恶性肿瘤病人胰十二指肠切除术后胰瘘及胆瘘的防治

目的 总结恶性肿瘤病人胰十二指肠切除术（PD）主要并发症胰瘘、胆瘘的初步处理经验和体会，并探讨其防治措施。方法 对1998年1月至2003年1月间的20例PD术后并发胰瘘、胆瘘病例进行回顾性分析。结果 全组病例手术均获得成功。术后并发胰瘘2例，死亡1例；并发胆瘘2例，死亡1例；另1例死于肝肾综合症，余17例治愈出院。远期效果在进一步随访中。结论 术后并发胰瘘应以内科治疗为主，通过减少胰液的分泌，并且保持局部引流的通畅，多数胰瘘可治愈。术后并发胆漏，通过保持支架管及局部引流通畅，多可治愈，出现肝汁性腹膜炎时应考虑手术处理。     

Biliopancreatic fistula and abscess formation in the bursa omentalis associated with intraductal papillary mucinous cancer of the pancreas

We describe an unusual case of biliopancreatic fistula, free perforation, and subsequent abscess formation within the lesser peritoneal sac associated with intraductal papillary mucinous carcinoma (IPMC). A 71-year-old man presented with general fatigue and loss of appetite that had persisted for 1 month. Abdominal computed tomography (CT) revealed findings consistent with an intraductal papillary mucinous neoplasm (IPMN) of the pancreas, accompanied by abscess formation in the bursa omentalis. Gastrointestinal fiberscopy revealed a swollen papilla of Vater expanded by sticky mucus, and a communication between the pancreatic duct and bile duct was demonstrated by the injection of indigo carmine solution into the pancreatic duct. Percutaneous transhepatic abscess drainage (PTAD) was performed on the day of admission. After this procedure, the patient was managed for 1 month and supported nutritionally with glycemic control for diabetes mellitus. After admission, the patient had an episode of obstructive jaundice that was treated by retrograde biliary drainage. Pancreaticoduodenectomy with lymph node dissection was then performed. Pathological examination revealed IPMN with patchy, scattered carcinoma of the pancreatic head and uncinate process with the formation of a biliopancreatic fistula. Bile duct epithelium in the area of the biliopancreatic fistula demonstrated atypical papillary epithelium suggestive of tumor invasion.     

Pancreatic carcinoma coexistent with pancreatic pseudocyst which penetrated into the stomach

We report a case of pancreatic adenocarcinoma coexisting with a pancreatic pseudocyst, which showed gradual disappearance during preoperative examinations. The patient, an 83-year-old woman, had upper abdominal and back pain, and abdominal computed tomography (CT), on December 6, 1997, revealed an 11.0 ≧ 5.8 cm cystic mass in the pancreas. On December 11, abdominal magnetic resonance imaging showed that the cyst had reduced in size to 3.8 ≧ 2.4 cm, and was enveloped in a large solid tumor. Repeat abdominal CT, on January 5, 1998, showed disappearance of the cystic lesion, while an obvious pancreatic tumor had invaded the posterior wall of the stomach and the left adrenal gland. Distal pancreatectomy combined with total gastrectomy and left adrenal glandectomy were performed on January 7, 1998. Histological examination revealed a moderately differentiated ductal adenocarcinoma with an abscess in the tumor, which had developed a fistula to the ulceration of the stomach. The large cyst presented on admission seemed to have penetrated into the stomach, and had disappeared within 1 month. Received: June 28, 1999 / Accepted: February 28, 2000     

胰十二指肠切除术后胰瘘的原因及临床分析

目的 分析胰十二指肠切除术后胰瘘的原因及预防经验。方法 回顾分析1994～2003年行胰十二指肠切除术的63例患者的临床资料，对影响胰瘘发生的因素和采取的治疗方法进行总结。结果 胰瘘与吻合技术有关，胰瘘的发生与残胰断面的处理以及胰实质的坚硬度、胰管的直径有关；胰管内支撑引流可预防PD术后胰瘘。结论 胰管内支撑引流和良好的胰切面血供是预防PD术后胰瘘的关键。     

经会阴引流在防治直肠癌Dixon术后吻合口瘘中的作用

目的:评价经会阴骶前引流对防治直肠癌Dixon术后吻合口瘘的作用;方法:回顾分析我院1995年10月~2005年10月直肠癌前切除术351例,按术后经会阴骶前引流和经腹盆底引流分为两组,比较两组瘘的发生率,腹膜炎的发生率,瘘发生后的处理方式,平均愈合时间。结果:在经腹腔盆底引流组(A)和经会阴骶前引流组(B)中,吻合口瘘发生率分别为6.67%(10/150)和2.49%(5/201),具有统计学意义(P<0.05);腹膜炎A组6/10,B组0;瘘发生后A组7例行结肠外置术,B组5例均经冲洗引流而愈,未行二次手术;吻合口平均愈合时间:A组为28天;B组为12天。结论:经会阴骶前引流在防治直肠癌Dixon术后吻合口瘘中起着非常重要的作用。     

