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.     

胰头结石的手术方式选择(附12例报告)

目的:探讨治疗胰头结石的手术方式选择。方法:回顾分析2002年至2011年我院收治的12例胰头结石病人的临床资料,并结合复习有关文献。结果:12例病人均伴有慢性胰腺炎,1例伴有胰头癌,3例伴有糖尿病。12例病人均行手术,其中行胰管切开取石、胰管空肠吻合术7例,胰十二指肠切除术3例,保留十二指肠的胰头切除术2例。结论:胰头结石手术治疗方法应根据具体情况采取不同的手术方式,对胰头部胰管结石的年轻病人可考虑行保留十二指肠的胰头切除术。     

胰头肿块型慢性胰腺炎的诊断与治疗

目的：探讨胰头肿块型慢性胰腺炎的诊治方法。方法：对近15年行胰十二指肠切除术并经病理证实的17例胰头肿块型慢性胰腺炎的临床资料进行回顾性分析。结果：本组术前均不能排除胰头癌。17例均行胰十二指肠切除术，术后发生胰漏1例，其余恢复顺利，效果良好。结论：胰头肿块型慢性胰腺炎早期诊断困难，尤其应与胰头癌相鉴别。对不能排除胰头癌或出现顽固性疼痛，胆管、胰管及十二指肠梗阻时，应行胰十二指肠切除术。     

保留十二指肠胰头切除术在胰头部肿块治疗中的应用价值

胰头部与十二指肠关系密切,既往行胰头切除时同时切除十二指肠,被认为是不可避免的。1972年Beger等首先为慢性胰腺炎施行保留十二指肠胰头切除术（DPPHR,Beger手术）,有较高长时间的疼痛缓解率。Imaizimi等于1990年报道改良的Beger手术,施行保留十二指肠胰头全切除术（DPTPHR）,主要用于无须行淋巴结清扫的胰头部低度恶性肿瘤。保留十二指肠胰头切除仅切除胰头病灶,不破坏消化道解剖连续性和生理功能,改善了术后生活质量。近年来,保留十二指肠胰头切除术在临床上得到比较广泛的应用,令人关注。     

胰头部肿块型慢性胰腺炎的诊断与个体化术式的选择(附10例报道)

目的探讨胰头部肿块型慢性胰腺炎的诊断要点与个体化术式的选择原则。方法回顾性分析2000年4月至2011年9月期间我院收治的10例胰头部肿块型慢性胰腺炎患者的临床资料。结果本组平均发病年龄47.3岁,平均病程69.1 d,平均总胆红素99.4μmol/L,CA19-9 55～78 U/ml。10例B超检查示肝内胆管及胆总管扩张,5例CT检查报告胰头部占位性病变伴主胰管不规则扩张或钙化灶,2例MRCP检查诊断胆总管下段占位。3例术中多点穿刺快速活检后行胆胰管引流术,7例术前误诊为胰头癌或壶腹癌均行胰十二指肠切除,术后出现并发症8例,死亡1例,9例平均随访44.2个月无复发和癌变。结论把握发病年龄、病程、波动性黄疸等临床特征和CA19-9水平及CT、MRCP等影像检查要点是胰头部肿块型慢性胰腺炎与胰头癌鉴别诊断的关键,用个体化术式合理实施胰十二指肠切除、胆胰管内外引流术是胰头部肿块型慢性胰腺炎外科处理明智的选择。     

胰头部肿块鉴别诊断和临床对策

胰头部肿块的鉴别诊断中最为困难的是胰头肿块型胰腺炎与胰腺癌的鉴别。近年来,血清肿瘤标记物检查、多排螺旋CT和内镜超声引导穿刺活检等技术的发展为临床鉴别诊断提供了很多帮助,但仍有部分病人不能通过非手术方法获得确诊。对于这些病人,在与病人及家属进行充分沟通后,可以考虑行剖腹探查,建议术中对胰头部肿块行细针多点穿刺细胞学检查,并由专业人员及时处理标本。慢性胰腺炎是胰腺癌的癌前病变,并且可以导致胰管、胆管及十二指肠梗阻,行胰十二指肠切除术或保留十二指肠的胰头切除术能切除病变,缓解疼痛症状,改善病人的生活质量。但由于该手术创伤大,术后并发症发生率较高,应严格掌握手术适应证,加强围手术期处理,由经验丰富的医师实施手术,将并发症的发生率降到最低。     

