降低胰十二指肠切除术后外科并发症的临床体会

目的探讨减少胰十二指肠切除术后外科并发症的方法。方法对我科2004年1月-2010年1月行胰十二指肠切除术的77例患者术式选择和术后并发症进行回顾性分析。结果77例均作标准的Whipple术,胰颈空肠套人端侧吻合51例,套入端端吻合21例,胰管空肠粘膜吻合5例,全组77例中共9例发生外科并发症,其中胰漏3例,上消化道出血2例,腹腔出血1例,功能性胃排空障碍3例。结论注意术式选择的个体化和精细的手术技巧是减少胰十二指肠切除术后严重并发症发生的重要措施。     

沟槽状胰腺炎的临床研究进展

沟槽状胰腺炎(GP)是一种主要累及胰腺沟槽区的慢性胰腺炎,因起病隐匿,大多数临床医师对它缺乏基本的认识,容易误诊。GP发病机制尚不明确,其临床表现与胰腺癌极为相似,主要是餐后上腹部疼痛、恶心、呕吐、体质量进行性下降。目前尚无统一的诊断标准。对高度怀疑GP,部分学者建议采用分步治疗的方法。因此,笔者对相关文献进行整理,探讨GP的最新研究进展,以提高对该病的认识和诊治水平。     

胰十二指肠切除术后肠内营养支持的临床应用

目的 探讨肠内营养（EN）支持对胰十二指肠切除术患者的临床效果。方法 回顾分析胰十二指肠切除术22 例病人的临床资料,采用术中置空肠造瘘管术后常规EN方法,观察EN实施后效果及并发症情况。结果 本组22例病人中,21例痊愈,1例死亡。痊愈患者中,未出现胰瘘和胃肠吻合口瘘,肠道功能均在 3～5d内恢复,并逐步恢复经口进食。术后出现胆瘘1例,经有效的引流后痊愈;肺部感染2例,经抗感染后治愈;1例死亡患者因胰瘘并腹腔感染致腹腔内反复出血而衰竭死亡。结论 采用空肠造瘘管进行胰十二指肠切除术后的EN支持治疗,方法简单易于掌握,效果良好。     

Reduction of in-hospital mortality following regionalisation of pancreatic surgery in the south-east of The Netherlands

Background

In the late nineties of the former century, surgery for pancreatic and peri-ampullary cancer in the southern part of The Netherlands was performed mainly in low-volume hospitals (<5 resections/year). Results reported by the Comprehensive Cancer Center South (CCCS) in 2005 revealed the clearly disappointing results of this practice. The former stimulated the regionalisation of pancreatic surgery by 3 collaborating surgical units into one non-academic teaching hospital in the eastern part of the CCCS-region starting from July 2005.

Methods

All of the 76 patients in this regional cohort group in whom a resection of a (peri-)pancreatic tumour was performed with curative intent have been followed up prospectively. The results of surgical morbidity and in-hospital mortality were compared with the results of the CCCS cohort group which were reported previously.

Results

Ever since the regionalisation the annual number of patients undergoing resection of a pancreatic tumour increased from 10 to 33, resulting in a total number of 76 patients. Post-operative complications, reoperation rate and in-hospital mortality decreased significantly to 34.2%, 18.4% and 2.6% respectively, as compared to 71.9%, 37.8 and 24.4% in the time period before regionalisation (p < 0.01).

Conclusion

These unique comparative prospective data derived from daily practice in a collaborative surgical region in The Netherlands (CCCS) support the need for centralisation of pancreatic surgery in order to improve standard of care in pancreatic surgery. This can be achieved by collaboration in a large regional hospital.     