Diagnosis and treatment of insulinomas--analysis of 6 cases

Six patients with insulinoma treated from 1977-1986 are analysed. All patients had symptoms of neuro-glucopenia, hypoglycemic coma and sympathetic irritation. The fasting blood glucose level was below 30 mg%. The fasting plasma IRI was 17.3-19.84 mu u/ml and the IRI/glucose ratio was greater than 0.3 in four patients. The symptoms disappeared after the tumor was removed in three patients. One patient was complicated by pancreatic fistula after tumor resection, but was cured by drainage. One patient who had multi-insulinomas undiagnosed preoperatively had Whipple's triad after operation. One was treated by other methods because of his cardiovascular disorders. The percutaneous transhepatic portal catheterization segment IRI assay is a reliable method, especially when combined with abdominal selective arteriography, for the pre-operative diagnosis of insulinoma. The IRI/glucose ratio is more reliable than either glucose or IRI alone.     

胰十二指肠切除经肠系膜上血管蒂后间隙胰肠直接套入式吻合的临床研究

目的:探讨预防胰十二指肠切除术后胰肠吻合口漏的有效安全术式。方法:2003年1月～2006年6月共施行经肠系膜上血管蒂后间隙胰肠直接套入式吻合的胰十二指肠切除术43例,并与同期的56例传统的胰十二指肠切除术(Child)进行对比。结果:改良手术组43例患者,未发生胰肠吻合口漏,发生胆肠吻合口漏2例,经2～3周的充分引流治愈。腹腔感染2例,经抗感染及充分引流后治愈。胃应激性溃疡4例,经加大抑酸剂用量及应用凝血药物后治愈。传统手术组56例,发生不同程度的胰肠吻合口漏3例,腹腔引流液淀粉酶>9000IU/L,其中2例经应用生长抑素十四肽、静脉高营养及禁饮食,通畅的腹腔引流21～32d后治愈。1例82岁高龄患者死亡。其他术后并发症与改良手术组比较差异无统计学意义,P>0.05。结论:经肠系膜上血管蒂后间隙胰肠直接套入式吻合的胰十二指肠切除术对预防胰肠吻合口漏的发生有一定的意义,是治疗壶腹周围癌的安全有效术式,值得进一步应用研究。     

开腹配合彩超引导^125I粒子植入术治疗晚期胰腺癌16例临床分析

目的研究开腹手术配合彩超引导下放射性^125I粒子组织间植入治疗晚期胰腺癌的方法、疗效及并发症。方法回顾性分析16例晚期胰腺癌患者,于术前行放射微粒三维立体定向治疗计划系统（TPS）预定粒子数。开腹探查后,先行肿瘤穿刺活检证实为胰腺癌;直视下配合彩超引导行^125I粒子组织间植入术。取上腹正中切口,暴露胰腺肿块后,应用彩超探查肿瘤范围、大小,确定进针方向及范围,利用粒子枪植入粒子,注意保护血管、胰管和胆管。其中7例行胆肠吻合术,5例行胃空肠吻合术。术后2周行腹部X片或腹部CT扫描检查。结果术后11例疼痛完全或部分缓解,有效率80％,显效时间2-50d,中位起效时间10d。1例术后2周复查时发现2颗粒子游走到肝脏,2例出现胰瘘,3例出现胃排空障碍。结论开腹配合彩超引导^125I粒子植入术治疗晚期胰腺癌定位准确,粒子排列均匀,并发症较少,有较好的止痛效果,部分患者可提高生存质量,延长带瘤生存期。     

High operative risk of cool-tip radiofrequency ablation for unresectable pancreatic head cancer

BACKGROUND AND OBJECTIVES: To report and discuss the effect, complications and mortality of cool-tip radiofrequency ablation (RFA) for unresectable pancreatic cancer. METHODS: During October 2003 to July 2004, sixteen patients with unresectable pancreatic cancer were treated by open cool-tip RFA. One-half of the 16 patients had tumors located in the pancreatic head. A 5-mm minimum safe distance between RFA site and major peripancreatic vessels was kept to avoid injury to the vessels. RESULTS: Six of twelve patients with back pain got pain relief postoperatively. Pancreatic fistula occurred in three patients (18.8%) and healed smoothly in 7-10 days with routine abdominal drainage. The mortality was 25% (4/16). In the four death cases, tumors were all located in the pancreatic head; three patients with tumor close to portal vein died suddenly of massive gastrointestinal hemorrhage on the 4th, 30th, 40th postoperative day respectively and a 79-year-old patient died of acute renal failure on the 2nd postoperative day. CONCLUSIONS: Standard use of cool-tip RFA was dangerous for pancreatic head cancer close to portal vein, in which a 5-mm minimum safe distance between RFA site and major peripancreatic vessels might not be enough to avoid injury to the vessels.     

