术中超声在胰管结石手术中的应用

目的 探讨术中超声在胰管结石诊治中的临床应用价值.方法 回顾性分析2006年1月至2007年6月11例胰管结石患者的临床及影像学资料.患者手术中均行超声检查,评价主胰管有无扩张、扩张程度,胰管结石的部位及数目.结果 术中超声提示患者主胰管均有不同程度扩张,平均内径(1.0±0.4)cm(0.6～2.0 cm).胰管结石单发1例(9.1%),多发10例(90.9%),其中2例术前误诊为单发结石.结石位于胰头部4例,全胰弥漫分布7例.声像图上结石部位显示为强回声,伴声影.所有患者均在术中超声引导下行胰管切开取石、胰管空肠Roux-en-Y吻合术.结论 术中超声是一种简便、无创的检查方法,可较为准确地定位胰管结石的部位,为手术治疗提供有价值的影像学信息.     

胰管结石的诊断和治疗(附35例临床分析)

目的探讨胰管结石的诊断和治疗方法。方法回顾性分析过去10余年问治疗的35例胰管结石患者的临床资料。结果全部35例中33例出现持续性左上腹痛伴左腰背部放射痛,上腹部压痛25例。35例均行B型超声检查,诊断阳性率为88.57%(31/35);23例行腹部CT检查,诊断阳性率为78.26%(18/23);19例行逆行胰胆管造影检查,诊断阳性率为100%(19/19);19例行磁共振胰胆管成像检查,诊断阳性率为94.73%(18/19)。患者分别采用手术治疗和内镜治疗。手术治疗16例,采用的术式包括胰管切开取石、胰管空肠Roux-en-Y侧侧吻合术(11例)或胰管空肠侧侧吻合、空肠空肠侧侧吻合术(3例)或胰十二指肠切除术(Child法2例),均将结石取出;内镜治疗胰管结石19例,结石均在3枚或3枚以下、局限在胰头或胰体部、直径小于1cm,取石网篮和气囊取出结石11例,放置胰管支架8例。全组无死亡病例,治疗后3周内症状都不同程度地得到缓解,随诊28例,随诊率为80%,随诊时间为1～43个月。结论胰管结石一旦诊断,均应给予积极的治疗。首选内镜治疗,内镜治疗有着严格的适应证;不适合内镜治疗并且无手术禁忌证的患者均应采取手术治疗。     

胰管结石的手术治疗

目的 探讨胰管结石的手术治疗方法。方法23例慢性胰腺炎伴胰管结石患者,14例行胰管切开取石、胰管空肠侧侧Roux-en—Y吻合术（2例有黄疸者加做胆管内引流术）,4例行胰体尾切除术（其中2例加做胰肠’吻合术）,1例行胰管成型取石术。4例因胰头肿大行胰十二指肠切除术（2例术后证实为胰头癌）。其中16例术中应用激光碎石。结果术中见23例主胰管直径0．8～2．0cm,多发结石17例、单发结石6例。手术均成功,行激光碎石者碎石率100％。无手术并发症。术后随访,20例术前有上腹痛者,17例术后腹痛消失,3例减轻;9例合并糖尿病者,4例血糖恢复正常,2例胰岛素用量减少,3例糖尿病未得到控制;术后第3年出现糖尿病1例;5例合并脂肪泻者,2例脂肪泻消失,1例减轻,2例无明显变化。2例合并胰头癌患者分别于术后1a2个月、1a8个月死亡。结论手术治疗胰管结石疗效较好,但应合理选择适应证和手术方式。     

