胰管结石合并胰腺癌的诊治分析(附9例报道)

目的总结胰管结石合并胰腺癌的诊治经验。方法回顾性分析2005年1月至2015年12月期间中山大学孙逸仙纪念医院收治的9例胰管结石合并胰腺癌患者的临床资料,总结其临床特征、影像学诊断方法和手术方式。结果 9例胰管结石合并胰腺癌患者中,4例行B超联合CT血管造影(CTA),均诊断为胰管结石合并胰腺癌;4例行磁共振胰胆管造影/磁共振血管显像(MRCP/MRA),3例考虑胰管结石合并胰腺癌;3例行经内镜逆行性胰胆管造影(ERCP),均诊断为胰腺癌。所有患者均行手术治疗,包括胰十二指肠切除术4例,胰体尾及脾切除术3例,胰管切开取石、远端胰管空肠吻合术1例,腹腔镜探查、活检术1例。术后无死亡病例,发生应激性溃疡出血1例,B级胰瘘1例。所有患者均获访,随访时间5~36个月,中位数为13个月。随访期间死亡7例,5例生存时间超过1年,2例生存时间超过3年。结论对于反复发作的胰管结石患者应该警惕合并胰腺癌的可能,CT和MRCP均可作为该病的进一步检查方法;影像学检查发现胰腺肿物、无手术禁忌证时,均应积极行手术治疗,推荐行标准的胰十二指肠切除或胰体尾切除术。     

胰管结石40例诊治体会

目的探讨胰管结石合理的分型及个体化治疗方式。方法回顾性分析2004年10月至2014年5月我院收治的40例胰管结石患者的临床资料,男性20例,女性20例,平均年龄(37±12)岁。所有患者均术前确诊,其中确诊率B超88.6%(31/35),CT为77.4%(24/31),MRCP为92.6%(25/27)。手术治疗27例,内镜治疗13例,采用陈勇军等提出的胰管结石分型对其分型。结果根据结石的位置、胰管有无狭窄及术中探查结果,将胰管结石分为3型:Ⅰ型16例,胰管结石位于主胰管,7例行胰管切开取石+胰管空肠Roux-en-Y吻合,9例行ERCP取石,其中6例ERCP取石+支架,3例ERCP取石+ENPD;Ⅱ型20例,胰管结石位于主胰管和分支胰管,均行胰管切开取石+胰管空肠Roux-en-Y吻合,合并胰尾切除1例,胰十二指肠切除1例,Frey手术1例;Ⅲ型4例,胰管结石位于分支胰管,主要行ERCP胰管支架引流。全组无死亡病例,术后胰瘘1例(3.7%),内镜治疗后急性胰腺炎1例(7.7%),结石残留8例(20%),4例Ⅱ型结石,4例为分支胰管结石。38例获得随访,至今生存,疼痛症状均明显缓解。结论胰管结石处理复杂,正确的分型对其个体化治疗具有重要意义,胰管切开取石+胰管空肠Roux-en-Y吻合仍是外科治疗首选手术方式,内镜技术已然成为一种重要的治疗手段。     

胰管结石诊治体会(附29例报告)

目的探讨胰管结石的诊断与治疗。方法回顾性分析29例胰管结石的临床资料。结果21例有慢性胰腺炎病史,其中12例有胆道结石,合并胰腺癌2例,B超诊断正确率89.7%(26/29),CT诊断正确率65.0%(13/20),内镜逆行性胆管胰管造影术及磁共振胰胆管成像诊断正确率均为100%(6/6及4/4)。行内镜下括约肌切开术取石6例,胰管切开取石、胰管空肠Roux-en-Y吻合术16例,十二指肠乳头成形、胰石取出术3例,胰管切开取石、胰腺假性囊肿空肠Roux-en-Y吻合2例,胰头十二指肠切除1例,剖腹探查术1例。结论慢性胰腺炎、胆石症是形成胰管结石的主要原因,影像学检查是术前诊断的主要方法,胰管切开取石、胰管空肠吻合是胰管结石主要手术方式。     

