慢性胰腺炎的外科治疗

目的 改善慢性胰腺炎的外科治疗效果。方法 回顾性分析我院外科1983－2000年收治的34例慢性胰腺炎病人的临床资料，并将其分为慢性钙化性胰腺炎及慢性梗阻性胰腺炎两组。结果 男性23例（68％），女性11例（32％），平均年龄52.89岁。嗜酒者23例（67.65%），合并胆石症者13例（38.24%），继往有急性胰腺炎发作者11例（32.35%）。主诉腹痛者28例（82.35%），合并黄疸者17例（50％），慢性钙化性胰腺炎与慢性梗阻性胰腺炎在某些临床表现间存在显著性差异，提示二者可能存在不同的发病机制。34 病人分别采用9种不同的手术方式，无围手术期死亡。Puestow手术及胰十二指肠切除可有效地缓解疼痛，并可改善胰外分泌功能，对胰内分泌的影响不大。Puestow手术并行胆肠吻合适于合并胆道狭窄的慢性胰腺炎病人，而仅行胆道引流效果不佳。结论 慢性胰腺炎的外科治疗应采用个体化原则，如合并胰管扩张可行Puestow引流手术，胰头炎性包块病人应行切除手术。     

慢性胰腺炎所致梗阻性黄疸——附25例报告

慢性胰腺炎所致梗阻性黄疸是临床黄疸中的一种少见类型,易于误诊。本组25例中术前误诊18例(其中6例术中仍误为胰头癌),仅7例诊断为慢性胰腺炎。25例均经手术治疗,17例行总胆管十二指肠吻合或总胆管—空肠Roux-en-y式吻合,术后均顺利恢复,黄疸消退:2例行Oddis氏括约肌切开成形术,均于术后1年内黄疸复发,其中1例死于胆道感染;6例误诊为胰头癌者均行胰十二指肠切除术,4例痊愈,2例死亡。本文对慢性胰腺炎所致梗阻性黄疸的发病机制,分类分型、诊断及治疗原因进行了讨论。     

从病理解剖学探讨慢性胰腺炎手术治疗的合理性

目的 探讨病理解剖学改变对慢性胰腺炎手术方式选择的指导意义,评价外科治疗的远近期效果,为设计合理化手术方案提供临床依据。方法 回顾性研究北京大学第一医院2000-2010年外科治疗60例慢性胰腺炎病人的临床资料。结果 围手术期死亡1例（1.7%）。60例慢性胰腺炎病人合并腹痛43例（71.7%）,42例手术后疼痛获缓解,远期复发17例（40.5％）。合并胰管扩张和（或）胰管结石行改良Puestow术21例,远期复发8例（38.1%）;6例行不同范围胰头切除术者未见症状复发,11例仅行胆肠吻合者2年内疼痛复发9例（81.2%）。合并胆道梗阻者33例（55%）,单纯或联合其他手术的胆肠吻合均能缓解黄疸,单纯胆肠吻合后33.3%（4/12）新发腹痛,5例胰头切除术后病人长期随访无黄疸和腹痛复发。结论 根据慢性胰腺炎病理解剖学改变选择具针对性手术效果良好,合理的切除加充分的胰胆引流可显著改善临床症状。     

慢性胰腺炎的手术适应证和术式选择

目的提高慢性胰腺炎的外科治疗效果. 方法回顾性总结分析55例慢性胰腺炎外科治疗资料.发病因素:嗜酒5年以上、胆系结石、急性胰腺炎病史分别占38.2%,29.1%和20.0%.主要临床表现:慢性腹痛、梗阻性黄疸、体重减轻、消化不良、糖尿病分别为98.2%,38.2%,34.5%,20.0%和10.9%.全组均因慢性腹痛或伴有胰管和(/或)胆管梗阻、结石、胰腺钙化、肿块、假性囊肿等行外科治疗,共采用了10种术式. 结果无手术死亡和严重并发症.术后效果良好43例(78.2%),症状减轻好转10例(18.2%),无效2例(3.6%). 结论慢性胰腺炎长期慢性腹痛并胰胆管梗阻、结石、肿块、假性囊肿适于外科治疗,应根据病变类型和特点选择不同的术式.胰管梗阻扩张、结石或假性囊肿宜行胰管或囊肿空肠吻合,胰头肿块并胆、胰管梗阻可行胰头十二指肠切除或胆胰管空肠吻合术.     