胰管结石的诊断与治疗

目的 探讨胰管结石的诊断方法及如何选择合理的治疗方式.方法 对2005年3月至2009年8月收治的16例胰管结石患者的临床资料进行回顾性分析.结果 15例患者以不同程度的上腹痛就诊,1例以不规则腹泻就诊.血、尿淀粉酶高于正常值上限3例,血糖升高4例.B超、CT、MRI、ERCP和腹部平片的诊断率分别为93.8%(15/16)、68.8%(11/16)、57.1%(4/7)、100%(2/2)和50%(3/6).治疗方式包括内镜下胰管括约肌切开取石+胰管支架引流术2例,胰管切开取石、胰管空肠Roux-en-Y吻合术12例,胰十二指肠切除术1例,胰体尾切除+胰管空肠Roux-en-Y吻合术1例.全组无手术死亡病例.治疗后腹痛症状均有明显改善.随访14例,无结石复发,失访2例,随访率为87.5%,随访时间为1～53个月.结论 胰管结石首选B超检查,多种影像技术的联合应用可明显提高诊断率.全面的影像学检查是判断选择内镜治疗抑或是手术治疗的重要依据.随着内镜治疗技术的逐步成熟,ERCP将与外科手术一样成为胰管结石重要的治疗手段.     

内镜逆行胰胆管造影在胰管结石诊治中的临床价值

目的：探讨内镜逆行胰胆管造影（ERCP）在胰管结石（PDS）诊断与治疗中的价值。方法：回顾分析1998年1月－2000年12月本院经ERCP诊治的18例PDS患者的治疗方式和结果。结果：18例PDS患者临床上均以上腹痛为主要首发症状且合并慢性胰腺炎,其中1例合并胰腺癌。经B超检查,10例患者检出有PDS或胰管扩张;全部病例经ERCP检查后均明确显著有PDS和胰管扩张。经ERCP＋乳头括约肌切开术（EST）／胰管括约肌切开术（EPST）成功取石4例;行EPST＋体外震波碎石（ESWL）及ESWL＋胰管内支架引流（ERPD）者各1例,半年后复查时胰石消失：行ERPD者12例。3例患者置管后3个月内因伴主胰管多发、巨大结石和胰腺癌而接受手术治疗。18例患者经1－11个月的随访,腹痛近期（＜3个月）缓解率为88．9％,远期（＞3个月）缓解率为75．0％,体重、脂肪泻、胰腺内、外分泌功能不足表现有不同程度的改善。ERCP术后早期并发症主要为一过性高淀粉酶血症,支架阻塞是其晚期并发症。结论：ERCP能清晰显示结石的位置、大小、形态及数量,是诊断PDS的主要手段。经ERCP取石具有安全可靠、创伤小、疗效满意及患者易于接受等优点,在PDS的治疗中亦具有较大临床应用价值。     

内镜诊治胰腺导管内乳头状粘液性肿瘤的应用

目的探讨胰腺导管内乳头状粘液性肿瘤(IPMN)的诊断、内镜下治疗,以提高对该疾病的认识及内镜对其诊断及治疗的意义。方法回顾性分析经内镜诊治的IPMN患者12例,总结并分析他们的一般情况、临床症状、影像学检查、实验室检查、内镜下治疗等方面资料。结果 12例IPMN患者以老年男性为主,无特异性临床表现,主要发生部位为胰头或钩突部,CT主要表现为囊实性低密度影,其内可有壁结节,胰管扩张伴或不伴胆管扩张,2例侵及胰腺实质。磁共振胰胆管造影(MRCP)主要表现为胰管扩张,胰腺萎缩,胰头部圆形高信号影。内镜下逆行胰胆管造影(ERCP)显示十二指肠乳头膨大,开口扩张,可见胶冻样粘液流出,胰管造影显示胰管全程扩张或胰头部囊状扩张,3例伴胆总管、肝内胆管扩张。9例行ERCP治疗,清除粘液栓并置入胰管支架,3例同时置入胆管支架。结论 IPMN是一种特殊类型的胰腺囊性疾病,影像学检查有其独特的表现,ERCP对其诊断及治疗有重要意义。     

