外科治疗老年壶腹周围癌

Ｖａｔｅｒ壶腹周围癌 (Ｖａｔｅｒ’ｓｐｅｒｉａｍｐｕｌｌａｙｃａｒｃｉｎｏｍａ,ＶＰＣ)是老年消化系常见肿瘤之一 ,首选手术切除。我们自1980年 4月～ 1999年 10月对 6 3例老年ＶＰＣ患者进行胰十二指肠切除术 ;并对其周围淋巴结进行不同方法处理 ,现总结如下。一、临床资料1.一般资料 :6 3例中 ,男 44例 ,女 19例 ;年龄为 6 0～ 79岁 ,平均 6 7.8岁。2 .ＶＰＣ的原发部位 :经手术和病理证实 :34例 (5 2 .4%)来源于胰管末端 ,12例 (19.0 %)来源于壶腹固有黏膜 ,7例(11.1%)来源于胆总管末端 ,6例 (9.5 %)来源于十二指肠黏膜 ,4例 (6 .3…     

壶腹周围癌伴获得性血友病A1例

患者,男,71岁,上腹部胀痛20余天入院,胀痛呈持续性,进油腻食物后疼痛明显,间断性向腰背部放射.无发热,无恶心、呕吐、腹泻、腹胀.起病以来,精神、饮食、睡眠较差,大小便正常,体重无明显变化.既往血吸虫肝病13年,否认高血压、糖尿病、手术、外伤、输血史,出血等病史,无血友病家族史.体检:皮肤巩膜无黄染,无瘀斑,浅表淋巴结无肿大.     

Ampullary carcinoma： Effect of preoperative biliary drainage on surgical outcome

AIM： To evaluate the influence of preoperative biliary drainage on morbidity and mortality after surgical resection for ampullary carcinoma.
METHODS： We analyzed retrospectively data for 82 patients who underwent potentially curative surgery for ampullary carcinoma between September 1993 and July 2007 at the Singapore General Hospital, a tertiary referral hospital. Diagnosis of ampullary carcinoma was confirmed histologically. Thirty-five patients underwent preoperative biliary drainage （PBD group）, and 47 were not drained （non-PBD group）. The mode of biliary drainage was endoscopic retrograde cholanoiopancreatography （n = 33） or percutaneous biliary drainage （n = 2）. The following parameters were analyzed： wound infection, intra-abdominal abscess, intra-abdominal or gastrointestinal bleeding, septicemia, biliary or pancreatic leakage, pancreatitis, gastroparesis, and re-operation rate. Mortality was assessed at 30 d （hospital mortality） and also longterm. The statistical endpoint of this study was patient survival after surgery.
RESULTS： The groups were well matched for demographic criteria, clinical presentation and operative characteristics, except for lower hemoglobin in the non- PBD group （10.9 ± 1.6 vs 11.8 ± 1.6 in the PBD group）.Of the parameters assessing postoperative morbidity, incidence of wound infection was significantly less in the PBD than the non-PBD group [1 （2.9%） vs 12 （25.5%）]. However, the rest of the parameters did not differ significantly between the groups, i.e. sepsis [10 （28.6%） vs 14 （29.8%）], intra-abdominal bleeding [1 （2.9%） vs 5 （10.6%）], intra-abdominal abscess [1 （2.9%） vs 8 （17%）], gastrointestinal bleeding [3 （8.6%） vs 5 （10.6%）], pancreatic leakage [2 （5.7%） vs 3 （6.4%）], biliary leakage [2 （5.7%） vs 3 （6.4%）], pancreatitis [2 （5.7%） vs 2 （4.3%）], gastroparesis [6 （17.1%） vs 10 （21.3%）], need for blood transfusion [10 （28.6%） vs 17 （36.2%）] and re-operation rate [1 （2.9%） vs 5 （10.6%）]. There was no early mortality in either group. Median survival was 44 mo （95% CI： 34.2-53.8） in the PBD group and 41 mo （95% CI： 27.7-54.3; P = 0.86） in the non-PBD group.
CONCLUSION： Biliary drainage before surgery for ampullary cancer significantly reduced postoperative wound infection. Overall mortality was not influenced by preoperative drainage.     

