十二指肠副乳头的诊断及其治疗应用

十二指肠副乳头为胚胎时期副胰管进入十二指肠的开口,成年后发生退化,但部分人群的十二指肠副乳头退化不明显,表现为解剖变异。超声内镜、内镜下逆行胰胆管造影、磁共振胰胆管成像对其有较高的诊断价值。十二指肠副乳头通常只需随访,对于并发肿瘤的患者,则可根据情况选择内镜下治疗或外科手术治疗。在主胰管中断或狭窄变形导致插管困难的患者中,十二指肠副乳头可用于插管造影进行胰腺分裂症、胰腺炎、胰腺结石等疾病的诊断。此外,通过十二指肠副乳头括约肌切开后进行插管、球囊扩张、副胰管支架置入等方法,可以缓解胰腺分裂症及慢性胰腺炎患者的临床症状。通过十二指肠副乳头进行插管取石,对胰腺结石患者也有较好疗效。该文对其临床特征、病理特点、诊断及相关治疗作一综述。     

内镜超声检查术对十二指肠囊肿的诊断价值

目的 研究内镜超声检查术（EUS）对十二指肠囊肿的诊断价值.方法 分析十二指肠囊肿患者的临床表现,普通胃镜、EUS的结果和随访结果,研究总结该病的超声影像学特征.结果 105例十二指肠囊肿患者均无与病灶相关的症状,该病在超声内镜下具有特征性的影像学改变,即黏膜下病灶位于肠壁内,探头触压病灶易变形,内呈无回声状,边界清楚,源于黏膜下层,后方有回声增强效应,周围肠壁层次结构正常.EUS可明确病灶的起源、大小和性质并与其他黏膜下病变相鉴别.术后随访5年病灶无明显变化.结论 十二指肠囊肿属良性疾病,EUS对该病的诊断具有较好的临床价值.     

内镜超声检查术对十二指肠囊肿的诊断价值

目的 研究内镜超声检查术(EUS)对十二指肠囊肿的诊断价值.方法 分析十二指肠囊肿患者的临床表现,普通胃镜、EUS的结果和随访结果,研究总结该病的超声影像学特征.结果 105例十二指肠囊肿患者均无与病灶相关的症状,该病在超声内镜下具有特征性的影像学改变,即黏膜下病灶位于肠壁内,探头触压病灶易变形,内呈无回声状,边界清楚,源于黏膜下层,后方有回声增强效应,周围肠壁层次结构正常.EUS可明确病灶的起源、大小和性质并与其他黏膜下病变相鉴别.术后随访5年病灶无明显变化.结论 十二指肠囊肿属良性疾病,EUS对该病的诊断具有较好的临床价值.     

内镜超声检查术对十二指肠囊肿的诊断价值

目的 研究内镜超声检查术(EUS)对十二指肠囊肿的诊断价值.方法 分析十二指肠囊肿患者的临床表现,普通胃镜、EUS的结果和随访结果,研究总结该病的超声影像学特征.结果 105例十二指肠囊肿患者均无与病灶相关的症状,该病在超声内镜下具有特征性的影像学改变,即黏膜下病灶位于肠壁内,探头触压病灶易变形,内呈无回声状,边界清楚,源于黏膜下层,后方有回声增强效应,周围肠壁层次结构正常.EUS可明确病灶的起源、大小和性质并与其他黏膜下病变相鉴别.术后随访5年病灶无明显变化.结论 十二指肠囊肿属良性疾病,EUS对该病的诊断具有较好的临床价值.     

