胰十二指肠切除术治疗壶腹部癌和胰头癌临床分析

壶腹周围癌是指胆胰壶腹周围2cm范围内的恶性肿瘤，包括壶腹部癌（胆总管末端壶腹癌和十二指肠乳头癌）、胰头癌及十二指肠降段的恶性肿瘤．胰十二指肠切除术是治疗壶腹周围癌的主要方式，但该手术对于壶腹部癌和胰头癌的疗效有所差别．将我院近7年收治病例的情况报道并分析如下。     

再次手术治疗胰十二指肠切除术后慢性腹痛一例

患者,男,53岁.因"胰十二指肠切除术后7年,反复上腹痛伴恶心、呕吐5年,再发1个月"入院.7年前患者因"壶腹部占位"行保留幽门的胰十二指肠切除,Child式消化道重建(捆绑式胰肠吻合).病理诊断:壶腹部乳头状腺癌,大小约2 cm×1 cm × 1 cm,浸润十二指肠全层,胆总管壁内亦见癌组织浸润,胰周淋巴结可见癌转移,十二指肠、胆总管及胰腺切缘阴性.     

老年壶腹周围癌病人的外科治疗

一般认为壶腹周围癌(periampullary carcinoma)是指来源于十二指肠乳头或其周围lcm范围内组织或器官发生的恶性肿瘤,包括胰头癌、壶腹部癌、胆总管下段癌及乳头周围的十二指肠癌,按其发生比例高低依次为胰头癌、壶腹部癌、胆总管下段癌和十二指肠癌,但胰腺来源的壶腹周围癌预后远不如非胰腺来源的壶腹周围癌 [1].     

努力提高壶腹周围肿瘤的外科治疗技术水平

胆总管在穿过十二指肠壁时与胰管汇合 ,汇合后略膨大 ,称Vater壶腹 (简称壶腹 )。壶腹及其外周环绕的括约肌向十二指肠肠腔突出 ,使十二指肠粘膜隆起形成十二指肠乳头。在壶腹周围 (包括壶腹 ) ,上述组织结构所发生的肿瘤统称为壶腹周围肿瘤 ,并以恶性居多。壶腹周围的恶性肿瘤包括来自壶腹、胆总管下端、十二指肠乳头和胰头的癌肿 ,临床上把前三者连同胰头癌统称为壶腹周围癌。目前 ,外科手术仍是治疗壶腹部肿瘤的主要手段 ,提高壶腹部肿瘤的外科治疗技术水平是患者获得治愈的唯一途径。壶腹部肿瘤因其组织来源不同其生物学行为亦表现出很…     

根治性胰十二指肠切除术治疗壶腹部周围恶性肿瘤术后并发症的防治

目的 探讨根治性胰十二指肠切除术(RPD)治疗壶腹部周围恶性肿瘤导致术后出血、胰瘘、胆瘘和死亡的重要影响因素和防治措施.方法 回顾性分析华中科技大学同济医学院附属同济医院胆胰外科中心在2006年1月至2008年6月期间接受RPD术的156例壶腹部周围恶性肿瘤患者的临床资料,其中男性97例,女性59例,年龄37～79岁,平均56.9岁.其中胰头颈部肿瘤72例,胆总管下端肿瘤35例,壶腹部肿瘤27例,十二指肠乳头部肿瘤22例.结果 156例RPD患者中,4例发生了消化道应急性溃疡大出血,2例发生胰肠吻合口出血;术后出血的发生率为3.9%(6/156).6例发生并发症的患者中,1例因并发严重的肺部感染和呼吸窘迫综合征,在ICU住院2个月后死于呼吸功能衰竭(0.7%).1例胰肠吻合口出血患者于再次剖腹切开胰肠吻合口处空肠缝扎胰腺断端出血点后第3天发生胰瘘;1例胆总管下端肿瘤患者于术后11 d发生胆瘘.2例胆瘘、胰瘘患者均经超声引导下穿刺引流等保守治疗后痊愈.结论 及时有效地处理出血、胰瘘、胆瘘可大大降低壶腹部周围恶性肿瘤患者围手术期的病死率.     