胰管结石合并胰腺癌的诊断及外科治疗

目的提高胰管结石合并胰腺癌的术前诊断率及外科治疗水平。方法回顾性分析1989年1月至2009年1月经外科治疗的胰管结石合并胰腺癌患者16例的临床资料,总结临床特征、影像学诊断和手术方式。结果胰管结石合并胰腺癌时,癌肿均发生于含结石胰管处。术前影像学诊断确诊率不高,B超、CT、内镜胰胆管造影(ERCP)和磁共振成像/磁共振胰胆管成像(MRI/MPCP)对本病的确诊率分别为31.2%(5/16)、68.8%(11/16)、66.7%(4/6)及60.0%(3/5)。16例患者均行手术治疗,无一例死亡,术后均获得随访3个月至6.5年,其1、3、5年生存率分别为62.5%(10/16)、18.8%(3/16)及6.2%(1/16)。手术切除和肿瘤分化程度是影响预后重要因素。结论长期胰管结石反复发作是引起胰腺癌发生的重要原因;多种影像学联合检查及术中探查有助于提高胰管结石合并胰腺癌的确诊率;根治性手术是唯一可治Ⅹ本病的方法 。     

胰管结石的分型及手术治疗

目的：探讨胰管结石的分型及手术方法。方法对8例行手术治疗的胰管结石合并慢性胰腺炎或胰腺癌患者病历资料进行分析。8例患者术前均行腹部B超、上腹部CT平扫＋增强或磁共振胆胰管水成像（MRCP）检查以明确诊断。其中Ⅰ型2例,采用胰头十二指肠切除术;Ⅱ型1例,采用胰尾切除＋脾切除＋胰管空肠吻合术;Ⅲ型5例,采用胰管切开取石并胰管空肠吻合术。结果8例均成功手术,1例术后并发胰漏,经非手术治疗后好转;5例糖尿病患者术后3例血糖恢复正常。结论胰管结石发病率虽然不高,但常合并胰腺炎、糖尿病甚至胰腺癌,后果严重,依胰管结石部位分型并选择合理的手术方法极为重要。     

慢性胰腺炎合并胰管结石11例的诊治经验

目的 探讨慢性胰腺炎合并胰管结石的诊断与治疗。方法 对1996—2002年间11例慢性胰腺炎合并胰管结石患者的临床资料进行回顾性分析。结果 腹痛、腰背痛、内、外分泌功能障碍是慢性胰腺炎合并胰管结石的常见症状，B超、CT、逆行胰胆管造影检查均可明确诊断。本组中9例行胰管空肠引流术，1例合并胰头癌行胰十二指肠切除术，1例胰尾切除术，10例术后腹痛消失。结论 B型超声可作为胰管结石的首选检查方法；胰管切开取石和胰管空肠引流为胰管结石的合理术式；胰管结石易合并胰腺癌，应加以重视。     

胰管结石的分型及外科治疗方式的选择

目的 探讨胰管结石的分型方法,并根据分型选择合理的外科治疗方式.方法 回顾性分析2000年1月至2010年12月89例接受手术治疗的胰管结石患者,男性57例,女性32例,平均年龄(52±23)岁.所有患者都经磁共振胰胆管成像确诊,根据结石的位置、胰管有无狭窄,将胰管结石分为3型:Ⅰ型43例,胰石位于主胰管,主要采用内镜取石或胰管切开取石+胰管空肠吻合术；Ⅱ型39例,胰石同时位于主胰管和分支胰管,主要采用胰管切开取石+胰管空肠吻合术和(或)胰腺区段切除；Ⅲ型7例,结石位于分支胰管,主要采用胰腺区段切除.结果 全组病例手术均获得成功,术后胰漏6例(6.7％),经非手术治疗后痊愈；吻合口出血2例(2.2％),其中1例死亡；结石残留6例(6.7％),均为分支胰管结石残留.78例获得随访,57例生存至今；5例患者有间隙性腹痛需要内科治疗,7例患糖尿病(2例为胰腺次全切除,5例为胰体尾切除),结石复发5例,其中3例行第2次手术.结论 根据结石在胰管内而不是在胰腺实质的部位提出的胰管结石分型方式,对于以“取尽结石并保留胰腺功能”为原则的胰管结石外科治疗具有一定的指导价值.     

