Predicting resectability of periampullary cancer with three-dimensional computed tomography

The radiographic assessment of extent of tumor burden and local vascular invasion appears to be enhanced with three-dimensional computed tomography (3D-CT). The purpose of this study was to evaluate the impact of preoperative 3D-CT in determining the resectability of patients with periampullary tumors. Intraoperative findings from exploratory laparotomy were gathered prospectively from 140 patients who were thought to have periampullary tumors and were deemed resectable after undergoing preoperative 3D-CT imaging. CT findings were compared to intraoperative findings, and the accuracy of 3D-CT in predicting tumor resectability and, ultimately, the likelihood of obtaining a margin-negative resection were assessed. Of the 140 patients who were thought to have resectable periampullary tumors after preoperative 3D-CT, 115 (82%) were subsequently determined to have periampullary cancer. The remaining 25 patients had benign disease. Among the patients with periampullary cancer, the extent of local tumor burden involving the pancreas and peripancreatic tissues was accurately depicted by 3D-CT in 93 % of the patients. 3D-CT was 95% accurate in determining cancer invasion of the superior mesenteric vessels. Preoperative 3D-CT accurately predicted periampullary cancer resectability and a margin-negative resection in 98% and 86% of patients, respectively. For patients with pancreatic adenocarcinoma (n=85), preoperative 3D-CT resulted in a resectability rate and a margin-negative resection rate of 79% and 73%, respectively. The ability of 3 D-CT to predict a margin-negative resection for periampullary cancer, including pancreatic adenocarcinoma, relies on its enhanced assessment of the extent of local tumor burden and involvement of the mesenteric vascular anatomy. Presented in part at the Fourth Americas Congress of the American Hepato-Pancreato-Biliary Association, Miami, Florida, February 27-March 2, 2003. Supported in part by a grant from the Stavros S. Niarchos Foundation.     

CLINICAL ANALYSIS OF 150 PATIENTS WITH PERIAMPULLARY CARCINOMA

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Islet cell tumor arising from a heterotopic pancreas in the duodenal wall with ulceration

A rare case of symptomatic islet cell tumor arising from heterotopic pancreas in the duodenum with ulceration is described. Gastrointestinal bleeding was the only sign observed in this patient. Tagged red blood cell scan, upper endoscopy, and computed tomography scan showed active bleeding ulcer from a periampullary mass. Removal of the submucosal tumor was done to prevent future re-bleeding. Histologic and immunohistochemical characterization of the tumor showed an endocrine tumor that expressed a variety of endocrine peptides.     

十二指肠乳头旁憩室与胆结石的关系探讨(附167例分析)

目的 探讨十二指肠憩室在胆结石发病中的作用。方法 回顾性分析我院行逆行胰胆管造影(ERCP)检查的167例患者,其中合并乳头憩室31例(憩室组),无合并乳头憩室136例(非憩室组)。分析比较两组患者年龄、胆结石的发病率、结石发生部位及结石成分方面的差异。结果 本组167例患者中,合并乳头憩室31例,占18.56％。憩室组平均年龄62岁,明显高于非憩室组的52岁(P<0.01),且憩室发生率随年龄的增大而增高。本组发现的86例胆结石患者中24例合并十二指肠憩室,胆结石并憩室发生率27.9％;而非结石组81例中仅7例合并十二指肠憩室,占8.6％。结石组并十二指肠憩室的发生率明显高于非结石组(P<0.05)。本组中乳头旁憩室胆结石发生率(100％)明显高于乳头周围型憩室者(46.2％),有显著性差异(P<0.05)。乳头旁憩室患者的原发性胆总管结石发生率明显高于继发性胆总管结石及胆囊结石,且结石成分主要为胆色素结石。结论 十二指肠乳头旁憩室患者胆结石发病率显著增高,且主要与原发性胆总管结石相关。     