胰管内超声在鉴别胰腺癌和慢性胰腺炎中的临床应用价值

目的与常规影像学检查对比,评价胰管内超声对胰腺癌和慢性胰腺炎的诊断价值;方法对１８例经手术证实和临床诊断为胰癌和慢性胰腺炎的患者行胰管内超声检查,且与常规腹部超声、计算机断层扫描、逆行胰胆管造影作比较;结果胰管内超声对胰癌和慢性胰腺炎的诊断符合率明显优于常规影像学检查;结论胰管内超声在胰癌和慢性胰腺炎的临床鉴别诊断中是一种可行且有效的检查方法。     

胰腺癌前病变诊断和治疗

目的 通过对7例胰腺癌前病变患者的临床诊断和治疗分析,探讨此类疾病诊断方法的应用及治疗策略.方法 收集2006年1月-2007年12月92例手术治疗胰腺肿瘤中有癌前病变的7例患者,其中黏液囊腺瘤(MCN)1例、导管内乳头状黏液瘤(IPMN)2例、胰腺内分泌肿瘤1例、胰腺上皮内瘤变(PanIN)Ⅰ级、Ⅱ级及Ⅲ级各1例.采用免疫荧光分析法测定患者血清CA19-9.7例上腹部均行超声和螺旋CT检查;1例行超声内镜检查及穿刺;2例行逆行胰胆管造影检查.结果 胰腺癌前病变临床表现不典型,影像学检查常无实质性肿块,但PanIN可伴有胰管扩张、狭窄;IPMN在胰头处可表现为囊性扩张的胰管;囊腺瘤等在胰体尾处可表现为单个孤立的囊肿.肿瘤指标CA19-9在此类疾病中可轻度增高.但对诊断作用有限.手术切除可治愈,并可防止肿瘤的进一步癌变.结论 对疑为胰腺癌前病变患者需积极选用多种影像学方法进行诊断,并予以积极的手术探查及切除.     

内镜综合治疗在胰瘘治疗中的临床价值

目的　评估内镜综合治疗用于胰瘘治疗的疗效及安全性。方法　2006年8月至2019年12月间在南京大学医学院附属鼓楼医院接受内镜治疗的胰瘘病例,依据纳排标准,最终45例纳入回顾性分析,主要观察内镜治疗方式、介入次数、技术成功率、桥接成功率、胰瘘愈合率、胰瘘愈合时间以及并发症发生情况。结果　45例中,33例（73.3%）仅接受内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）治疗,其中胰管完全断裂7例（21.2%）,治疗方式包括鼻胰管置入24例、胰管支架置入22例、胰管狭窄球囊或探条扩张12例、乳头括约肌切开8例、胰管结石清理3例;12例（26.7%）接受内镜联合治疗,其中胰管完全断裂5例（41.7%）,治疗方式包括ERCP引流联合内镜超声引导下穿刺引流9例、内镜超声引导下胰管穿刺引流联合ERCP会师术1例、ERCP引流联合经皮引流2例。内镜下中位介入3.0（2.0,5.0）次,41例（91.1%）内镜治疗技术成功,28例（62.2%）桥接成功,中位随访59.7（43.7,111.4）个月,33例（73.3%）胰瘘愈合、6例（13.3%）胰瘘未愈合、6例（13.3%）失访。有13例（28.9%）出现术后短期（1周内）并发症,包括急性胰腺炎5例、支架或引流管脱落或移位或堵塞5例、囊腔感染4例、囊肿增大2例、出血1例（部分病例存在2种或2种以上并发症）,均经保守治疗或内镜下治疗后好转,无原发病或手术相关的死亡。结论　内镜综合治疗用于胰瘘治疗安全、有效,ERCP是胰瘘内镜下治疗的基础,在胰管完全离断综合征等情况下,ERCP、内镜超声引导下穿刺引流及内镜下清创等综合技术联合应用对胰瘘的治疗具有临床价值。     

