近端胰腺保守性切除在胰腺良性—交界恶性肿瘤中的应用
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摘要
研究目的：
胰腺良性及交界恶性肿瘤包括了囊腺瘤、囊实性假乳头状瘤、非侵袭性胰岛细胞瘤、导管内乳头状瘤等多种不同病理类型的肿瘤。这些肿瘤患者如果肿瘤能彻底切除,预后良好。包括胰腺中段切除、局部切除、肿瘤剜除在内的保守性胰腺切除在胰腺的良性和低度恶性肿瘤中已得到一定应用。在近端胰腺,尤其是靠近主胰管和胆管的肿瘤,行保守切除常导致胰胆管损伤,术后可能发生严重瘘等并发症,一向认为比较危险。在此我们回顾了近年本院近端胰腺的良性和交界恶性肿瘤的保守性切除的患者资料,探讨近端胰腺肿瘤保守切除的安全性和有效性。
材料与方法：
查阅了浙江大学医学院附属第二医院自2000年1月至2013年1月这13年间诊断为胰腺良性肿瘤并行手术治疗的114例患者,其中位于近端胰腺,包括胰腺头部、钩突部、颈部及近端体部的患者57例,这其中,33例行胰腺近端保守切除,24例行胰十二指肠切除术。33例行近端胰腺保守性切除的病例中包括20例胰腺肿瘤剜除术,13例中段切除。病理类型包括11例胰岛细胞瘤、11例胰头囊腺瘤、8例胰腺囊实性假乳头状瘤、2例假性囊肿和1例脂肪瘤。统计了肿瘤的大小及所在位置,行近端胰腺切除的术中出血、术后住院时间及术后胰瘘情况,并对上述病例进行随访,评估术后恢复情况。
结果：
33例保守切除的患者中20例患者成功行肿瘤剜除术,包括胰头部11例和钩突1例,颈部及近端体部的患者8例。13例胰腺颈部及近端体部肿瘤的患者由于剜除后主胰管损伤,行胰腺中段切除术。其中8例肿瘤靠近主胰管的胰头肿瘤患者中,5例发生了术中主胰管损伤,并行修补术。术后23例患者发生了胰瘘,包括15例剜除的患者和8例胰腺中段切除的患者。其中8例靠近主胰管的胰头肿瘤患者中,7例在剜除术后发生了胰瘘,主胰管修补的5例患者,均发生了明显的胰瘘,24小时引流量最高达1200m1。虽然没有明显腹部感染征象,因为保留引流管时间长(胰瘘患者术后引流时间达5-292天),所有的胰瘘患者根据国际胰瘘学组(ISGPF)的胰瘘分级定义为A-B级胰瘘。2例患者因为肿瘤靠近胆总管,手术中同时行胆囊切除,胆管内置入导尿管,注入美兰检查。其中一例患者术中发现胆瘘,术中行修补,并于胆总管内置入T管。5例患者发生术后胃排空障碍,1例患者发生术后出血,经对症处理后好转。患者平均随访45.7个月(7-150个月),所有患者均存活,无肿瘤复发、转移征象。没有新发糖尿病及胰腺外分泌不足征象。
结论：
包括胰腺肿瘤剜除术和胰腺中段切除术在内的保守性胰腺切除术对于胰腺良性、交界恶性肿瘤而言是安全、有效的,即使肿瘤较大、靠近主胰管。虽然保守性切除,特别是剜除术后胰瘘的发生率较胰十二指肠切除术、胰体尾切除术高,但是经过通常引流,患者能得到良好的恢复。与传统的胰十二指肠切除术相比,胰腺保守性切除术具有手术时间短,术中出血少,术后腹腔感染等并发症少,手术死亡率低等优点。由于最大限度地保留了正常的胰腺组织,因而保守性胰腺切除术后糖尿病及胰腺外分泌功能不足的发生率低。
Aim of the research
Pancreatic benign or borderline tumors include cystadenoma, ascomal pseudopapillomatosis, insulinoma, intraductal papilloma, et al. patients with tumor mentioned above could be cured if tumors could be resected totally. Conservative resection including partial pancreatectomy, local pancreatic resection and pancreatic tumor enucleation has been used in operations of benign and low-grade malignant pancreatic tumor. It is considered to be dangerous to do conservative resection for the proximal pancreatic tumor, especially for tumors near to main pancreatic duct and bile duct. In this research, we reviewed the patients records to have conservative resection for the proximal tumor in our hospital, and show the evidences about the safety and usefulness of conservative resection of pancreatic benign or borderline tumors.
Materials and method
We reviewed114patients diagnosed as "pancreatic benign tumor" and having operation from2000.01.01to2013.01.01in the second affiliated hospital to medical college of Zhejiang university.57pancreatic tumors of them located in the proximal pancreas, including head, uncinate process, neck and proximal body of pancreas, of which,33cases received conservative resection,24cases received duodenopancreatectomy.33cases received conservative resection in the proximal pancreas.20of them received pancreatic tumor enucleation. The other13received middle segment pancreatectomy. The pathology types of these32cases is as follows:11cases are insulinoma,11cases are pancreatic cystadenoma,8cases are pancreatic cystic pseudopapillary tumor,2cases are pseudocyst and1case is adipoma. We collected the information of volume, position of tumors, blooding in the operation of enucleation, length of stay after operation and pancreatic fistula after operation.
Results
20of33patients received conservative resection of the proximal pancreas finished pancreatic tumor enuleation, of which,11cases located in the head of pancreas,1in uncinate process of pancreas and8in the neck and proximal body of pancreas. The other13cases finished middle segment pancreatectomy because of the injury of main pancreatic duct during the operation of pancreatic tumor enuleation in the neck and proximal body of pancreas. There are8cases having the tumors near the main pancreatic duct, of which,5caused injury of main pancreatic duct during operations and had to do the main pancreatic duct repair.23of32cases happened postoperative pancreatic fistula after the operation, including15patients after the pancreatic tumor enuleation and8patients after the middle segment pancreatectomy.7of8cases having tumors near the main pancreatic duct happened postoperative pancreatic fistula after enucleation.5patients received main pancreatic duct repair had severe postoperative pancreatic fistula, the maximum drainage volume of peritoneal fluid was up to1200ml/day. The pancreatic fistula in23cases is defined as A-B grade pancreatic fistula according to the standard of International Study Group on Pancreatic Fistula(ISGPF), because of the long drainage duration(the drainage time of pancreatic fistula patients varies from5days to292days), though there is no obvious peritoneal infection.2patients received cholecystectomy during the operation because of tumors near to common bile duct, one of them happened biliary fistula and repaired during the operation.5patients happened delayed gastric emptying(DGE) and1patient happened hemorrhage after operation. All of the complications were cured after symptomatic treatment. The average follow-up time of patients mentioned above is45.7months(from7months to150months). All patients are survived with no tumor recurrence and metastasis, with no symptoms of new-onset diabetes mellitus and dysfunction of exocnne pancreas.
Conclusion
It is feasible and safe to do conservative resection for benign and borderline tumor of the proximal pancreas, even though the tumor is large and near main pancreatic duct. The rate of pancreatic fistula is high after the conservative resection compared with pancreatoduodenectomy and distal pancreatectomy, but it is safe for patients through the successful drainage. The conservative resection for pancreatic benign and borderline tumors of the proximal pancreas has the advantages on the operation time, operation blooding, complications such as peritoneal infection, events of death compared with conditional operations such as panreatoduodenectomy. Conservative resection is benefit to keep pancreas in good condition because of the least injury of pancreas during the operation.