十二指肠乳头腺瘤的内镜治疗

目的 探讨十二指肠乳头内镜下切除术（EP）治疗十二指肠乳头腺瘤（AA）的临床应用价值.方法 回顾分析长海医院消化内镜中心EP治疗AA成功率、并发症发生率、术后残留率及局部复发率等.结果 2005年7月至2009年7月EP治疗经内镜及病理确诊的从19例：散发AA18例（94.7%）,其中十二指肠多发腺瘤合并AA 1例;家族性腺瘤性息肉病并AA 1例（5.3%）.EP治疗一次性整块切除11例（57.9%）,分片切除8例（42.1%）.平均随访24.5个月（7～48个月）,首次EP后残留4例（21.1%）,EP治疗成功率为89.5%（17/19）.近期并发症：出血3例,轻症急性胰腺炎3例,急性胆管炎2例;远期并发症：胆管下端开口狭窄合并急性胆管炎1例,长期胆管支架置入后合并胆总管多发结石及急性胆管炎各1例.未发生穿孔等严重并发症以及EP术中转手术或死亡.结论 EP是治疗AA及其早期癌变的一种安全、有效的方法.     

胶囊内镜对十二指肠乳头的检出率及其影响因素分析

目的 分析胶囊内镜对十二指肠乳头及小肠疾病的检出率,探讨可能影响十二指肠乳头检出率的潜在因素.方法 回顾分析369例因疑似小肠疾病而行胶囊内镜检查患者的十二指肠乳头检出率及小肠疾病检出率.为了解直视内镜对十二指肠乳头的漏检率,另对369例胃镜检查患者统计其十二指肠乳头检出率.对胶囊内镜分别采用手动逐帧及15帧/s2种速率进行读片,统计2种读片速率的十二指肠乳头检出率及每例检出者所获取乳头图片的帧数.计算胶囊内镜检查者中不同性别与年龄组间十二指肠乳头检出率差异有无统计学意义.统计胶囊内镜检查前不同肠道准备组间分别在手动逐帧、15帧/s2种读片速率时十二指肠乳头检出率差异有无统计学意义.结果 标准直视胃镜的十二指肠乳头漏诊率为22.0%;手动逐帧读片十二指肠乳头检出率明显高于15帧/s(32.2%比13.6%,P=0.001),检出时所需乳头图片的平均帧数前者少于后者(3.7帧比7.0帧);胶囊内镜对小肠疾病的检出率为67.2%,明显高于对十二指肠乳头的检出率32.2%(P=0.000);不同性别与年龄组问的十二指肠乳头检出率差异均无统计学意义;检查前各种肠道准备组问在不同读片速率时十二指肠乳头检出率差异亦均无统计学意义.结论　胶囊内镜对十二指肠乳头检出率较低,但不能简单地与其对小肠疾病的检出率划等号.影响胶囊内镜对十二指肠乳头检出率的主要因素包括十二指肠降部特殊的解剖结构、读片者浏览图片的速率及胶囊内镜本身的缺陷.     

原发性十二指肠乳头癌的诊断

我院自1997年8月至2004年4月，共诊断原发性十二指肠乳头癌52例，现总结报告如下。     

微探头内镜超声在十二指肠病变诊断中的应用价值

目的 评价微探头内镜超声诊断十二指肠病变的临床应用价值.方法 回顾性总结37例十二指肠病变行微探头内镜超声检查患者的临床资料,以内镜黏膜下切除术标本或手术切除标本病理诊断为最终诊断结果,统计微探头内镜超声及内镜下活检对十二指肠病变的诊断符合率.结果 微探头内镜超声对十二指肠病变的总体诊断符合率为78.38％ (29/37),其中对十二指肠脂肪瘤和十二指肠腺瘤具有较高的诊断符合率,分别为4/4和10/12,对十二指肠早癌及炎性增生性病变的诊断符合率相对较低,分别为2/4和3/8.内镜下活检对十二指肠病变的总体诊断符合率为40.54％(15/37),其中对十二指肠类癌和十二指肠腺瘤具有较高的诊断符合率,分别为1/1和7/12,对十二指肠间质瘤及脂肪瘤的诊断符合率相对较低,分别为1/10和1/4.结论 内镜下活检不能作为诊断十二指肠病变的金标准,而微探头内镜超声对十二指肠病变具有较好的临床应用价值.     

