薄层轴位T2WI脂肪抑制序列鉴别诊断壶腹周围病变

目的 探讨薄层轴位T2WI脂肪抑制序列对壶腹周围病变的鉴别诊断价值.方法 顺序收集临床资料完整的壶腹周围病变95例,均行上腹部MR检查,同时对感兴趣区行薄层扫描.结果 MRCP结合常规MRI对壶腹周围病变的诊断准确率为75.79%.薄层扫描可显示约2.5 mm小结石和10 mm的肿块,增加薄层扫描后准确率为92.63%,增加薄层扫描前后准确率之间差异有统计学意义.结论 在常规扫描的基础上增加感兴趣区薄层扫描有助于壶腹周围小病变的鉴别诊断.     

Imaging for the diagnosis and staging of periampullary carcinomas

Multiple imaging modalities are available for investigating patients with a suspected periampullary neoplasm. The relative utility of each imaging modality is discussed regarding its role in diagnosis and staging. A general imaging approach to patients with a distal biliary obstruction also is presented.     

完全腹腔镜下Roux—en—Y胆管空肠吻合术在胆系疾病中的应用

目的报道完全腹腔镜下Roux—en—Y吻合术的手术方法,探讨腹腔镜下Roux—en—Y吻合术在胆系疾病手术中的应用价值。方法对103例患者行完全腹腔镜下胆肠Roux—en—Y吻合术,其中多次手术取石后,胆总管结石再发合并胆管狭窄28例,医源性胆道损伤3例,胆总管囊肿24例,肝门部胆管癌36例,胰头癌及壶腹癌12例。所有手术均采用5个Trocar进行操作。首先在腹腔镜下处理胆道病变,即切开胆总管、取净结石;修整并切开损伤胆总管;切除扩张的胆总管;切除肿瘤部位胆管或者纵行切开恶性黄疸患者胆总管引流等;同时为胆肠吻合前做好肝管断端的准备。然后更换腹腔镜位置,于镜下切断空肠及其系膜,行空肠间侧侧吻合。将腹腔镜位置复位,镜下将Roux—en—Y胆支空肠襻牵拉至肝门处行胆肠侧侧或者端侧吻合。最后留置腹腔引流管。结果全组病例均成功完成手术,残余胆（肝）管直径0．4～3．2锄,平均0．9Gin。术后胆汁漏3例,经腹腔引流1周～1个月治愈。2例胆道损伤伴阻塞性黄疸患者,术后均出现应激性溃疡及腹腔内出血,1例腹腔内出血经再次腹腔镜手术止血治愈,另1例经腹腔引流、抑酸及止血药物治疗2d后治愈。95例患者获随访,随访率92．2％（95／103）,随访时间4～93个月,平均48-3个月。胰头、壶腹癌及上段胆管癌患者,随访期间14个月内因转移及消耗死亡,均无手术并发症发生;3例胆总管结石患者分别于术后2、3、5年发生反流性胆管炎,来院经抗炎对症治疗后痊愈出院;其余患者随访期间均无胆道、胆肠吻合口狭窄等并发症发生。结论完全腹腔镜下胆肠Roux—en—Y吻合术是胆道疾病需行胆肠吻合手术治疗的最佳、首选术式,但术者需具有丰富的腹腔镜手术经验。     

机器人与开腹胰十二指肠切除术治疗壶腹周围癌的近期疗效对比分析

目的:对比分析机器人胰十二指肠切除术(RPD)与开腹胰十二指肠切除术(OPD)治疗壶腹部周围癌的近期疗效。方法:2015年1月至2018年12月行胰十二指肠切除术的63例患者,根据手术方式分为RPD组(n=28)与OPD组(n=35),评估RPD与OPD的手术效果。结果:RPD组手术时间[403(337,474)min vs.299(189,425)min,P=0.001]长于OPD组,但术中出血量[164.29(50,200)mL vs.355.14(100,500)mL,P=0.001]、输血率(25%vs.77.1%,P<0.001)、住院时间[(13.96±2.71)d vs.(18.20±8.72)d,P=0.016)]优于OPD组;两组胰瘘、胆漏、胃排空延迟、腹腔感染等并发症发生率差异无统计学意义(P>0.05),术后腹腔引流管拔除时间、再次手术率、病死率两组差异亦无统计学意义(P>0.05)。结论:与OPD相比,RPD术后住院时间短,术中出血量、输血率更低,但手术时间更长,两种术式并发症发生率相当,RPD是安全、可行的,可能具有更大的发展潜力。     

