胰腺囊性肿瘤的鉴别诊断（附10例分析）

胰腺囊性肿瘤是一种很少见的胰腺肿瘤，约占全部胰腺肿瘤的11％～15％，其中大部分病情发展慢，治疗效果好，有别于胰腺实质性癌肿。主要包括胰腺囊腺瘤、胰腺囊腺癌、胰腺乳头状囊性肿瘤及胰实质性肿瘤的缺血液化或感染所致的退行性病理改变。现将我们近年来收治的10例胰腺囊性肿瘤诊疗情况总结报告如下。     

胰腺囊性肿瘤与假性胰腺囊肿的鉴别诊断

目的：提高对胰腺囊性肿瘤诊断的认识，减少这种少见肿瘤的误诊误治。方法：对上海中山医院1958年4月～1995年7月经病理证实的15例胰腺囊性肿瘤病人进行回顾性分析，并与1962年9月～1995年7月收治的76例假性胰腺囊肿病人的临床表现和辅助检查特点进行比较。分析误诊的原因，探讨鉴别诊断的方法。结果：15例胰腺囊性肿瘤中，仅有6例（40％）术前明确诊断为胰腺囊性肿瘤，其余9例（60％）术前被误诊为胰腺假性囊肿或中上腹肿块而行手术，其中7例术中被诊为囊性肿瘤而获相应的根治性切除，另2例被错误地进行了内引流术．结论：胰腺囊性肿瘤非常少见，其临床特征、影象学表现与假性胰腺囊肿相似而常导致误诊。但只要综合运用病史分析、影象学特点、囊液分析、术中活检、术中和术后观察等方法，就能提高诊断的准确率。     

胰腺间变癌的诊断和治疗(附2例临床病理分析)

胰腺间变癌（anaplastic carcinoma of the pancreas）是一种极为罕见的胰腺外分泌恶性肿瘤，预后很差。国内外的文献中曾有各种各样的术语来描述这类肿瘤，如胰腺肉瘤样癌、多形性腺癌、胰腺间变癌、小细胞癌等；目前多倾向于用胰腺间变癌来描述该类肿瘤。我们最近收治两例，现结合国内外相关文献，探讨胰腺间变癌的组织来源、病理分型、诊断和鉴别诊断以及预后等相关特征。[第一段]     

胰腺肿瘤的内镜超声诊断

胰腺深处人体腹膜后位，肿瘤发生常隐匿起病，如为恶性，确诊已属晚期，外科根除率低，预后极差，其中胰腺癌5年生存率只有4％，且化放疗均不敏感，能否延长生存，其前提是早期诊断。     

胰腺实性-囊性-乳头状肿瘤的临床病理特征及鉴别诊断(附1例报告)

胰腺实性 -囊性 -乳头状肿瘤 ( SCPN )极少见 ,自 195 9年首次报告以来 ,至今世界上仅有 15 0余例报道 ,其约占胰腺非内分泌肿瘤的 0 .17%～ 2 .7% ,至今组织学来源尚未确定。2 0 0 1年 11月我们收治 SCPN患者 1例 ,现结合文献对其病理特征、临床特征及鉴别诊断进行讨论。患者女 ,18岁。因上腹疼痛 5天入院。查体 :左上腹可触及一拳头大小肿物 ,有压痛。CT检查 :见胰尾部有一 9.2 cm×7.2 cm类圆形软组织块影 ,边界尚清 ,密度不均。入院后第 3天在硬膜外麻醉下行脾及胰体尾切除术。术中见胰尾部有一约 10 cm× 9cm肿物 ,质软 ,与周围有…     

第二讲 胰腺外分泌功能

胰腺是仅次于肝脏的人体内第二大外分泌器官。胰腺外分泌部分由腺泡、导管和间质3个部分组成．腺泡是合成、贮存和分泌消化酶的部位．导管的主要功能是分泌水和电解质，也是输送胰液的导管。胰腺的内分泌部分是胰岛．胰岛细胞产生胰岛索、胰高糖素等激素．经血液循环作用于多个靶器官。     