内镜下十二指肠乳头切除术在乳头部肿瘤诊断中的价值

目的:评价内镜下十二指肠乳头切除术(endos-copic papillectomy,EP)在乳头部肿瘤诊断中的临床价值.方法:分析2008-01/2012-03来我院的16例经病理检查确诊的十二指肠乳头部肿瘤患者的相关资料,评价EP在十二指肠乳头部肿瘤诊断中的临床价值.结果:16例患者中,内镜活检诊断为腺瘤者12例,慢性炎症改变者4例.EP将乳头部肿瘤组织切除后整体送检行病理学检查确诊为低分化腺癌者2例,高分化腺癌1例,腺瘤13例(其中1例腺瘤恶变,4例常规内镜活检诊断为慢性炎症改变者术后均确诊为腺瘤),EP术后准确率明显高于内镜活检法(P<0.05).超声内镜(endoscopic ultrasonography,EUS)检查提示病变均起源于黏膜层,胰胆管扩张者9例,未见黏膜下层连续性中断及胰胆管受累者,无腹膜后淋巴结肿大者;12例高回声病变者术后病理检查结果均为腺瘤,1例高回声病变局部见低回声区者术后病理检查结果为腺瘤恶变,3例低回声病变者术后病理检查结果均为腺癌.EP术后2例低分化腺癌者、1例腺瘤恶变者及1例腺瘤者胆管开口处见病变残留,提示胆管受累,但术前EUS检查均未提示胆管受累;1例高分化腺癌及11例腺瘤者病灶均完整切除,术后切缘阴性.EP术后除2例出现黑便外,无急性胰腺炎、穿孔及其他并发症发生,无患者死亡.结论:EP术将乳头部肿瘤组织切除后整体送检行病理学检查可提高诊断准确率,为治疗方法的抉择提供科学依据.     

十二指肠乳头癌诊断的现状与进展

十二指肠乳头癌（CPV）是一类原发于十二指肠大乳头的恶性肿瘤,临床罕见。大多数研究均表明,CPV手术切除率和预后优于其他壶腹部周围癌。近年来,局部切除的疗效已被广泛认可。因此,早期诊断已成为正确选择治疗时机和治疗策略以提高远期生存率的关键。然而,临床上术前准确判断十二指肠乳头肿瘤性质和分期仍然存在众多困难,局部切除适应证亦有争议。此文就目前CPV的早期诊断、局部切除适应证判断等方面进行综述,旨在为临床医师选择更好的诊断评估方法提供参考。     

十二指肠乳头部微胆石的内镜诊治

目的探索十二指肠乳头部微胆石的内镜诊治方法和价值。方法对反复胆绞痛、术后再发胆绞痛、特别是发生急性胰腺炎者进行内镜乳头切开,观察乳头有无排石,收集胆汁进行显微镜检。结果在完成内镜检查治疗的319例患者中发现微胆石34例（10.7%,34/319）;依来源分：胆囊型（Ⅰ型）8例,胆管型（Ⅱ型）7例,胆囊胆管混合型（Ⅲ型）19例。单纯内镜治疗26例;内镜联合胆囊切除8例。结论微胆石临床发病率不高,但危害和风险大,内镜是最有效的诊断和治疗方法,Ⅰ型和Ⅲ型可联合切除胆囊。     

