreatic fistula. None of the patients with pancreatic fistula required reoperation or died in the postoperative course. CONCLUSION: A standardized technique and a continuing effort to improve perioperative management may be responsible for low mortality and surgical morbidity rates after pancreatic head resection. Pancreatic complications occur with Whipple, PPPD and DPPHR procedures with a similar prevalence. Pancreatic fistula no longer seems to be a major problem after pancreatic head resection and rarely necessitates surgical treatment.     

保留十二指肠的胰头切除术治疗胰头部良性肿瘤2例报告并国内文献复习

目的：探讨保留十二指肠的胰头切除术（DPPHR）治疗胰头部良性肿瘤的价值。 方法：报告中国医科大学附属第一医院于2011年度实施2例DPPHR的临床资料,并结合国内近10年中9篇文献报道共66例DPPHR的资料,对所有68例DPPHR的并发症及手术疗效进行回顾性分析。 结果：68例中13例（19.2%）发生术后并发症,其中胰瘘10例（14.7%）,十二指肠瘘1例（1.5%）,胃瘫1例（1.5%）,胆系感染1例（1.5%）,均非手术治疗治愈。住院时间11~57 d,平均17 d,无住院期间病死病例。有随访资料44例,随访时间3个月至6年,均无复发。 结论：DPPHR是治疗胰头部良性肿瘤安全、有效的术式。     

Duodenum-preserving pancreatic head resection: long-term results

Early and late results from 298 patients with chronic pancreatitis who were surgically treated by means of duodenum-preserving pancreatic head resection (DPPHR) were prospectively analyzed. The aim of this operative procedure is to treat complications of chronic pancreatitis caused by inflammatory enlargement of the pancreatic head by decompressing the common bile duct, the pancreatic duct, the duodenum, and the retropancreatic intestinal vessels. End points of the study were early and late postoperative outcome. The follow-up period ranged from 1 to 22 years with a median follow-up of 6 years. In-hospital mortality was 1%, postoperative morbidity was 28.5%, and the rate of repeat laparotomy was 5.7%. Diabetes mellitus developed early in the postoperative period in six patients (2%). After a median follow-up of 6 years, late mortality was 8.9%. In the late follow-up period 88% of our patients were completely free of pain or had infrequent episodes and 63% were able to return to work. DPPHR might be considered as an alternative surgical technique in the treatment of chronic pancreatitis if the dominant lesion is in the pancreatic head.     

保留十二指肠的胰头切除术治疗胰腺分隔症并发慢性胰腺炎的疗效分析

目的探讨保留十二指肠的胰头切除术对胰腺分隔症并发慢性胰腺炎的治疗效果。方法回顾性分析 1989～ 1997年间 2 2例胰腺分隔症并发慢性胰腺炎患者接受保留十二指肠的胰头切除术的临床资料。结果本组术后平均住院时间为 13d ,无手术死亡 ,无严重并发症发生。术后随访 33个月 ,胰腺内分泌功能无明显变化 ,部分患者外分泌功能受损 ,腹痛分数由术前的 5 8± 1 1降为 3 4± 1 2 (P <0 0 5 )。结论保留十二指肠的胰头切除术是一种治疗胰腺分隔症并发慢性胰腺炎的理想手术     

A duodenum-preserving and bile duct-preserving total pancreatic head resection with associated pancreatic duct-to-duct anastomosis

A duodenum-preserving pancreatic head resection technique was first reported in 1980, but the indications have been limited to benign pancreatic disease as it involves a subtotal pancreatic head resection. In 1988 we detailed a duodenum-preserving total pancreatic head resection (DPTPHR) technique. This procedure involved a total pancreatic head resection and as such expanded the indications for this approach to include tumorigenic masses. The original method involved closure of the proximal pancreatic duct and an anastomosis of the pancreatic duct of the distal pancreas to a newly created small hole in the duodenum (we termed this a "pancreatoduodenostomy"). Our current technique involves a duct-to-duct anastomosis of the proximal pancreatic duct and the distal pancreas to better preserve anatomic structure. DPTPHR was performed in 26 patients from 1988 to 2002, including 12 cases of DPTPHR with pancreatoduodenostomy and 14 cases of DPTPHR with pancreatic duct-to-duct anastomosis. No differences were observed between the two methods with respect to operative time or blood loss during surgery. Postoperatively, there was one case of cholecystitis and one case of pancreatitis in a patient who underwent a pancreatoduodenostomy; both of these patients were treated conservatively with curative intent. No complications were observed in the group undergoing duct-to-duct anastomosis. The advantage of duct-to-duct anastomosis is that the pancreatic head is totally resected, thus allowing removal of neoplastic disease such as an intraductal papillary mucinous tumor and also therapy for chronic pancreatitis. A key benefit of this procedure is that sphincter function of the duodenal papilla is preserved permitting drainage of pancreatic/bile juice into the duodenum, preserving a more physiologic state than is the case after a pancreatoduodenostomy. Supported in part by a Grant-in-Aid for Scientific Research (63480311) from the Ministries of Education, Science, and Culture of Japan.