Robotic pancreaticoduodenectomy with biodegradable ductal stenting (Archimedes BPS®)

BackgroundPostoperative Pancreatic Fistula (POPF) development remains a challenge after pancreaticoduodenectomy, occurring in 3–45% of cases [1]. The placement of a trans-anastomotic Wirsung stent is usually done in high-risk patients to decrease incidence and severity of POPF.MethodsHerein, we present a fully robotic pancreaticoduodenectomy with a biodegradable ductal stent interposition in a 47 y.o. female with a main duct IPMN of the pancreatic head and a fistula risk score of 6 (Moderate-risk).VideoAfter gastrocolic ligament division and hepatic flexure and duodenum mobilization, the loco-regional lymphadenectomy was performed. Following gastric transection with endo-GIA, the bile duct and gastroduodenal artery have been divided, and the cholecystectomy performed. The neck of the pancreas has been transected, the jejunum divided with endo-GIA and mobilized from the Treitz ligament, and the uncinate process dissected from the mesenteric vessels. A Blumgart anastomosis has been performed between the soft-texture pancreatic stump and the jejunal loop with the interposition of a 6 Fr/60 mm long, medium degrading stent (20 days) in the 2 mm duct (Archimedes BPS®, AMG Int., Winsen-Germany). The hepatico-jejunostomy and gastro-jejunostomy have been performed distally on the same loop. Three abdominal drains have been positioned.ResultsSurgery lasted 480 min, with 175 mls blood loss. The patient postoperatively developed a biochemical leak and was discharged home by day 12. She was readmitted a month later for an amylase-negative intra-abdominal abscess that was successfully treated with percutaneous drainage.ConclusionBiodegradable pancreatic stent positioning could be an effective strategy in reducing POPF occurrence in high-risk patients.     

Novel treatment strategy using Trafermin® consisting of bFGF for intractable pancreatic fistula following gastrectomy for gastric cancer-a case report with literature reviews

Despite recent perioperative technological advances in gastric cancer, intractable pancreatic fistula is still a major critical complication following gastrectomy and should be specifically targeted in the effort to improve postoperative outcomes. We preliminary report here a successfully treated case with intractable pancreatic fistula using Trafermin? consisting of basic fibroblast growth factor (bFGF). A 67-year-old man underwent laparoscopic proximal gastrectomy with radical lymphadenectomy for early proximal gastric cancer (pT1bN0M0). After surgery, pancreatic fistula was occurred. Pancreatic fistula persisted for three months despite of surgical and several conservative treatments. After obtaining informed consent, we started to inject 50 μg/day of Trafermin? through a drainage tube into the dehiscence of pancreas. Consequently, pancreatic fistula was successfully closed within three weeks. Our novel treatment technique is simple, rapid and not costly. If informed consent was obtained from patients with low risk of recurrences, this technique should be recommended as one of the treatment choices for intractable pancreatic fistula following curative gastrectomy for gastric cancer.     

TH胶胰管栓塞在Whipple术中的应用

胰瘘为Whipple术后最严重的并发症之一,直接影响了手术疗效。本组观察了10例Whipple术中采用TH胶栓塞胰管,以期防止胰瘘的临床效果。结果表明,该方法能有效地阻断胰液分泌,减少胰瘘的发生;该方法可免去传统的胰肠吻合和胰液引流,简化手术操作,缩短术时,有助于病人的术后恢复。     

Intraperitoneal and intrapleural gemcitabine in patients with advanced pancreatic cancer

We performed intraperitoneal and intrapleural dosing gemcitabine (GEM) to eight patients with advanced pancreatic cancer having peritoneal or pleural carcinomatosis and evaluated its actions and safety. GEM (500 mg/m2) was infused into the abdominal cavity or thoracic cavity after drainage of peritoneal or pleural effusion. We checked the change of serum GEM concentration and the side effects after the GEM administration. Then, we repeated the GEM administration observing their systematic symptoms and evaluated the alteration of peritoneal or pleural effusion and cytology. Plasma concentration of GEM by infusing into the abdominal cavity or thoracic cavity was lower than by intravenous injection. In three of the five cases of peritoneal carcinomatosis, intraperitoneal administration revealed a decrease of peritoneal effusion. In two of the three cases of pleural carcinomatosis, intrapleural administration revealed a decrease of pleural effusion. Four cases had leukocytopenia of grade 1/2, three cases had thrombocytopenia, and two cases had alopecia as side effects, although all of them were minor side effects. Intraperitoneal and intrapleural dosing GEM had minor side effects and could improve QOL for the patients with advanced pancreatic cancer associated with peritoneal or pleural carcinomatosis.     