全景胃镜对十二指肠主乳头观察的随机对照研究

目的探讨全景胃镜对十二指肠主乳头观察的效果和安全性。方法2017年3月至2017年12月在解放军总医院消化内镜中心接受无痛胃镜检查的患者按照随机化分组、自身对照原则,将符合入选标准的研究对象按就诊顺序编号,采用随机数字表法随机分为两组,分别进行普通胃镜检查(A组)或者全景胃镜检查(B组)。以十二指肠主乳头的观察情况作为主要评价指标,比较两组对十二指肠主乳头的观察率。结果根据入组标准共纳入100例患者,其中A组51例、B组49例。B组十二指肠主乳头全部观察率优于A组[79.59%(39/49)比41.18%(21/51),χ^2=15.366,P=0.000],而对十二指肠主乳头的总体观察率(全部、部分观察率之和)与A组比较差异无统计学意义[100.00%(49/49)比92.16%(47/51),χ^2=2.221,P=0.136]。所有患者顺利完成检查,无出血、穿孔、死亡等并发症发生。结论全景胃镜广阔的视野有效提高了十二指肠主乳头观察的有效性和安全性。     

Histomorphological study on the minor duodenal papilla

The morphological characteristics of the minor duodenal papilla were studeied histologically using surgically resected specimens according to the presence or absence of an opening of the accessory pancreatic duct in 30 patients (22 with a ductal opening and 8 without such an opening) who had undergone pancreatoduodenectomy within the past 4 years. The follwoing results were found: 1) The minor duodenal papilla was composed fundamentally of the accessory pancreatic duct, pancreatic tissue of the dorsal pancreas whcih penetrated the duodenal proper muscular tunics and the surrounding fibrous connective tissue. 2) In those specimens with a ductal opening, smooth muscle fiber bundles dervied from the duodenal proper muscular tunics surrounded the accessory pancreatic duct and seemed to possess sphincter action similar to that of Oddi sphincter muscles. 3) In those specimens without a ductal opening, the accessory pancreatic duct terminated blindly in the minor duodenal papilla which was comprised mostly of pancreatic tissue and seemed to have no sphincter muscles. 4) Islet cells in the pancreatic tissue of the minor duodenal papilla were rich in B-cells which were round to ovoid in shape and sharply outlined.GastroenterolJpn 1991;26:356-362     

十二指肠乳头部结石嵌顿内镜下治疗的回顾性研究

目的 研究乳头部结石嵌顿病例特点和内镜治疗效果,探讨针状刀切开在治疗嵌顿结石中的有效性。方法 收集2007年至2016年316例乳头部结石嵌顿病例资料。观察内镜治疗结果及操作方法,分析年嵌顿结石占同期全部胆管结石百分比变化趋势及胆管直径和嵌顿结石直径的变化趋势。结果 316例患者均在内镜下成功解除梗阻并置鼻胆管引流（100.0％）,其中231例（73.1％）需采用针状刀切开。按年分层显示,十二指肠乳头部结石嵌顿者占同期全部胆管结石百分比呈减少趋势（P=0.000）。胆总管直径（P=0.000）及嵌顿结石直径（P=0.000）均呈减小趋势。结论 近年来十二指肠乳头部结石嵌顿有减少趋势,胆总管直径和嵌顿结石直径存在逐渐减小的变化趋势。针状刀括约肌切开是处理乳头部嵌顿结石的主要方式。     

内镜诊断十二指肠憩室病

目的:探讨十二指肠镜诊断十二指肠憩室病的方法要点和临床意义,指导临床治疗.方法:按内镜常规操作方法,用日本PEXT FD-32A十二指肠镜,对十二指肠进行观察.结果:本组25例,检出率为11%,其中合并出血3例,有11例曾先后经上消化道X线钡剂及十二指肠镜,对比检查,其结果差异显著.结论:十二指肠憩室病临床症状缺乏特异性,诊断困难,临床症状虽不严重,但并发症常危及生命,其发病率与年龄无关,经与X线造影比较,其检出率显著高于X线造影,说明十二指肠镜检查,是本病可靠的诊断手段     

