胰头肿块型慢性胰腺炎的治疗

胰头肿块型慢性胰腺炎已被视为胰腺癌的癌前病变,并且可以导致胰管、胆管及十二指肠梗阻,其与胰头癌的鉴别诊断困难,然而二者的预后截然不同。因此,胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,以切除病变,缓解疼痛症状,改善病人的生活质量。胰头部肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括胰十二指肠切除术（保留或不保留幽门的Whipple 手术）和保留十二指肠的胰头切除术（Beger手术及其改良术式）。手术方式尽可能采用胰十二指肠切除术,不仅切除了胰头部肿块、解除了胆道、胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;如胰头肿块巨大,行胰十二指肠切除术有极大风险,可考虑行保留十二指肠的胰头切除术。     

胰头部肿块型慢性胰腺炎诊断与治疗

胰头部肿块型慢性胰腺炎从临床表现上很难与胰头癌相鉴别,目前已将发生于胰头部的肿块型慢性胰腺炎视为胰腺癌发生的癌前病变。影像学检查在肿块型慢性胰腺炎诊断中起着重要作用,对于手术指征的掌握、胰头部肿块的可切除性、手术方式的选择以及手术困难程度的估计很有帮助。胰头部肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括胰十二指肠切除术（保留或不保留幽门的Whipple手术）和胰头部分切除加胰管引流术（Frey 手术,Beger 手术）。胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,手术方式尽可能采用胰十二指肠切除术,因为它不仅切除了胰头部肿块、解除了胆道和胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;如胰头肿块巨大,行胰十二指肠切除有极大风险,可考虑行保留十二指肠的胰头切除术。     

胰头肿块型慢性胰腺炎的诊断与治疗

目的：探讨胰头肿块型慢性胰腺炎的诊治方法。方法：对近15年行胰十二指肠切除术并经病理证实的17例胰头肿块型慢性胰腺炎的临床资料进行回顾性分析。结果：本组术前均不能排除胰头癌。17例均行胰十二指肠切除术，术后发生胰漏1例，其余恢复顺利，效果良好。结论：胰头肿块型慢性胰腺炎早期诊断困难，尤其应与胰头癌相鉴别。对不能排除胰头癌或出现顽固性疼痛，胆管、胰管及十二指肠梗阻时，应行胰十二指肠切除术。     

保留十二指肠的胰头切除术的手术要点

1972年Beger首先实施保留十二指肠的胰头切除术(DPRHP)治疗慢性胰腺炎以来[1],由于该术式在切除胰头病变的同时,保留了消化道的完整性,更加符合生理,且创伤较小,提高了术后的生存质量,目前已经成为欧洲国家及日本治疗胰头部良性占位病变的标准术式之一.保留十二指肠的胰头切除术适用于慢性胰腺炎(肿块型)和胰腺的良性疾病(浆液性或黏液性囊性肿瘤、实性假乳头状瘤、胰腺导管内乳头黏液性肿瘤、胰岛细胞瘤靠近胰管无法局部切除者、神经内分泌肿瘤和淋巴上皮囊肿)[2],低度恶性肿瘤不需要淋巴结廓清,也可行保留十二指肠胰头切除,然而囊腺癌是否适合此手术还存在争议.     

慢性胰腺炎的手术方式

对10年来35例慢性胰腺炎的手术治疗进行了回顾,其症状以腹痛为主,影像学表现可分为胰头肿块型,胰腺弥漫性炎症型,左半侧胰腺炎三型。手术方式分为胰腺肿块切除和胰腺单纯引流两种类型。对肿块型和胰头癌的鉴别进行了讨论,并介绍一种新的保留十二指肠的胰头全切除术。     

胰头占位性病变的诊断与治疗

目的 总结胰头占位性病变的诊断与治疗经验.方法 回顾性分析2011年1月至2014年4月中国医科大学附属第一医院收治的247例胰头占位性病变患者的临床资料.术前均行胰腺增强CT和(或)胰腺MRI等影像学检查.血清学检查包括AFP、CA19-9、CA125、CEA,对于怀疑自身免疫性胰腺炎的患者检查血清IgG4.临床诊断为胰头癌、胰头肿块、肿块型胰腺炎的患者行术中病理学检查.胰头癌根据肿瘤的分期及浸润程度选择胰十二指肠切除术、扩大的胰十二指肠切除术或胆肠吻合和(或)胃肠吻合术.肿块型慢性胰腺炎在患者及家属充分了解并同意的前提下选择行保留十二指肠的胰头切除术或胰十二指肠切除术.胰腺良性及低度恶性肿瘤应在肿瘤完整切除的基础上尽量保留肿瘤周围的组织和器官,行个体化治疗.结果 胰头实性占位性病变194例,其中胰头癌125例、胰头肿块45例、肿块型慢性胰腺炎9例、自身免疫性胰腺炎11例,胰岛素瘤4例;胰头囊性占位性病变53例,其中黏液性囊腺瘤12例、浆液性囊腺瘤8例、胰腺囊肿17例、实性假乳头状瘤12例、导管内乳头状黏液瘤4例.病理学检查确诊胰腺癌的71例患者术前肿瘤系列检查阳性率分别为:AFP为7.0％ (5/71)、CA19-9为94.4％ (67/71)、CA125为42.3％(30/71)、CEA为0.12例肿块型慢性胰腺炎肿瘤系列检查阳性率分别为:AFP为1/12、CA19-9为4/12、CA125为1/12、CEA为0.119例患者进行手术治疗获得病理学诊断,其中胰头癌71例、肿块型慢性胰腺炎7例、胰岛素瘤4例、胰腺结核1例,黏液性囊腺瘤8例、浆液性囊腺瘤4例、胰腺假性囊肿6例、巨大淋巴管瘤1例、淋巴上皮囊肿1例、实性假乳头状瘤12例、导管内乳头状黏液瘤4例.247例胰头占位性病变患者中,61例行胰十二指肠切除术,4例行保留十二指肠的胰头切除术,4例行胰头、胰颈部切除术,2例行钩突部分切除术,9例行肿瘤摘除术,38例行胆肠吻合和(或)胃肠吻合术,22例行ERCP+内支架治疗,18例行PTCD+内支架治疗,1例行剖腹探查,88例未行治疗.结论 胰头占位性病变的临床诊断及鉴别诊断主要依靠病史、临床表现、实验室检查及超声、CT、MRI检查.根据肿瘤性质、疾病种类个体化制订手术方案,对胰头良性及低度恶性的肿瘤应行个体化治疗,在肿瘤完整切除的基础上尽量保留肿瘤周围的组织和器官,术中病理学诊断有利于手术方案的选择.     

胰头结石的手术方式选择(附12例报告)

目的:探讨治疗胰头结石的手术方式选择。方法:回顾分析2002年至2011年我院收治的12例胰头结石病人的临床资料,并结合复习有关文献。结果:12例病人均伴有慢性胰腺炎,1例伴有胰头癌,3例伴有糖尿病。12例病人均行手术,其中行胰管切开取石、胰管空肠吻合术7例,胰十二指肠切除术3例,保留十二指肠的胰头切除术2例。结论:胰头结石手术治疗方法应根据具体情况采取不同的手术方式,对胰头部胰管结石的年轻病人可考虑行保留十二指肠的胰头切除术。     

胰头肿块型慢性胰腺炎

胰头肿块慢性胰腺炎术前易误诊为胰头癌,术中发现胰头部肿块,行胰十二指肠切除,经标本病理检查方确诊为慢性胰腺炎.我院于1990年1月～1997年5月曾对术前疑诊为胰头癌134例进行了手术切除,标本病理检查确诊15例为慢性胰腺炎,列为术前误诊病例.由于胰头肿块型慢性胰腺炎的临床表现与胰头癌有许多相似之处.给两者的鉴别诊断带来了不少困难,经病例分析下列病情有助于胰头肿块型慢性胰腺炎的诊断:1.发病年龄较轻,本组的平均年龄较胰头癌低11岁(44.2:59.4岁);2.黄疸程度较浅,血清胆红素低于170μmol/L,经内科治疗可以减退;3.入院前病期较长,平均为17.2个月,而胰头癌为2.2个月;4CA19-9测定,凡CA19-9值     

胰头肿块型慢性胰腺炎8例报道

目的分析胰头肿块型慢性胰腺炎与胰头癌的鉴别诊断,并选择有效的手术治疗方法。方法回顾性分析我院2008年1月至2014年1月期间8例胰头肿块型慢性胰腺炎患者的临床病理资料。患者术前行血液肿瘤标志物等检测,肝胆胰彩色多普勒超声、CT强化、MRI、MRCP等影像学检查。结果 8例患者中有长期饮酒或酗酒史4例,既往急性胰腺炎病史5例,慢性胆囊炎病史3例,胆囊结石2例。主要症状为不同程度的黄疸6例和左上腹疼痛5例。术前血清化验高血糖4例,胆红素持续性增高6例,CA19-9增高5例,CEA增高2例(同时CA19-9增高)。影像学检查均提示胰头部肿块。行标准的胰十二指肠切除术6例,保留十二指肠的胰头切除术2例。8例患者术中均行细针穿刺多点细胞学检查提示慢性胰腺炎变化,术后病理均为慢性胰腺炎。术前CA19-9、CEA单独或共同升高患者于术后1周复查CA19-9、CEA均降至正常水平。所有患者术后均未出现胰漏、胆汁漏等严重并发症,黄疸和腹痛均缓解。1例保留十二指肠的胰头切除术后3个月出现间断性呕吐,上消化道造影显示十二指肠重度狭窄,再次手术探查发现十二指肠挛缩,以降段明显,行胃空肠吻合,症状缓解。患者术后定期门诊复查率为100%,随访时间1~6年,所有患者均未出现肿块复发、黄疸、腹痛等。结论胰头肿块型慢性胰腺炎和胰头癌患者虽均以黄疸和腹痛为主要症状,但其特点不同,前者轻微、波动性、间歇性,后者持续并渐进性加重;了解既往病史对鉴别二者有一定意义;CA19-9、CEA作为鉴别胰头肿块型慢性胰腺炎与胰头癌意义不大,对胰头肿块型慢性胰腺炎患者术中行胰头部肿块细针多点穿刺活检,首选保留十二指肠胰头切除术,胰头肿块与周围血管粘连重呈浸润性改变患者需行胰十二指肠切除术。     

慢性胰腺炎合并胰管结石的外科治疗

目的 探讨慢性胰腺炎合并胰管结石的外科治疗方法.方法 回顾性分析66例慢性胰腺炎合并胰管结石患者的临床资料,将其分为4型:Ⅰ型28例分布在胰头部;Ⅱ型30例在胰体部;Ⅲ型1例在胰尾部;Ⅳ型7例在胰头、胰体、胰尾部主胰管.10例(Ⅰ型4例,Ⅱ型5例,Ⅳ型1例)经镇痛、抑酸、应用生长抑素、抗感染等治疗.10例(Ⅰ型)行内镜取石术.Ⅰ型14例行胰头十二指肠切除术和保留十二指肠胰头部分切除术;Ⅱ型25例行胰管切开取石+胰管空肠吻合术;Ⅲ型1例行胰尾部+脾切除术;Ⅳ型6例行Puestow-Gillesby和胰颈部离断+胰管探查取石+胰管两断端空肠Roux-en-Y吻合术.结果 62例随访2个月至15年,Ⅰ型术后结石复发4例,Ⅱ型2例,Ⅲ型0例,Ⅳ型3例.结论 慢性胰腺炎合并胰管结石确诊后应争取早日手术治疗,根据结石分布范围选择相应的治疗方式.正确的术前及术中诊断、分型及个体化处理在预防慢性胰腺炎合并胰管结石外科治疗后结石复发中有重要意义.     

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??Diagnosis and treatment of chronic pancreatitis with mass in the head of the pancreas ZHANG Zhong-tao, YIN Jie.Department of General Surgery, Beijing Friendship Hospital Affiliated to Capital University of Medical Sciences, Beijing 100050, China Corresponding author: ZHANG Zhong-tao, E-mail: zhangzht@medmail. com.cn Abstract Chronic pancreatitis (CP) with mass and pancreatic cancer are difficult to identify from the Clinical performance. At present, we have the CP with mass as a precancerous lesion of pancreatic cancer. Imaging methods in the diagnosis of the CP with mass plays an important role, which is very helpful for the Indications for surgery of the hands, of resectable pancreatic head tumor, and surgical options, as well as estimates of the difficulty of the surgery. Surgical strategy in CP with mass has been directed at the pancreatic head with a variety of tactics including pancreatoduodenectomy(Whipple procedure with or without pylorus preservation) and partial resection of the pancreatic duct drainage(Frey operation, Beger operation ). Once the diagnosis of the CP with mass should be clear that the surgical treatment, pancreatoduodenectomy is preformed in the treatment of CP with mass, not only resection of the pancreatic head mass, the lifting of the bile duct and pancreatic duct and obstruction of the duodenum, but also in addition to the potential causes of pancreatic cancer. Pancreatoduodenectomy is great risk When the great mass of pancreatic head, but the partial head resection can be accomplished with relative safety.     

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??Treatment of Chronic pancreatitis(CP) with an inflammatory mass ZHANG Zhong-tao,YIN Jie. Beijing Friendship Hospital,Capital Medical University,Beijing100050,China
Corresponding author: ZHANG Zhong-tao,E-mail: zhangzht@medmail.com.cn
Abstract Chronic pancreatitis(CP) with an inflammatory mass has been thought of as a precancerous lesion of pancreatic cancer, and it can lead to obstruction of the pancreatic duct, bile duct and duodenum. The CP with mass and pancreatic cancer are difficult to identify from clinical performance, and their prognosis are very different. Once CP with mass has been diagnosed it should be clear that surgical treatment is necessary in order to remove the focus, ease pain, and improve the patient's quality of life. Surgical strategy in CP with mass has been directed at the pancreatic head with a variety of tactics including pancreatoduodenectomy (Whipple procedure with or without pylorus preservation) and duodenum-preserving resection of the pancreatic head (Beger operation and other operations). Pancreatoduodenectomy is preformed in the treatment of CP with mass, not only resection of the pancreatic head mass, lifting the obstruction of the pancreatic duct, bile duct and duodenum, but also removing the potential causes of pancreatic cancer. Pancreatoduodenectomy is a great risk When the pancreatic head mass is large, but the partial head resection can be accomplished with relative safety.     

Familial pancreatic cancer: report of one Japanese family

Most familial pancreatic carcinomas have been reported from European countries and the United States, and there has been only one report from Japan. A 50-year-old Japanese woman presented with a pancreatic head mass and underwent pylorus-preserving pancreatoduodenectomy with portal vein resection. The histological diagnosis was well-differentiated adenocarcinoma of the head of the pancreas. Her mother died of pancreatic head carcinoma, which had been shown on computed tomography at the age of 70 years. One of her uncles on her fathers side had had pancreatic tail carcinoma, and at the age of 59, had undergone distal pancreatectomy, splenectomy, wedge resection of the liver, and partial resection of the colon. The histological diagnosis was moderately differentiated tubular adenocarcinoma of the pancreas. He had had a subtotal gastrectomy for early gastric cancer (tubular adenocarcinoma limited to the mucosa) at the age of 53. He died of recurrence of the pancreatic tail carcinoma 3 months after the distal pancreatectomy had been performed. This communication reports a second Japanese family with familial pancreatic cancer, as shown by pancreatic carcinomas in two first-degree relatives and in one third-degree relative.     

Preservation of the pylorus in resection of the head of the pancreas

Whipple's pancreatoduodenectomy was the standard operation for diseases of the head of the pancreas for more than 40 years, but the results were vitiated in part by poor gastrointestinal function and malnutrition. Reintroduced in 1978, pylorus-preserving proximal pancreatoduodenectomy (PPPP) has had an increasing impact on pancreatic surgery as its benefits have been recognized: improved nutritional status, decreased incidence of postgastrectomy syndromes, and a technically easier operation. Postoperative mortality rates and 5-year survival rates are comparable with those of the classic Whipple procedure. PPPP is indicated for most patients with chronic pancreatitis of the pancreatic head. It is also appropriate for patients with periampullary cancer and for those with pancreatic cancer arising from the lower part of ‘the head and the uncinate process. More than 650 patients have now undergone PPPP: 31% for chronic pancreatitis and 66% for periampullary and pancreatic cancers. We assess the indications for PPPP, outline the operation, and review the results.     

Uncinatectomy: a novel surgical option for the management of intraductal papillary mucinous tumors of the pancreas

An intraductal papillary mucinous tumor (IPMT) is a rare cystic lesion of the pancreas, comprising only 1% of all pancreatic exocrine neoplasms. The prognosis for these lesions is typically favorable as compared with invasive ductal carcinomas. Nevertheless, the management of IPMTs involves surgical resection due to their malignant potential. When located in the pancreatic head, the conventional treatment for IPMT is pancreatoduodenectomy. Some authors have advocated limited pancreatectomy for low-grade IPMTs of the pancreas, thereby decreasing the morbidity of more extensive resection. In this report, we describe our technique of minimal pancreatectomy, whereby the uncinate process and associated branch duct were completely extirpated while preserving remainder of the pancreatic head, duodenum, and pancreatic ducts. The case presented underscores the feasibility and advantages of minimal pancreatic resection in the management of such tumors.     

Current standards of surgery for pancreatic cancer

BACKGROUND: Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade. METHODS: An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years. RESULTS: Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85-90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival. CONCLUSION: The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.     

Carcinoma of the pancreatic head

Focusing mainly on invasive ductal carcinoma of the pancreas, the history of radical surgery for this type of cancer is reviewed, including pancreatoduodenectomy, total pancreatectomy, extended radical surgery with main vascular resection and extended lymphadenectomy/retroperitoneal soft-tissue clearance, pylorus-preserving pancreaticoduodenectomy. In addition, duodenum-preserving pancreatic head resection, which has recently attracted attention in this field, as an operative technique for less-malignant, noninvasive intraductal papillary adenocarcinoma is also reviewed.     

The impact of pylorus-preserving pancreatoduodenectomy on surgical treatment for cancer of the pancreatic head

Pylorus-preserving pancreatoduodenectomy (PPPD) was reintroduced in 1978. This pylorus-preserving modification was designed to minimize complications related to gastric resection, such as early satiety, marginal ulceration, and bile reflux gastritis, as well as diarrhea and dumping. Since 1978, PPPD has been performed preferentially for benign and malignant diseases of the periampullary region and pancreatic head. Some groups have argued against PPPD for cancer of the pancreatic head, because the pylorus-preserving procedure is likely to compromise the field of resection and does not allow lymph node dissection of the peripyloric and perigastric groups. However, comparative survival rates after PPPD have been the same as, or better than, those with classic pancreatoduodenectomy, showing the rationale for PPPD as a radical resection procedure for cancer of the pancreatic head. PPPD can be performed with low mortality. Delayed gastric emptying, which is the most common complication in the immediate postoperative period after PPPD, is always transient. Many investigators have shown that body weight and the majority of nutritional parameters are better than after PD. PPPD does not appear to cause any negative outcomes. We conclude that PPPD is the surgical procedure of choice for cancer of the head of the pancreas. Received: April 13, 2001 / Accepted: June 6, 2001     

Stomach saving duodenopancreatectomy. Indications and contraindications. The most important surgical steps

Discussion on pylorus-preserving pancreatoduodenectomy (PPPD) in case of ductal adenocarcinoma is controversal. Aim of the present study was the comparison of survival in patients resected by the classic Whipple operation (Whipple) or the pylorus-preserving procedure. From April 1986 to June 1998 all patients operated for proven diagnosis of ductal pancreatic cancer were documented prospectively concerning patient's characteristics, kind of surgery, complications and histopathological staging according to the UICC-classification of 1992. During the observation period 100 patients underwent pancreatoduodenectomy, 38 cases as Whipple, 62 as PPPD. Average of age was 59.9 +/- 10.3 years without significant differences. Mortality was 6.0% in total, 5.5% post Whipple, and 6.5% post PPPD. Eighty-three percent of the resected specimen were node positive. The median survival time was 9.9 and 10.5 months, 5-year survival 2.6% and 10%, respectively without significant differences. Actually, only node positive patients reached 5-year survival. Even better survival figures following PPPD than after classic Whipple procedure make the pylorus-preserving procedure the standard operation in ductal cancer of the pancreatic head. Distal gastric resection is only mandatory in case of tumor involvement of the duodenopancreatic angle. Since only node negative cases survived 5 years, extensive surgery exceeding anatomical pancreatic head resection does not appear to be beneficial.