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。     

胰头肿块型慢性胰腺炎8例报道

目的分析胰头肿块型慢性胰腺炎与胰头癌的鉴别诊断,并选择有效的手术治疗方法。方法回顾性分析我院2008年1月至2014年1月期间8例胰头肿块型慢性胰腺炎患者的临床病理资料。患者术前行血液肿瘤标志物等检测,肝胆胰彩色多普勒超声、CT强化、MRI、MRCP等影像学检查。结果 8例患者中有长期饮酒或酗酒史4例,既往急性胰腺炎病史5例,慢性胆囊炎病史3例,胆囊结石2例。主要症状为不同程度的黄疸6例和左上腹疼痛5例。术前血清化验高血糖4例,胆红素持续性增高6例,CA19-9增高5例,CEA增高2例(同时CA19-9增高)。影像学检查均提示胰头部肿块。行标准的胰十二指肠切除术6例,保留十二指肠的胰头切除术2例。8例患者术中均行细针穿刺多点细胞学检查提示慢性胰腺炎变化,术后病理均为慢性胰腺炎。术前CA19-9、CEA单独或共同升高患者于术后1周复查CA19-9、CEA均降至正常水平。所有患者术后均未出现胰漏、胆汁漏等严重并发症,黄疸和腹痛均缓解。1例保留十二指肠的胰头切除术后3个月出现间断性呕吐,上消化道造影显示十二指肠重度狭窄,再次手术探查发现十二指肠挛缩,以降段明显,行胃空肠吻合,症状缓解。患者术后定期门诊复查率为100%,随访时间1~6年,所有患者均未出现肿块复发、黄疸、腹痛等。结论胰头肿块型慢性胰腺炎和胰头癌患者虽均以黄疸和腹痛为主要症状,但其特点不同,前者轻微、波动性、间歇性,后者持续并渐进性加重;了解既往病史对鉴别二者有一定意义;CA19-9、CEA作为鉴别胰头肿块型慢性胰腺炎与胰头癌意义不大,对胰头肿块型慢性胰腺炎患者术中行胰头部肿块细针多点穿刺活检,首选保留十二指肠胰头切除术,胰头肿块与周围血管粘连重呈浸润性改变患者需行胰十二指肠切除术。     

慢性胰腺炎的手术方式

对10年来35例慢性胰腺炎的手术治疗进行了回顾,其症状以腹痛为主,影像学表现可分为胰头肿块型,胰腺弥漫性炎症型,左半侧胰腺炎三型。手术方式分为胰腺肿块切除和胰腺单纯引流两种类型。对肿块型和胰头癌的鉴别进行了讨论,并介绍一种新的保留十二指肠的胰头全切除术。     

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??Diagnosis and treatment of chronic pancreatitis with mass in the head of the pancreas ZHANG Zhong-tao, YIN Jie.Department of General Surgery, Beijing Friendship Hospital Affiliated to Capital University of Medical Sciences, Beijing 100050, China Corresponding author: ZHANG Zhong-tao, E-mail: zhangzht@medmail. com.cn Abstract Chronic pancreatitis (CP) with mass and pancreatic cancer are difficult to identify from the Clinical performance. At present, we have the CP with mass as a precancerous lesion of pancreatic cancer. Imaging methods in the diagnosis of the CP with mass plays an important role, which is very helpful for the Indications for surgery of the hands, of resectable pancreatic head tumor, and surgical options, as well as estimates of the difficulty of the surgery. Surgical strategy in CP with mass has been directed at the pancreatic head with a variety of tactics including pancreatoduodenectomy(Whipple procedure with or without pylorus preservation) and partial resection of the pancreatic duct drainage(Frey operation, Beger operation ). Once the diagnosis of the CP with mass should be clear that the surgical treatment, pancreatoduodenectomy is preformed in the treatment of CP with mass, not only resection of the pancreatic head mass, the lifting of the bile duct and pancreatic duct and obstruction of the duodenum, but also in addition to the potential causes of pancreatic cancer. Pancreatoduodenectomy is great risk When the great mass of pancreatic head, but the partial head resection can be accomplished with relative safety.     