胰十二指肠切除术围手术期并发症分析

目的：探讨5年来实施的50例胰十二指肠切除术围手术期并发症。方法：应用胰十二指肠切除术治疗壶腹周围癌患者50例。结果：全组围手术期死亡率0％，并发症发生率26％（13／50），并发症中以切口感染发生率最高10％（5／50），严重并发症为多脏器功能衰竭（MOF），成人呼吸窘迫综合征（ARDS）等。结论：虽然胰十二指肠切除术术后并发症发生率仍然较高，如对解剖结构熟悉，提高手术技巧及熟练程度，应用胰腺导管引流、TPN及重症监护呼吸机等新技术，可减少其严重并发症。     

壶腹周围癌的影像学诊断方法进展

壶腹周围癌是起源于十二指肠壶腹周围2 cm以内,包括Vater壶腹、胆总管下段、胰管开口处、十二指肠乳头及其附近的十二指肠黏膜等处的肿瘤,肿瘤体积较小,临床症状出现较晚,故早期诊断是临床医师面临的共同难题。此文就壶腹周围癌的影像学诊断进展作一综述。     

黄疸前期壶腹周围癌的诊断和治疗

目的 探讨黄疽前期壶腹周围痛的临床特点,提高早期诊断率和手术疗效.方法 回顾性分析1998年1月至2005年12月收治的27例黄疸前期壶腹周围癌的临床资料.结果 黄疸前期壶腹周围癌的临床症状多为非特异性,主要包括上腹部饱胀不适(92.6%)、上腹部胀痛或隐痛(55.6%)以及不规则发热等(29.6%).B超、CT、MRCP、ERCP和内镜超声(EUS)等影像学检查有助于早期诊断,其阳性发现率分别为75.6%、85.2%、83.3%、84.6%和88.9%.本组27例患者中,19例行区域性胰十二指肠切除术,5例行胰十二指肠切除联合血管切除,3例行胆管或胆囊空肠Roux-en-Y吻合术,总切除率为88.9%.无手术死亡,术后并发症发生率为7.4%.术后1、3、5年生存率分别为100%、70.8%、41.7%.结论 壶腹周围癌在黄疸前期有其临床特点和影像学异常改变.如能在黄疸前期作出明确诊断,仍然是提高手术切除率和改善预后的一个重要途径.     

Surgical resection for esophageal carcinoma： Speaking the language

The terminology used to describe esophagectomy for carcinoma can be confusing, even for specialists in gastrointestinal disease. As a result, specific terms are often used out of their intended context. To simplify the nomenclature, two points regarding procedures for surgical resection of the esophagus are critical: the extent of resection (radical vs standard) and the operative approach (choice of incisions). It is important to understand that the radicality of the resection may have little to do with the operative approach, with the exception of esophagectomy without thoracotomy (transhiatal esophagectomy), which mandates the performance of a standard or non-radical resection. Esophagectomy has emerged as the standard curative treatment option for patients with esophageal carcinoma; however, unlike the surgical resection of other types of solid tumors, many different surgical options and/or approaches exist for these patients. This heterogeneity of care may result from the fact that the esophagus is accessible through more than one body cavity (left hemithorax, right hemithorax, abdomen). In addition, and partially as a result of its accessibility, different types of surgical specialists harbor this operation in their armamentarium, including general surgeons, thoracic surgeons, and surgical oncologists. Despite this enthusiasm amongst surgeons, little consensus exists as to which option is most oncologically sound. Further, the details of the various surgical approaches and procedures for resection of the esophagus are often difficult to comprehend, even for specialists in gastrointestinal disease, with much of the relevant terminology used out of its intended context. To facilitate the understanding of the surgical options for esophageal carcinoma, it is useful to view the operation from two angles: the extent of resection (Aradical@ vs Astandard@) and the operative approach (choice of incisions).     

335例壶腹周围癌手术分析

目的 我院近十年来开展的335例壶腹周围癌的手术情况，以期能为逐步提高其外科手术治疗的安全性和疗效提供有益帮助。方法 分析1990年1月至1999年12月间在我院普外科施行手术的335例壶腹周围癌患的临床资料，其中胰头癌237例，壶腹部癌98例。结果 胰头癌与壶腹部癌手术切除率分别为13．5％与66．3％，总手术切除率为29％，根治性手术死亡率为7．69％与5．45％，手术并发症发生率分别为26．9％与32．7％。本组手术并发症主要是：胰瘘、胆瘘、出血、腹腔感染、吻合口梗阻。结论 要最大眼度地提高壶腹周围癌的手术切除率和长期生存率，降低手术死亡率、并发症发生率，除了提高早期诊断率以外，更重要的是一支专业手术组医师梯队的建立。     