超声对提高胆管疾病诊断率的研究——注射Ceosunin及纵、横旋转扫查法的意义

对肝外胆管扩张(7—15mm)42例施行了Ceosunin注射后(利胆法)超声观察。被证实胆管有梗阻性病变18例中,72％(13例)胆管增宽,16％(3例)无明显变化,12％(2例)缩小;胆管径均值从9.8mm增宽达11.7mm。非梗阻组24例中92％(22例)胆管径缩小,8％(2例)无明显变化,无1例增宽;胆管径均值从9.6mm缩小至6.3mm。梗阻组中9例壶腹周围癌(其中6例肿瘤径≤2cm)经利胆法后胆管径均增宽,采用胆管纵旋转扫查法及横旋转扫查法,使8例肿瘤得以显示。利胆法及旋转扫查法的应用使胆管下段病变显示率从41％提高到88％。对胆管扩张病例施行利胆法,以管径没有缩小为疑诊胆管梗阻的标准,其Sensitivity为89％,Specificity为92％;Accuracy为90％。本方法对判断胆管轻度扩张的病理意义有较高临床价值。为壶腹周围肿瘤的早期诊断提供了无创伤的手段。     

Initial and long-term outcome after palliative surgical drainage of 269 patients with malignant biliary obstruction.

AIMS: This study aimed to analyse the current outcome after palliative surgical drainage of malignant biliary obstruction. METHOD: From 1992 to 2003, perioperative parameters and the incidence and indications of readmissions were analysed in 269 patients who underwent a palliative biliary bypass for periampullary carcinoma. RESULTS: Hospital mortality occurred in seven patients and median postoperative stay was 10 days. Anastomotic leakage occurred in three patients and intraabdominal haemorrhage in eight patients. Overall 75 patients experienced a complication. Nine patients underwent a relaparotomy during initial hospital admission. Overall, 142 patients were readmitted, 13 for indications related to the biliary bypass, 11 for surgery-related indications. Twenty-five patients were readmitted for radiochemotherapy, 112 for progressive disease and 23 for indications not related to the disease. Median survival was 7.5 months and the 3-year survival 3%. Survival was significantly lower in patients with metastases and in those who underwent elective bypass for gastric outlet obstruction. CONCLUSION: Current hospital mortality after palliative biliary bypass as well as readmission rates for complications related to the biliary bypass or surgical procedure are low. Surgical biliary bypass is a safe and effective palliative treatment for patients with malignant biliary obstruction.     

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目的 探讨7例再次剖腹手术行壶腹部癌根治性切除的病人在第一次手术时未行根治性切除的原因。方法 结合术后随访,详细回顾病例资料。结果 第一次剖腹手术时认为癌肿不能切除3例,漏诊3例,误诊1例;第二次手术前结合内镜逆行胰胆管造影（ERCP）、CT等检查,均明确诊断为壶腹部癌,其中CT显示壶腹部占位5例,均未见胰外转移及血管侵犯。均再次剖腹施行胰十二指肠切除术。结论 胆道远端恶性梗阻病人术前ERCP、CT等影像学诊断极为重要,有助于明确诊断,减少手术盲目性,避免再次手术。     

128层螺旋CT对十二指肠乳头旁憩室诊断价值研究

目的探讨MSCT后重组技术对十二指肠乳头旁憩室（PAD）的诊断价值和临床意义。资料与方法60例经MSCT检查确诊的十二指肠乳头旁憩室的MSCT表现和临床资料进行回顾性分析。结朵60例患者共发现十二指肠乳头旁憩室64个，表现为十二指肠腔外的囊状突出，可呈液性囊状影、液-气囊状影及气体囊状影等，位于十二指肠降段与姨头之间。MPR重组技术从不同方位显示十二指肠乳头旁憩室形态、位置及与胆总管、胰腺之间的关系。结论MSCT及其后重组技术有助于PAD的诊断，明确PAD与周围组织的关系，在PAD的诊断中具有较好的临床应用价值。     

Total Laparoscopic Roux-en-Y Cholangiojejunostomy for the Treatment of Biliary Disease

Background and Objectives:

Roux-en-Y cholangiojejunostomy (RCJS) has been widely used in biliary bypass surgeries, but in most reported literature, an assisted mini-incision was needed, and studies reporting total laparoscopic Roux-en-Y cholangiojejunostomy (TLRCJS) are rare. The goal of this study was to investigate how to treat hepatic portal bile duct diseases and perform jejunojejunostomy and cholangiojejunostomy totally laparoscopically. We evaluated the feasibility of TLRCJS in treating biliary tract diseases.

