高龄患者壶腹部肿瘤局部切除加胰胆管成形术七例体会

壶腹部肿瘤外科治疗的标准术式仍然是胰十二指肠切除术(PD)[1] ,PD 治疗壶腹部肿瘤虽然可以达到根治的效果,但因手术复杂、创伤大、并发症多而受到一定的限制,尤其对常年合并基础病的高龄患者来说,手术风险高.而壶腹部肿瘤局部切除手术相对简单、创伤小、术后并发症少,可以达到PD 手术相似的治疗效果.笔者回顾总结我院自2006 年6 月至2009 年5月施行壶腹部肿瘤局部切除术的高龄患者7 例,现报道如下.     

高龄Vater壶腹部肿瘤局部切除37例疗效分析

【目的】分析高龄Vater壶腹部肿瘤局部手术切除的治疗效果。【方法】37例60岁以上确诊为Vater壶腹部肿瘤患者全麻下行局部肿瘤切除术,观察记录患者术后临床反应、并发症以及患者的生存状态。【结果】全组无死亡病例,手术过程顺利,术中失血量平均为90mL,手术时间平均1h30min。6例（16．2％）术后复发,术后并发症7例（18．9％）,其中2例改行胰十二指肠的切除手术,其余患者没有复发及转移状态的现象发生。【结论】对高龄Vater壶腹部肿瘤患者进行局部肿瘤切除,手术创伤小、术后恢复快,不失为更好、更安全的选择。     

壶腹部肿瘤局部切除术的临床体会

目的观察壶腹部肿瘤局部切除术的疗效。方法回顾本院20例壶腹部肿瘤患者,均行局部切除术,对术后并发症、存活率进行分析。结果术后发生并发症共3例,占15.0%。至今仍存活9例患者,存活年限均大于1年,存活率为45.0%。结论局部切除术治疗壶腹部肿瘤,具有创伤小、恢复快、术后并发症发生率低的优点,疗效较好,可作为壶腹部肿瘤患者,尤其是老年患者的首选手术方法。     

壶腹部癌19例诊断分析

目的：探讨壶腹部癌的诊断和治疗方法。方法：回顾分析19例经病理证实为壶腹部癌患者的临床资料。结果：19例壶腹部癌患者以梗阻性黄疸和上腹部不适、疼痛为突出表现;影像学检查主要表现为壶腹部肿物及胆、胰管扩张;内镜提示十二指肠乳头及附近粘膜病变。行胰十二指肠切除术15例,十二指肠肿瘤局部切除术1例,3例未行手术。结论：上腹部不适、疼痛是壶腹部癌的早期症状,超声及内镜检查,尤其是内镜检查和活检对壶腹部癌的发现和诊断具有重要的作用。胰十二指肠切除术是治疗的首选方法。     

内镜下乳头括约肌切开术护理体会

内镜民头括约肌切开术（ＥＳＴ）治疗胆管结石、胆总管下端炎性狭窄及壶腹部周围肿瘤引起的胆管梗阻共７２例，其中４９例ＥＳＴ后引流通畅，２３例胆管结石取净，临床症状消失。良好的心理护理、术中助手的配合与术后护理是ＥＳＴ成功的关键。     

内镜黏膜下剥离术治疗老年早期上消化道肿瘤的效果

目的 探讨内镜黏膜下剥离术治疗老年上消化道早期肿瘤的疗效.方法 收集安徽医科大学附属安庆医院消化内科2017年3月至2019年10月收治的67例老年上消化道早期肿瘤患者的临床资料,患者入院后均行内镜黏膜下剥离术(ESD),术后跟踪随访,评估内镜治疗的术前术后病理结果、并发症发生率、病灶整块切除率、住院时间、术后残留及复...     

光动力疗法联合化疗对老年人消化道肿瘤疗效及生活质量的影响

目的:观察光动力疗法(photodynamictherapy,PDT)联合化疗对老年人中晚期消化道肿瘤的疗效并比较其对生活质量的影响,探寻老年人中晚期消化道肿瘤的治疗方法。方法:15例选用保守方法治疗的老年中晚期消化道肿瘤,其中食管癌7例,结肠癌4例,直肠癌4例。全部患者进行内镜下PDT联合化疗,其中6例还在PDT前行内镜下肿物切除术。于治疗前及治疗后1,2,3,6,9,12个月复查内镜并进行临床症状评定,并对患者采用世界卫生组织生活质量测定量表简表WHOQOL-BREF)进行调查,随访生活质量、生存(时间,观察毒副作用。结果:15例患者平均随访时间7.5(0.5～16)个月;临床症状缓解率80/15);半年生存率73%(11/15),1年生存率40%6/15);中位((生存期为9个月;内镜下完全应答率27%(4/15),部分应答率为47%(7/15)。与治疗前比较,患者PDT联合化疗后3个月生理和心理领域的生活质量差异有显著性意义(F=4.307～7.899,P<0.05)。有1例出现皮肤过敏反应,副反应发生率为7%(1/15);1例食管癌患者术后1周出现大出血,并发症发生率为7%1/15)。(结论:PDT联合化疗可显著改善老年肿瘤患者的临床症状和生活质量,是治疗老年中晚期消化道肿瘤又一有效手段。     

内镜黏膜下剥离术联合黏膜切除术在非壶腹部十二指肠占位性病变治疗中的应用价值研究

目的评估内镜黏膜下剥离术(ESD)与内镜黏膜下剥离术联合黏膜切除术(ESD+EMR)在非壶腹部十二指肠占位性病变治疗中的疗效及安全性。方法选取2015年4月至2019年4月在首都医科大学附属北京友谊医院应用ESD术及ESD+EMR术治疗的14例非壶腹部十二指肠占位性病变患者为研究对象,根据手术方式的不同将患者分为ESD组和ESD+EMR组,回顾性分析患者的基线资料、手术方式、并发症发生情况与转归、病理结果及手术时间等资料。结果 14例患者均成功完成内镜下治疗,整块切除率为100%(14/14)。其中ESD 4例,完全切除率为100%(4/4),ESD+EMR 10例,完全切除率为80%(8/10)。总体并发症发生4例(4/14,28. 6%),均为围手术期穿孔。在4例ESD的操作中,1例来源于黏膜下层的病变最大直径较大(16 mm),术前予外科手术备案,术中发生穿孔(1/4,25. 0%),行腹腔镜下十二指肠修补术后好转出院。在10例ESD+EMR的操作中,发生穿孔3例(30%,3/10),其中2例行内镜下金属夹封闭术治疗后好转; 1例为内镜下金属夹封闭术治疗不佳,转外科开腹探查修补术后好转出院。ESD组与ESD+EMR组内镜下病灶最大直径分别为(16±7)、(16±6) mm,差异无统计学意义(P=0. 971);手术时间分别为(71. 8±39. 7)、(32. 0±18. 4) min,差异具有统计学意义(P=0. 022)。结论对于空间狭小、操作困难的非壶腹部十二指肠占位性病变,ESD及ESD+EMR治疗均是安全有效的,相比于ESD,ESD+EMR操作更快捷有效,具有良好的临床应用前景。     

内镜超声引导下腹腔神经丛阻滞在晚期腹部肿瘤所致癌性腹痛中的应用

目的:评价内镜超声引导下腹腔神经丛阻滞对晚期腹部肿瘤患者的止痛作用.方法:对12例晚期腹部肿瘤患者行内镜超声引导下腹腔神经丛阻滞.在内镜超声引导下,将细针穿刺到腹腔神经丛区域并注射无水酒精.术前和术后分别填写视觉疼痛类比量表(VAS)进行评分,评估疗效.结果:所有患者均成功进行了腹腔神经丛阻滞,并且没有并发症发生.12例患者术后腹痛缓解有效率达83%.并且疗效能持续较长时间.结论:内镜超声引导下腹腔神经丛阻滞是治疗晚期腹部肿瘤腹痛较有效、安全的方法.     

局部切除术治疗壶腹部癌

壶腹部癌的治疗方法根据肿瘤治疗原则，目前仍首选胰十二指肠切除术。对于体质差，合并有严重心、肺疾病，经济困难，而且肿瘤直径在2．0cm之内者，宜行局部切除术。自1996年10月～2001年10月作者共行局部切除术治疗壶腹部癌23例，术后辅以化疗及免疫治疗，近期效果满意，报告如下：     

Microscopic transduodenal excision of an ampullary adenoma: A case report and review of the literature

BACKGROUNDTransduodenal local excision is an alternative treatment approach for benign ampullary tumors. However, this procedure has technical difficulties, especially during reconstruction of the pancreaticobiliary ducts. An operating microscope has been widely used by surgeons for delicate surgery due to its major advantages of magnification, illumination, and stereoscopic view. The application of an operating microscope in transduodenal excision of ampullary tumors has not been reported.CASE SUMMARYA 55-year-old woman was admitted for investigation of recurrent upper abdominal pain. Physical examination and laboratory tests found no abnormalities. Imaging identified a large mass in the descending part of the duodenum. Esophagogastroduodenoscopy revealed a 3.5-cm-sized villous growth over the major duodenal papilla. Pathology of the endoscopic biopsy indicated a villous adenoma with low-grade dysplasia. Microscopic transduodenal excision of the ampullary tumor was performed. The final pathological diagnosis was villous-tubular adenoma with low-grade dysplasia. The patient was discharged on postoperative day 12 after an uneventful recovery. Endoscopic retrograde cholangiopancreatography was performed 3 mo postoperatively and showed no bile duct or pancreatic duct strictures and no tumor recurrence. The patient is continuing follow-up at our clinic and remains well.CONCLUSIONOperating microscope-assisted transduodenal local excision is a feasible and effective option for benign ampullary tumors.     

Ectopic opening of the common bile duct into the duodenal bulb with recurrent choledocholithiasis: A case report

BACKGROUNDEctopic opening of the common bile duct is a condition with low incidence. Patients with an ectopic common bile duct opening have a high incidence of common bile duct stones and acute cholangitis. Patients with atypical symptoms and imaging findings are easily misdiagnosed; moreover, it is difficult to retrieve stones by endoscopic retrograde cholangiopancreatography, and common bile duct stones are prone to postsurgical recurrence.CASE SUMMARYA 45-year-old male patient presented with “intermittent upper abdominal pain and elevated liver enzymes for 1 wk”. Transabdominal ultrasound indicated dilation of the common bile duct and the presence of stones. Magnetic resonance imaging showed that the common bile duct was dilated with stones and that its opening was ectopic. Endoscopic retrograde cholangiopancreatography revealed an abnormal opening of the common bile duct into the duodenal bulb and the presence of common bile duct stones. Laparoscopic extrahepatic choledochectomy and hepatoenteric anastomosis were performed. After surgery, the patient recovered well and was discharged. The patient has been followed up for 2 years since the operation. He has not experienced stone recurrence, and his liver function and quality of life are good.CONCLUSIONImproved understanding of ectopic opening of the common bile duct is needed for clinicians to provide patients with appropriate treatment.     

内镜黏膜下剥离术及内镜下黏膜切除术治疗十二指肠癌前病变及十二指肠早期癌的临床研究

目的 探索内镜黏膜下剥离术（ESD）及内镜下黏膜切除术（EMR）治疗十二指肠癌前病变及十二指肠早期癌的效果及安全性。方法 回顾性分析2016年9月－2021年3月16例于该院发现并行ESD及EMR治疗的十二指肠癌前病变或十二指肠早期癌患者的临床资料,分析ESD及EMR的临床疗效及安全性。结果 16例患者中,14例病变位于降段乳头对侧或偏对侧,2例病变位于球降交界部,病变大小0.8～2.6 cm,平均（1.2±0.7）cm,切除标本大小1.5～3.5 cm,平均（2.2±0.8）cm,手术时间54～127 min,平均（68.6±25.9）min。9例一次性整块切除病变;7例沿病变外周3 mm环形切开黏膜层及黏膜下层,用圈套器圈套切除,残留组织用碗状热凝钳切除;用止血夹对吻缝合或止血夹联合尼龙绳行荷包缝合创面。术后1例患者行ESD整块剥离后发生术后穿孔,追加腹腔镜下局部修补手术,术后患者恢复良好出院,其余患者均无并发症发生,效果良好。结论 对于十二指肠黏膜的癌前病变及十二指肠早期癌,内镜微创切除治疗是一种重要的治疗方法,疗效确定,术后迟发性穿孔是主要并发症。     