胰头部局限性胰腺炎致梗阻性黄疸的诊治

文章报告９例胰头部局限性胰腺炎合并梗阻性黄疸的诊断与治疗经验。其病理特点是病变局限在胰腺沟突部位的节段性慢性炎症，部分胰腺实质被增生的纤维结缔组织所代替，临床上常疑诊为胰头癌。９例患者中行胆总管空肠吻合３例，胰头十二指肠切除２例，疗效满意。胆囊空肠吻合４例，术后黄疸均消退，１例黄疸消退后行胰头十二指肠切除；随访期间４例中３例术后发生胆总管结石，其中１例发生胰头癌。文章对该病的病因、病理和手术方式进行了讨论。     

胰头肿块型胰腺炎的诊断与治疗

胰头肿块型慢性胰腺炎从临床表现上很难与胰头癌相鉴别,影像学检查在肿块型慢性胰腺炎诊断中起重要作用,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.目前已将发生于胰头的肿块型慢性胰腺炎视为胰腺癌发生的癌前病变.胰头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)和胰头部分切除(Beger手术)加胰管引流术(Frey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;若胰头肿块巨大胰十二指肠切除有极大风险,可考虑保留十二指肠的胰头切除术.     

假瘤样胰腺炎的诊断及处理：附8例报告

为探讨假瘤样胰腺炎的诊断和处理，对１９９０～１９９７年间手术治疗的８例假瘤样胰腺炎进行了回顾性分析。患者均表现为胰腺局部占位性病变，行剖腹探查术。２例胰头部肿块行胰十二指肠切除术（Ｗｈｉｐｐｌｅ手术），１例尾部肿块行胰尾加脾切除术，３例头体部肿块伴有胆总管扩张梗阻性黄疸者行胆总管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术，２例胰头部肿块无黄疸者行胆总管切开、Ｔ管引流术，术后病理检查均为炎症性改变。随诊结果显示：患者黄疸消退、肿块缩小、临床症状好转。结果表明：慢性局灶性胰腺炎不能排除恶性病变者宜行肿块切除术。胰腺炎性肿块伴有胆总管扩张、梗阻性黄疸者可行内引流术，无黄疸者可行外引流术     

保留十二指肠胰头切除术

保留十二指肠胰头切除术最早由Beger倡导,该手术仅切除病变的胰头,保留胃、十二指肠及胆道的正常联系性,适用于慢性胰腺炎及部分胰头部良性肿瘤,并有许多改良术式,为胰腺外科领域中的重要术式。保留十二指肠胰头切除术的理论基础和适应证慢性胰腺炎作为一种炎症性疾病,表现为胰腺实质不可逆的纤维化,导致胰腺内、外分泌功能下降,引起消化不良、体重减轻和糖尿病;并进一步导致胰腺假性囊肿、十二指肠梗阻及胆管狭窄等。腹部疼痛是慢性胰腺炎最主要症状,其中50%的病人因无法控制疼痛而需手术处理。慢性胰腺炎疼痛的机制仍未完全明确,传统理论…     

Clinical analysis of chronic pancreatitis with mass

目的 探讨胰头肿块型慢性胰腺炎的诊治方法.方法 对我院近10年38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 本组病例主要症状为上腹部疼痛(100％)、黄疸(47.4％)和体重明显下降(42.1％),B超检查阳性率94.1％,CT、ERCP和MRCP阳性率均为100％.症状较轻,或因并存严重并发症的8例和病理切片排除恶性病变的5例行内科综合治疗,症状严重行胰头十二指肠切除16例,胆管空肠吻合5例、胰管空肠吻合1例,囊肿空肠吻合3例.结论 本病诊断主要依靠影像学检查.症状较轻,可行内科治疗.症状严重,发生胆胰管梗阻或不能排除恶性病变者应行胰头十二指肠切除手术为主.     

慢性胰腺炎致梗阻性黄疸的外科治疗方式与合理性分析

目的探讨慢性胰腺炎所致梗阻性黄疸的外科治疗及其合理性.方法回顾性研究我院1985年1月至2004年12月20例慢性胰腺炎伴非结石性梗阻性黄疸的临床特点及诊治措施.结果（1）本组病例主诉黄疸,90.0%无典型慢性胰腺炎临床表现及影像特征,胰内段胆总管狭窄是特征性影像表现;（2）本组病理诊断为弥漫性胰腺慢性炎症,并造成胰内段胆总管狭窄;（3）本组选择Oddi括约肌成形术（2例）或胆肠吻合术（18例）,胆道引流效果稳定;（4）单纯T管引流者无法撤除引流管.结论本研究关注慢性胰腺炎病例中伴胆道梗阻,但缺乏典型临床及影像表现者,占同期住院慢性胰腺炎的15.0%;其伴发梗阻性黄疸与胰腺炎症直接相关;胆道引流术可缓解梗阻,胆囊或胆总管空肠吻合是安全、经济的治疗措施;单纯T管引流不是理想的选择;无胰管病变及慢性胰腺炎其他症状时无须针对胰腺进行手术操作.     