Hydatid cyst of the pancreas:Report of an undiagnosed case of pancreatic hydatid cyst and brief literature review

AIM: To overview the literature on pancreatic hydatid cyst(PHC) disease, a disease frequently misdiagnosed during preoperative radiologic investigation.METHODS: PubMed, Medline, Google Scholar, and Google databases were searched to identify articles related to PHC using the following keywords: hydatid cyst, hydatid disease, unusual location of hydatid cyst, hydatid cyst and pancreas, pancreatic hydatid cyst, and pancreatic echinococcosis. The search included let-ters to the editor, case reports, review articles, original articles, meeting presentations and abstracts that had been published between January 2010 and April 2014 without any restrictions on language, journal, or country. All articles identified and retrieved which contained adequate information on the study population(including patient age and sex) and disease and treatment related data(such as cyst size, cyst location, and clinical man-agement) were included in the study; articles with in-sufficient demographic and clinical data were excluded. In addition, we evaluated a case of a 48-year-old fe-male patient with PHC who was treated in our clinic.RESULTS: A total of 58 patients, including our one new case,(age range: 4 to 70 years, mean ± SD: 31.4 ± 15.9 years) were included in the analysis. Twenty-nine of the patients were female, and 29 were male. The information about cyst location was available from studies involving 54 patients and indicated the follow-ing distribution of locations: pancreatic head(n = 21), pancreatic tail(n = 18), pancreatic body and tail(n = 8), pancreatic body(n = 5), pancreatic head and body(n = 1), and pancreatic neck(n = 1). Extra-pancreatic locations of hydatid cysts were reported in the studies involving 44 of the patients. Among these, no other focus than pancreas was detected in 32 of the patients(isolated cases) while 12 of the patients had hydatid cysts in extra-pancreatic sites(liver: n = 6, liver + spleen + peritoneum: n = 2, kidney: n = 1, liver + kidney: n = 1, kidney + peritoneum: n = 1 and liver + lung: n = 1). Serological information was available in the studies involving 40 patients, and 21 of those pa-tients were serologically positive and 15 were serologi-cally negative; the remaining 4 patients underwent no serological testing. Information about pancreatic cyst size was available in the studies involving 42 patients; the smallest cyst diameter reported was 26 mm and the largest cyst diameter reported was 180 mm(mean ± SD: 71.3 ± 36.1 mm). Complications were avail-able in the studies of 16 patients and showed the fol-lowing distribution: cystobiliary fistula(n = 4), cysto-pancreatic fistula(n = 4), pancreatitis(n = 6), and portal hypertension(n = 2). Postoperative follow-up data were available in the studies involving 48 patients and postoperative recurrence data in the studies of 51 patients; no cases of recurrence occurred in any patient for an average follow-up duration of 22.5 ± 23.1(range: 2-120) mo. Only two cases were reported as having died on fourth(our new case) and fifteenth days respectively. CONCLUSION: PHC is a parasitic infestation that is rare but can cause serious pancreato-biliary complica-tions. Its preoperative diagnosis is challenging, as its radiologic findings are often mistaken for other cystic lesions of the pancreas.     

Pancreatic cancer: Advances in treatment

Pancreatic cancer is a leading cause of cancer mortality and the incidence of this disease is expected to continue increasing. While patients with pancreatic cancer have traditionally faced a dismal prognosis, over the past several years various advances in diagnosis and treatment have begun to positively impact this disease. Identification of effective combinations of existing chemotherapeutic agents, such as the FOLFIRINOX and the gemcitabine + nab-paclitaxel regimen, has improved survival for selected patients although concerns regarding their toxicity profiles remain. A better understanding of pancreatic carcinogenesis has identified several pre-malignant precursor lesions, such as pancreatic intraepithelial neoplasias, intraductal papillary mucinous neoplasms, and cystic neoplasms. Imaging technology has also evolved dramatically so as to allow early detection of these lesions and thereby facilitate earlier management. Surgery remains a cornerstone of treatment for patients with resectable pancreatic tumors, and advances in surgical technique have allowed patients to undergo resection with decreasing perioperative morbidity and mortality. Surgery has also become feasible in selected patients with borderline resectable tumors as a result of neoadjuvant therapy. Furthermore, pancreatectomy involving vascular reconstruction and pancreatectomy with minimally invasive techniques have demonstrated safety without significantly compromising oncologic outcomes. Lastly, a deeper understanding of molecular aberrations contributing to the development of pancreatic cancer shows promise for future development of more targeted and safe therapeutic agents.     

Laparoscopic pancreatectomy: Indications and outcomes

The application of minimally invasive approaches to pancreatic resection for benign and malignant diseases has been growing in the last two decades. Studies have demonstrated that laparoscopic distal pancreatectomy(LDP) is feasible and safe, and many of them show that compared to open distal pancreatectomy, LDP has decreased blood loss and length of hospital stay, and equivalent post-operative complication rates and shortterm oncologic outcomes. LDP is becoming the procedure of choice for benign or small low-grade malignant lesions in the distal pancreas. Minimally invasive pancreaticoduodenectomy(MIPD) has not yet been widely adopted. There is no clear evidence in favor of MIPD over open pancreaticoduodenectomy in operative time, blood loss, length of stay or rate of complications. Robotic surgery has recently been applied to pancreatectomy, and many of the advantages of laparoscopy over open surgery have been observed in robotic surgery. Laparoscopic enucleation is considered safe for patients with small, benign or low-grade malignant lesions of the pancreas that is amenable to parenchyma-preserving procedure. As surgeons’ experience with advanced laparoscopic and robotic skills has been growing around the world, new innovations and breakthrough in minimally invasive pancreatic procedures will evolve.     

Pancreaticoduodenectomy following total gastrectomy:A case report and literature review

We present a case of afferent loop syndrome(ALS)occurring after pancreaticoduodenectomy(PD)in a patient who had previously undergone total gastrectomy(TG),and review the English-language literature concerning reconstruction procedures following PD in patients who had undergone TG.The patient was a69-year-old man who had undergone TG reconstruction by a Roux-en-Y method at age 58 years.The patient underwent PD for pancreas head adenocarcinoma.A jejunal limb previously made at the prior TG was used for pancreaticojejunostomy and hepaticojejunostomy.Despite normal patency of the hepaticojejunostomy,he suffered from repeated postoperative cholangitis which was brought on by ALS due to shortness of the jejunal limb(15 cm in length).We therefore performed receliotomy in which the hepaticojejunostomy was disconnected and reconstructed using a new Y limb 40-cm in length constructed in a double Roux-en-Y fashion.The refractory cholangitis resolved immediately after the receliotomy and did not recur.Review of the literature revealed the lack of any current consensus for a standard procedure for reconstruction following PD in patients who had previously undergone TG.This issue warrants further attention,particularly given the expected future increase in the number of PDs in patients with a history of gastric cancer.     

Analysis of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy

AIM: To explore the morbidity and risk factors of postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy.METHODS: The data from 196 consecutive patients who underwent pancreaticoduodenectomy, performed by different surgeons, in the General Hospital of the People’s Liberation Army between January 1^st, 2013 and December 31^st, 2013 were retrospectively collected for analysis. The diagnoses of POPF and clinically relevant (CR)-POPF following pancreaticoduodenectomy were judged strictly by the International Study Group on Pancreatic Fistula Definition. Univariate analysis was performed to analyze the following factors: patient age, sex, body mass index (BMI), hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pancreatic duct diameter, pylorus preserving pancreaticoduodenectomy, pancreatic drainage and pancreaticojejunostomy. Multivariate logistic regression analysis was used to determine the main independent risk factors for POPF.RESULTS: POPF occurred in 126 (64.3%) of the patients, and the incidence of CR-POPF was 32.7% (64/196). Patient characteristics of age, sex, BMI, hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pylorus preserving pancreaticoduodenectomy and pancreaticojejunostomy showed no statistical difference related to the morbidity of POPF or CR-POPF. Pancreatic duct diameter was found to be significantly correlated with POPF rates by univariate analysis and multivariate regression analysis, with a pancreatic duct diameter ≤ 3 mm being an independent risk factor for POPF (OR = 0.291; P = 0.000) and CR-POPF (OR = 0.399; P = 0.004). The CR-POPF rate was higher in patients without external pancreatic stenting, which was found to be an independent risk factor for CR-POPF (OR = 0.394; P = 0.012). Among the entire patient series, there were three postoperative deaths, giving a total mortality rate of 1.5% (3/196), and the mortality associated with pancreatic fistula was 2.4% (3/126).CONCLUSION: A pancreatic duct diameter ≤ 3 mm is an independent risk factor for POPF. External stent drainage of pancreatic secretion may reduce CR-POPF mortality and POPF severity.