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??Treatment of Chronic pancreatitis(CP) with an inflammatory mass ZHANG Zhong-tao,YIN Jie. Beijing Friendship Hospital,Capital Medical University,Beijing100050,China
Corresponding author: ZHANG Zhong-tao,E-mail: zhangzht@medmail.com.cn
Abstract Chronic pancreatitis(CP) with an inflammatory mass has been thought of as a precancerous lesion of pancreatic cancer, and it can lead to obstruction of the pancreatic duct, bile duct and duodenum. The CP with mass and pancreatic cancer are difficult to identify from clinical performance, and their prognosis are very different. Once CP with mass has been diagnosed it should be clear that surgical treatment is necessary in order to remove the focus, ease pain, and improve the patient's quality of life. Surgical strategy in CP with mass has been directed at the pancreatic head with a variety of tactics including pancreatoduodenectomy (Whipple procedure with or without pylorus preservation) and duodenum-preserving resection of the pancreatic head (Beger operation and other operations). Pancreatoduodenectomy is preformed in the treatment of CP with mass, not only resection of the pancreatic head mass, lifting the obstruction of the pancreatic duct, bile duct and duodenum, but also removing the potential causes of pancreatic cancer. Pancreatoduodenectomy is a great risk When the pancreatic head mass is large, but the partial head resection can be accomplished with relative safety.     

胰头肿块型慢性胰腺炎18例外科治疗体会

【摘要】〓目的〓探讨胰头肿块型慢性胰腺炎的外科治疗效果。方法〓回顾性分析1999年1月~2013年12月15年间经手术治疗的18例胰头肿块型慢性胰腺炎患者的临床资料。18例中4例合并胰管结石,5例合并胰腺囊肿;10例行胰十二指肠切除术,4例行胰管空肠Roux-y吻合术,2例行胰腺囊肿空肠Roux-y吻合术,1例行胆总管空肠Roux-y吻合术,1例同时行胰肠吻合和胃空肠吻合术。结果〓17例完成手术,1例损伤肠系膜上静脉大出血术中死亡。术后出现胸腔积液2例,切口裂开1例。获随访13例,行胰十二指肠切除术8例疼痛完全消失;胰肠或胆肠吻合4例疼痛部分缓解;1例顽固性疼痛,反复住院治疗。结论〓外科手术是胰头肿块型慢性胰腺炎的有效治疗方式,胰十二指肠切除术效果显著。     

Indications and outcomes of surgical management of chronic pancreatitis: literature review

Surgical management of chronic pancreatitis remains a challenge for surgeons. Last decades, the improvement of knowledge regarding to pathophysiology of chronic pancreatitis, improved results of major pancreatic resections, and new diagnostic techniques in clinical practice resulted in significant changes in the surgical approach of this condition. Intractable pain, suspicion of malignancy, and involvement of adjacent organs are the main indications for surgery, while the improvement of patient's quality of life is the main purpose of surgical treatment. The surgical approach to chronic pancreatitis should be individualized based on pancreatic anatomy, pain characteristics, exocrine and endocrine function, and medical co-morbidity. The surgical treatment approach usually involves pancreatic duct drainage procedures and resectional procedures including longitudinal pancreatojejunostomy, pancreatoduodenectomy, pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger's procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey's procedure). Recently, non-pancreatic and endoscopic management of pain have also been described (splancnicectomy). Surgical procedures provide long-term pain relief, improve the patients? quality of life with preservation of endocrine and exocrine pancreatic function, and are associated with low mortality and morbidity rates. However, new studies are needed to determine which procedure is safe and effective for the surgical management of patients with chronic pancreatitis.     

从TaTME发展看直肠癌微创外科治疗进步

随着科学技术的进步和对疾病本身认识的深入，直肠癌的外科治疗从局部切除到全直肠系膜切除（TME），从开放手术到腹腔镜手术，再从腹腔镜手术到机器人手术，目前已经进入微创时代。在此时代背景下，经肛门全直肠系膜切除（TaTME） 应运而生。正如TME的提出者Heald所言：“TaTME是近30年直肠癌外科治疗技术的集大成者”，其发展的每一个阶段都有很强的代表性，已成为直肠癌微创外科治疗技术进步发展的一个缩影。     

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??The advantages and disadvantages of transanal total mesorectal excision YAO Hong-wei, YANG Ying-chi, ZHANG Zhong-tao. Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, ?? National Clinical Research Center for Digestive Diseases,Beijing 100050, China
Corresponding author: ZHANG Zhong-tao, E-mail??zhangzht@
medmail.com.cn
Abstract The procedure of transanal total mesorectal excision (TaTME) surgery has been developing but controversial in recent years. The TaTME operation attempts to achieve the unity of minimally invasive and cosmetic effects on the basis of ensuring the radical resection of rectal cancer, and even embodies the concept of natural orifice transluminal endoscopic surgery (NOTES).The procedure of TaTME represents the latest trends in the field of rectal cancer surgery. However, many scholars believe that TaTME will increase the surgical difficulty and risk of rectal cancer, and even leave the distal stump of mesorectum, resulting in increased risk of local recurrence of rectal cancer. Therefore, how to standardize the surgical indications and operation procedures of TaTME surgery, is one of the hot and difficult problems in colorectal surgery in china. In addition, the orderly organization of clinical studies in TaTME surgery, and conducting TaTME surgery related high-level evidence-based medicine evidence, are also one of the relatively urgent task.     