Impact of Screening Examinations on Survival in Familial Adenomatous Polyposis

Background: Prophylactic family screening and surgery has improved the outcome of patients with familial adenomatous polyposis (FAP) largely preventing deaths due to colorectal cancer. The present study compared the mortality rates and causes of death of FAP patients diagnosed by symptoms (probands) or by family screening (call-up). Methods: The study comprised all 236 FAP patients registered in the Finnish Polyposis Registry until the end of June 1998. There were 116 probands and 120 call-up patients with a median age of 36.8 and 22.8 at diagnosis and median follow-up times of 6.3 and 9.9 years, respectively. Cumulative crude and relative survival estimates were calculated for each group and the causes of death were determined. Results: The life expectancy was significantly better in the call-up group than in the probands after colectomy (P &lt; 0.001). The survival rates of the call-up group equaled those expected for a comparable group in the general population up to 18 years after colectomy. The main cause ofdeath was colorectal cancer accounting for 54 out of 68 deaths: four in the call-up group (all rectal stump cancer) and 50 in probands. Upper GI-tract cancer caused four deaths (periampullary cancer two, stomach cancer two) and two deaths were due to postoperative pulmonary embolism. Conclusion: The survival of FAP patients is significantly improved by prophylactic screening and surgery. Further improvement may be possible by using restorative proctocolectomy instead of colectomy and ileorectal anastomosis and by regular upper GI-tract endoscopic surveillance.     

胰腺及壶腹周围癌诊治40年经验总结

本文分析40年来胰腺及壶腹周围癌诊断和治疗的进展。以1978～1989年手术治疗的67例胰腺及壶腹周围癌和1990年～1991年6月的9例与作者1964年报告的90例结果做了对照。1.1977年以前主要诊断根据是临床梗阻性黄疸。1978年以后B超、ERCP、PTC、CT和十二指肠镜检查等已普遍应用,多能确定肿瘤位置或提出异常所在。2.手术切除率由31.1％提高到77.8％。3.术后并发病和死亡原因,早年多因直接与手术有关的并发病,而近年则多为非直接与手术有关的原因,如心肌梗塞、ARDS。4.术后5年绝对生存率由12.5％升到21.1％。3例已健康生存14年以上。     

Molecular Analysis of PIK3CA, BRAF, and RAS Oncogenes in Periampullary and Ampullary Adenomas and Carcinomas

Background  Mutations of KRAS are known to occur in periampullary and ampullary adenomas and carcinomas. However, nothing is known about NRAS, HRAS, BRAF, and PIK3CA mutations in these tumors. While oncogenic BRAF contributes to the tumorigenesis of both pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasms/carcinomas (IPMN/IPMC), PIK3CA mutations were only detected in IPMN/IPMC. This study aimed to elucidate possible roles of BRAF and PIK3CA in the development of ampullary and periampullary adenomas and carcinomas. Methods  Mutations of BRAF, NRAS, HRAS, KRAS, and PIK3CA were evaluated in seven adenomas, seven adenomas with carcinoma in situ, and 21 adenocarcinomas of the periampullary duodenal region and the ampulla of Vater. Exons 1 of KRAS; 2 and 3 of NRAS and HRAS; 5, 11, and 15 of BRAF; and 9 and 20 of PIK3CA were examined by direct genomic sequencing. Results  In total, we identified ten (28.6%) KRAS mutations in exon 1 (nine in codon 12 and one in codon 13), two missense mutations of BRAF (6%), one within exon 11 (G469A), and one V600E hot spot mutation in exon 15 of BRAF. BRAF mutations were present in two of five periampullary tumors. All mutations appear to be somatic since the same alterations were not detected in the corresponding normal tissues. Conclusion  Our data provide evidence that oncogenic properties of KRAS and BRAF but not NRAS, HRAS, and PIK3CA contribute to the tumorigenesis of periampullary and ampullary tumors; BRAF mutations occur more frequently in periampullary than ampullary neoplasms.     