Risk factors for post-endoscopic retrograde cholangiopancreatography cholangitis in patients with hepatic alveolar echinococcosis—an observational study

BackgroundHepatic alveolar echinococcosis (HAE) is considered to be one of the most deadly chronic parasitic diseases in the world. We have shown that the incidence of cholangitis in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) was increased significantly. On this finding, we carried out, a preliminary study on the risk factors for cholangitis after ERCP.AimsTo retrospectively detect the risk factors for post-ERCP cholangitis in patients with biliary tract affected by HAE.MethodsThe study included data from 51 cases of AE who had undergone therapeutic ERCP between January 2015 and December 2019. Demographic and treatment data were extracted from the medical records, and the association between potential risk factors and the development of post-ERCP cholangitis was evaluated using a collected database.ResultsThere were five cases of mild cholangitis after ERCP (Tokyo criteria), and no moderate or severe cholangitis occurred. The incidence rate of cholangitis after ERCP was 9.8%. Univariate analysis showed hilar bile duct stenosis (p = .016), endoscopic retrograde biliary drainage (p = .007), a stent diameter ≥8.5 Fr (p = .000) and single stent implantation (p = .010) were risk factors for post -ERCP cholangitis. All cases of cholangitis improved under conservative treatment.ConclusionPatients with hilar bile duct compression or endoscopic retrograde biliary drainage appeared to be more likely to develop post-ERCP cholangitis. The number and diameter of biliary stents may influence post-ERCP cholangitis. Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors for screening.

KEY MESSAGES

• Many studies reported the post-ERCP complications in patients with hepatic alveolar echinococcosis and found that the incidence of post-ERCP cholangitis was significantly high. Therefore, we conducted a preliminary study on the risk factors of postoperative cholangitis in patients who underwent ERCP.
• The incidence rate of cholangitis after ERCP was 9.8%. We found that hilar bile duct stenosis, and endoscopic retrograde biliary drainage, were risk factors for cholangitis, and stent diameter and the number of stent implantation may influence the incidence rate of cholangitis after ERCP.
• Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors of screening.

     

可拆卸钛夹联合橡皮圈辅助内镜逆行胰胆管造影术在困难胆管插管中的临床应用

目的 评价可拆卸钛夹联合橡皮圈辅助内镜逆行胰胆管造影术（ERCP）在合并憩室内乳头的困难胆管插管中的疗效和安全性。方法 回顾性分析2020年3月－2021年10月因各种胆道疾病在该院行ERCP的869例患者的临床资料,对困难胆管合并憩室内乳头初始行常规插管失败的127例患者,使用可拆卸钛夹联合橡皮圈辅助技术再次行胆管插管,观察患者胆管插管成功率、辅助后插管成功时间和术后并发症发生率等情况。结果 困难插管患者127例（14.61%,127/869）。其中,14例合并有憩室内乳头的困难插管患者,经常规插管方法无法进入胆管,采用可拆卸钛夹联合橡皮圈的辅助技术再次进行胆管插管后,13例（92.86%）患者插管成功,插管时间（6.23±2.87）min,1例尝试数次仍未能进入胆管。术后2例发生高淀粉酶血症,1例发生轻度胰腺炎,无其他并发症发生。结论 可拆卸钛夹联合橡皮圈的辅助技术用于合并有憩室内乳头的困难胆管插管患者,安全、有效。值得临床应用推广。     

内镜下治疗十二指肠乳头括约肌切缘出血的护理配合技巧

目的 探讨内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)术后十二指肠乳头括约肌切缘出血内镜下止血治疗的操作护理配合与技巧.方法 纳入2011年3月至2020年2月在我院内镜中心行ERCP治疗后出现十二指肠乳头括约肌切缘或周围出血并行内镜下止血...     

