胰头癌扩大根治术研究进展

胰腺癌是全世界范围内发病率和死亡率不断上升的致命恶性肿瘤。胰头是胰腺癌发生的主要部位,由于其解剖位置特殊,早期症状常不明显,发现时多属晚期,预后极差。目前,外科手术可能是胰头癌有限的治疗方法中唯一有效的治愈方法,患者的术后远期疗效也随着外科技术及手术方式的不断发展在一定程度上得以提高。手术方式的选择由最初的标准切除术逐步演变为更加接近根治性切除的扩大根治术,包括联合血管切除、扩大淋巴结清扫及联合脏器的切除,但其治疗效果在某些方面仍存在诸多争议。     

No mortality after 150 consecutive pancreatoduodenctomies with duct-to-mucosa pancreaticogastrostomy

BACKGROUND AND OBJECTIVES: The mortality rate after pancreatoduodenectomy (PD) remains 0-5% at major surgical centers with the major cause of operative death being a leak at the pancreaticojejunal anastomosis. The aim of this retrospective study was to evaluate the safety of duct-to-mucosa pancreaticogastrostomy (PG) at a single institute. METHODS: One hundred fifty consecutive patients with pancreato-biliary diseases undergoing duct-to-mucosa PG following PD between 1995 and 2005 were evaluated. One hundred forty patients underwent a pylorus-preserving PD and 10 patients underwent a conventional PD (Whipple operation). External drainage of pancreatic juice was performed in 77 cases. RESULTS: The mean operating time was 378 min and the mean blood loss was 1,640 ml. Blood transfusion was not required in 97 patients (65%). The morbidity rate was 50% (75/150), but the mortality rate was 0%. Pancreatic fistulae occurred in 11 patients (7%). Gender, age, operative procedure, portal vein resection, external drainage of the pancreatic juice, operative time, blood loss and blood transfusion did not affect the rate of pancreatic fistula. The rate of pancreatic fistulae tended to be lower in pancreatic carcinoma (3%) than non-pancreatic carcinoma (11%). CONCLUSIONS: Duct-to-mucosa PG is a safe procedure for reconstruction following PD.     

Gastric emptying after pancreatoduodenectomy with total stomach preservation and selective proximal vagotomy

This study evaluates postoperative gastric emptying following a new method of pancreatoduodenectomy with total stomach preservation and selective proximal vagotomy performed on 10 patients with diseases affecting the head of the pancreas, 7 being malignant and 3 benign. Reconstruction was carried out using the Billroth I and Billroth II techniques in 5 patients each, respectively. Early postoperative gastric emptying was evaluated by the time before intragastric tube removal and the resumption of oral intake, as well as by barium gastric radiography, while late postoperative gastric emptying was evaluated by the acetaminophen method. No difference was seen in early postoperative gastric emptying between the two surgical techniques, the mean time which elapsed before intragastric tube removal being 4.4 days for the Billroth I and 4.5 days for the Billroth II patients, and the mean time until the resumption of oral intake being 6.8 days for the Billroth I and 7.0 days for the Billroth II patients. A significant delay in gastric emptying was seen in the Billroth II patients compared to a normal control group, 30 and 45 min after acetaminophen administration, but the difference in gastric emptying between the Billroth I and II patients was not significant. Moreover, both techniques impaired gastric emptying much less than Traverso's pylorus-preserving pancreatoduodenectomy.     

Horizontal traumatic laceration of the pancreas head: A rare case report

IntroductionThis case report is intended to inform acute care surgeons about treating rare horizontal laceration of the pancreas head caused by blunt trauma.Case presentationA 57-year-old woman who sustained blunt abdominal trauma during a car crash was transported to the emergency center of our hospital with unstable vital signs due to hemorrhagic shock. Computed tomography showed transection of the pancreas head and massive intra-abdominal hemorrhage. She was referred for emergency surgery because of a transient response. Laparotomy at five hours after the accident initially revealed consistent massive bleeding from branches of the superior mesenteric artery and vein, which we resolved by suturing the vessels without damaging the main trunks. A horizontal laceration and complete transection of the pancreatic head were then confirmed but the main pancreatic duct remained intact. The lower part of the pancreatic head including the uncus with the attached part of the duodenum was resected, and the pancreatic stump remaining after transection was fixed by suturing. The jejunal limb was attached to the remnant duodenum by side-to-side functional anastomosis. Although gastric emptying was delayed for one month after surgery, the postoperative course was good and the patient recovered at three months thereafter. The embryonic border of pancreas head accompanied with pancreatic divisum was considered for this laceration without disruption of the main pancreatic duct.DiscussionBlunt pancreatic trauma usually causes vertical transection and thus, horizontal transection is considered rare. The embryological anatomical border between the ventral and dorsal pancreas due to pancreatic divisum was supposed to be transected and therefore the main pancreatic duct was not damaged.ConclusionHemorrhagic shock and rare pancreatic head trauma were treated by appropriate intraoperative management.     

Pancreatoduodenectomy for locally advanced or recurrent colon cancer: Report of two cases

A 66-year-old man, who had ascending colon cancer which invaded the duodenum, pancreas, and superior mesenteric vein, underwent a curative resection including an extended right hemicolectomy, pylorus-preserving pancreatoduodenectomy, and a partial resection of the superior mesenteric vein. The pathological examination revealed adenocarcinoma of the colon, which directly invaded the duodenum and pancreas, thus causing duodenocolic fistula. Tumor infiltration to the superior mesenteric vein was not histologically proven. Two out of 40 lymph nodes were also involved. The patient is still alive and disease-free 37 months after the operation. A 72-year-old man, with a history of surgery two previous times for ascending colon cancer and its recurrence, underwent a third operation including a resection of the former ileocolic anastomosis en bloc by means of a pylorus-preserving pancreatoduodenectomy with a curative intent. The pathological examination revealed adenocarcinoma of the colon, which directly invaded the duodenum and pancreas. Seven out of 31 lymph nodes were also involved. The patient died of recurrence 24 months after the third operation. These two cases demonstrated the usefulness of a resection of the colon en bloc by means of a pancreatoduodenectomy in patients with either locally advanced colon cancer or locally advanced recurrent colon cancer.     

Early and late complications of pylorus-preserving pancreatoduodenectomy in Japan 1998

Early (within 1 month after operation) and late (more than 1 month after surgery) complications after pylorus-preserving pancreatoduodenectomy (PpPD) were analyzed in 1066 Japanese patients collected from 74 authentic institutions in Japan. As early postoperative complications after PpPD, delayed gastric emptying was evident in 46% of patients, pancreatoenterostomy leakage in 16%, intra-abdominal infection in 14%, cholangitis in 8.9%, hepaticojejunostomy leakage in 4.7%, intra-abdominal hemorrhage in 3.5%, upper gastrointestinal hemorrhage in 3.2%, and duodenojejunostomy leakage in 2.0%. Delayed gastric emptying resolved 1—24 months after PpPD (mean, 3.1 months). The direct operative mortality (death within 1 month after the operation) was 2.4%. Univariate and multivariate analysis of pancreatoenterostomy leakage showed that male sex (P = 0.0151) and soft consistency of the pancreas (P < 0.0001) were independent significant factors. Univariate analysis of delayed gastric emptying showed that establishment of gastrostomy (P < 0.0001), length of the preserved duodenum (P = 0.0406), gastric juice output (P = 0.0001), length of gastric tube placement (P < 0.0001), and administration of cisapride (P = 0.0059) were significant variants. As late complications, stomal ulcer was evident in 3.6% of patients, cholangitis in 6.7%, and liver abscess in 1.2%. Glucose intolerance appeared in 61 patients, resolved in 15, showed no change in 170, was absent in 695, and was ameliorated in 17. As a result, the dosage of hypoglycemic agents or insulin showed no change in 187 patients, decreased in 16, and increased in 52. Diabetes appeared 0—42 months after PpPD (mean, 102 months). When present, diabetes deteriorated 0—36 months postoperatively (mean, 6.3 months). Univariate analysis of the appearance or deterioration of diabetes showed that diabetes occurred more frequently in the following patients; those with Billroth I reconstruction compared with those with Billroth II (P = 0.0041), those with pancreatogastrostomy vs those with pancreatojejunostomy (P = 0.0229), those with pancreatogastrostomy vs those with end-to-side pancreatojejunostomy (P = 0.0165), and those with total tube drainage vs those with pancreatico-whole thickness anastomosis (P = 0.0392); a high American Society of Anesthesiologist (ASA) score (P = 0.0211) and pancreatoenterostomy leakage (P = 0.0361) were also significant factors. Postoperative body weight loss (>3 kg) was evident in 62% of patients. Body weight loss reached a maximum 4.2 ± 5.8 months after PpPD (mean, 6.0 kg) and returned to the preoperative level 4.8 months thereafter. These results suggest that PpPD has been performed safely in Japan, the operative mortality being 2.4%. However, delayed gastric emptying was evident in 46% of the patients and pancreatoenterostomy leakage in 16%. Impairment of glucose tolerance occurred in about 10% of patients more than 1 month after PpPD. Therefore, during the early postoperative period, patients should be closely monitored for pancreatoenterostomy leakage and delayed gastric emptying and in the late postoperative period, glucose tolerance should be carefully followed-up.     

扩大淋巴结清扫对胰头癌患者预后效果的观察

目的 探讨扩大淋巴结清扫对胰头癌患者疗效及预后的影响.方法 回顾性分析136例胰头癌患者的临床资料,根据治疗方法的不同将患者分为扩大组和常规组,每组各68例.常规组患者接受胰十二指肠切除术及常规淋巴结清扫,扩大组患者接受胰十二指肠切除术及扩大淋巴结清扫.比较两组患者的术中、术后指标及并发症发生率.结果 扩大组患者的手术时间长于常规组,术中出血量多于常规组(P﹤0.05).扩大组患者术后胃排空延迟的发生率高于常规组,阳性淋巴结检出数多于常规组,原位癌复发率低于常规组,差异均有统计学意义(P﹤0.05).术后两组患者吻合口瘘、腹腔出血及腹腔感染的发生率比较,差异均无统计学意义(P﹥0.05).随访5~33个月,两组患者的中位生存时间比较,差异无统计学意义(P﹥0.05).结论 对于行胰十二指肠切除术的胰头癌患者,扩大淋巴结清扫范围可提高阳性淋巴结检出率,降低原位癌复发率,但对患者的远期疗效无明显影响,同时加重了对患者机体的损伤,延长了手术时间,增加了术中出血量及胃排空延迟的发生率,不建议常规对患者采用扩大淋巴结清扫术,尤其是年老及身体状况较差者.     

老年胰十二指肠切除术36例临床分析

目的探讨老年人胰十二指肠切除术指征,提高手术切除率及减少术后并发症的发生。方法回顾性总结2004～2010年间我院收治的36例≥65岁老年胰十二指肠切除术病例的临床资料,采用闭锁式胰腺套入吻合Child术式进行手术,使用术前＂减黄＂等措施减少手术并发症。结果 36例行胰十二指肠切除术患者中全部为恶性。胰瘘发生率为2.7%,36例患者中35例痊愈,死亡1例（死于肝衰竭）。结论可靠的诊断及合适的探查和适应证的严格把控能提高手术切除率。对老年人而言,完善的围手术期准备和精湛的手术技巧对提高胰十二指肠切除手术安全性、降低并发症尤为重要。