Gallbladder carcinoma, progressed along cholecystoduodenal fistula--a case report

A 75-year-old woman had an operation for gallstone ileus without cholecystectomy in other hospital and she was admitted to our hospital because of duodenal adenoma with severe atypia and small carcinoid in proximal duodenal wall. Distal gastrectomy and cholecystectomy were performed. Histological studies revealed the existence of cholecystoduodenal fistula and suggested the existence of gallbladder carcinoma progressed to the duodenal wall through the fistula. Cystic duct dissection and lymph nodes dissection were performed. It has been theorized that a cholecystoduodenal fistula may represent a significant risk factor in the development of gallbladder carcinoma because of the chronic reflux of duodenal contents which includes pancreatic juice. Our case may support this theory. In this case, we thought that the formation of gallbladder cancer could have been avoided if the cholecystectomy was performed in the first operation for gallstone ileus. It is very important that cholecystectomy should be performed when an existence of cholecystoduodenal fistula is highly suspected.     

A case of carcinoma arising from an anal fistula

Carcinoma arising from a chronic anal fistula is an uncommon condition. A 53-year-old woman visited our clinic, complaining of refractory anal fistulas that had persisted for over a period of 15 years, which had started to discharge pus and mucus through external fistulous openings several months ago. A cytologic study of the perianal discharges and a biopsy of the external openings were useful in preoperatively detecting a cancer complicating an anal fistula. An abdominoperineal rectal amputation with an extended dissection of the relevant lymph nodes was performed. Histopathological findings revealed a mucus-producing adenocarcinoma with ly1, v0 in vessel invasion, and the stage of cancer was determined as being stage II, H0P0a2n0 (0/129). It is emphasized that cancer should be suspected whenever examining an old fistula, especially one with mucous discharges.     

Pazopanib-Induced Severe Acute Pancreatitis

Pazopanib is an oral angiogenesis inhibitor targeting vascular endothelial growth factor receptors, platelet-derived growth factor receptors, and c-Kit approved for the treatment of renal cell carcinoma and soft tissue sarcoma. Nonselective kinase inhibitors, such as sunitinib and sorafenib, are known to be associated with acute pancreatitis. There are few case reports of severe acute pancreatitis induced by pazopanib treatment. We present a case of severe acute pancreatitis caused by pazopanib treatment for cutaneous angiosarcoma. The patient was an 82-year-old female diagnosed with cutaneous angiosarcoma. She had been refractory to docetaxel treatment and began pazopanib therapy. Three months after pazopanib treatment, CT imaging of the abdomen showed the swelling of the pancreas and surrounding soft tissue inflammation without abdominal pain. After she continued pazopanib treatment for 2 months, she presented with nausea and appetite loss. Abdominal CT showed the worsening of the surrounding soft tissue inflammation of the pancreas. Serum amylase and lipase levels were 296 and 177 IU/l, respectively. She was diagnosed with acute pancreatitis induced by pazopanib treatment and was managed conservatively with discontinuation of pazopanib, but the symptoms did not improve. Subsequently, an abdominal CT scan demonstrated the appearance of a pancreatic pseudocyst. She underwent endoscopic ultrasound-guided pseudocyst drainage using a flared-end fully covered self-expandable metallic stent. Then, the symptoms resolved without recurrence. Due to the remarkable progress of molecular targeted therapy, the oncologist should know that acute pancreatitis was recognized as a potential adverse event of pazopanib treatment and could proceed to severe acute pancreatitis.Key Words: Angiosarcoma, Pazopanib, Drug-induced acute pancreatitis     

保留十二指肠的胰头切除治疗胰头良性肿瘤6例临床分析

[目的]探讨保留十二指肠的胰头切除术（DPRPH）在治疗胰头良性肿瘤上的安全性，并总结临床经验。[方法]2003年3月～2007年6月对6例胰头良性肿瘤成功实施DPRPH，探讨具体操作方法及术后并发症，评价术后生存质量。[结果]无手术死亡率。术后发生胰瘘1例．逆行性胆管炎1例，总并发症率33．3％。随访3个月至4年，无术后糖尿病、胆管狭窄、慢性消化不良发生，无肿瘤复发。[结论]DPRPH是一种安全、有效治疗胰头良性肿瘤的术式。     

Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature.