胃粘膜异型增生54例临床病理学回顾性研究

目的 通过对胃粘膜上皮异型增生（gastric epithelial dysplasia,GED)的内镜描述、病理组织学分级、不同治疗方法和癌变的回顾性研究,使内镜表现与组织学形态有机结合,为病理和临床医生制定规范统一的GED描述术语和诊断分级标准,为GED的治疗方法和预后判断提供客观依据。方法 选取54例具有随访资料的GED病例,进行HE、Goden-Sweet网染、P53和CEA免疫组化染色,观察内镜形态、组织学分级和治疗方法与癌变的关系。结果 高度GED内镜形态表现为褪色和灰白色,光泽消失,质地变硬且弹性差,呈平坦凹陷或平坦凸起伴浅表糜烂并且大于0.5cm,与癌变关系非常密切（P＜0．05）。低度GED多为隆起型,与增生性息肉和萎缩性胃炎难鉴别。结论 低度异型增生（low grade dysplasia)应当密切随访,或做内镜局部粘膜病灶切除后随访。高度异型增生应做内镜局部粘膜病灶切除或胃部分切除后密切随访。     

Size,location and patency of the minor duodenal papilla as determined by dye‐injection endoscopic retrograde pancreatography

Background: The accessory pancreatic duct (APD) sometimes is developmentally obliterated near the duodenum. We evaluated patency of the minor duodenal papilla by dye‐injection endoscopic retrograde pancreatography to determine whether patency was related to papillary size and location. Methods: We injected 2–3 mL of contrast material containing indigocarmine into the main pancreatic duct via an endoscopic catheter in 104 patients. It was endoscopically observed whether dye was extruded from the minor papilla. Size of the minor papilla and distance from the orifice of the major duodenal papilla to the apex of the minor papilla were measured endoscopically with measuring forceps. Results: The APD was patent in 56 of 104 cases (54%). Size of the minor papilla varied considerably from 3 to 6 mm, but showed no correlation with patency. Half of the patients with chronic pancreatitis (6/13) had the minor papilla larger than 6 mm. In cases where the terminal APD had a cudgel or tapering‐off configuration, the minor papilla was larger than in cases where the duct had a stick shape. The minor papilla was patent in 9 out of 10 cases (90%) when it was near the major papilla (≤ 1.5 cm). Frequency of a patent minor papilla was 16 out of 33 (48%) when it existed 1.5 to 2.0 cm from the major papilla, and 31 out of 61 (51%) when the distance was more than 2.0 cm. Conclusions: The minor papilla was more frequently patent when it was close to the major papilla (P < 0.05).     

Prospective Observation of Small Adenomas in Patients After Colorectal Cancer Surgery Through Magnification Chromocolonoscopy

Purpose This study was designed to confirm the safety of not removing small adenoma in patients who undergo colorectal cancer surgery. Methods Patients who underwent surveillance colonoscopy after surgery were enrolled. The study was approved by our institutional review board. Colonoscopy was performed with magnification chromocolonoscopy. Benign adenomas of 6 mm or less in size, diagnosed based on both nonmagnified and magnified observation, were left unresected with a maximum of three polyps per patient. The sites of the polyps were marked by tattooing. Interval colonoscopy was performed predominantly yearly or biennially. Increase in size by 2 mm or larger was defined as significant. In follow-up, polyps were removed if they grew larger than 6 mm, were suspicious for high-grade dysplasia, or the patients requested to have polyps removal. Results Five hundred polyps in 284 patients met the above criteria and were not resected, and 412 polyps were followed by repeat colonoscopy. The mean observation period was 3.6 ± 2.2 years and the mean number of repeat colonoscopy was 3.6 ± 1.6. At the final colonoscopy, 71 percent of 412 polyps showed no change in size, 15 percent increased, 3 percent decreased, and 11 percent could not be identified. Eighty-eight polyps were resected endoscopically, and histology showed neither cancer nor adenomas with high-grade dysplasia. Two hundred fifty-five polyps detected in the same patient cohort during index/repeat colonoscopy were removed, including four adenomas with high-grade dysplasia and two T1 cancers. Conclusions Leaving small polyps is safe even in patients who have undergone colorectal cancer surgery, provided that careful observation is guaranteed. Supported in part by Grant-in-Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology of Japan. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.