根治性胰十二指肠切除术治疗壶腹部周围恶性肿瘤术后并发症的防治

目的 探讨根治性胰十二指肠切除术(RPD)治疗壶腹部周围恶性肿瘤导致术后出血、胰瘘、胆瘘和死亡的重要影响因素和防治措施.方法 回顾性分析华中科技大学同济医学院附属同济医院胆胰外科中心在2006年1月至2008年6月期间接受RPD术的156例壶腹部周围恶性肿瘤患者的临床资料,其中男性97例,女性59例,年龄37～79岁,平均56.9岁.其中胰头颈部肿瘤72例,胆总管下端肿瘤35例,壶腹部肿瘤27例,十二指肠乳头部肿瘤22例.结果 156例RPD患者中,4例发生了消化道应急性溃疡大出血,2例发生胰肠吻合口出血;术后出血的发生率为3.9%(6/156).6例发生并发症的患者中,1例因并发严重的肺部感染和呼吸窘迫综合征,在ICU住院2个月后死于呼吸功能衰竭(0.7%).1例胰肠吻合口出血患者于再次剖腹切开胰肠吻合口处空肠缝扎胰腺断端出血点后第3天发生胰瘘;1例胆总管下端肿瘤患者于术后11 d发生胆瘘.2例胆瘘、胰瘘患者均经超声引导下穿刺引流等保守治疗后痊愈.结论 及时有效地处理出血、胰瘘、胆瘘可大大降低壶腹部周围恶性肿瘤患者围手术期的病死率.     

管型吻合器在胰十二指肠切除术中胆肠吻合的应用

<正>胰十二指肠切除术是治疗胰头癌、壶腹癌、胆总管下段癌、壶腹周围的十二指肠癌的首选方法。但胰十二指肠切除术手术过程复杂且创伤很大,切除范围包括部分胰腺、邻近的十二指肠、胆总管下端、部分胃及空肠上端,并且需作胆总管、胰管、胃与空肠的吻合。在3个吻合中,胆肠吻合因其位置较深,故     

联合血管切除重建的胰十二指肠切除术疗效分析

目的 探讨联合血管切除重建的胰十二指肠切除术的临床疗效.方法 回顾性分析2007年1月至2011年5月第三军医大学西南医院收治的56例术前诊断为胰腺肿瘤行联合血管切除重建的胰十二指肠切除术患者的临床资料,统计患者围手术期并发症发生率、病死率及术后生存情况.结果 本组患者平均手术时间为473 min(234～853 min),术中平均输血量为781 ml(0～900 ml),其中7例患者未输血;中位住院时间为25.9 d(17～100 d);43例患者进行了人工血管重建.56例患者围手术期并发症发生率为34％ (19/56),病死率为7％(4/56).术后病理诊断:胰头导管腺癌42例,壶腹部癌5例,胆管下端癌3例,十二指肠乳头癌4例,胰头神经内分泌癌1例,胰腺浆液性囊腺瘤1例.随访截至2011年8月,患者1年生存率为57％(32/56),平均生存时间为13.5个月.32例生存患者体质量均不同程度增加,无腹痛.术后3个月内5例患者有轻度腹泻,需要服用止泻药;1例患者术后1个月发现人造血管内血栓形成、中等量腹腔积液,半年后侧支循环形成,腹腔积液消失.结论 对于伴有血管侵犯的胰腺肿瘤患者,应积极行联合血管切除重建的胰十二指肠切除术,能改善胰腺癌晚期患者的生命质量.     

壶腹周围癌某些相关基因表达与预后的关系

胆总管在穿经十二指肠壁时与胰管汇合后略膨大,称胆胰壶腹（简称壶腹）。壶腹及其外周环绕的括约肌向十二指肠腔突出,使二十指肠粘膜隆起形成十二指肠乳头。在壶腹周围（包括壶腹）上述组织结构所发生的肿瘤统称壶腹周围肿瘤,可为良性或者恶性,以恶性居多。恶性肿瘤包括来自壶腹、胆总管下端、十二指肠乳头和胰头的癌肿,临床上把前三者统称壶腹部癌,连同胰头癌统称壶腹周围癌。     

