Comparison of Linear Array Endoscopic Ultrasound and Helical Computed Tomography for the Staging of Periampullary Malignancies

Background: The purpose of this study was to compare linear array endoscopic ultrasound (EUS) and helical computed tomography (CT) scan in the preoperative local staging evaluation of patients with periampullary tumors.Methods: Patients evaluated with EUS and CT for suspected periampullary malignancies from 1996 to 2000 were analyzed. Surgical/pathology staging results were the reference standard.Results: Forty-eight patients (28 men and 20 women; mean age, 62 ± 4.9 years; range, 18–90 years) were identified. Malignancy was histologically confirmed in 44 patients. Parameters evaluated included tumor size, lymph node metastases, and major vascular invasion. EUS was significantly more sensitive (100%), specific (75%), and accurate (98%) than helical CT (68%, 50%, and 67%, respectively) for evaluation of the periampullary mass (P < .05). In addition, EUS detected regional lymph node metastases in more patients than helical CT. Sensitivity, specificity, and accuracy of EUS were 61%, 100%, and 84%, in comparison to 33%, 92%, and 68%, respectively, with CT. Major vascular involvement was noted in 9 of 44 patients. EUS correctly identified vascular involvement in 100% compared with 45% with CT (P < .05).Conclusions: Linear array EUS was consistently superior to helical CT in the preoperative local staging of periampullary malignancies.Presented in part at the Society of Surgical Oncology Parallel Session, Washington, DC, March 2001.     

胰十二指肠切除术102例临床经验总结

目的总结胰十二指肠切除术（PD）的并发症、死亡率和远期效果。方法对30年施行的102例PD的手术并发症、死亡率和生存率进行回顾性分析。结果组织学诊断包括：壶腹周围癌48例、胰头癌43例、胰头慢性炎症4例、胃癌和结肠癌胰腺转移各2例、十二指肠腺瘤、胰头部囊腺瘤和胰岛细胞瘤各1例。近15年胰头癌切除率增加。总手术死亡率9.9%。死因包括胰瘘3例和上消化道出血2例，术中大出血、术后腹腔内继发出血、呼吸衰竭、腹腔内感染和脑出血各1例。恶性肿瘤1～5年存活率分别为57％、38％、27％、19％和8％。结论出血和胰瘘是导致PD术后死亡的主要并发症。胰肠和胆肠吻合口的腔内引流是预防胆瘘和胰瘘的有效方法。为了增加肿瘤切除率，当有经验的外科医生也无法排除胰头肿大和梗阻性黄疸是肿瘤引起时，即使未获得病理学的支持，也应施行PD。     

壶腹周围癌的影像学诊断方法

壶腹周围癌为消化系统恶性肿瘤，虽较早引起梗阻性黄疸，但早期诊断较困难。近年来影像学诊断技术的发展，为临床提供了较可靠的诊断依据。本文对壶腹癌的几种影像学诊断方法作一综述。     

ERCP在诊治十二指肠壶腹周围疾病中的应用

目的：探讨ERCP在诊断和治疗十二指肠壶腹周围良恶性疾病中的应用。方法：自1999年1月～2003年4月，173例壶腹周围良恶性疾病患者经ERCP选用十二指肠乳头活检，常规乳头切开或针刀切开，乳头气囊扩张，胆道结石取石术，放置鼻胆管、塑料内支架或金属内支架等方法。结果：173例壶腹周围疾病中，良性病变99例，95例(95．9％)得到内镜诊断或治疗，其中壶腹周围炎性狭窄治疗成功率95．4％(83／87)，同时伴有结石40例，结石取出率92．5％(37／40)，其中乳头结石嵌顿取石治疗成功率100％(12／12)。壶腹周围恶性肿瘤74例，内镜活检病理证实壶腹周围腺癌48例(64．9％)，经内镜引流共43例(58．1％)，其中鼻胆管引流20例、塑料内支架13例、金属内支架10例。结论：在乳头结石嵌顿、壶腹周围炎性狭窄治疗中．内镜治疗效果显著，在壶腹周围恶性肿瘤术前病理诊断、胆道置管减黄，晚期患者姑息性胆道置管引流中，有一定的临床应用价值。     

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

AIM:To elucidate surgical outcomes of pancreaticoduodenectomy(PD)in patients with liver cirrhosis.METHODS:We studied retrospectively all patients who underwent PD in our centre between January 2002and December 2011.Group A comprised patients with cirrhotic livers,and Group B comprised patients with non-cirrhotic livers.The cirrhotic patients had ChildPugh classes A and B(patient’s score less than 8).Preoperative demographic data,intra-operative data and postoperative details were collected.The primary outcome measure was hospital mortality rate.Secondary outcomes analysed included duration of the operation,postoperative hospital stay,postoperative morbidity and survival rate.RESULTS:Only 67/442 patients(15.2%)had cirrhotic livers.Intraoperative blood loss and blood transfusion were significantly higher in group A(P=0.0001).The mean surgical time in group A was significantly longer than that in group B(P=0.0001).Wound complications(P=0.02),internal haemorrhage(P=0.05),pancreatic fistula(P=0.02)and hospital mortality(P=0.0001)were significantly higher in the cirrhotic patients.Postoperative stay was significantly longer in group A(P=0.03).The median survival was 19 mo in group A and 24 mo in group B.Portal hypertension(PHT)was present in 16/67 cases of cirrhosis(23.9%).The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT(P=0.001).Postoperative morbidity(0.07)and hospital mortality(P=0.007)were higher in cirrhotic patients with PHT.CONCLUSION:Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis.PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis;therefore,it is only recommended in patients with Child A cirrhosis without portal hypertension.     

