Significance of mesenteric lymphadenopathy after pancreaticoduodenectomy for periampullary carcinomas: evaluation with serial MDCT studies

OBJECTIVE: To evaluate the significance of mesenteric lymphadenopathy arising after pancreaticoduodenectomy (PD) for periampullary carcinomas. MATERIALS AND METHODS: Serial multidetector CT (MDCT) studies in 44 patients after PD for periampullary carcinomas (Group A) were retrospectively reviewed, the incidence and interval changes of mesenteric lymphadenopathy were evaluated, and comparisons were made with 21 patients who underwent PD for benign diseases (Group B). RESULTS: In Group A, mesenteric lymphadenopathy was seen in 31 of 44 (70.5%) patients. The short axis diameter of the largest lymph node ranged from 6.2 to 11.5mm (mean+/-S.D.: 8.6+/-1.4mm), and the short-axis-to-long-axis (S/L) ratio ranged from 0.46 to 0.99 (mean+/-S.D.: 0.69+/-0.12). Six of the 31 (19.4%) mesenteric lymphadenopathy cases showed interval increases in size on follow-up studies, and three cases showed new development of mesenteric lymphadenopathy: all of these nine cases had concurrent recurrence in the mesenteric root. In Group B, 11 (52.4%) had mesenteric lymphadenopathy. The short axis diameter of the largest lymph node ranged from 5.6 to 10.9mm (mean+/-S.D.: 8.0+/-1.9mm) and the S/L ratio ranged from 0.48 to 0.93 (mean+/-S.D.: 0.67+/-0.12). Differences in the incidence, short axis diameter and S/L ratio were not significant between Groups A and B (p=0.154, 0.271 and 0.654, respectively). CONCLUSION: Mesenetric lymphadenopathy after PD less likely reflects recurrence. Lymph node metastasis may be suggested only when coexisting recurrent mass is found in the proximal mesenteric root.     

Advanced bile duct carcinoma in a 15-year-old patient with pancreaticobiliary maljunction and congenital biliary cystic disease

We report a case of advanced bile duct carcinoma arising in a 15-year-old female with pancreaticobiliary maljunction and congenital biliary cystic disease. Pancreaticoduodenectomy and partial resection of the liver was performed. Surgical and histopathological findings indicated advanced tubular adenocarcinoma, classified as final stage IVb according to the General rules for surgical and pathological studies on cancer of the biliary tract proposed by the Japanese Society of Biliary Surgery, 5th edition, and stage IV according to the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC), 6th edition. She underwent chemotherapy with gemcitabine HCl after discharge. She died of cachexia 14 months after the surgery. Although it is well known that biliary malignancies arise frequently in patients with pancreaticobiliary maljunction, it is uncommon for advanced bile duct carcinoma to occur in a 15-year-old female. We should pay attention to the possibility of biliary malignancy in patients with pancreaticobiliary maljunction and congenital biliary cystic disease, even when the patients are juveniles.     

Angiography is Indicated for Every Sentinel Bleed after Pancreaticoduodenectomy

Background  Delayed massive bleeding is one of the leading causes of mortality after pancreaticoduodenectomy (PD) and is often preceded by sentinel bleed. Immediate and accurate diagnosis of sentinel bleed is essential to save patients from a delayed massive hemorrhage. Angiography is probably the procedure of choice for patients with sentinel bleed after PD, as it will localize the bleeding point and provide interventional embolization. The purpose of this study is to test the efficiency of angiography as the initial management for patients with sentinel bleed after pancreaticoduodenectomy. Methods  The study group consisted of 283 patients who underwent PD from July 2002 to June 2007. Angiography and arterial embolization were performed for every sentinel bleed and detected pseudoaneurysm. Patients (n = 311) from a previous study (July 1996–June 2002) were used as a historical control group. Results  Sentinel bleed was detected in 20 patients in study group. Of these, angiography-detected pseudoaneurysm was evident in seven (35%); all were successfully embolized. Delayed massive hemorrhage occurred in three of 13 patients with sentinel bleed but negative angiography. All three were operated on; one died of uncontrolled bleeding. The number of hemodynamically unstable patients before transfusion, units of transfused packed cells, and bleeding related mortalities were significantly less in study group than the control group. Conclusions  Institution of angiography for every detected sentinel bleed after PD enabled us to embolize seven pseudoaneurysms before massive hemorrhage. Most importantly, bleeding-related mortality was significantly less than in the absence of angiography.     

肠系膜上血管或门静脉受压性胰头部恶性肿瘤根治性胰十二指肠切除术的技巧

目的 探讨肠系膜上血管或门静脉受压性胰头部恶性肿瘤的根治性胰十二指肠切除技巧.方法 在2005年3月至2007年3月,术前采用多排螺旋CT薄层扫描和血管重建技术评估56例肠系膜上血管或门静脉受压性胰头部恶性肿瘤患者的邻近血管是否受侵犯和肿瘤的可切除性;术中运用预置肠系膜上静脉、门静脉、脾静脉三阻断带或四阻断带(附加肠系膜下静脉),以及肠系膜上静脉与肠系膜上动脉交叉牵引下完整切除胰腺钩突部的方法,顺利地完成了56例根治性胰十二指肠切除.结果 术前判断胰腺肿瘤是否侵犯血管和可切除性的准确率分别为98%和100%.56例患者中,37例行三阻断和2例行四阻断后用5-0无创血管缝合线缝合肠系膜上静脉出血点;1例行肠系膜上静脉部分切除修补;手术时间5～8 h;出血量200～600 ml.无术中及术后大出血和胰瘘发生.随访至今,2例患者因肝脏多发性肿瘤转移,分别于术后7个月和9个月死亡.其他54例至今存活良好.结论 术前多排螺旋CT薄层扫描、血管重建技术可较准确地判断胰腺肿瘤是否侵犯血管和是否可根治性切除;采用三阻断或四阻断和肠系膜上血管交叉牵引方法可较顺利地完成肠系膜上血管或门静脉受压性胰头部恶性肿瘤的根治性胰十二指肠切除.     

