十二指肠乳头内生性腺瘤内镜下诊断与治疗（附8例报告）

目的探讨十二指肠乳头内生性腺瘤的内镜下诊治方法。方法2005年6月～2008年10月对8例B超、MRCP影像学检查提示胆总管及肝内胆管不同程度的扩张,乳头开口及下段狭窄,进一步行ERCP及IDUS检查,发现病变并予以治疗。结果2例绒毛管状腺瘤伴上皮中度不典型增生及1例管状腺瘤行胰十二指肠乳头切除术：1例绒毛管状腺瘤术后病理局部癌变,3个月后肝转移行介入化疗及栓塞2次,16个月全身复查未见异常;1例管状腺瘤伴上皮中度不典型增生者术后病理局部印戒细胞癌,术后6、14个月随访全身复查未见异常。1例管状乳头状腺瘤行十二指肠乳头内镜下切除术后置入胆管支架内引流,6个月后复发并癌变,术后10个月死亡;1例绒毛管状腺瘤伴上皮中度不典型增生行十二指肠乳头内镜下切除术后置入胆管支架内引流,术后6、12个月复查未见异常;1例绒毛管状腺瘤伴上皮中度不典型增生术后病理与术前相同,且切除干净,未随访。1例绒毛状管状腺瘤伴高级上皮内瘤变,胆道塑料支架置入术,术后4个月反复胆道感染,内镜下更换为金属支架。1例乳头状腺瘤置入胆管支架内引流,术后失访。1例管状腺瘤拒绝治疗,电话至12个月随访无异常不适。结论十二指肠乳头内生性腺瘤临床罕见,且易于癌变,对乳头切开后黏膜层及肌层增厚的患者尤其有增生性病变者应常规多点取活检,避免乳头内腺瘤及恶性变病灶的遗漏,并对相关病灶及时内镜下或手术治疗。

Endoscopic Diagnosis and Treatment of Endogenous Adenoma of the Duodenal Papilla: Report of 8 Cases

Objective To explore the diagnosis and treatment of endogenous adenoma of the duodenal papilla by endoscopy. Methods Between June 2005 and October 2008, eight patients who had dilated common and intrahepatic bile ducts with strictured opening of the papilla and lower segments shown by B-ultrasonography or MRCP, were enrolled in this study. The patients were assigned to receive ERCP and IDUS for diagnosis and treatment. Results In this series, three patients received pancreatico- duodenectomy because of tubulovillous adenoma （ two cases） or tubular adenoma （ one case） complicated with moderate atypical epithelial hyperplasia; one of the two cases with tubulovillous adenoma was confirmed as having local cancer by postoperative pathological examination, and then received interventional therapy and embolization because of liver metastasis in 3 months; the patient who had tubular adenoma was diagnosed with local signet ring cell cancer after the operation, and was followed up at 6 and 14 months afterwards by physical examination, which showed no abnormalities. Endoscopic snare papillectomy followed by bile duct stenting for drainage was performed on two patients, one of them was diagnosed with tubulo-papillary adenoma after the surgery and then showed recurrent tumor at 6 months, resulting death at 10 months; the other one was confirmed as having tubulovillous adenoma complicated with moderate atypical epithelial hyperplasia, this patient showed no abnormalities during follow-up at 6 and 12 months. Plastic bile duct stent was employed in one patient with severe atypical epithelial hyperplasia, but was replaced by metal stent because of repeated infection of the bile duct. One patient with papillary adenoma was lost to follow-up after bile duct stenting for intradrainage. One patient refused any treatment for the tubular adenoma; follow-up by phone showed no abnormality in this case in 12 months. Conclusions Endogenous adenoma of the duodenal papilla is rare detected. The tumor is very likely to turn to malignant. Multi-point biopsy is necessary for the patients with hyperplasia of the mucosal and muscle layers.