胰腺良性及交界恶性肿瘤包括了囊腺瘤、囊实性假乳头状瘤、非侵袭性胰岛细胞瘤、导管内乳头状瘤等多种不同病理类型的肿瘤。这些肿瘤患者如果肿瘤能彻底切除,预后良好。包括胰腺中段切除、局部切除、肿瘤剜除在内的保守性胰腺切除在胰腺的良性和低度恶性肿瘤中已得到一定应用。在近端胰腺,尤其是靠近主胰管和胆管的肿瘤,行保守切除常导致胰胆管损伤,术后可能发生严重瘘等并发症,一向认为比较危险。在此我们回顾了近年本院近端胰腺的良性和交界恶性肿瘤的保守性切除的患者资料,探讨近端胰腺肿瘤保守切除的安全性和有效性。
材料与方法：
查阅了浙江大学医学院附属第二医院自2000年1月至2013年1月这13年间诊断为胰腺良性肿瘤并行手术治疗的114例患者,其中位于近端胰腺,包括胰腺头部、钩突部、颈部及近端体部的患者57例,这其中,33例行胰腺近端保守切除,24例行胰十二指肠切除术。33例行近端胰腺保守性切除的病例中包括20例胰腺肿瘤剜除术,13例中段切除。病理类型包括11例胰岛细胞瘤、11例胰头囊腺瘤、8例胰腺囊实性假乳头状瘤、2例假性囊肿和1例脂肪瘤。统计了肿瘤的大小及所在位置,行近端胰腺切除的术中出血、术后住院时间及术后胰瘘情况,并对上述病例进行随访,评估术后恢复情况。
结果：
33例保守切除的患者中20例患者成功行肿瘤剜除术,包括胰头部11例和钩突1例,颈部及近端体部的患者8例。13例胰腺颈部及近端体部肿瘤的患者由于剜除后主胰管损伤,行胰腺中段切除术。其中8例肿瘤靠近主胰管的胰头肿瘤患者中,5例发生了术中主胰管损伤,并行修补术。术后23例患者发生了胰瘘,包括15例剜除的患者和8例胰腺中段切除的患者。其中8例靠近主胰管的胰头肿瘤患者中,7例在剜除术后发生了胰瘘,主胰管修补的5例患者,均发生了明显的胰瘘,24小时引流量最高达1200m1。虽然没有明显腹部感染征象,因为保留引流管时间长(胰瘘患者术后引流时间达5-292天),所有的胰瘘患者根据国际胰瘘学组(ISGPF)的胰瘘分级定义为A-B级胰瘘。2例患者因为肿瘤靠近胆总管,手术中同时行胆囊切除,胆管内置入导尿管,注入美兰检查。其中一例患者术中发现胆瘘,术中行修补,并于胆总管内置入T管。5例患者发生术后胃排空障碍,1例患者发生术后出血,经对症处理后好转。患者平均随访45.7个月(7-150个月),所有患者均存活,无肿瘤复发、转移征象。没有新发糖尿病及胰腺外分泌不足征象。
结论：
包括胰腺肿瘤剜除术和胰腺中段切除术在内的保守性胰腺切除术对于胰腺良性、交界恶性肿瘤而言是安全、有效的,即使肿瘤较大、靠近主胰管。虽然保守性切除,特别是剜除术后胰瘘的发生率较胰十二指肠切除术、胰体尾切除术高,但是经过通常引流,患者能得到良好的恢复。与传统的胰十二指肠切除术相比,胰腺保守性切除术具有手术时间短,术中出血少,术后腹腔感染等并发症少,手术死亡率低等优点。由于最大限度地保留了正常的胰腺组织,因而保守性胰腺切除术后糖尿病及胰腺外分泌功能不足的发生率低。
Aim of the research
Pancreatic benign or borderline tumors include cystadenoma, ascomal pseudopapillomatosis, insulinoma, intraductal papilloma, et al. patients with tumor mentioned above could be cured if tumors could be resected totally. Conservative resection including partial pancreatectomy, local pancreatic resection and pancreatic tumor enucleation has been used in operations of benign and low-grade malignant pancreatic tumor. It is considered to be dangerous to do conservative resection for the proximal pancreatic tumor, especially for tumors near to main pancreatic duct and bile duct. In this research, we reviewed the patients records to have conservative resection for the proximal tumor in our hospital, and show the evidences about the safety and usefulness of conservative resection of pancreatic benign or borderline tumors.
Materials and method
We reviewed114patients diagnosed as "pancreatic benign tumor" and having operation from2000.01.01to2013.01.01in the second affiliated hospital to medical college of Zhejiang university.57pancreatic tumors of them located in the proximal pancreas, including head, uncinate process, neck and proximal body of pancreas, of which,33cases received conservative resection,24cases received duodenopancreatectomy.33cases received conservative resection in the proximal pancreas.20of them received pancreatic tumor enucleation. The other13received middle segment pancreatectomy. The pathology types of these32cases is as follows:11cases are insulinoma,11cases are pancreatic cystadenoma,8cases are pancreatic cystic pseudopapillary tumor,2cases are pseudocyst and1case is adipoma. We collected the information of volume, position of tumors, blooding in the operation of enucleation, length of stay after operation and pancreatic fistula after operation.
Results
20of33patients received conservative resection of the proximal pancreas finished pancreatic tumor enuleation, of which,11cases located in the head of pancreas,1in uncinate process of pancreas and8in the neck and proximal body of pancreas. The other13cases finished middle segment pancreatectomy because of the injury of main pancreatic duct during the operation of pancreatic tumor enuleation in the neck and proximal body of pancreas. There are8cases having the tumors near the main pancreatic duct, of which,5caused injury of main pancreatic duct during operations and had to do the main pancreatic duct repair.23of32cases happened postoperative pancreatic fistula after the operation, including15patients after the pancreatic tumor enuleation and8patients after the middle segment pancreatectomy.7of8cases having tumors near the main pancreatic duct happened postoperative pancreatic fistula after enucleation.5patients received main pancreatic duct repair had severe postoperative pancreatic fistula, the maximum drainage volume of peritoneal fluid was up to1200ml/day. The pancreatic fistula in23cases is defined as A-B grade pancreatic fistula according to the standard of International Study Group on Pancreatic Fistula(ISGPF), because of the long drainage duration(the drainage time of pancreatic fistula patients varies from5days to292days), though there is no obvious peritoneal infection.2patients received cholecystectomy during the operation because of tumors near to common bile duct, one of them happened biliary fistula and repaired during the operation.5patients happened delayed gastric emptying(DGE) and1patient happened hemorrhage after operation. All of the complications were cured after symptomatic treatment. The average follow-up time of patients mentioned above is45.7months(from7months to150months). All patients are survived with no tumor recurrence and metastasis, with no symptoms of new-onset diabetes mellitus and dysfunction of exocnne pancreas.
Conclusion
It is feasible and safe to do conservative resection for benign and borderline tumor of the proximal pancreas, even though the tumor is large and near main pancreatic duct. The rate of pancreatic fistula is high after the conservative resection compared with pancreatoduodenectomy and distal pancreatectomy, but it is safe for patients through the successful drainage. The conservative resection for pancreatic benign and borderline tumors of the proximal pancreas has the advantages on the operation time, operation blooding, complications such as peritoneal infection, events of death compared with conditional operations such as panreatoduodenectomy. Conservative resection is benefit to keep pancreas in good condition because of the least injury of pancreas during the operation.
引文
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24. Vella, A., M. Camilleri, and R.A. Rizza, The gastrointestinal tract and glucose tolerance. Curr Opin Clin Nutr Metab Care,2004.7(4):p.479-84.
25. Dinneen, S., J. Gerich, and R. Rizza, Carbohydrate metabolism in non-insulin-dependent diabetes mellitus. N Engl J Med,1992.327(10):p. 707-13.
26. Permert, J., et al., Islet hormone secretion in pancreatic cancer patients with diabetes. Pancreas,1997.15(1):p.60-8.
27. Permert, J., et al., Islet amyloid polypeptide in patients with pancreatic cancer and diabetes. N Engl J Med,1994.330(5):p.313-8.
28. Ding, X., et al., Pancreatic cancer cells selectively stimulate islet beta cells to secrete amylin. Gastroenterology,1998.114(1):p.130-8.
29. Li, J. and T.E. Adrian, A factor from pancreatic and colonic cancer cells stimulates glucose uptake and lactate production in myoblasts. Biochem Biophys Res Commun,1999.260(3):p.626-33.
30. Wang, F., S. Gupta, and E.A. Holly, Diabetes mellitus and pancreatic cancer in a population-based case-control study in the San Francisco Bay Area, California. Cancer Epidemiol Biomarkers Prev,2006.15(8):p.1458-63.
31. Liu, J., et al., The intracellular mechanism of insulin resistance in pancreatic cancer patients. J Clin Endocrinol Metab,2000.85(3):p.1232-8.
32. Stoita, A., I.D. Penman, and D.B. Williams, Review of screening for pancreatic cancer in high risk individuals. World J Gastroenterol,2011.17(19):p.2365-71.
33. Chow, W.H., et al., Risk of pancreatic cancer following diabetes mellitus:a nationwide cohort study in Sweden. J Natl Cancer Inst,1995.87(12):p.930-1.
34. Chari, S.T., et al., Probability of pancreatic cancer following diabetes:a population-based study. Gastroenterology,2005.129(2):p.504-11.
35. Pannala, R., et al., New-onset diabetes:a potential clue to the early diagnosis of pancreatic cancer. Lancet Oncol,2009.10(1):p.88-95.
36. Canto, M.I., et al., Screening for early pancreatic neoplasia in high-risk individuals:a prospective controlled study. Clin Gastroenterol Hepatol,2006. 4(6):p.766-81; quiz 665.
37. Canto, M.I., et al., Screening for pancreatic neoplasia in high-risk individuals: an EUS-based approach. Clin Gastroenterol Hepatol,2004.2(7):p.606-21.
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23. Pelaez-Luna, M., et al., Resectability of presymptomatic pancreatic cancer and its relationship to onset of diabetes:a retrospective review of CT scans and fasting glucose values prior to diagnosis. Am J Gastroenterol,2007.102(10):p. 2157-63.
24. Vella, A., M. Camilleri, and R.A. Rizza, The gastrointestinal tract and glucose tolerance. Curr Opin Clin Nutr Metab Care,2004.7(4):p.479-84.
25. Dinneen, S., J. Gerich, and R. Rizza, Carbohydrate metabolism in non-insulin-dependent diabetes mellitus. N Engl J Med,1992.327(10):p. 707-13.
26. Permert, J., et al., Islet hormone secretion in pancreatic cancer patients with diabetes. Pancreas,1997.15(1):p.60-8.
27. Permert, J., et al., Islet amyloid polypeptide in patients with pancreatic cancer and diabetes. N Engl J Med,1994.330(5):p.313-8.
28. Ding, X., et al., Pancreatic cancer cells selectively stimulate islet beta cells to secrete amylin. Gastroenterology,1998.114(1):p.130-8.
29. Li, J. and T.E. Adrian, A factor from pancreatic and colonic cancer cells stimulates glucose uptake and lactate production in myoblasts. Biochem Biophys Res Commun,1999.260(3):p.626-33.
30. Wang, F., S. Gupta, and E.A. Holly, Diabetes mellitus and pancreatic cancer in a population-based case-control study in the San Francisco Bay Area, California. Cancer Epidemiol Biomarkers Prev,2006.15(8):p.1458-63.
31. Liu, J., et al., The intracellular mechanism of insulin resistance in pancreatic cancer patients. J Clin Endocrinol Metab,2000.85(3):p.1232-8.
32. Stoita, A., I.D. Penman, and D.B. Williams, Review of screening for pancreatic cancer in high risk individuals. World J Gastroenterol,2011.17(19):p.2365-71.
33. Chow, W.H., et al., Risk of pancreatic cancer following diabetes mellitus:a nationwide cohort study in Sweden. J Natl Cancer Inst,1995.87(12):p.930-1.
34. Chari, S.T., et al., Probability of pancreatic cancer following diabetes:a population-based study. Gastroenterology,2005.129(2):p.504-11.
35. Pannala, R., et al., New-onset diabetes:a potential clue to the early diagnosis of pancreatic cancer. Lancet Oncol,2009.10(1):p.88-95.
36. Canto, M.I., et al., Screening for early pancreatic neoplasia in high-risk individuals:a prospective controlled study. Clin Gastroenterol Hepatol,2006. 4(6):p.766-81; quiz 665.
37. Canto, M.I., et al., Screening for pancreatic neoplasia in high-risk individuals: an EUS-based approach. Clin Gastroenterol Hepatol,2004.2(7):p.606-21.