胰十二指肠切除中合并肝动脉变异患者的诊治

目的 探讨肝动脉解剖变异在胰十二指肠切除术中的临床特点及处理原则.方法 回顾性研究2000年1月至2007年7月收治的176例胰十二指肠切除术患者的临床及影像学资料,探讨相关肝动脉变异的类型、影像学检查及术中处理原则.结果 经术中证实,176例患者中20例存在与胰十二指肠切除术相关的肝动脉变异,其中副肝右动脉起自肠系膜上动脉9例(5.1%),替代肝右动脉起自肠系膜上动脉5例(2.8%),肝总动脉起自肠系膜上动脉4例(2.3%),替代肝右动脉起自胃十二指肠动脉2例(1.1%).术前增强螺旋CT资料可明确诊断起源于肠系膜上动脉的变异肝动脉.20例患者中18例完整保留变异肝动脉,其中包含1例贯穿胰腺实质的变异肝总动脉;2例变异肝右动脉损伤患者积极处理后无严重不良后果.结论 术前增强螺旋CT多能准确显示肝动脉变异情况,合理的手术操作可妥善处理各种肝动脉变异.     

Presidential Address: Adjusting the Art and the Science of Surgery

Why are there so many opinions for surgical treatments? Why do surgeons not agree on the same definitions? To adjust the art and science of surgery, we should understand the reason behind this Tower of Babel and ourselves by grasping the three biological lessons of history. These lessons are instincts of man – our instincts have not changed for as long as there has been recorded history. The lessons were elucidated by Will and Ariel Durant and these are competition, selection, and reproduction. How might they be applied to improving our surgical science?First, competition has always forced individuals or small groups to strengthen themselves with cooperation. Cooperate or not survive. Cooperation increases with social development and technology. Next, we must realize that nature relishes diversity. We are all born unequal and diverse. The second biological lesson is selection; which individual among a diverse group of individuals will succeed (by improving)? Therefore, by nature, man’s instincts provide diverse opinions and bias. This creates a myopic view when surgeons try to discern the truth. The results are the trendy bandwagons that divert us, like tonsillectomy. Too much diversity is bad, and a balance is required. Man’s third lesson of history is reproduction. Better stated is that nature loves quantity. We naturally give priority to quantity over quality. To obtain quality rather than just quantity, we need the antidotes for competition and diversity – that would be cooperation using the Deming guidelines of leadership, profound knowledge, and technology. One example of this urge for quantity and diversity is our lack of standardized definitions. These three biological lessons can be summarized by viewing competition as an impediment for quality improvement in the complex challenges of modern healthcare. Cooperation (trust) is the antidote to the bandwagon effect of unproven treatments. Cooperation and technology can be joined to establish a successful team using the global technology of the internet (“Club Web”). To improve, we must measure real cases in a registry and generate a standard set of definitions and benchmarks. A focus group that trusts each other through the common interest of a disease or organ could succeed. Only then does comparison (and improvement) become possible.     

胰十二指肠切除术中不同胰肠吻合方法的疗效比较

目的 比较胰十二指肠切除术中不同胰肠吻合方法的临床疗效.方法 回顾性对比分析92例行胰十二指肠切除术患者的临床资料,根据术中胰肠吻合方法分为捆绑式胰肠吻合组(A组,48例)和胰管对肠黏膜吻合组(B组,44例).结果 两组患者手术时间、术中出血量、术后住院时间和总并发症发生率比较差异无统计学意义(P＞0.05)；A组肛门排气时间长于B组[(101.73±6.47) min比(98.73±6.87) min],胰瘘发生率低于B组[6.2％ (3/48)比20.5％(9/44)],消化障碍发生率高于B组[18.8％(9/48)比4.5％(2/44)],差异均有统计学意义(P＜0.05).结论 两种胰肠吻合方法均能取得良好的临床疗效,捆绑式胰肠吻合可有效减少术后胰瘘的发生,胰管对肠黏膜吻合能有效减少消化障碍的发生,应根据术中情况选择最佳的吻合方式.     

胰十二指肠切除术13例报告

目的：评价改良的胰十二指肠切除术效果，减少并发症，降低死亡率。方法：回顾性分析1995－05－2000－05，作者采用改良的胰十二指肠切除术治疗胰腺癌等恶性肿瘤共13例，观察手术效果。结果：无胰瘘、胆瘘及胃肠吻合口瘘发生，无手术死亡，随访生存11－56个月，效果较好，结论：手术方法正确，吻合技术操作可靠，是减少并发症，降低死亡率的关键。     

胰十二指肠切除术患者围手术期状况与预后的关系

目的 探讨胰十二指肠切除术（PD）后并发症及死亡率发生、预防及处理的相关问题。方法 回顾分析1985年7月至2002年12月期间我院106例施行PD患者的临床资料。结果 本组术后共发生并发症37例（34．91％），其中严重并发症发生率为19．81％（21／106），死亡11例（10．38％）。术前总胆红素〉342μmol／L组与总胆红素4342μmol／L组相比，总并发症和严重并发症发生率显著增高（P〈0．05）；出现并发症或死亡患者的术中出血量、术中输血量及手术时间均明显高于无并发症患者（P〈0．05）。结论 PD近年来的安全性和可切除性已明显提高，但需要有良好的技术、精细的操作、手术经验及围手术期的精心治疗和护理，是减少并发症和死亡率的关键。