壶腹部癌的临床病理特征及诊断与治疗

目的 总结壶腹部癌的临床病理特征,探讨该病的诊断及治疗方法.方法 回顾性分析2000年1月至2010年12月北京协和医院收治的187例壶腹部癌患者的临床资料,根据手术方式将患者分为胰十二指肠切除术组(162例)和局部切除术组(25例),观察壶腹部癌的临床病理特征,探讨该病的诊断和治疗方法,分析两组患者的治疗效果.计量资料采用t检验,计数资料采用x2检验,Kaplan-Meier法绘制生存曲线,生存率比较采用Log-rank检验.结果 本组患者行B超、CT、MRI、ERCP检查阳性率分别为9.3％(15/161)、43.9％ (65/148)、21.3％ (19/89)、83.9％( 135/161).高分化腺癌87例,中分化腺癌64例,低分化腺癌27例,腺管癌变9例.T1、T2期壶腹部癌患者行胰十二指肠切除术与局部切除术的生存率比较,差异无统计学意义(x2 =3.163,P＞0.05);T3、T4期壶腹部癌患者行胰十二指肠切除术的预后优于行局部切除术者(x2=6.309,P＜0.05).结论 壶腹部癌以高分化腺癌为主.影像学检查中ERCP确诊率最高.T1、T2期壶腹部癌患者行局部切除术已达到根治目的,而T3、T4期患者应行胰十二指肠切除术.     

Carcinoma of the pancreas and periampullary region: a 41 year experience.

A retrospective review of 329 cases of adenocarcinoma of the pancreas and 31 adenocarcinomas of the ampulla and and common bile duct seen between the years 1929 and 1973 was carried out. The most common complaints for carcinoma of the pancreas were pain, weight loss, and jaundice in that order of frequency; while jaundice was the most common complaint with periampullary lesions. The most common procedure carried out was a gastric and/or biliary bypass. Thirty-five patients underwent pancreatoduodenectomy. The survival of this latter group was longer and better than those undergoing bypass and in 40% of patients with ampullary carcinoma a cure was effected. Patients undergoing bypass did not live longer than patients undergoing simple exploratory laparotomy. Duration of symptoms and location of tumor within the pancreas (excluding ampullary tumors) did not appear significantly to alter the prognosis. In view of our experience it is felt that pancreatoduodenectomy should be undertaken whenever the tumor is deemed resectable as this provides the only chance for cure and the best palliation.     

胰十二指肠切除联合D2＋胰周淋巴结清扫术

对可切除的胰头癌、远端胆管癌和壶腹周围癌,根治性切除是其预后的重要决定性因素之一。为了达到Rn切除,临床上有多种切除方式如胰头十二指肠切除＋胰周淋巴结的清扫术等。南京医科大学第一附属医院设计和应用了胰头十二指肠切除联合D2＋胰周淋巴结清扫术（在胰十二指肠切除术基础上进行广泛的腹膜后淋巴结清扫）治疗远端胆管癌,安全有效。     

胆胰十二指肠结合部切除治疗壶腹部周围癌的疗效分析

目的探讨胆胰十二指肠结合部切除治疗壶腹部周围癌的临床应用。方法自2005年1月—2006年7月采用该术式治疗壶腹部周围癌15例，其中乳头癌6例，壶腹癌5例，胆总管下端癌4例。合并心肺疾患7例，糖尿病2例。切除范围：十二指肠降段，距胆胰管汇合部切除胰头1—2cm及胆总管至左右肝管汇合处下方。术中注意清扫区域淋巴结，行冰冻病理切片检查证实各切缘无肿瘤残存。结果全组手术成功率为100％，术后未出现胃瘫、十二指肠漏、胆漏或明显胰漏等严重并发症，均痊愈出院。1例死于术后2个月上消化道应激性溃疡大出血，其余14例均存活。随访3—16个月，随访期间未发现肿瘤复发或转移。结论胆胰十二指肠结合部切除术是治疗壶腹部周围癌的一种新术式，比乳头局部切除术范围大，但是手术难度和创伤均较常规胰十二指肠切除术明显降低，近期疗效满意。     

Clinical behavior and prognostic factors of periampullary adenocarcinoma.