胰腺实性假乳头状肿瘤的组织病理特征分析

目的 分析总结胰腺实性假乳头状肿瘤(SPT)的组织病理特点.方法 回顾性分析51例SPT患者的临床资料,通过免疫组化法检测其中39例SPT组织蜡块中神经特异性烯醇化酶(HSE)、突触素(SYN)、神经细胞黏附分子1(CD_(56))、神经内肽酶(CD_(10))、巢蛋白(Nestin)、波形蛋白(Vim)、S100收集组织蛋白(S100)、a1抗糜蛋白酶(a1-ACT)、a1抗胰蛋白酶(a1-AT)、上皮膜抗原(EMA)、抗广谱细胞角蛋白单抗(AE1/AE3)、角蛋白多肽(CK19)的表达.结果 SPT组织病理特征为假乳头结构形成和区域性坏死,无腺泡结构.39例SPT中,NSE表达率达97.4%,CD_(56)和CD_(10)的表达率均为84.6%,Nestin和Vim表达率分别为64.0%和87.0%,S100的表达率为79.5%,a1-ACT和a1-AT的表达率分别为82.1%和79.5%,而SYN的表达率仅12.8%,EMA、AE1/AE3和CK19等表达很少,呈弱阳性反应.结论 SPT典型病理特征是由于肿瘤组织不同区域相对缺血、缺氧所造成的退行性变的结果,SPT表达多种组织来源的抗原,反映其可能来源于胰腺干细胞及与其发育密切相关的胚胎神经嵴的神经前体细胞,且在发育过程中发生分化不成熟的结果.     

胰腺实性假乳头肿瘤的临床病理特征

胰腺实性假乳头肿瘤(SPT)是一种少见的具有低度恶性潜能的实体性肿瘤,1996年WHO将其正式命名并重新归类为交界性肿瘤,通过综述该病的临床病理特征有助于临床医生进一步正确认识和重视该病种,避免临床误诊、误治。     

磁共振扩散加权成像鉴别诊断胰腺神经内分泌肿瘤和胰腺癌

目的 探讨磁共振扩散加权成像(DWI)及其表观弥散系数(ADC)在胰腺神经内分泌肿瘤与胰腺癌鉴别诊断中的应用价值.方法 回顾性分析经病理证实的17例神经内分泌肿瘤及16例胰腺癌患者的DWI检查结果(弥散敏感因子b值取0和800 s/mm2),在ADC图上测量肿瘤的最小ADC值,采取非参数检验对所得数据进行统计学检验...     

Aging and pancreatic exocrine function

Basal pancreatic exocrine functions as well as responses to endogenous (BPJ diversion) and exogenous (injection of CCK-8 or secretin) stimulations were examined in young (6- and 12-month-old) and old (24- to 26-month old) female Fischer 344 rats. Basal secretions were not significantly different between young and old rats. BPJ diversion significantly stimulated pancreatic secretions of fluid, bicarbonate, and protein in all animals. The pancreatic protein response (mg/kg/hr) to BPJ diversion was significantly attenuated with respect to age [57.59±16.16, 43.73±6.94, and 20.75±3.95, for 6-, 12-, 24- to 26- month-old rats, respectively, mean ±se, F(2,20)=3.49, P < 0.05]. The pancreatic responses to secretin (0.086, 0.432, and 1.728 nmol/kg) were not significantly different between young and old rats. Intravenous injection of CCK-8 (0.033, 0.167, and 0.667 nmol/kg) produced a significant increase in protein output in all age groups. In young animals, stepwise increases in protein output were observed, whereas, in old rats, increments in response to the larger two doses of CCK-8 (0.167 and 0.667 nmol) were smaller than that produced by 0.033 nmol/kg of CCK-8. In conclusion, the basal secretions in old rats were comparable with those in young ones, but the reserve capacity for protein secretion appears to decrease in old compared to young rats.This study was in part supported by Mitsui Life Insurance Foundation, 1985; Uehara Memorial Foundation, 1986; and the Japanese Agency for Science and Technology.     

The influence of cutting the pancreatic nerve plexus on exocrine function in the pancreas of rats

This study was performed to clarify changes in protein synthesis and exocrine enzymes of the pancreas after cutting the pancreatic nerve plexus of Wistar rats. The rats were divided into two groups, consisting of a group that underwent cutting of the pancreatic nerve plexus (neurotomy group) and a group that underwent a sham operation (control group).³H-leucine uptake in the pancreatic protein fraction of the neurotomy group at 3, 5 and 7 days after the operation was significantly lower than that of the control group (P<0.05-0.01), and this low uptake returned to the normal range at 14 days. Amylase, lipase and trypsin values in pancreatic tissue of the neurotomy group decreased during the period of from 1 to 7 days, and there were significant differences in the values of the respective enzymes at 5 or 7 days between the neurotomy and the control group (P<0.05). Thereafter, all enzyme values increased to within the normal range. Upon examination of pancreatic blood flow using a microsphere, the neurotomy group showed a significant reduction at 7 days compared with the control group (P<0.05), and thereafter exhibited recovery of blood flow. These results indicate that after cutting the pancreatic nerve plexus, exocrine function in the pancreas is reduced immediately but recovers within a short period of time, and that these changes in exocrine function are affected by blood flow in the pancreas. Supported partially by the grants from the Japanese Ministry of Health & Welfare.     