胰腺假性囊肿诊断与治疗分析

目的分析胰腺假性囊肿(PPC)的诊断及治疗方法。方法回顾性分析1994年3月～2012年5月航天中心医院诊治的30例PPC患者的临床资料。结果 PPC诊断均结合病史、临床表现、血及尿淀粉酶、影像学检查,明确囊肿的部位、大小、厚度及胰管形态改变等。病例均进行多普勒超声、腹部CT检查,部分病例进行磁共振胆胰管成像(MRCP)检查,内镜逆行胆胰管造影(ERCP)检查仅在少数怀疑有胰管狭窄而需要行内镜治疗的的病例中进行。行期待观察治疗9例,经皮穿刺外引流8例,内镜下治疗3例,手术治疗10例(外引流4例、囊肿胃吻合术2例、囊肿空肠吻合术3例、囊肿单纯切除术1例)。治愈27例,复发2例,死亡1例。出现并发症8例(胰瘘2例、上消化道出血2例、切口感染4例)。结论 PPC的治疗需采取个体化的综合治疗,系统全面的诊断,尤其针对胰管形态学改变的诊断对治疗方式的选择具有指导意义。     

Pancreaticobiliary fistula associated with pancreatolithiasis

We report here a case of pancreaticobiliary fistula associated with pancreatolithiasis. A 47-year-old female without a habit of alcohol drinking was admitted by her family physician after suffering from mild acute pancreatitis. Computed tomography revealed mild acute pancreatitis with pancreatolithiasis at the head of the pancreas. The pancreatolithiasis was exposed to the inner surface of the common bile duct and possibly compressed and narrowed the Wirsung and Santorini ducts, resulting in the pancreatitis attack. We used extracorporeal shock wave lithotripsy to treat the pancreatolithiasis. After complete elimination of stones by extracorporeal shock wave lithotripsy, endoscopic retrograde cholangiography showed an apparent pancreaticobiliary fistula between a branch of the Santorini duct and the lower portion of the common bile duct. There was no communication between the bile duct and the Wirsung duct or its branches; therefore, the diagnosis was not pancreaticobiliary maljunction. There have only been a few reports of pancreaticobiliary fistula without an association with pancreatic pseudocysts or intraductal papillary-mucinous pancreatic neoplasm, and there have only been few reports of pancreaticobiliary fistula with pancreatolithiasis.     

EFFECT OF EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY AND ENDOSCOPIC TREATMENT ON SYMPTOMS AND PANCREATIC FUNCTION IN PANCREATOLITHIASIS

Aims: To investigate the efficacy of extracorporeal shockwave lithotripsy (ESWL) combined with endoscopic treatment for pancreatolithiasis and assess the pancreatic functions after treatment. Patients: Forty‐eight cases with pancreatolithiasis in the main pancreatic duct (MPD) treated by ESWL combined with endoscopic treatments were investigated. Methods: The disappearance rate of abdominal symptoms, the frequency of admission for acute exacerbation of pancreatitis before and after treatment, the relationship of removal of pancreatic stones with recurrence and stricture of the MPD, and pancreatic functions before and after treatment were examined. Results: Treatment for pancreatolithiasis improved symptoms in 95.1% and significantly reduced the frequency of admission for 1 year from 1.4 to 0.2 on average. Pancreatic stones were excellently eliminated in 93.8%. Even in cases complicated with the stricture of MPD, combination with endoscopic techniques provided treatment efficacy comparable to that in cases without such complications. The Bentiromide test significantly improved within 3 months after treatment. It improved 1–2 and 2–3 years after treatment but there was no significant difference. Endocrine functions were maintained in 93.6%, 74.3%, 66.7%, and 64.3% within 3 months, 1–2 years, 2–3 years, and 3 or more years, respectively, after treatment. Conclusions: ESWL combined with endoscopic treatment provides comparable treatment efficacy in cases with and without stricture of the MPD. Treatment for pancreatolithiasis is useful for not only alleviating abdominal symptoms but also maintaining pancreatic exocrine function and management of the diabetes.     