Postoperative adjuvant arterial chemoembolization improves survival of hepatocellular carcinoma patients with risk factors for residual tumor： A retrospective control study

AIM: To evaluate the effect of postoperative adjuvant transcatheter arterial chemoembolization (TACE) on the prognosis of hepatocellular carcinoma (HCC) patients with or without risk factors for the residual tumor. METHODS: From January 1995 to December 1998, 549 consecutive HCC patients undergoing surgical resection were included in this research. There were 185 patients who underwent surgical resection with adjuvant TACE and 364 patients who underwent surgical resection only. Tumors with a diameter more than 5 cm, multiple nodules, and vascular invasion were defined as risk factors for residual tumor and used for patient stratification. Kaplan-Meier method was used to analyze survival curve and Cox proportional hazard model was used to evaluate the prognostic significance of adjuvant TACE.RESULTS: In the patients without any risk factors for the residual tumor, the 1-, 3-, 5-year survival rates were 93.48%,75.85%, 62.39% in the control group and 97.39%, 70.37%,50.85% in the adjuvant TACE group, respectively. There was no significant difference in the survival between two groups (P = 0.3956). However, in the patients with risk factors for residual tumor, postoperative adjuvant TACE significantly prolonged the patients‘ survival. There was a statistically significant difference in survival between two groups (P= 0.0216). The 1-, 3-, 5-year survival rates were 69.95%, 49.86%, 37.40% in the control group and 89.67%,61.28%, 44.36% in the adjuvant TACE group, respectively. Cox proportional hazard model showed that tumor diameter and cirrhosis, but not the adjuvant TACE, were the significantly independent prognostic factors in the patients without risk factors for residual tumor. However, in the patients with risk factors for residual tumor adjuvant TACE, and also tumor diameter, AFP level, vascular invasion, were the significantly independent factors associated with the decreasing risk for patients‘ death from HCC. CONCLUSION: Postoperative adjuvant TACE can prolong the survival of patients with risk factors for residual tumor,but can not prolong the survival of patients without risk factors for residual tumor.     

胰十二指肠切除术后胰漏的预防

胰十二指肠切除术(PD)是治疗壶腹周围癌的主要手段。但术后胰漏的发生率较高。1998年2月至2003年1月，我们采用PD治疗壶腹周围癌46例，术后仅2例发生胰漏。现将我们的体会介绍如下。     

MicroRNA profiling in periampullary carcinoma

BackgroundMicroRNA expression patterns in many physiological and oncogenic processes have been established. However, the role of aberrant miRNA expression in periampullary carcinoma (PAC) has not been elucidated. We hypothesize that PAC may have differential expression of miRNAs which may differentiate the tumor histological subtypes.MethodsFresh paired tumor and control samples were collected from the PAC patients undergoing Whipple's pancreaticoduodenectomy. Microarray miRNA profiling was performed utilizing tumor (n = 40) and control tissues; adjacent normal pancreas (n = 22), six each distal CBD, duodenum and ampulla. Data obtained was subjected to statistical and bioinformatic analysis. Differentially expressed miRNAs obtained were validated using qPCR in an independent set of samples.ResultsComparison of PAC tissue samples with controls revealed 29 common and differentially expressed miRNAs (20 upregulated and 9 downregulated) with a higher statistical significance (p < 0.001) and fold change (log2 FC > 1.5). A subset of 16 miRNAs (15 overexpressed and 1 underexpressed) differed in expression levels between pancreatobiliary and intestinal subtypes. Among these, miR-375, miR-31 and miR-196a expressions varied significantly between histological subtypes. Differential expression profiles of miRNAs specific to TNM staging was also observed in PAC subtypes. Target gene prediction for the differentially expressed miRNAs in PAC revealed that target genes are enriched for certain pathways. Particularly, Wnt signaling pathway genes appear to be relevant targets for most of the differentially expressed miRNAs.ConclusionDifferentially expressed common miRNA signatures identified in PAC subgroups may have a role in pathogenesis of PAC and miR-375, miR-31 and miR-196a expression patterns may differentiate PAC subtypes.     