Alterations of exocrine pancreatic enzymes in virus-induced diabetic cattle as revealed by immunohistochemistry

Summary The pancreatic tissue of normal and virus-induced diabetic cattle was investigated by the indirect immunofluores cence technique. Seven secretory proteins (chymotrypsinogen A, trypsinogen, carboxypeptidase A, RNase, DNase, -amylase and lipase) were localized in normal bovine pancreatic acinar cells but in diabetic animals amylase, lipase and carboxy peptidase were either not detectable or markedly diminished. Decrease in amylase content has been reported previously in other diabetic animals. The diminution of the three pancreatic enzymes may be related to the destruction of pancreatic endo crine tissue that occurs in these diabetic animals. Key words: Bovine exocrine pancreas, pancreatic enzymes, dia betes, immunofluorescence, cattle     

Plasma osmolality and exocrine pancreatic secretion

To confirm the influence of plasma osmolality on exocrine pancreatic secretion, hypertonic saline (4% saline) was given intravenously to dogs with gastric and pancreatic fistulae. Intravenous administration of hypertonic saline caused a reduction of pancreatic juice flow and bicarbonate output, but did not alter protein output stimulated by secretin and cerulein. The changes of pancreatic juice flow(X) exhibited negative correlations with the changes in plasma osmolality(Y)(Y = -2.2X + 6A, r = -0.74,p < 0.01). Plasma osmolality and plasma vasopressin level were measured simultaneously. Plasma osmolality was elevated from 292 to 315 mOsm/kg with concurrent increase of plasma vasopressin level from 2.4 to 19.6 pg/ mL. On the other hand, exogenous administration of vasopressin inhibited pancreatic juice flow and bicarbonate output dose-dependently. In conclusion, elevation of plasma osmolality decreased exocrine pancreatic secretion stimulated by secretin and cerulein, and vasopressin may play an important role in its mechanism.     

胰腺外分泌功能检查的临床应用现状与评价

胰腺外分泌功能检查是评估胰腺功能的主要方法,其分为直接胰功能试验和间接胰功能试验。目前许多胰腺外分泌功能检测的试验由于侵入性,操作复杂或稳定性差等因素,临床应用诊断价值有限。为此,对目前已应用于临床的胰腺外分泌功能试验方法进行分析评估,同     

Limited pancreatectomy: significance of postoperative maintenance of pancreatic exocrine function

This study attempted to clarify whether limited pancreatectomy (duodenum-preserving total pancreatic head resection [DPTPHR], or medial pancreatectomy [MP], maintain pancreatic exocrine function more than conventional pancreaticoduodenectomy (Whipple) or pylorus-preserving pancreaticoduodenectomy (PPPD). A total of 125 patients (18 with Whipple, 71 with PPPD, 13 with DPTPHR, and 23 with MP) were studied. Fecal chymotrypsin and p-type amylase, and pancreatic function diagnostant (PFD) tests were used for evaluation. There were no differences in preoperative background. Pancreatic function was seen to be significantly lower after surgery than before surgery in patients who underwent the Whipple procedure and PPPD (P < 0.05), but there was no difference between pre- and postoperative pancreatic function in patients who underwent DPTPHR and MP. Postoperative pancreatic function was shown to be significantly worse in Whipple procedure and PPPD patients than in those with DPTPHR and MP (P < 0.05). Patients who underwent the Whipple procedure and PPPD showed significantly lower pancreatic function than patients who underwent DPTPHR and MP (P < 0.05). There was no difference in pancreatic function between patients who underwent DPTPHR and those with MP. DPTPHR and MP, both of which preserve the entire duodenum, maintain pancreatic function more than the Whipple procedure and PPPD.     