胰管结石的诊断和外科治疗

目的探讨胰管结石的诊断和外科治疗的方法及疗效。方法回顾性分析 19例胰管结石患者的临床资料。结果胰管结石患者临床上均以上腹部疼痛为主要首发症状且合并慢性胰腺炎 ,其中 6例并发胰腺癌。经B超检查 19例中有 15例发现有胰管结石或胰管扩张 ,内窥镜逆行胰胆管造影检查 9例 ,CT检查 8例。行胰管切开取石 ,胰管 空肠Roux en Y吻合 12例 ,胰头十二指肠切除 4例 ,胰管切开取石及胰体尾切除 3例。随访发现 6例并发胰腺癌者于术后 9～ 2 6个月死亡。术后腹痛完全缓解 11例 ,1例部分缓解 ,1例结石复发 ,症状无缓解。结论B超、CT及内窥镜逆行胰胆管造影是诊断胰管结石最主要的手段。手术治疗方式的选择主要取决于以下 3个方面 :(1)胰管结石的部位 ;(2 )主胰管有无狭窄 ;(3)是否合并胰腺癌。     

胰管结石合并胰腺癌10例诊治回顾分析

目的 探讨胰管结石与胰腺癌的关系以及胰管结石伴发胰腺癌的临床特点、诊断及治疗.方法 回顾性总结分析1992年3月至2007年9月期间我院收治的10例胰管结石合并胰腺癌患者的临床资料.结果 本组病例多以上腹部疼痛为首发症状(8/10),缺乏特异性症状; B型超声和CT诊断阳性者分别为4例(4/10)和6例(6/10),ERCP诊断阳性者为5例(5/5); 术前确诊7例(7/10),疑诊2例,漏诊1例.10例患者中8例行胰十二指肠切除术,1例行活检术,1例由于漏诊行胰管切开取石、胰管空肠吻合术.结论 多种诊断方法联合应用可提高胰管结石合并胰腺癌诊断的准确率,但目前该病的术前诊断阳性率不高,应常规行术中病理学检查; 其首选术式为胰十二指肠切除术.     

胰管结石的诊断和外科治疗

目的 探讨胰管结石的诊断和外科治疗措施.方法 回顾性分析2004年至2008年湖北省十堰市郧阳医学院太和医院手术治疗的22例胰管结石患者的临床资料,探讨该病的诊断和治疗方法.结果 B超检查的阳性率为77%(17/22),CT检查为89%(17/19),MRCP检查(3/3)和ERCP检查(5/5)均为100%.6例采用胰十二指肠切除术,14例采用胰管切开取石+胰管空肠吻合术,2例采用胰尾切除术.全组2例确诊胰腺癌,无手术死亡,3例出现手术并发症.21例患者术后腹痛症状有不同程度缓解,1例腹泻加重,血糖增高;3例患者结石复发.结论 联合影像学检查对胰管结石的诊断和指导治疗具有重要作用;本病仍以手术治疗为主,手术方式根据结石位置和是否合并胰腺肿瘤决定.     

磁共振胰胆管成像与经内镜逆行胰胆管造影对胆胰疾病诊断价值的比较研究

目的 评价磁共振胰胆管成像(MRCP)与经内镜逆行胰胆管造影(ERCP)对胆胰疾病的诊断价值.方法 对134例怀疑为胆胰管疾病病人行MRCP,并与58例ERCP比较,所有病例均经手术病理证实.结果 134例MRCP均获成功,在行ERCP中54例成功,4例失败者改行PTC检查成功.MRCP和ERCP总的诊断准确率分别为90.3%和88.9%.结论 MRCP对胆胰系统疾病中恶性梗阻所致的梗阻性黄疸诊断准确性较高,对胆总管、肝内胆管较小结石的诊断不如ERCP敏感及准确,而且不能治疗,提示MRCP和ERCP各有优越点,二者合理应用可提高胆胰系统疾病的诊断符合率.     

MRCP与ERCP对胆胰系疾病诊断价值比较

目的评价磁共振胰胆管显影(MRCP)与经内镜逆行胰胆管造影(ERCP)对胆胰系疾病的诊断价值. 方法 40例疑有胆胰系疾病患者均行MRCP和ERCP检查,比较两者结果. 结果 40例MRCP、ERCP胰管、胆管均显影.MRCP敏感度87%(34/39),特异度100%(1/1),准确度88%(35/40);ERCP敏感度100%(39/39),特异度100%(1/1),准确度100%(40/40).两者相比较,统计学上无差异. 结论 ERCP和MRCP诊断胆胰系疾病准确率无差异,但在明确梗阻性黄疸病因方面,目前MRCP尚不能取代ERCP.     