Conservation of pancreatic tissue by combined gastric, biliary, and pancreatic duct drainage for pain from chronic pancreatitis

In patients with chronic pancreatitis, the sclerosing process of the pancreas may constrict not only the pancreatic duct for also the bile duct and duodenum. This study analyzes the prevalence of these obstructive lesions in 58 consecutive patients with chronic pancreatitis requiring surgery for either pain (57 patients) or for painless jaundice (1 patient). There was significant biliary obstruction in 21, 4 of whom also had symptomatic duodenal obstruction. All 21 patients with biliary and duodenal obstruction were among the 38 with a dilated pancreatic duct suitable for pancreaticojejunostomy (modified Puestow procedure). None of the 20 patients with small duct pancreatitis had biliary or duodenal obstruction. Pseudocysts were distributed evenly between the two groups (9 of 38 patients with a dilated duct versus 4 of 20 patients with small duct pancreatitis). Pancreaticojejunostomy combined with choledochoenterostomy and gastrojejunostomy in appropriately selected patients provided good to excellent long-term (mean 3.6 years) relief of pain in 30 of 36 patients (83 percent). There was no correlation between successful relief of pain and development of pancreatic exocrine or endocrine insufficiency or calcification. Stenosis of the bile duct developed some years subsequent to pancreaticojejunostomy in four patients and required a second operation for choledochoenterostomy in three. Three other patients required secondary pancreatic resections due to failure of the pancreaticojejunostomy to relieve pain. It is often possible to effect excellent relief of symptoms with maximal conservation of remaining pancreatic functions despite sclerotic obstruction of multiple organ systems.     

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??Rationality of surgical managements according to the pathological anatomy of chronic pancreatitis GAO Hong-qiao, CAI Meng-shan, MA Yong-su, et al. Department of General Surgery, Peking University First Hospital, Beijing 100034, China
Corresponding author: YANG Yin-mo, E-mail: yangyinmo@263.net
Abstract Objective To investigate the outcome after surgery directed by pathological anatomy of chronic pancreatitis and provide evidence for surgical procedures. Methods The clinical material of 60 patients with chronic pancreatitis who underwent surgical treatment between 2000 and 2010 were investigated retrospectively. Result 43 cases (71.7%) presented with abdominal pain, Perioperative mortality was 1.7% (1 case). Forty-two patients with abdominal pain were all relieved after surgery, but long-term recurrence occered in 17 cases (40.5%). Modified Puestow procedure was performed on 21 patients with dilatation of pancreatic duct and/or lithiasis, long-term pain recurrence occered in 8 cases (38.1%); Six patients undergoing pancreatic head resection had no recurrence in the long-term follow-up; Pain recurrence rate of 11 cases with only cholangioenterostomy was 81.2% (9 cases) within 2 years. Chronic pancreatitis with common bile duct obstruction occurred in 33 cases(55%), cholangioenterostomy alone or combined with partly pancreatic resection or pancreatic duct drainage procedures could alleviate symptoms of biliary obstruction, 4(33.3%) cases after pure biliary drainage emerged abdominal pain, 5 cases of pancreatic head resection had no recurrence of jaundice and abdominal pain after long-term follow-up. Conclusion Surgical procedures should be selected according to the pathological anatomy of chronic pancreatitis. Reasonable pancreatic head resection and adequate bile and/or pancreatic drainage could significantly improve the long-term outcomes.     

A case of obstructive jaundice caused by incarceration of pancreatic stones in the ampulla of papilla Vater

A very rare case of obstructive jaundice caused by the incarceration of pancreatic stones in the ampulla of papilla Vater is reported. A forty-eight-year-old man, who had been taking alcohol daily for 10 years, was admitted to our hospital because of recurrent attacks of upper abdominal pain. Biochemical analysis demonstrated typical pattern of chronic pancreatitis. US, CT and ERCP showed a markedly dilated pancreatic duct and pancreatic calcifications. Cholecystolithiasis, or dilatation of the choledochus was not noted. Conservative treatment was performed under the diagnosis of chronic calcifying pancreatitis for one month. Then, obstructive jaundice, severe epigastralgia, and high fever occurred. Obstructive jaundice with sudden onset and existence of pancreatic stones suggested incarceration of pancreatic stones in the bile duct, and cephalic pancreaticoduodenectomy was performed. The largest pancreatic stone was incarcerated into the ampulla of papilla Vater. Histopathological analysis of the pancreas showed severe chronic pancreatitis. No report of the similar case can be found in the literature. Incarceration of pancreatic stones into biliary system might be very rare, however, should not be forgotten in differential diagnoses of obstructive jaundice in chronic pancreatitis patients.     