慢性胰腺炎伴胰管结石的诊断与外科治疗

目的：探讨慢性胰腺炎伴胰管结石的诊断特点与手术方法的选择。方法：回顾分析外科治疗的慢性胰腺炎伴胰管结石的16例临床资料。结果：16例中常见的临床症状是腹痛(占100％)、食欲不振及恶心呕吐(占62．5％)、脂肪泻(占12．5％)、消瘦(占18．8％)及腹部肿块(占6．3％)。胰管扩张及胰腺结石的B超诊断率分别为81．3％及75．0％；胰管结石的腹部平片诊断率为81．3％；胰管结石的CT和MRI诊断率均为61．5％，包括胰头部局限性肿大为23．1％和胆总管扩张15．4％。手术方式包括胰管切开减压胰管空肠内引流术10例(Partington手术9例及Puestow手术1例)，胰十二指肠切除术3例(Child方法)，胰体尾部切除术3例(联合胆总管切开、T管引流术2例)。结论：严格选择适应证和合理的手术方式，对改善慢性胰腺炎伴胰管结石患者的生活质量和控制疾病发展具有重要作用。     

Chirurgisches Vorgehen bei chronischer Pankreatitis

The major aims of surgical therapy in chronic pancreatitis (CP) are pain relief and good long-term quality of life with preservation of endocrine and exocrine organ function. The surgical approach is therefore focused on drainage of the congested pancreatic (and bile) duct as well as resection of fibrotic and calcified tissue. Draining procedures alone are adequate for drainage of pseudocysts (cystojejunostomy) and the pancreatic duct (Partington) if no inflammatory tumor is present in the organ. Most CP patients present with unclear head mass and subsequent duct dilation. In these patients the different modifications of duodenum-preserving pancreatic head resections (e.g. Beger, Bern) offer a preferable option. Partial duodenopancreatectomy is an alternative but may be difficult to perform due to inflammatory changes around the portal vein and venous collaterals. Segmental resection and V-shaped excision may be appropriate in special situations (segmental fibrosis, small duct disease) and are performed less frequently (approximately 5 %) in the entire surgical CP population. In cases of suspected CP-related malignancy, formal resections (partial, distal or total pancreaticoduodenectomy) must be the surgical procedures of choice and be performed according to oncological principles.     

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??Rationality of surgical managements according to the pathological anatomy of chronic pancreatitis GAO Hong-qiao, CAI Meng-shan, MA Yong-su, et al. Department of General Surgery, Peking University First Hospital, Beijing 100034, China
Corresponding author: YANG Yin-mo, E-mail: yangyinmo@263.net
Abstract Objective To investigate the outcome after surgery directed by pathological anatomy of chronic pancreatitis and provide evidence for surgical procedures. Methods The clinical material of 60 patients with chronic pancreatitis who underwent surgical treatment between 2000 and 2010 were investigated retrospectively. Result 43 cases (71.7%) presented with abdominal pain, Perioperative mortality was 1.7% (1 case). Forty-two patients with abdominal pain were all relieved after surgery, but long-term recurrence occered in 17 cases (40.5%). Modified Puestow procedure was performed on 21 patients with dilatation of pancreatic duct and/or lithiasis, long-term pain recurrence occered in 8 cases (38.1%); Six patients undergoing pancreatic head resection had no recurrence in the long-term follow-up; Pain recurrence rate of 11 cases with only cholangioenterostomy was 81.2% (9 cases) within 2 years. Chronic pancreatitis with common bile duct obstruction occurred in 33 cases(55%), cholangioenterostomy alone or combined with partly pancreatic resection or pancreatic duct drainage procedures could alleviate symptoms of biliary obstruction, 4(33.3%) cases after pure biliary drainage emerged abdominal pain, 5 cases of pancreatic head resection had no recurrence of jaundice and abdominal pain after long-term follow-up. Conclusion Surgical procedures should be selected according to the pathological anatomy of chronic pancreatitis. Reasonable pancreatic head resection and adequate bile and/or pancreatic drainage could significantly improve the long-term outcomes.