Longitudinal changes of plasma pancreatic enzymes and hormones in experimental pancreatolithiasis in dogs

Plasma pancreatic enzymes and hormones were longitudinally observed after producing partial obstruction of the major pancreatic duct in dogs to study an initial state of chronic pancreatitis or pancreatolithiasis. Fasting plasma immunoreactive cationic trypsin was elevated during the first six months and then decreased in a subgroup with pancreatic opposite at the end of the 12-month period. Similar but less prominent changes were found in fasting plasma immunoreactive pancreatic polypeptide (IRPP). Plasma amylase, glucose, or immunoreactive insulin or glucagon (IRG) show no significant variation. Plasma IRG and IRPP responses to intravenous insulin were reduced in the subgroups with marked pancreatic changes towards the end of the 12-month period. These results suggest that plasma pancreatic enzymes and hormones remain elevated as long as pancreatic damage is mild and then start to decline as the damage progresses in chronic pancreatitis or pancreatolithiasis.Supported by a grant from the Intractable Pancreatic Disease Research Commitee from the Health and Welfare Ministry of Japan.     

Annular pancreas associated with pancreatolithiasis: a case report

We present a case of annular pancreas associated with pancreatolithiasis. A 41 year-old Japanese man with epigastric pain was admitted to the surgical service at Miyazaki Medical College Hospital. Contrast duodenography revealed severe stenosis of the descending duodenum. Cholangiography showed a stenotic segment of the intrapancreatic common bile duct surrounded by calcifications. Computed tomography of the abdomen revealed calcifications in the posterior region of the pancreatic head. Percutaneous cannulation of the pancreatic ductal system, using ultrasonic guidance, demonstrated a slightly dilated pancreatic duct in the body, stenosis of the duct of Wirsung in the pancreatic head, a normal duct of Santorini, and calcifications in the duct of an annular pancreas which communicated with the duct of Wirsung. At surgery, the second portion of the duodenum was completely encircled by the annular pancreas, and a Whipple procedure was performed. Including this patient, 170 adult cases of annular pancreas have been reported in Japan since 1922. Surgery was performed on 122 patients; 106 of these procedures were well documented. A Whipple procedure was performed on 16 patients, including the present case. Nine of these 16 patients had associated malignant disease, while the others had benign pancreatic disease. This is the fifth reported case of pancreatolithiasis associated with an annular pancreas in Japan. This case emphasizes that an annular pancreas may predispose to localized chronic pancreatitis and pancreatolithiasis.     

A diagnostic approach to inflammatory disease of the pancreas by means of endoscopic retrograde cholangio-pancreatography

Role of ERCP in the diagnosis of inflammatory lesions of the pancreas was evaluated and following conclusions were obtained. 1) Following criteria were considered to be practical for clinical diagnosis of chronic pancreatitis by ERCP; a) More than moderate irregularity or rigidity of margin, dilatation, or irregularity in caliber of PDS, whether extensive or localized, or b) Cyst formation or c) Obstruction of PDS. These criteria permit to diagnose 100% of pancreatolithiasis, 82% of chronic pancreatitis without pancreatolithiasis and 64% of histologically diagnosed chronic pancreatitis but about 13% of "false positive results" must be taken into consideration. 2) ERCP plays an important role in detecting and locating localized or scattered lesions without noticable abnormalities in P-S test. It is also useful in deciding an indication for surgical intervention. However, it has limitations in detecting minimal to moderate pancreatitis. Some of these cases are often picked up by P-S test. 3) Combined approach with ERCP and P-S test is required for diagnosis of inflammatory lesions of the pancreas and either one is incomplete by itself.     