B超、磁共振胆胰管成像、内镜逆行胰胆管造影术在诊断胆总管结石中的价值

目的 探讨B超、磁共振胆胰管成像(MRCP)、内镜逆行胰胆管造影术(ERCP)在胆总管结石诊断中的价值.方法 收集2005年8月至2007年10月怀疑为胆总管结石且同时行B超、MRCP、ERCP的患者384例,对3种检查方法 进行比较分析.结果 384例患者中,最后经ERCP确诊胆总管结石者370例;B超诊断胆总管结石者268例,其中8例为假阳性,诊断准确率为70.3%(260/370);MRCP诊断362例,其中6例为假阳性,诊断准确率96.2%(356/370).有7例患者MRCP发现有胆总管结石和胆总管扩张,ERCP造影仅发现胆总管扩张,但在用取石网篮和取石气囊清理胆道时取出小结石.结论 B超对于胆总管结石的诊断具有一定的准确率,可作为最基本的检查手段,MRCP和ERCP对于胆总管结石的诊断具有较高的一致性,MRCP可部分替代诊断性ERCP,联合应用MRCP和ERCP可提高胆管结石诊断准确率.     

NMR cholangiography in the diagnostic algorithm of candidates to video laparocholecystectomy

BACKGROUND: High resolution magnetic resonance cholangiopancreatography (MRCP) is a non invasive imaging modality for depicting the pancreatobiliary tree. It can demonstrate dilation, stenosis and intraductal filling defects of both the biliary and the pancreatic duct. The imaging quality of high resolution MRCP is excellent. MRCP appears to be more effective and less invasive than endoscopic retrograde cholangiopancreatography (ERCP) to evaluate many pancreatic and biliary diseases as choledocholithiasis, malignant obstruction, incomplete or failed ERCP, postsurgical alterations of the biliary tract (as biliary-enteric anastomoses), sclerosing cholangitis, chronic pancreatitis, and congenital anomalies of the biliary and pancreatic duct. METHODS: MRCP was performed in 21 non selected patients with suspected choledocholithiasis and demonstrated the presence of stones in the biliary tract in 5 of them. In these 5 patients sequential endoscopic-laparoscopic treatment was performed and confirmed in all cases the presence of stones in the biliary tree. Laparoscopic cholecystectomy (VLC) and transcystic cholangiography was attempted in the restant 16 patients. RESULTS: Laparoscopic transcystic cholangiography confirmed in all cases the response of MRCP. CONCLUSIONS: MRCP has the potential to replace ERCP in the management of patients candidate to VLC with suspected choledocholithiasis.     

Diagnosis and treatment of gallbladder and common bile duct stones: our experience

AIM: The aim of this study was to verify the possibility to identify and treat common bile duct (CBD) stones by means of preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) with a reduction of postoperative complications. METHODS: We have carried out a retrospective monocenter analysis of 104 consecutive patients who underwent a laparoscopic or open cholecystectomy performed by a single surgeon at the VII Division of General Surgery, Second University of Naples, between 2002 and 2006. Before the operation, we have performed highly selective studies like MRCP and ERCP to identify and treat CBD stones in patients affected by pancreatitis, jaundice, high liver function tests or in case of common bile duct dilation at the US examination, without intraoperative cholangiography. RESULTS: Of 104 patients with indication for a cholecystectomy, 22 patients (21.2%) presented high levels of cholestasis tests; 13 patients (12.5%) presented common bile duct dilation at the US examination (>6 mm diameter). Both groups underwent a MRCP which was positive in 8 patients (7.7%), confirming the diagnosis of common bile duct stones. For these reasons we removed CBD stones using preoperative ERCP. CONCLUSION: Preoperative ERCP and RMCP, without intraoperative cholangiography, is not associated with a significant increase in morbility/mortality associated with CBD stones before surgical treatment.     