Impact of Regional Lymph Node Evaluation in Staging Patients With Periampullary Tumors

Background Two distinct lymph nodes reproducibly assessed by computed tomography for the evaluation of periampullary tumors are the common bile duct (CBD) node and the gastroduodenal artery (GDA) node. We examined whether radiographical enlargement of either lymph node predicts tumor resectability, nodal metastasis, or patient survival. Methods Ninety-four consecutive patients underwent attempted curative resection of periampullary tumors between September 2001 and June 2003. A single radiologist recorded in a retrospective, blinded fashion the short- and long-axis measurements of the CBD and GDA nodes. Results Sixty-one percent (n = 57) of tumors were resectable by pancreaticoduodenectomy. Overall, actual 6-, 12-, and 18-month survival was 87%, 68%, and 63%, respectively. Enlarged radiographical nodal size by either axis was not associated with the presence of metastasis to these lymph nodes or with reduced overall patient survival. Only a CBD node short-axis size >10 mm predicted unresectability (odds ratio, 3.2; P = .036). Liver metastasis and/or carcinomatosis were present in 43% of unresectable patients, and this was associated with decreased survival at both 1 year (25% vs. 77%; P < .001) and 18 months (19% vs. 72%; P <.001). A pathologic diagnosis of metastasis to the GDA node, but not the CBD node, was associated with a similarly decreased survival (1 year: 33% vs. 78%, P = .028; 18 months: 22% vs. 70%, P = .023). Conclusions For presumed periampullary malignancy, a CBD node short-axis size >10 mm predicts tumor unresectability. Metastatic disease to the GDA node, particularly for pancreatic adenocarcinoma, portends a poor prognosis equivalent to that of hepatic or peritoneal spread. Given these findings, radiographical CBD lymph node measurements may guide selection for performing laparoscopic staging with or without ultrasonography in conjunction with GDA nodal biopsy in patients with periampullary malignancy. Presented in part at the annual meetings of the American Hepato-Pancreatico-Biliary Association on April 15, 2005 and The Pancreas Club on May 15, 2005.     

胰十二指肠切除术328例临床分析

目的总结胰十二指肠切除术(pancreaticoduodenectomy,PD)的手术经验,分析并发症和远期疗效。方法回顾性分析2001年1月—2011年1月间施行的328例PD的临床资料,包括标准PD281例,保留幽门的PD 8例,扩大PD 39例。结果全组手术并发症发生率为34.1%(112/328)。前5位并发症依次为胃排空延迟(16.5%),胰瘘(11.9%),出血(7.0%),腹腔感染(5.2%),肺部感染(4.9%)。再手术率为6.1%(20/328)。病死率为3.0%(10/328)。壶腹周围癌202例中1,3,5年生存率分别为79.1%,51.5%,33.8%,中位生存期为38个月;淋巴结阴性患者(144例)的1,3,5年生存率分别为81.7%,57.6%,40.6%,中位生存期为47个月;淋巴结阳性患者(58例)的1,3,5年生存率分别为72.1%,36.4%,16.8%,中位生存期为24个月;淋巴结阴性患者的长期生存率显著高于淋巴结阳性患者(P=0.003)。胰头癌42例中1,3,5年生存率分别为67.6%,29.1%,9.7%,中位生存期为16个月,其中淋巴结阳性患者(11例)的3年以上...     

A rare case of periampullary carcinoma with ectopic ending of Vater＇s ampulla

A 71-year-old woman was referred to our department complaining of painless progressive jaundice for the last 3 too. Magnetic resonance imaging and magnetic resonance cholangiopancreatography （MRCP） showed the ectopic hepatopancreatic ampulla draining into the fourth part of the duodenum adjacent to the duodenojejunal flexure; the irregular morphology of the duodenojejunal flexure likely due to a soft tissue mass. Laparotomy confirmed the presence of the abnormal ampulla of Vater located at the fourth part of the duodenum and a soft tissue tumor about 6 cm × 5 cm×5 cm with a peduncle adjoining the ampulla. Resection of the tumor, including some peripheral tissue, and a Roux-Y loop anastomosis choledochojejunostomy were performed. Pathological examination indicated an intestinal villous adenoma accompanied by severe dysplasia and focal canceration. Periampullary carcinoma with ectopic ending of the Vater＇s ampulla into the fourth part of the duodenum is rather rare. The embryonic genetic background of this anomaly has not yet been fully explained. It is worth mentioning that MRCP is useful for demonstrating anomalies and anatomic variants of the biliary tract system and pancreatic duct.