Evaluation of lanreotide effects on human exocrine pancreatic secretion after a single dose: preliminary study

BACKGROUND: Total parenteral nutrition and somatostatin or analogues represent a consolidated therapeutic approach for external fistulas, a frequent complication of major pancreatic surgery. AIMS: To establish the effects of the somatostatin analogue lanreotide on exocrine pancreatic secretion. METHODS: Eight patients, undergoing pancreaticoduodenectomy for malignancy, were enrolled in the trial. The volume and composition of pancreatic secretion were evaluated after one single subcutaneous injection of lanreotide 0.5 mg or placebo in a randomised, double-blind cross-over trial. RESULTS: In the seven patients completing the study, the 24-h output volume was 208.6+/-41.3 and 253.9+/-72.4 ml after lanreotide and placebo, respectively. During the first 6 hours values were 48.1+/-14.7 and 77.6+/-21.4 ml (p=0. 02). No significant difference between treatments was detected in the qualitative composition of 24-h pancreatic secretion, although bicarbonate secretion remained lower after the active drug at all the observation intervals. Peak lanreotide levels were detected 15-30 min after drug injection. Clinical and laboratory tolerability was good. CONCLUSIONS: Lanreotide induced a statistically significant reduction in the output volume with respect to placebo in the first 6 hours after administration, but not thereafter. The present results encourage a new study to be undertaken in a larger sample and with a multiple dosing scheme of treatment.     

Duodenum preservation in pancreatic head resection to maintain pancreatic exocrine function (determined by pancreatic function diagnostant test and cholecystokinin secretion)

Background/Purpose

Organ-preserving surgery, such as pylorus-preserving pancreatoduodenectomy (PPPD), duodenum-preserving pancreatic head resection (DPPHR), or medial pancreatectomy (MP), is one of the recent advances in pancreatic surgery. There was a previous report that preservation of the duodenum maintained pancreatic function. However, concerning the resected pancreas, patients were divided into two groups; one group included pancreatic head resections such as Whipple, PPPD, and complete DPPHR, and the other group included MP that removed only the pancreatic neck and preserved the pancreatic head and distal pancreas. The present study was designed to clarify the significance of duodenum preservation, in comparison with duodenum removal, in patients with pancreatic head resection, in terms of pancreatic function, determined by a pancreatic function diagnostant (PFD) test and cholecystokinin (CCK) secretion.

Methods

The subjects were 61 patients (10 with Whipple, 41 with PPPD, and 10 with complete DPPHR). PFD tests and postprandial plasma CCK secretion were used for evaluation.

Results

There was a significant difference between pre- and postoperative PFD values in the patients who received Whipple or PPPD; however, there was no difference in those who had complete DPPHR. Concerning the postoperative PFD value, complete DPPHR was superior to Whipple and PPPD. Regarding postprandial CCK secretion, the pre- and postoperative values were significantly different in the patients with Whipple or PPPD, but there was no difference in those with complete DPPHR. Comparing the three kinds of operations, complete DPPHR was superior to the other two procedures in its maintenance of pancreatic function. There was the significant correlation between CCK and PFD in our patients in the Spearman Rank Correlation (P < 0.0029) and Fisher’s r to z (P < 0.0058).

Conclusions

When pre- and postoperative pancreatic exocrine function and postprandial CCK secretion were measured in patients with pancreatic head resection, it was found that preservation of the entire duodenum was an important factor for maintaining pancreatic function.     

Effect of cysteamine on insulin release and exocrine pancreatic secretionin vitro

Cysteamine is known to deplete somatostatin from pancreatic D cells. In the isolated perfused rat pancreas we investigated its effects on somatostatin and insulin release as well as exocrine pancreatic secretion in the presence of 16.7 mM glucose and 180 pM CCK-8. At a concentration of 0.1 mM, cysteamine had no significant effect on pancreatic endocrine and exocrine functions. At 10 mM, however, cysteamine released somatostatin (380±70 vs 100±20 fmol/20 min), inhibited insulin output (890±120 vs 13210±3260 units/20 min) and reduced exocrine pancreatic secretion (volume: 12±2 vs 20±2 l/20 min; lipase: 31±3 vs 60±7 units/20 min). We conclude that the complex changes induced by cysteamine are consistent with a physiological role of endogenous somatostatin in the regulation of insulin release. The reduction of exocrine pancreatic secretion, however, was at least in part, if not completely, mediated via the insuloacinar axis rather than a direct effect of cysteamine-released somatostatin on pancreatic acinar cells.This study was supported by the Deutsche Forschugsgemeinschaft (DFG grant Mu 543/3-3).