A rare case of periampullary carcinoma with ectopic ending of Vater＇s ampulla

A 71-year-old woman was referred to our department complaining of painless progressive jaundice for the last 3 too. Magnetic resonance imaging and magnetic resonance cholangiopancreatography （MRCP） showed the ectopic hepatopancreatic ampulla draining into the fourth part of the duodenum adjacent to the duodenojejunal flexure; the irregular morphology of the duodenojejunal flexure likely due to a soft tissue mass. Laparotomy confirmed the presence of the abnormal ampulla of Vater located at the fourth part of the duodenum and a soft tissue tumor about 6 cm × 5 cm×5 cm with a peduncle adjoining the ampulla. Resection of the tumor, including some peripheral tissue, and a Roux-Y loop anastomosis choledochojejunostomy were performed. Pathological examination indicated an intestinal villous adenoma accompanied by severe dysplasia and focal canceration. Periampullary carcinoma with ectopic ending of the Vater＇s ampulla into the fourth part of the duodenum is rather rare. The embryonic genetic background of this anomaly has not yet been fully explained. It is worth mentioning that MRCP is useful for demonstrating anomalies and anatomic variants of the biliary tract system and pancreatic duct.     

National compliance to an evidence-based multidisciplinary guideline on pancreatic and periampullary carcinoma

BackgroundWe evaluated national compliance to selected quality indicators from the Dutch multidisciplinary evidence-based guideline on pancreatic and periampullary carcinoma and identified areas for improvement.MethodsCompliance to 3 selected quality indicators from the guideline was evaluated before and after implementation of the guideline in 2011: 1) adjuvant chemotherapy after tumor resection for pancreatic carcinoma, 2) discussion of the patient within a multidisciplinary team (MDT) meeting and 3) a maximum 3-week interval between final MDT meeting and start of treatment.ResultsIn total 5086 patients with pancreatic or periampullary carcinoma were included. In 2010, 2522 patients were included and in 2012, 2564 patients. 1) Use of adjuvant chemotherapy following resection for pancreatic carcinoma increased significantly from 45% (120 out of 268) in 2010 to 54% (182 out of 336) in 2012 which was mainly caused by an increase in patients aged <75 years. 2) In 2012, 64% (896 of 1396) of patients suspected of a pancreatic or periampullary carcinoma was discussed within a MDT meeting which was higher in patients aged <75 years and patients starting treatment with curative intent. 3) In 2012, the recommended 3 weeks between final MDT meeting and start of treatment was met in 39% (141 of 363) of patients which was not influenced by patient and tumor characteristics.ConclusionCompliance to three selected quality indicators in pancreatic cancer care was low in 2012. Areas for improvement were identified. Future compliance will be investigated through structured audit and feedback from the Dutch Pancreatic Cancer Audit.     

Elevated pre-operative neutrophil to lymphocyte ratio predicts disease free survival following pancreatic resection for periampullary carcinomas

BackgroundThe pre-operative neutrophil-to-lymphocyte ratio (NLR), when ≥5 has been associated with reduced survival for patients with various gastrointestinal tract cancers, however, it's prognostic value in patients with periampullary tumour has not been reported to date.ObjectivesTo determine the prognostic value of pre-operative NLR in terms of survival and recurrence of resected periampullary carcinomas.MethodsThis was a retrospective cohort study of consecutive patients undergoing pancreatoduodenectomy (PD) for periampullary carcinoma (pancreatic, ampullary, cholangiocarcinoma) identified from a departmental database. The effect of NLR upon survival and recurrence was explored.ResultsOverall median survival amongst 228 patients was 24 months (inter-quartile range [IQR]: 12–43). The median survival for those whose NLR was <5 was not significantly greater than those patients whose NLR was ≥5 (24 months [IQR: 14–42] versus 13 months [IQR: 8–48], respectively; p = 0.234). However, for those that developed recurrence, survival was greater in those with an NLR <5 at (20 months [IQR: 12–27] versus 11 months [IQR: 7–22], respectively; p = 0.038). This effect was most marked in those patients with cholangiocarcinoma (p = 0.019) whilst a trend to worse survival was seen in those with pancreatic adenocarcinoma. No effect was seen in patients with ampullary carcinoma (p = 0.516).ConclusionsThis study provides further evidence that pre-operative NLR offers important prognostic information regarding disease-free survival. This effect, however, is dependent upon the tumour type amongst patients undergoing PD.     

