黄疸前期壶腹周围癌的早期诊断

本文报告我科１９８８年以来收治的１５例上腹隐痛不适、隐痛伴发热，Ｂ超显示胆囊及胆道扩张但无黄疸存在的病人，经十二指肠低张造影、ＣＴ、ＥＲＣＰ等检查，诊断为黄疸前期壶腹周围癌、手术切除率６６．７％，随访５年，５年以上生存４例，本文讨论对上腹隐痛不适，伴发热病例（类似胃炎、胆囊炎）不能忽视Ｂ超筛选，发现胆囊胀大，胆道扩张者，应进一步检查，及时发现那些黄疸前期壶腹周围癌病例，以提高手术切除率和延长生存时     

黄疸前期壶腹周围癌诊治体会

目的：探讨壶腹周围癌早期诊断的相关因素。方法：对我院1988年1月至2002年11月收治的19例黄疸前期壶腹周围癌的临床资料作回顾分析。结果：本组19例,手术治疗18例,切除12例,切除率为66．7％(12／18)。病死率为5．3％(1／19)。全组病人经BUS检查,其阳性率为91．7％(22／24),壶腹周围占位的诊断率为57．9％(11／19)。CT检查15例,阳性发现率为86．7％(13／15),壶腹周围占位的诊断率为73．3％(11／15)。当BUS,CT,ERCP等影像学联合检查时：阳性率达100％,壶腹周围占位的诊断率为94．7％(18／19)。这些阳性发现主要包括胆胰管的扩张以及发现壶腹周围的占位性病变等。结论：壶腹周围癌在黄疸前期是有其临床特点和(或)影像学异常改变的,临床医生应针对可疑病人进行全面细致的检查,才可以减少误漏诊情况的发生。提高早期诊断率和手术切除率,改善疗效。     

胰头和乏特氏壶腹癌早期的鉴别诊断

本文描述胰头和乏特氏壶腹癌的早期症状特点。胰头癌主要表现为胆道内压增高引起胆管扩张症状,如上腹饱胀,餐后加重,嗳气、纳差等消化不良症状,后期才出现无痛性进行性黄疸;而乏特氏壶腹癌则由于癌肿在腔内生长,容易发生胆道梗阻,导致早期出现黄疸,或伴胃肠道出血、贫血等征象。并借助新技术,如B超、CT、PTC、ERCP、血管造影、免疫学等检查可早期作出鉴别诊断。     

胰头癌外科疗效的临床分析

目的总结胰头癌的外科疗效，探讨提高胰头癌疗效的综合治疗方法。方法回顾性总结、分析172例胰头癌病人的临床资料及外科疗效，并总结同期106例壶腹周围癌（除外胰头癌）的外科疗效。结果29例胰头癌行根治性切除，切除率为16．9％，切除术后1、3、5年存活率分别为61．5%、26．9％、3．8％，中位生存期为14．6个月；未行手术切除者中位生存期为5．7个月。61例壶腹周围癌（除外胰头癌）行根治性切除，切除率为57．5％（61／106），术后5年生存率为26．9％。结论提高胰头癌的手术切除率有望延长病人的生存期，改进、规范胰头癌术式可提高胰头癌的手术切除率和术后长期生存率。     

影像学检查技术在壶腹周围癌诊断上的合理应用

目的：探讨影像学检查技术在壶腹周围诊断上的合理应用。方法：对我院185例壶腹周围癌（包括胰头癌119例、十二指肠乳头癌41例、Vater壶腹癌13例、胆总管下段癌12例）的临床特点和各种影像学检查资料进行回顾性分析。结果：本组CT诊断胰头癌的准确率为90．9％；ERCP对十二指肠乳头癌的确诊率为100％；ERCP和MRCP对壶腹癌和胆总管下段癌的诊断价值优于其他检查。78％的病人上腹饱胀／隐痛出现时间早于黄疸1－3月。血清CA19－9值在3／4以上的胰头癌、壶腹癌和胆总管下段癌病人超过正常值。结论：凡有中上腹部饱胀、隐痛、血清CA19－9值升高、胆总管和（或）胰管扩张的病人应有步骤地进行各种影像学检查。超声检查发现胰头部有肿块，宜行CT检查。如未发现肿块，则行ERCP。凡ERCP检查时观察到有肿瘤征象的病人，不宜作胰胆管造影而仅作活检。MRCP可用于胰胆管造影失败的壶腹癌和胆总管下段癌。超声内镜对壶腹周围癌的诊断和鉴别诊断也起重要作用。     

壶腹周围病所致梗阻性黄疸术前诊断的评价

目的 评价彩色多谱勒超声，CT，ERCP对壶腹周围病变所致梗阻性黄疸的诊断价值。方法 86例患者全部经彩色多谱勒超声检查，CT检查34例，ERCP检查24例。结果 彩超、CT、ERCP对胰头癌诊断的准确性分别为92．6％，88．2％和33．3％；对胆总末端及壶腹诊断的准确性分别为58．3％，66．7％和100％；对十二指肠乳头癌的准确性分别为62．5％，20％和100％；对良性病变所致狭窄诊断的准确性分别为27．3％50％和50％。结论 多数壶腹周围病变所致梗阻性黄疸患者，彩,,CT检查足以可以明确病因诊断；ERCP对胰头癌和胆道末端炎性狭窄所致梗阻性黄疸准确率不高，应根据超声、CT检查结果和治疗需要而选择。     

ERCP对壶腹周围癌的早期诊断价值

目的 探讨ERCP对壶腹周围癌的早期诊断价值和合理应用。方法 对我院1997年1月至2002年12月收治的2l例典型的壶腹周围癌患者的临床特点和ERCP检查资料进行回顾性统计分析。结果 所有病例均经剖腹手术和病理检查证实为壶腹周围癌，90．5％的患者出现上腹饱胀不适的时间早于黄疸l～2个月，壶腹周围癌的ERCP直接、间接征象和特征性改变明显。结论 重视壶腹周围癌早期非特异性症状，若B超发现阳性征象，应及时、合理地应用ERCP检查，同时结合CT、MRCP等其他影像学方法以达到早期诊断的目的。     

外科手术治疗345例壶腹周围癌的回顾性分析

目的 总结近年来新的诊断和治疗技术对壶腹周围癌外科手术疗效的影响。方法 回顾性分析１９５８～１９７６年,１９７７～１９８７年、１９８８～１９９８年３个时间段的壶腹周围癌３４５例在我院的手术治疗情况。结果 １９５８～１９７６年的１２８例中,胰头癌、壶腹癌、胆管下端癌及十二指肠癌所占比例分别为６１．７％、２２．６％、１０．２％及５．５％,切除率分别为２７％、８６％、３８％及５７％（４／７）;１９７７～     

Vater壶腹周围恶性肿瘤11例诊治体会

目的总结Vater壶腹周围恶性肿瘤的临床诊治方法。方法2004年1月至2009年9月间,对渐进性无痛性黄疸病人通过B型超声、CT、磁共振胰胆管成像（MRCP）、血清学检查及肿瘤标记物检测,利用经内镜逆行胰胆管造影（ERCP）技术筛选出Vater壶腹周围恶性肿瘤。结果诊断Vater壶腹周围恶性肿瘤11例,其中6例行标准Whipple手术,行姑息减黄术2例,行内镜胆道内支架放置术（ERBD）3例;治疗效果明显,无胰漏、吻合口漏、出血等明显并发症发生。结论ERCP技术在Vater壶腹周围恶性肿瘤的诊治中有其独到的价值,但仍然存在不足之处。     

怎样通过PTC鉴别壶腹周围癌和胆总管下端结石

壶腹周围癌与胆总管下端结石都可出现阻塞性黄疸。由于肠腔积气等原因,B 超常难以鉴别。此时PTC 可提供较可靠的线索。在开始注入造影剂时,就可置病人于头高位。如为结百可见造影剂沿结石与胆管壁之间进入梗阻远端,继而进入肠腔。而壶腹周围癌即使病人直立1小时亦很难使远端显影。这是因为结石与胆管壁不会粘连,造影剂能通过梗阻部位。而壶腹周围癌出现阻塞性黄疸时,胆管壁多已爱到破坏,互相粘连融合,完全闭锁,造影剂很难到达梗阻     

Pancreatic and periampullary carcinoma

During the 10-year period from 1972 to 1981, 179 patients were treated for pancreatic and periampullary carcinoma (40 resections, 91 bypasses, 39 laparotomies and 9 non-operated) in Oulu University Central Hospital. Mortality after resections was 10% and complication rate 33%. In 1977-1981, mortality after resections decreased from 30 to 3% (p less than 0.05) but resectability or survival did not improve. Median survival following resection for pancreatic and periampullary carcinoma was 8 and 34 months (p less than 0.001). The 5-year cumulative survival rate for resected periampullary carcinomas was 42 +/- 16%. We conclude that 5-year survival after resection for periampullary carcinoma is significantly better than after resection for pancreatic carcinoma. The effect of modern imaging techniques on resectability and survival is negligible. Age as such is not a limiting factor for resection. We recommended a prophylactic duodenal bypass is conjunction of biliary diversion for unresectable carcinoma. The acceptable mortality after resection encourages us to continue an aggressive policy in surgical treatment. However, attention should be drawn to a more careful patient selection and proper preparation.     

Postoperative complications and survival after pancreatoduodenectomy in patients aged over 70 years

An analysis of postoperative complications and survival was conducted in 31 patients undergoing pancreatoduodenectomy (PD) for carcinoma of the pancreas or periampullary carcinoma. Of them, 11 were over 70 years of age and 20 were under 70. Anastomotic leakage was the most common complication after PD. Definite pancreatic leakage was found in one patient in the over 70 group, and one case each of pancreatic, biliary, and gastric leakage were found in the under 70 group. All complications were treated conservatively without any further operative intervention. The overall morbidity rate was 41.9% (13/31), being 45.5% (5/11) in the over 70 group and 40.0% (8/20) in the under 70 group, and no operative deaths occurred within 30 days after surgery. The cumulative survival rate of the patients aged over 70 years with carcinoma of the pancreas or periampullary carcinoma did not differ significantly from the rate of those under 70. It was thus concluded that PD achieves an adequate prognosis and survival in patients over 70 years of age.     

Surgical treatment of carcinoma of the hypopharynx and cervical esophagus]

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arose after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 patients underwent surgical exploration (operability rate 59.5%) and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.9%) and palliative in 23 (14.1%). In 33 cases of laryngo-pharyngo-cervical segmentary esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent laryngo-pharyngo-total esophagectomy and the digestive tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus refusing laryngectomy with an hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded with patients operated for carcinoma of the hypopharynx than with patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs 26% and 43% vs 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)     

Combined portal vein and liver resection for carcinoma of the biliary tract

Twenty-nine patients with advanced carcinoma of the bile duct or gallbladder underwent combined portal vein and liver resection. Segmental excision of the portal vein was performed in 16 cases and wedge resection of the vessel wall in 13. The operative mortality rate was 17 per cent. The median survival for the 24 patients who left hospital was 19.8 months. Actuarial survival rates at 1, 3 and 5 years for all 29 patients were 48 per cent, 29 per cent, and 6 per cent respectively, whereas the median survival for 46 patients with unresectable carcinoma was 3 months and the 1 and 3-year actuarial survival rates were 13 per cent and zero respectively. This difference in survival times between patients undergoing hepatectomy with portal vein resection and those with unresectable carcinoma were statistically significant (P less than 0.01). Combined portal vein and liver resection is recommended as a reasonable surgical approach in selected patients with advanced carcinoma of the biliary tract.     

Operative outcome and problems of right hepatic lobectomy with pancreatoduodenectomy for advanced carcinoma of the biliary tract

From 1979 to 1996, 32 patients underwent at least right hepatic lobectomy with pancreatoduodenectomy (right HPD) for advanced carcinoma of the biliary tract at our institute. Twelve of the 32 patients underwent hepatoligamentopancreatoduodenectomy (HLPD). Curative resection was achieved in 20 (63%) of the 32 patients, but the operative outcomes were not satisfactory. Operative deaths occurred in 15 (47%) of the 32 patients, and postoperative complications in 29 (91%). The overall cumulative 1-, 3-, and 5-year survival rates were 12%, 6%, and 3%, respectively. These results suggested that simultaneous hepatectomy of the right lobe and pancreatoduodenectomy is undesirable, especially when accompanied by vascular resection and reconstruction. Since 1997, we have used partial pancreatectomy and partial duodenectomy instead of pancreatoduodenectomy for access to peripancreatic lesions, and this has markedly improved the operative outcome. From 1997 to 2004, 42 patients underwent resection of the right hepatic lobe, extrahepatic bile duct, and other related organs for advanced carcinoma of the biliary tract. There were postoperative complications in 13 (31%), but no operative death occurred. Recent advances in operative procedures and perioperative management may offer greater safety for right HPD, but the appropriate applications of and the necessity for right HPD are still matters of controversy and require further discussion.     

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.     

Surgical management of 552 carcinomas of the extrahepatic bile ducts (gallbladder and periampullary tumors excluded). Results of the French Surgical Association Survey.

Five hundred fifty-two cases of primary carcinoma of the extrahepatic bile ducts (gallbladder and periampullary tumors excluded) collected from 55 surgical centers were reviewed retrospectively. Three hundred seven patients (56%) had upper-third lesions (proximal carcinoma), whereas 71 (13%) and 101 (18%), respectively, had middle-third and lower-third bile duct carcinomas. The remaining patients had diffuse lesions. Resectability rates were 32% for upper-third localization compared to 47% and 51% for middle-third and lower-third localization, respectively. The operative mortality rate for proximal carcinomas was significantly lower with resection (16%) compared with palliative surgery (31%) (p less than 0.05). Overall 1-year survival (operative deaths excluded) was 68% after tumor resection compared to 31% after palliative surgery (p less than 0.001). Long-term results after surgical resection correlated with local and regional extension of the disease. The results of this study show that resection of extrahepatic bile duct carcinomas, particularly in an upper-third localization, often is associated with worthwhile long-term survival.     

Indication for and problems of hepatopancreatoduodenectomy for carcinoma of the biliary tract based on the statistical registry in Japan

Hepatopancreatoduodenectomy (HPD) as radical surgery for advanced carcinoma of the biliary tract was previously eschewed due to the high rate of postoperative complications. However, recently many institutes have performed it due to the improvement of operative procedures, such as hepatectomy and pancreatoenterostomy, and of pre-intra-postoperative management. Four hundred and sixty-five patients undergoing HPD were registered in Japan during the past 10 years, of whom 355 had carcinoma of the gallbladder and 110 carcinoma of the bile duct. The 30-day operative mortality rate was 9.2% (43 patients). The 5-year survival rates according to the Kaplan-Meier method was 18.1% (32 patients). Survival rates of those with ss and se or si gallbladder cancer were 36% and more than 10%, respectively, but that of those with se or si bile duct cancer was less than 6%. Only 3 patients with 16 lymph node metastases survived for more than 5 years. Fewer patients with biliary infiltration survived for more than 5 years compared with those with hepatic infiltration in carcinoma of the gallbladder. For such patients, extended surgery combining so-called total resection of the hepatoduodenal ligament is thought necessary.     

Status of surgical treatment of biliary tract cancer

Complete surgical resection of biliary tract carcinoma remains the best treatment. The Japanese Society of Biliary Surgery has organized a registry project and established a classification of biliary tract carcinoma. We report here the status of biliary surgery in Japan. For hilar bile duct carcinoma, major hepatectomy is needed to increase the resection rate, and total caudate lobectomy is required for curative resection. The 5-year survival rate was 39.1%. Middle and distal bile duct carcinomas were treated with pancreatoduodenectomy (PD) or pylorus-preserving PD (PPPD) or bile duct resection alone. The 5-year survival rate was 44.0%. The treatment of gallbladder carcinoma with pT1 lesions is cholecystectomy. The treatment of pT2 lesions is extended cholecystectomy or various hepatectomy with or without extrahepatic bile duct resection along with lymphadenectomy. Treatment of pT3 and pT4 lesions includes hepatectomy with or without bile duct resection, combined with vascular resection, extended lymphadenectomy, and autonomic nerve dissection. Several groups in Japan have performed hepatopancreatoduodenectomy. The 5-year survival rate of pT1, pT2, pT3, and pT4 were 93.7, 65.1, 27.3, and 13.8%. PD or PPPD is the standard operation for carcinoma of the papilla of Vater. The 5-year survival rate was 57.5%.     

Biliary tract cancer--treatment options

Cancers of the extrahepatic biliary tract are rare, but they pose great problems from diagnostic and therapeutic points of view. Surgical resection offers the only prospect of cure for patients with this type of cancer. The resectability rates vary from 50% for tumours in the lower common bile duct to only 10% for tumours in the upper third. For the first group of patients there is a 5-year survival rate of 20-30% in several reports and for the other 10-15%. The operative mortality is acceptable low. For tumours in the liver hilum a liver resection is recommended. Most patients can only be helped by a by-pass procedure. The operative by-pass procedure carries a significant morbidity and mortality and most patients should be drained by PTC or preferably endoscopically. The effects of radiotherapy and chemotherapy have so far been insignificant. The combined use of intraarterial chemotherapy combined with radiotherapy seems to offer some advantage and this treatment modality must undergo further trials.