This paper analysed the literature published in the last 15 years regarding the onset of pancreatic fistula after pancreaticoduodenectony carried out for tumours in the periampullary region, in the head of the pancreas and in the distal common bile duct. Out of 8370 pancreatic resections we were able to go by only 2684 cases, which showed the type of treatment used in the remaining stump, the rates of leakage and relative mortality. The data collected were analysed statistically using the Cochran test and or the chi 2, evaluating the possible significant difference relative to the various methods of reconstruction. The onset of pancreatic fistrula was found to be statistically more frequent after ligation of the stump than after pancreatico-jejunal anastomosis (p = 0.001). Comparing the pancreatico-jejunal end-to-side anastomosis, to pancreatico-jejunal end-to-end and wirsung-jejunal end-to-side anastomosis the first one had shown a significantly higher rate only for leakage (respectively p = 0.008 and p = 0.010). The occlusion of the wirsung duct with biological substances showed better results compared to ligation (p = 0.001) only as regards onset of the fistula, while the comparison between the occlusion and the three types of anastomosis did not show any statistically difference, except for the pancreatico-jejunal end-to-side anastomosis, in which it was significant only as regards leakage (p = 0.009). The statistical analysis between pancreatico-gastrostomy and pancreatico-jejunal anastomoses indicated that the first technique had a lower morbidity rate than pancreatico-jejunal end-to-side (p = 0.001), pancreatico-jejunal end-to-end (p = 0.010) and wirsung-jejunal end-to-side (p = 0.011). We analysed and compared the results obtained before and after 1975, in order to discover whether was an improvement in the prevnetion or in the treatment of such a complication and its consequences. Furthermore, we tried to establish whether the transanastomotic drainage, the site of the neoplasm, the texture of pancreatic parenchyma and the patient's age could in any way influence the onset and course of the fistula.     

Reconstruction of the pancreatic duct after pancreaticoduodenectomy: a modification of the Whipple procedure

BACKGROUND AND OBJECTIVES: Pancreaticoduodenectomy is still associated with high morbidity and mortality even though there has been significant progress in the field of pancreatic surgery and postoperative follow-up. The pancreatoenteric anastomosis, regardless of the technique used, is a major cause for both morbidity and mortality after Whipple procedure. To overcome all problems resulting from anastomotic leakage, we used external drainage of the pancreatic duct. METHODS: In 24 patients who underwent pancreaticoduodenectomy in our Department from 1986 to 1995, a modification to the standard Whipple procedure was performed. Instead of pancreaticoenteric anastomosis, external drainage of the pancreatic duct remnant was performed. The pancreatic duct was intubated with a silastic tube, the external end of which was sutured to the skin. All patients received substitution therapy with pancreatic enzymes. RESULTS: Mortality in our group of patients was 4%. No complications due to the external drainage of the pancreatic duct were reported, while no patient developed diabetes mellitus after surgery. CONCLUSIONS: External drainage of the pancreatic duct remnant can be used alternatively to pancreatoenteric anastomosis after pancreatoduodenectomy. The technique is safe and simple to perform and appears to reduce overall operative time. It may be an option for patients with significant comorbidity and/or intraoperative hemodynamic instability which mandates expeditious completion of the operation.     

Internal compared with external drainage of pancreatic duct during pancreaticoduodenectomy： a retrospective study

Objective： To compare internal with external drainage of the pancreatic duct during pancreaticoduodenectomy with regard to the incidence of postoperative pancreatic fistula （POPF） and other complications. Methods： We retrospectively analyzed 316 patients who underwent pancreaticoduodenectomy with a placed drainage tube （external, n=128; internal, n=188） in the pancreatic duct from 1 January 1999 to 31 December 2011 in Tianjin Third Central Hospital of China. The incidence of POPF and some other complications were compared. Results： There was no difference in the incidence rates of POPF between those given an internal or external drainage tube （P=0.788）, but POPF was more severe in the former （P=0.014）. Intraperitoneal bleeding rate was also higher in the patients with internal drainage （P=0.040）, but operative time and postoperative hospitalization were longer in those with external drainage （P=0.002 and P=0.007, respectively）. There was no difference between the groups with regard to the incidence rates of gastrointestinal bleeding, delayed gastric emptying, pulmonary infection, or incision infection and in-hospital mortality. Conclusions： External drainage of the pancreatic duct during pancreaticoduodenectomy can decrease the severity of POPF, but operative time and postoperative hospitalization will be extended.