OBJECTIVE: The authors evaluated the outcome and potential prognostic factors of 60 patients with surgically resected periampullary tumors. SUMMARY BACKGROUND DATA: Periampullary carcinomas exhibit different clinical behaviors according to their site of origin. There are no prognostic factors for deciding the type of surgery to be used or for choosing patients with tumors that have a poor prognosis for adjuvant treatment. METHODS: A retrospective review was performed of 15 clinical and pathologic variables encountered among 60 patients with periampullary tumors. Tumors were divided into four groups according to their site of origin. Kaplan-Meier survival curves of the four groups were plotted and differences were evaluated with the log-rank test. Cox's proportional hazards model was used to test for separate and combined independent predictors of disease-free survival. RESULTS: Twenty-nine ampullary carcinomas, 20 ductal pancreatic carcinomas, 7 distal common bile duct carcinomas, and 4 carcinomas of the periampullary duodenum were found. Five-year disease-free survival was 43%, 0%, 0%, and 75%, respectively. According to the Cox analysis, absence of neural invasion and use of adjuvant chemotherapy were significant factors for longer survival of patients with ampullary tumors. Lymphatic invasion was related to a shorter survival in patients with pancreatic carcinoma. CONCLUSIONS: Five-year disease-free survival of patients with periampullary tumors is related to tumor type. Prognosis was better for ampullary tumors if neural invasion was absent and if adjuvant chemotherapy was used. Lymphatic invasion was associated with a shorter recurrence-free survival among patients with pancreatic carcinoma.     

Predictors of Survival in Periampullary Cancers Following Pancreaticoduodenectomy

Background  

Cancers of the ampulla of Vater, distal common bile duct, and pancreas are known to have dismal prognosis. It is often reported that ampullary cancers are less aggressive relative to the other periampullary carcinomas. We sought to evaluate predictors of survival for periampullary cancers following pancreaticoduodenectomy to identify biologic behavior.     

Implications of histological grade of tumour for the prognosis of radically resected periampullary adenocarcinoma.

OBJECTIVE: To study the influence of histological grade of tumour on the prognosis of radically resected periampullary cancers. DESIGN: Retrospective study. SETTING: Teaching hospital, Austria. SUBJECTS: 156 patients (papilla of Vater, n = 34, head of the pancreas, n = 105, and distal common bile duct, n = 17) who underwent partial pancreaticoduodenectomy for periampullary adenocarcinoma between 1 January, 1967 and 31 December, 1996. OUTCOME MEASURES: The relation between grade of tumour and site, T and N classification, extramural growth, invasion of vessels and resection margins, tumour volume, and survival time. RESULTS: Well differentiated lesions were significantly more common in the papilla of Vater (n = 15, 44%, p = 0.01) than in the pancreatic head or the common bile duct (n = 20, 19%, and n = 5, 29%, respectively). Only in ampullary lesions did the grade of tumour significantly affect the incidence of other histopathological risk factors (T p = 0.003; nodal status p = 0.01; extramural growth p = 0.0001; tumour volume p = 0.02) and survival time (p = 0.02); no significant correlations were found in cancers of the head of the pancreas or common bile duct. CONCLUSIONS: There was a significant difference in the distribution of grade of tumour between the different sites of origin of resected periampullary cancers. Grade of tumour correlated with T and N classification, tumour volume, extramural growth, and survival only in ampullary lesions.     

Results of surgical treatment of periampullary tumors: a thirty-five-year experience

Data on 126 consecutive patients with periampullary tumors resected at the Cleveland Clinic between January 1950 and December 1984 were reviewed. One hundred five patients underwent pancreatoduodenal resection, 10 patients total pancreatectomy, and 11 patients local resection of the tumor. The site of tumor was ampulla of Vater (59), head of the pancreas (30), duodenum (20), and distal common bile duct (11). Six patients had benign disease. The operative mortality rate for radical resection for the entire period was 7.8%; it has declined to 5.4% since 1974. The operative mortality rate for local resection was 9.1% (one patient). The overall 5-year survival rate for all malignant tumors of the periampullary area was 28% and 25.5% for invasive adenocarcinoma. Survival was affected primarily by location and histologic findings. The 5-year survival rate for adenocarcinoma of the ampulla of Vater was 37.2%, 27.5% for the duodenum, 16.7% for the distal common bile, and 4.3% for the pancreas (p = 0.0001). Papillary adenocarcinoma had a 5-year survival rate of 49.2% in contrast to 18.4% for nonpapillary ductal adenocarcinoma (p = 0.002). Patients with ampullary adenocarcinoma treated by local resection had a 5-year survival rate of 40.9%. These data justify continued use of a selective radical approach in the resection of most periampullary tumors with local resection for small tumors in high-risk patients.     