Surgical treatment of chronic pancreatic cholangiopathy

In a consecutive surgical series of 70 patients with chronic calcifying pancreatitis, 18 presented with fixed stenosis of the terminal common bile duct. Nine patients presented with jaundice and two had a palpable gallbladder. The most relevant laboratory datum in the series was a persistently high serum alkaline phosphatase level. Long tapering of the terminal common bile duct was the characteristic radiological sign in 45 of our patients. In five of the 18 cases compression of the terminal bile duct was due to cephalic pseudocysts. Hepaticojejunostomy-en-Y was the type of drainage chosen in 16 cases, and an end-to-side technique was used in 15 patients. Side-to-side choledochoduodenostomy was performed in two cases. In 14 patients, biliary drainage was associated with other surgical procedures on the pancreatic parenchyma. No postoperative complications due to the biliary drainage occurred in this series.     

Modified Puestow procedure for the management of chronic pancreatitis in children

Purpose

To present our experience with the modified Puestow procedure in the management of children with chronic pancreatitis.

Methods

Retrospective chart review of patients treated between 2003 and 2012.

Results

Six patients underwent a modified Puestow procedure (lateral pancreaticojejunostomy) for the management of chronic pancreatitis, three females and three males. Four patients had hereditary pancreatitis (three with confirmed N34S mutation in the SPINK1 gene), one patient had chronic pancreatitis of unknown etiology, and one patient with annular pancreas developed obstructive chronic pancreatitis. The pancreatic duct was dilated in all cases, with a maximum diameter of 5 to 10 mm. Median time between onset of pain and surgery was 4 years (range: 1–9). Median age at surgery was 7.5 years (range: 5–15). Median hospital stay was 12 days (range: 9–28). Median follow up was 4.5 years (range: 5 months to 9 years). All patients had temporary postoperative improvement of their abdominal pain. In two patients the pain recurred at 6 months and 2 years postoperatively and eventually required total pancreatectomy to treat intractable pain, 3 and 8 years after surgery. Two patients were pain free for two years and subsequently developed occasional episodes of pain. The two most recent patients are pain free at 1 year (obstructive chronic pancreatitis) and 5 months (hereditary pancreatitis) follow-up. Two patients developed type I diabetes mellitus 10 and 12 months postoperatively (one with hereditary and one with idiopathic chronic pancreatitis).

Conclusion

We conclude that the modified Puestow procedure in children is feasible and safe. It seems to provide definitive pain control and prevent further damage to the pancreas in patients with obstructive chronic pancreatitis. However, in patients with hereditary pancreatitis, pain control outcomes are variable and the operation may not abrogate the progression of disease to pancreatic insufficiency.     

Jaundice and chronic pancreatitis: common bile duct compression by pancreatic pseudocyst

In chronic pancreatitis, obstructive jaundice solely due to common bile duct compression by a pancreatic pseudocyst is highly unusual. In most of these cases, the jaundice is due to fibrotic stricture of the intrapancreatic portion of the common bile duct. We report two cases of obstructive jaundice in chronic pancreatitis with pseudocyst. Operative findings and follow-up during the postoperative period demonstrated compression by the pseudocyst over the common bile duct as the only etiologic factor of the jaundice. We believe that intraoperative cholangiography should be performed after drainage of a pseudocyst to correctly assess the etiology of obstruction.     

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目的：探讨华支睾吸虫病所致梗阻性黄疸的临床病理特点及治疗方法，提高诊治水平。方法：对近年来收治的华支睾吸虫病所致梗阻性黄疸8例病人进行回顾性总结和临床分析并文献复习。结果：8例病人均有明确食生鱼史。引起梗阻性黄疸的原因：1例合并有肝门部胆管癌，1例合并胆管结石，5例为炎性胆管狭窄。全部病人均有嗜酸性粒细胞增多症。CT和B超检查见胆管扩张。粪便中均找到华支睾吸虫卵。5例病人手术治疗。术中在胆管内发现华支睾吸虫成虫及虫卵。结论：华支睾吸虫病所致梗阻性黄疸的病因是炎性胆管狭窄、胆石症、胆管癌和成虫及虫卵阻塞胆管。食生鱼史、嗜酸性粒细胞增多症、粪便中找到华支睾吸虫卵、CT及B超特征性改变均有助于诊断。吡喹酮治疗有效。伴有胆管癌、胆结石及重症胆管炎时应及时手术。