Magnetic resonance cholangiopancreaticography as a diagnostic tool for common bile duct stones: a comparison with ERCP and clinical follow-up

BACKGROUND/AIMS: The diagnostic potential of magnetic resonance cholangiopancreaticography (MRCP) has improved as a result of evolving technique. MRCP has the advantage of negligible morbidity and mortality in contrast to endoscopic retrograde cholangiopancreatography (ERCP). This study was performed to evaluate MRCP as a replacement for diagnostic ERCP for the suspicion of common bile duct (CBD) stones. METHODS: From 1998 to 2001, MRCP was performed in 202 patients with a suspicion of CBD stones based on medical history (MH), cholestatic liver function tests (CL), both MH and CL or other reasons. ERCP was performed in all patients where MRCP indicated the presence of CBD stones and in those patients with a persistent strong clinical suspicion for CBD stones despite a negative MRCP. RESULTS: In 25 patients, MRCP suggested CBD stones which were proven with ERCP in 24 patients. Despite a negative MRCP, 27 patients had a subsequent ERCP. None of these patients appeared to have CBD stones. In this group, MRCP resulted in 100% sensitivity and 96% specificity in detecting CBD stones. Follow-up of all patients revealed 5 more patients with persistent clinical suspicion or cholestatic liver function values. Assuming CBD stones in these patients, MRCP had a sensitivity of 83 % and a specificity of 99% for this diagnosis. CONCLUSION: In the case of CBD stone suspicion, MRCP should be the diagnostic procedure of choice.     

腹腔镜、内镜在Mirizzi综合征I型患者中的应用(附11例报告)

目的探讨腹腔镜、内镜等微创技术在Mirizzi综合征(MS)Csendes I型患者"个体化诊疗"中的应用。 方法纳入成都中医药大学附属医院2013年11月至2015年12月施行腹腔镜胆囊切除术(LC)的患者900余例,进行回顾性分析。对病史中有黄疸、生化检查提示血胆红素升高和超声检查提示胆囊结石且肝总管或胆总管直径大于0.8 cm的患者,术前全部进行MRCP及ERCP,发现符合MS的患者24例,占同期LC患者的2.7%(24/900)。将其中Csendes I型11例纳入本研究,分析其临床特征及诊治特点。 结果11例Csendes I型患者中,Csendes Ia型6例,3例合并继发性胆总管结石,其中2例发生急性胆管炎;Csendes Ib型5例,2例合并继发性胆总管结石,其中1例发生急性胆管炎。所有患者行ERCP时一并清除胆总管内取石,留置ENBD管引流胆道,以改善肝功能。11例患者在ERCP后3～7 d成功施行了LC,仅1例Ia型患者胆囊管结石嵌顿,于LC中中转开腹,经胆囊管行胆道镜下的碎石取石。 结论怀疑MS的患者应行MRCP和ERCP,采用Csendes(1989,2008)标准进行准确分型,以便对肝外胆道的受损程度进行评估、合理抉择治疗策略。Csendes Ia型和Ib型患者均可行LC,但术中应利用胆道镜进行胆囊管探查及碎石取石,尽可能避免胆道探查,以防止医源性胆管狭窄。     

Efficacy of magnetic resonance cholangiopancreatography in detecting common bile duct lithiasis: our experience

It has been shown that magnetic resonance cholangiopancreatography (MRCP) has a diagnostic accuracy comparable to that of ERCP. The aim of this study was to compare the diagnostic accuracy of MRCP in patients with suspected choledocholithiasis, but with negative ultrasonography findings. Among 404 patients undergoing videolaparocholecystectomy for cholelithiasis, 48 with risk factors for coledocholithiasis were evaluated. All the patients with risk factors underwent preoperative hepatobiliary ultrasonography and MRCP. Patients were assigned to one of 2 main groups: A) patients with common bile duct stones at ultrasonography (15/48: 31%) and B) patients without evidence of common bile duct stones on ultrasonography (33/48: 69%), with B comprising two subgroups: B1) MRCP-positive for stones (7/33:21%) and B2) negative US and MRCP (26/33:79%). MRCP showed 100% sensitivity and 100% specificity. The high sensitivity of MRCP allows us to recommend a greater use of the procedure with avoidance of unnecessary ERCP, which should be reserved for therapeutic purposes only.