Role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma

AIM:To study the role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma.METHODS:In this study the authors retrospectively analyzed clinical records of patients with periampullary tumors diagnosed by ampullary biopsy taken after needle knife papillotomy in whom surface ampullary biopsies were non contributory.RESULTS:Between January 2008 and December 2010,38 patients with periampullary tumors were seen by us and initial side viewing endoscopy with surface biopsy from the papilla was positive for malignancy in 25 patients.Thirteen patients with a negative surface biopsy for malignancy underwent a repeat ampullary biopsy following needle knife papillotomy.There were 8(61.5%)males and 5(38.5%)females.The most common presenting symptom was jaundice(100%),followed by fever(46.2%),melena(38.5%),abdominal pain(30.8%)and weight loss(30.8%).All the patients had hyperbilirubinemia with a mean ± SD serum bilirubin of(11.2 ± 1.9)mg/dL(normal value <1 mg%)and the mean ± SD serum alkaline phosphatase was(288.0 ± 94.3)IU/L(normal value < 129 IU/L).Serum CA 19.9 level estimation was done in 11 patients;it was elevated(cut off value > 70.5 IU/L)in all of them with a median of 1200 IU/L(inter quartile range 274-3500).Side viewing endoscopy showed a bulky papilla in all of them.Adequate tissue was obtained in all of the 13 patients for histological evaluation;12 of the 13 patients were reported to have adenocarcinoma while one patient had adenoma.There were no complications from the needle knife papillotomy in any of the patients.CONCLUSION:Needle knife assisted ampullary biopsy appears to be a safe and effective diagnostic modality for periampullary carcinoma.     

十二指肠乳头旁憩室对老年患者ERCP的影响

目的探讨老年人十二指肠乳头旁憩室(PAD)与胆胰疾病的关系及其对ERCP的影响。方法回顾性分析老年病人380例,了解老年人PAD与胆管疾病的关系及对诊疗性ERCP的影响。结果发现老年人PAD患者105例,在老年人中发生率27.63%。本组ERCP插管造影成功率95.23%,并发胆管结石者72例,胆管下段良性狭窄15例;胆胰管及壶腹部肿瘤10例;慢性胰腺炎2例,胆总管乳头瘤1例,均进行了治疗性ERCP。术后并发症:4例出血,1例轻型胰腺炎,3例高淀粉酶血症均经内科治疗好转,无1例死亡。结论 ERCP治疗老年人十二指肠乳头周围憩室合并胆胰疾病的患者是安全有效的,年龄、憩室本身不是ERCP的禁忌证,所有治疗性ERCP的方法均适合高龄患者,疗效也是肯定的。     

Endoscopic treatment of periampullary duodenal duplication cysts in children:Four case reports and review of the literature

BACKGROUND Duodenal duplications are rare congenital anomalies of the gastrointestinal tract. As the periampullary variant is much rarer, literature is scant and only few authors have reported their experience in diagnosis and treatment, particularly with operative endoscopy.CASE SUMARY To report our experience with the endoscopic treatment in a series of children with periampullary duodenal duplication cysts, focusing on the importance of obtaining an accurate preoperative anatomic assessment of the malformations. The pediatric periampullary duodenal duplication cyst literature is reviewed. We conducted a systematic review according to the PRISMA guidelines. The PubMed database was searched for original studies on "duodenal duplication", "periampullary duplication" or "endoscopic management" published since 1990, involving patients younger than 18 years of age. Eligible study designs were case report, case series and reviews. We analyzed the data and reported the results in table and text. Fifteen eligible articles met the inclusion criteria with 16 patients, and analysis was extended to our additional 4 cases. Median age at diagnosis was 13.5 years. Endoscopic treatment was performed in 10(50%) patients, with only 2 registered complications.CONCLUSION Periampullary duodenal duplication cysts in pediatric patients are very rare. Our experience suggests that an accurate preoperative assessment is critical. In the presence of sludge or stones inside the duplication, endoscopic retrograde cholangio-pancreatography is mandatory to demonstrate a communication with the biliary tree. Endoscopic treatment resulted in a safe, minimally invasive and effective treatment. In periampullary duodenal duplication cyst endoscopically treated children, long-term follow-up is still necessary considering the potential malignant transformation at the duplication site.     

Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS...