Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinomad—part 3: Update on 5-year survival

The study objective was to update the survival analysis at the 5-year mark of patients undergoing standard versus radical (extended) pancreaticoduodenectomy (PD) for periampullary adenocarcinoma (cancers of the pancreas, ampulla, common bile duct, and duodenum). A prospective randomized trial was performed (April 1996 through June 2001) comparing survival after pylorus-preserving PD resection (standard) to survival after PD with distal gastrectomy and retroperitoneal lymphadenectomy (radical). An interim report (Ann Surg 1999;229:613) and report after closing the trial (Ann Surg 2002;236:355) showed no differences in survival between the standard and radical groups. Two hundred ninety-nine patients were randomized to either the standard or radical group. Five patients were excluded from final analysis because final pathology failed to reveal adenocarcinoma. The 5-year survival of the two groups was evaluated. The median live patient follow-up is now 64 months (5.33 years). For all periampullary cancer patients, those undergoing standard resection had 1- and 5-year survival rates of 78% and 25%, respectively, compared with 76% and 31% (P = 0.57) for those patients in the radical group. For pancreatic adenocarcinoma patients, the 1- and 5-year survival rates in the standard group were 75% and 13%, respectively, compared with 73% and 29% in the radical group (P = 0.13). The increased morbidity rate, longer operative time, and similar survival for radical PD led us to conclude that pyloruspreserving PD without retroperitoneal lymphadenectomy should be the procedure of choice for most patients with resectable periampullary adenocarcinoma. While there is an intriguing trend toward improved survival in patients with pancreatic adenocarcinoma in the radical group, this trend may be largely accounted for by the higher incidence of microscopically margin positive resections in the standard resection group (21%) compared with a 5% incidence in the radical group (P = 0.002). Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

胰头及壶腹周围良性病变误行胰十二指肠切除术

目的 探讨胰十二指肠切除术中良性病变所占比例及术前、术中明确诊断的方法.方法 回顾性分析我院1994～2004年期间73例术前诊断为胰头或壶腹周围恶性肿瘤而做胰十二指肠切除术病例中,术后病理诊断为良性病变者17例的临床、病理资料.结果 术后病理检查发现慢性胰腺炎12例,胰腺囊腺瘤恶变1例,十二指肠乳头状腺瘤2例,胆总管下段炎性狭窄2例.良性病变占整个胰十二指肠切除术病例的23.3%.结论 在做胰十二指肠切除术的良性病变中慢性胰腺炎占大多数.术中穿刺活检做冰冻切片病理检查是鉴别良、恶性病变的最有效方法.     

POSSUM评分对65岁以上老年人胰十二指肠切除术的意义

目的:探讨POSSUM评分(生理学和手术严重评分结合并发症与病死率系统,physiologicalandoperative-severityscoreforenUmerationofmortalityandmorbidity,POSSUM)对65岁以上老年人行胰十二指肠切除术的术后并发症及病死率的评定意义。方法:对1995年1月至2004年12月间作胰十二指肠切除术的68例(>65岁)胰头和壶腹周围癌患者(老年组)回顾性分析及POSSUM评分,并与同期中青年组(<65岁)128例患者作比较。结果:老年组术后并发症发生率为36.7%,手术病死率11.7%;中青年组分别为20.1%和2.3%。老年组术后并发症主要为肺部感染(14.7%),心律失常(11.7%),急性肾功能不全(5.8%),死亡的主要原因是各种感染所致多脏器衰竭,急性肾功能不全。老年组围手术期POSSUM评分预测术后并发症发生率和手术病死率与实际发生率差异无显著性意义(χ2=0.91,P>0.05)。结论:老年人胰头十二指肠切除术是高风险的手术,围手术期POSSUM评分能预测术后并发症发生率和手术病死率,并指导围手术期处理。     

基层医院开展胰十二指肠切除术的体会

目的：总结基层医院开展胰头癌行胰十二指肠切除术的经验。方法：回顾分析我院普外科6年来按Child方式行胰十二指肠切除术的11例胰头癌。结果：3例出现胰瘘,7例无并发症,11例均治愈出院,无死亡病例。结论：胰十二指肠切除术术中应重点预防胰肠吻合口瘘的发生,特别是肥胖患者。     

Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy

BACKGROUND: Leakage at the pancreaticoenteric anastomosis remains a common and serious complication after pancreaticoduodenectomy. Over the past decade, various measures directed towards prevention of pancreatic leakage have been studied. This article reviews the available data on the efficacy of these measures. DATA SOURCES: The Medline database from 1990 to 2000 was searched for studies on the prevention of pancreatic anastomotic leakage, and the bibliographies of the articles were reviewed for additional references. RESULTS: A meta-analysis of the results of prophylactic octreotide in preventing pancreatic fistula after pancreaticoduodenectomy from data available in three randomized controlled studies yielded an odds ratio of 1.08 (95% confidence interval 0.64 to 1.84). Pending further trials to clarify its role, the routine use of octreotide in pancreaticoduodenectomy cannot be recommended. Retrospective or nonrandomized prospective studies suggested that technical modifications such as duct-to-mucosa anastomosis, pancreaticogastrostomy and external pancreatic duct stenting may reduce the leakage rate, but there is a paucity of randomized trials. A randomized trial comparing pancreaticogastrostomy and pancreaticojejunostomy did not reveal a significant difference in the leakage rate. CONCLUSIONS: Further randomized controlled studies are required to determine the optimum technique of pancreaticoenteric anastomosis after pancreaticoduodenectomy.     

肠内营养在胰十二指肠切除术中的应用

目的回顾分析胰十二指肠切除术中采用胰胃吻合及空肠造瘘行肠内营养疗效。方法1998年1月～2007年1月共进行胰十二指肠切除胰胃吻合手术46例,采用胰胃双层套入式吻合法,胰管内放置支撑引流管,加空肠造瘘术行肠内营养。结果患者术后无胰瘘、胆瘘发生。结论胰十二指肠切除术中采用胰胃双层吻合安全、有效,明显减少胰瘘的发生,空肠造瘘行肠内营养支持应是胰十二指肠切除手术患者手术后的首选营养支持方案。     

保留幽门的胰十二指肠切除术的临床研究（附22例报告）

目的 掌握保留幽门的胰十二指肠切除术（简称PPPD术）及术后并发症的防治。方法 从手术适应症、手术方法及并发症对22例PPPD术后的病人进行回顾分析。结果 本组22例恶性肿瘤，病检十二指肠切缘均无癌瘤，3例术后发生暂时性胃排空障碍，不影响术后的满意效果，没有相关并发症。结论 PPPD术是治疗胰腺及壶腹周围癌的一种良好术式。     

胰腺损伤42例回顾分析

目的探讨胰腺损伤的诊断和治疗方法。方法回顾性分析1998～2003年收治的42例胰腺损伤的临床资料。结果胰腺损伤Ⅰ级4例，Ⅱ级14例，Ⅲ级15例，Ⅳ级6例，Ⅴ级3例。结果：术前确诊8例，其余34例术中确诊。保守治疗4例，行单纯外引流12例，胰头侧缝合加胰尾脾切除12例，胰头侧缝合、胰体尾侧断端与胃吻合10例，胰十二指肠切除术2例，十二指肠憩室化2例，死亡2例。结论术前确诊胰腺损伤较为困难，术前磁共振胰胆管造影检查可提高诊断率。对怀疑或诊断为胰腺损伤者，尽早手术探查，选择恰当的手术方式，可有效地减少其并发症，降低死亡率。     

Endoscopic ultrasound-guided antegrade stone removal in a patient with pancreatic stones and anastomotic stricture after end-to-side pancreaticojejunostomy

Pancreaticoenteric anastomotic stricture can occur as a late complication of pancreatic head resection and is difficult to manage. The surgically altered anatomies of patients that have undergone pancreatic head resection make it difficult to perform pancreatic duct drainage using conventional endoscopes, and it is especially difficult to endoscopically identify stenotic pancreaticojejunal anastomoses. A 40-year-old woman was referred to our department for the treatment of symptomatic multiple pancreatic stones and anastomotic stricture after end-to-side pancreaticojejunostomy. Endoscopic ultrasound-guided pancreaticogastrostomy was performed in an attempt to avoid re-surgery. At 18 days after the initial procedure, a guidewire was successfully placed in the jejunum through the anastomotic stricture. The anastomotic stricture was dilated using a dilation balloon, and all of the stones were pushed into the jejunum using a retrieval balloon. No complications were experienced during the procedure. At 22 months after the stone removal, the main pancreatic duct displayed a decreased diameter, and no stone recurrence was detected.