Balloon-endoscopic retrograde pancreatography employed for extracorporeal shockwave pancreatic lithotripsy

Painful pancreatolithiasis may be alleviated by removing pancreatic stones that occlude the pancreatic duct. In five patients with pancreatolithiasis, preoperative endoscopic retrograde pancreatography showed filling defects in the dilated main pancreatic duct. Endoscopic sphincterotomy and subsequent attempts at stone extraction with a basket and/or a balloon catheter failed to achieve complete clearance of stones. Extracorporeal shockwave lithotripsy (ESWL) was performed under fluoroscopic pancreatographic control, using an indwelling balloon catheter; complete removal of the stones was achieved. Balloon pancreatography facilitated visualization of radiolucent stones during ESWL. Insertion of the balloon catheter is easier than using a nasopancreatic tube, even when there are calculi near the duodenal papilla. This is method extends the repertoire of choices for focusing shockwaves on radiolucent pancreatic stones during ESWL.     

胰纤维化结石性糖尿病(附10例报告)

本文报告1975～1990年间收治的胰结石症18例中并发糖尿病之10例。讨论了胰纤维化结石性糖尿病之诊断及可能病因,强调了内外科密切配合、综合治疗的重要性。本病由于癌变率高,须密切随访,以免失去手术时机。     

Pancreatic Endocrine Function in Experimental Pancreatolithiasis in Dogs

In attempt to clarify changes of pancreatic endocrine function in human calcified pancreatitis at its earlier stages, an experimental model of pancreatolithiasis comparable to the human disease was produced in six dogs after incomplete ligation of the major pancreatic duct. Endocrine function was serially examined by intravenous glucose (0.5 g/kg) tolerance test and insulin (0.5 U/kg) tolerance test before and 3, 6, and 12 months after the duct ligation. Neither α nor β cell dysfunction became apparent until 12 months after the ligation. The disappearance rate of glucose in an intravenous glucose tolerance test decreased from 2.92 ± 0.41 (mean ± SE) of the preligation value to 1.58 ± 0.17%/min at the end of (be 12 months period (p < 0.02). Plasma insulin response to glucose was also reduced significantly. Although hypoglycemia induced during an intravenous insulin tolerance test was maximal in the 12th month, distinct response of plasma pancreatic glucagon to the hypoglycemia disappeared. Endocrine insufficiency of the pancreas observed in this experimental model was similar to that reported in human pancreatolithiasis, although the severity is less.     

The sixth nationwide epidemiological survey of chronic pancreatitis in Japan

ObjectivesA nationwide survey was conducted to clarify the epidemiological features of patients with chronic pancreatitis (CP) in Japan.MethodsTwo sequential surveys were conducted. In the first survey, both the prevalence and incidence of CP in Japan in 2007 were estimated by a questionnaire, which was mailed to 3027 randomly chosen Japanese facilities. In the second survey, the second questionnaire was then mailed to 1110 facilities selected by the first survey to clarify the clinicoepidemiological features of the patients.ResultsThe estimated annual prevalence of CP was 36.9 per 100,000; 53.2 in males and 21.2 in females. The estimated annual incidence was 11.9 per 100,000. The prevalence and the incidence of CP gradually increased in Japan as compared to former surveys. The sex ratio (male/female) of definitive and probable CP patients was 4.5, with a mean age of 59.4 years; 59.2 years in males and 60.2 years in females. Alcoholic (69.7%) was most the common and idiopathic (21.0%) was the second most common cause of CP. The proportion of alcoholic CP increased as compared to the 55.5% found in 1994. The clinical features of overall Japanese patients with CP were: abdominal pain (60.6%), malabsorbtion (12.2%), diabetes mellitus (39.7%) and pancreatolithiasis (75.7%). Alcoholic patients were characterized by high morbidity as compared to nonalcoholic patients: abdominal pain (alcoholic 65.0% vs nonalcoholic 53.0%, p < 0.0001), diabetes mellitus (44.8% vs 31.4%, p < 0.0001) and pancreatolithiasis (84.0% vs 60.8%, p < 0.0001).ConclusionThe prevalence and the incidence of CP, especially alcoholic CP, have been increasing in Japan.