十二指肠乳头肿瘤内镜下切除术的疗效分析（附3例报告）

目的评价、分析十二指肠乳头肿瘤内镜下切除的疗效及安全性。方法回顾性分析3例十二指肠乳头肿瘤内镜切除术患者的临床资料,总结其治疗效果及并发症情况。结果内镜下十二指肠乳头肿瘤切除成功率为100.0%(3/3),完全切除率为100.0%(3/3)。未出现任何手术并发症。所有病例均未复发。结论十二指肠乳头肿瘤内镜下切除术是安全、有效的方法。     

内镜下微创治疗良恶性胆管梗阻

目的总结内镜下微创治疗良恶性胆管梗阻的操作体会，探讨其应用价值。方法应用十二指肠镜行内镜下胆管引流术治疗1998年2月-2004年5月间的260例各类胆管梗阻患者，并进行总结探讨。结果该组行ENBD 164例，ERBD 76例，EMBE 8例．其中184例(74％)一次引流达到疗效满意，53例2次内镜治疗达到疗效满意。总体满意率91．2％。全部病例减黄有效，有效率100％。放置失败12例。所有病例操作过程中未发生损伤性并发症，发生早期胆管炎21例，并发症发生率8．6％，无死亡及需急诊手术的病例。结论内镜下微创治疗良恶性胆管梗阻相对于传统外科手术，具有安全有效、损伤小、并发症少、成功率高的特点，达到了微创和显效的目的。其推广和应用，将会有力地促进胆胰病学的发展。     

非X线引导引流梗阻性化脓性胆管炎的临床价值*

目的探讨非X线引导下床边引流急性梗阻性化脓性胆管炎(AOSC)的临床价值。方法连续收集该院行十二指肠镜治疗AOSC的临床病例,分析在非X线引导下床边使用十二指肠镜治疗AOSC的安全性及有效性。结果在介入室行内镜逆行性胰胆管造影术(ERCP)治疗AOSC患者中,插管成功146例,插管成功率为93.6%(146/156),胆红素明显下降146例,内镜治疗成功率为93.6%(146/156),出现轻型胰腺炎、高淀粉酶血症、胆管炎和十二指肠乳头穿孔等并发症共18例,发生率为11.5%(18/156);在非X线引导下床边行十二指肠镜治疗AOSC患者中,插管成功13例,插管成功率为86.7%(13/15),胆红素明显下降12例,内镜治疗成功率为80.0%(12/15),出现轻型胰腺炎、高淀粉酶血症和胆管炎并发症各1例,发生率为20.0%(3/15)。结论在非X线引导下床边十二指肠镜行超选胆管插管技术已经成熟,可以为部分AOSC重症患者或孕妇及不宜接受X线照射的患者解除胆道梗阻。     

Surgical method choice and coincidence rate of pathological diagnoses in transduodenal ampullectomy: A retrospective case series study and review of the literature

BACKGROUND Transduodenal ampullectomy(TDA) is not in wide clinical use due to its low radical effect and a high recurrence rate of tumors. However,TDA is still an effective treatment method; it has great clinical value in cases of duodenal benign tumors,precancerous lesions,and benign and malignant borderline tumors,and can avoid the risks associated with pancreaticoduodenectomy with larger resection range and greater thoroughness than endoscopic papillectomy.AIM To investigate the surgical method choice and the coincidence rate of pathological diagnoses in TDA for ampullary neoplasms.METHODS Ten patients with ampullary neoplasms underwent TDA based on the fact that their endoscopic biopsy results suggested benign lesions,and the endoscopic ultrasound(EUS)-assessed tumors were resectable. All cases underwent duodenal ampullary lesion endoscopic biopsy,intraoperative frozen-section pathological examination,and postoperative pathological examination.RESULTSThis study included seven patients with benign tumors and three with malignant tumors(1 pTis,2 pT1),according to the postoperative pathology results. The coincidence rate of the postoperative pathology results with the intraoperative frozen-section biopsy results was 100%(10/10),and the coincidence rate with the endoscopic biopsy results was 70%(7/10) based on pathological characteristics.The endoscopic biopsy false-negative rate was 30%(3/10). All patients were followed for 6 to 70 mo without tumor recurrence or metastasis.CONCLUSION The coincidence rate of postoperative pathology results,intraoperative frozensection pathology results,and endoscopic biopsy results is the restraining factor of TDA clinical application. Endoscopic biopsy results and EUS have importance relevance to surgical planning. Intraoperative frozen-section pathology results have a significant influence on the choice of surgical procedure.