Vascular involvement in periampullary tumors: MDCT,EUS, and CDU

In patients affected by periampullary tumors, surgical resection represents the only treatment with curative intent. Preoperative evaluation of vascular involvement is necessary to avoid surgical treatments unable of curative intent resection. The aim of our update article is to assess the performance of multidetector computed tomography (MDCT), endoscopic ultrasonography (EUS), and color Doppler ultrasonography (CDU) in the evaluation of vascular involvement of major peripancreatic vessels, in periampullary tumors, analyzing the current and past literature.     

壶腹周围癌可切除性术前评估与手术方法的改进

目的 探讨胰二二指肠切除术术前可切除性的评估和手术方法的改进对切除率,并发症发生率、手术死亡率和生态２率的影响。方法 阐述壶腹周围癌ＣＴ的鉴别诊断与术前手术可切除性的评估的方法,以及对壶腹周围癌,尤其是胰头癌行胰十二指肠切除 改进。结果 １３８例壶腹周围癌中,行胰十二指肠切除椁９８例,切除率７１％,并发症发生率１６．７％,手术死亡率６．５％。其中胰头癌１１２２列,行胰十二指肠切除术７２例,切除率７     

影像学检查技术在壶腹周围癌诊断上的合理应用

目的：探讨影像学检查技术在壶腹周围诊断上的合理应用。方法：对我院185例壶腹周围癌（包括胰头癌119例、十二指肠乳头癌41例、Vater壶腹癌13例、胆总管下段癌12例）的临床特点和各种影像学检查资料进行回顾性分析。结果：本组CT诊断胰头癌的准确率为90．9％；ERCP对十二指肠乳头癌的确诊率为100％；ERCP和MRCP对壶腹癌和胆总管下段癌的诊断价值优于其他检查。78％的病人上腹饱胀／隐痛出现时间早于黄疸1－3月。血清CA19－9值在3／4以上的胰头癌、壶腹癌和胆总管下段癌病人超过正常值。结论：凡有中上腹部饱胀、隐痛、血清CA19－9值升高、胆总管和（或）胰管扩张的病人应有步骤地进行各种影像学检查。超声检查发现胰头部有肿块，宜行CT检查。如未发现肿块，则行ERCP。凡ERCP检查时观察到有肿瘤征象的病人，不宜作胰胆管造影而仅作活检。MRCP可用于胰胆管造影失败的壶腹癌和胆总管下段癌。超声内镜对壶腹周围癌的诊断和鉴别诊断也起重要作用。     

323例简化捆绑式胰肠吻合的临床疗效

目的 探讨简化捆绑式胰肠吻合的临床疗效.方法 回顾性分析2005年3月至2010年5月华中科技大学同济医学院附属同济医院实施根治性胰十二指肠切除术治疗323例壶腹部周围癌患者的临床资料.胰肠吻合均采用简化的捆绑式胰肠吻合:胰腺断端游离3～4 cm;将6号或8号硅胶导尿管插入胰管内4～5 cm,胰腺断端外硅胶管为6～8 cm,用可吸收缝线将其缝合固定在胰腺断端上;胰腺断端交锁缝合止血.将空肠断端外翻2～3 cm,电灼损伤黏膜1 cm;回复外翻空肠,在空肠断端的系膜及其对侧和两者的中点与胰腺的下缘、上缘及其之间的胰腺被膜各对称性地缝合1针;并将空肠套在胰腺断端后打结固定.在确定空肠完整地套在胰腺游离段上后,用1-0可吸收线将空肠断端捆绑在胰腺游离段上.消化道重建均采用Child法.结果 323例患者顺利完成了简化的捆绑式胰肠吻合;1例胰肠吻合口出血患者于缝扎出血点后第3天发生胰瘘,置管引流出院1个月后自行痊愈.2例胆总管下端癌和2例胰腺钩突部癌患者分别于术后3、6和8、11 d发生胰瘘,经引流等保守治疗后痊愈.胰瘘发生率为1.5%(5/323).结论 简化的捆绑式胰肠吻合简单易行、安全、可靠,可明显降低胰瘘的发生率.     

双重连续锁边缝合胰胃吻合术

胰瘘是胰十二指肠切除术后最常见的并发症。针对胰腺质地柔软的患者,2011年1月至2012年6月华中科技大学同济医学院附属同济医院设计了双重连续锁边缝合胰胃吻合术,采用该方法对92例胰腺质地柔软的壶腹周围癌患者施行胰十二指肠切除术的消化道重建。中位胰胃吻合时间为12min,15例患者出现并发症,其中2例发生胰瘘（A级和B级各1例）。双重连续锁边缝合胰胃吻合术对胰腺质地柔软患者是一种安全、简单和可操作性强的新型胰胃吻合方式,有望为腹腔镜胰胃吻合提供新的选择。