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目的 探讨7例再次剖腹手术行壶腹部癌根治性切除的病人在第一次手术时未行根治性切除的原因。方法 结合术后随访,详细回顾病例资料。结果 第一次剖腹手术时认为癌肿不能切除3例,漏诊3例,误诊1例;第二次手术前结合内镜逆行胰胆管造影（ERCP）、CT等检查,均明确诊断为壶腹部癌,其中CT显示壶腹部占位5例,均未见胰外转移及血管侵犯。均再次剖腹施行胰十二指肠切除术。结论 胆道远端恶性梗阻病人术前ERCP、CT等影像学诊断极为重要,有助于明确诊断,减少手术盲目性,避免再次手术。     

Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Tumor staging and results

Regional pancreatectomy refers to an en bloc removal of a tumor in or adjacent to the pancreas with an adequate soft tissue margin and with its regional lymphatic drainage. The pancreatic segment of portal vein is part of the en bloc resection with venous reconstruction by end-to-end anastomosis without a graft. This operation, called a Type I regional pancreatectomy, may utilize either a total or subtotal removal of the pancreas. Localized arterial involvement by a neoplasm necessitates adding a segmental resection of the artery with vascular reconstruction, a Type II procedure. Sixty-one patients have had this procedure from 1972 through 1982. They are a subset of the 270 patients with cancer of the pancreas, ampullary and periampullary regions, duodenum, or terminal portion of the common bile duct who were treated by the author during this period. The 61 consist of 35 patients who had an infiltrating duct adenocarcinoma of the pancreas and 21 who had other kinds of malignant tumors. In addition, four were classified as having pancreatitis and a fifth patient had a pseudolymphoma. The resectability rate is about 30%. The present operative mortality rate is 8%. Approximately one-third of the patients are alive; 43% of the 21 patients with malignant tumors other than infiltrating duct adenocarcinoma of the pancreas are alive with a median survival time of 40 months (3-92 months). Forty-three per cent were Stage I but more than half were T3 or T4 lesions. Twenty-five per cent of patients with Stages II or III are alive. Twenty per cent of patients with infiltrating duct carcinoma of the pancreas are presently alive, 28% died of recurrent disease, and 26% died of other causes; more than 90% of these patients had advanced stage disease (Stage II or III).     

Favourable prognostic factors in a large UK experience of adenocarcinoma of the head of the pancreas and periampullary region

AIMS: To present the surgical experience in a regional unit, analysing the post-operative outcome, and determining risk factors for survival after pancreaticoduodenectomy for periampullary and pancreatic head carcinoma. METHODS: Data were collected on 251 patients with pancreatic head adenocarcinoma (133), ampullary carcinomas (88) and distal common bile duct (30), between 1987 and 2002. Survival was calculated using the Kaplan-Meier method. Clinical, surgical and histopathological records were examined by univariate and multivariate analysis to identify the independent prognostic predictors of survival. RESULTS: Median actuarial survival for carcinoma of the pancreatic head, ampulla and distal bile duct were 13.4, 35.5 and 16 months, respectively; p < 0.0001. On univariate analysis for the whole series, the age < or =60, tumour of the head of the pancreas, lymph node positive, resection margin R1, poorly differentiated tumours, and portal vein invasion significantly decreased survival. On multivariate analysis, poor tumour differentiation, surgical margin, lymph node metastases, and age independently influence survival. Mortality and morbidity were 4.8 and 29.9%, respectively. CONCLUSIONS: Pancreaticoduodenectomy for pancreatic and periampullary tumours is the only therapy that may cure patients and can be performed safely in centres with significant experience.