Methods:

TLRCJS were performed in 103 patients from January 2000 to August 2011. There were 28 cases of recurrent choledocholithiasis combined with stricture of the common bile duct (CBD) after several stone extractions, 3 patients with iatrogenic bile duct injury, 24 patients with choledochal cyst, 36 patients with hepatic portal cholangiocarcinoma, and 12 patients with cancer of the pancreatic head and periampullary cancer. All surgeries were performed through 5 trocars. First, laparoscopic surgery on the CBD was performed according to the original disease. The CBD was opened and stones were extracted in choledocholithiasis patients. In iatrogenic injury patients, strictured CBD was resected and repaired. Dilated CBD or choledochal cyst with tumor was transected. In patients with malignant jaundice, the CBD was opened longitudinally. At the same time, the bile duct was prepared for cholangiojejunostomy. Second, the positions of the laparoscope and surgeons were altered. The jejunal mesentery and jejunum were transected, and side-to-side jejunojejunostomy (JJS) was performed. The laparoscope and surgeon positions were exchanged again; the Roux-en-Y biliary limb was lifted close to the residual bile duct; and side-to-side or end-to-side choledochojejunostomy (CJS) was performed. Finally, an abdominal drainage tube was placed.

Results:

All the surgeries were performed successfully. The diameter of the residual bile duct ranged from 0.4 to 3.2 cm (average, 0.9 cm). Three patients had postoperative bile leakage and were treated from 1 week to approximately 1 month with abdominal drainage. Postoperative intraperitoneal hemorrhage and stress ulcer of the stomach occurred in 2 patients with biliary tract injury combined with obstructive jaundice. One with intraperitoneal hemorrhage was cured by another laparoscopic surgery. The other patient was cured after 2 days of abdominal drainage, antacids, and hemostatic drug therapy. The follow-up duration of 95 patients was 4 to 93 months (average, 48.3 months). The follow-up rate was 92.2% (95/103). Patients with cancer died of metastasis or cachexia during 14-month follow-up with no postoperative complication. Reflux cholangitis occurred in 3 patients 2, 3, and 5 years after the operation, respectively. No anastomotic stricture or other complication was found in other patients during the follow-up.

Conclusions:

TLRCJS is the best and first choice for patients with biliary tract diseases that need biliary-jejunal anastomosis. But it is essential that the surgeon has proficiency in laparoscopic surgeries.     

Pancreaticobiliary duct changes of periampullary carcinomas: quantitative analysis at MR imaging

Purpose

To quantitatively analyse the pancreaticobiliary duct changes of periampullary carcinomas with volumetric interpolated breath-hold examination (VIBE) and true fast imaging with steady-state precession (true FISP) sequence, and investigate the value of these findings in differentiation and preoperative evaluation.

Materials and methods

Magnetic resonance (MR) images of 71 cases of periampullary carcinomas (34 cases of pancreatic head carcinoma, 16 cases of intrapancreatic bile duct carcinoma and 21 cases of ampullary carcinoma) confirmed histopathologically were analysed. The maximum diameter of the common bile duct (CBD) and main pancreatic duct (MPD), dilated pancreaticobiliary duct angle and the distance from the end of the proximal dilated pancreaticobiliary duct to the major papilla were measured. Analysis of variance and the Chi-squared test were performed.

Results

These findings showed significant differences among the three subtypes: the distance from the end of proximal dilated pancreaticobiliary duct to the major papilla and pancreaticobiliary duct angle. The distance and the pancreaticobiliary duct angle were least for ampullary carcinoma among the three subtypes. The percentage of dilated CBD was 94.1%, 93.8%, and 100% for pancreatic head carcinoma, intrapancreatic bile duct carcinoma and ampullary carcinoma, respectively. And that for the dilated MPD was 58.8%, 43.8%, and 42.9%, respectively.

Conclusion

Quantitative analysis of the pancreaticobiliary ductal system can provide accurate and objective assessment of the pancreaticobiliary duct changes. Although benefit in differential diagnosis is limited, these findings are valuable in preoperative evaluation for both radical resection and palliative surgery.