孙爱学等胰头肿块型胰腺炎诊断和外科治疗进展第3期 435 为虽然手术方式多种多样但是应制定个体化治约20%的慢性胰腺炎患者和约90%的恶性肿瘤患疗方案因此其诊断及外科治疗越来越多的受到者均有胆管和胰管的同时扩张 [3] 慢性胰腺炎可临床工作者的关注本

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Chinese Journal of General Surgery 第 25 卷第 3 期 2016 年 3 月 Vol.25 No.3 Mar. 2016 文献综述 doi:10.3978/j.issn.1005-6947.2016.03.022 http://dx.doi.org/10.3978/j.issn.1005-6947.2016.03.022 Chinese Journal of General Surgery, 2016, 25(3):434 438.

1 Chinese Journal of General Surgery 第 25 卷第 3 期 2016 年 3 月 Vol.25 No.3 Mar 文献综述 doi: /j.issn Chinese Journal of General Surgery, 2016, 25(3): 胰头肿块型胰腺炎诊断和外科治疗进展孙爱学综述赵成功审校中国人民解放军第一五医院普通外科安徽合肥摘要随着慢性胰腺炎发病率的逐年升高胰头肿块型胰腺炎发病率也逐年升高在临床工作中胰头肿块型胰腺炎与胰腺癌较难鉴别但是两者的治疗方案决然不同且预后差别大因此胰头肿块型胰腺炎越来越多的受到临床工作者关注笔者就胰头肿块型胰腺炎的诊断和外科治疗做一综述以期望为临床提供一些参考关键词胰腺炎慢性 / 诊断胰腺炎慢性 / 治疗综述文献中图分类号 R657.5 Progress in diagnosis and surgical treatment for pancreatic head mass due to chronic pancreatitis SUN Aixue, ZHAO Chenggong (Department of General Surgery, 105th Hospital of Chinese PLA, Hefei , China) Abstract Key words The incidence of the mass-forming chronic pancreatitis of the pancreatic head has increased with the increasing prevalence of chronic pancreatitis over the years. In clinical practice, the differential diagnosis between this type of chronic pancreatitis and pancreatic cancer is often difficult. However, the treatment strategies and outcomes of the two are completely different. Thus, increasing attention has been paid to this condition by clinical staff. The authors, in this article, address the diagnosis and surgical treatment of mass-forming chronic pancreatitis of the pancreatic head, so as to provide some reference in clinical practice. Pancreatitis, Chronic/diag; Pancreatitis, Chronic/therap; Review CLC number: R657.5 慢性胰腺炎是由于各种病因导致的胰腺组织和功能不可逆转的慢性炎症性疾病在胰腺实质反复纤维化萎缩等过程中部分患者胰腺常出收稿日期修订日期现炎性肿块其中又尤以胰头部最多见这些患作者简介孙爱学中国人民解放军第一五医院住院医师者常伴有胆道梗阻胰管梗阻疼痛以及内外主要从事肝胆胰脾胃肠良恶性肿瘤等疾病诊治分泌功能紊乱近年来胰头肿块型胰腺炎发病方面的研究率逐年提高且难以与胰头癌鉴别苗毅教授 [1] 认通信作者赵成功 zcg105@sohu.com [30] Menke A, Yamaguchi H, Gress TM, et al. Extracellular matrix is reduced by inhibition of transforming growth factor beta1 in pancreatitis in the rat[j]. Gastroenterology, 1997, 113(1): [31] Friess H, Lu Z, Riesle E, et al. Enhanced expression of TGF-betas and their receptors in human acute pancreatitis[j]. Ann Surg, 1998, 227(1): 本文引用格式李满, 余佳, 王卫星. 急性胰腺炎胰腺组织修复机制的研究进展[J]., 2016, 25(3): doi: /j.issn Cite this article as: Li M, Yu J, Wang WX. Research progress in mechanism of pancreatic tissue repair after acute pancreatitis[j]. Chin J Gen Surg, 2016, 25(3): doi: /j.issn 本文编辑宋涛 434

2 孙爱学等胰头肿块型胰腺炎诊断和外科治疗进展第3期 435 为虽然手术方式多种多样但是应制定个体化治约20%的慢性胰腺炎患者和约90%的恶性肿瘤患疗方案因此其诊断及外科治疗越来越多的受到者均有胆管和胰管的同时扩张 [3] 慢性胰腺炎可临床工作者的关注本文将对肿块性胰腺炎的诊有胰腺萎缩胰腺癌则少见虽然国内有小样本断和外科治疗新进展做一综述报道 [12]胰腺萎缩胰腺周围及血管侵犯胰管扩张胰管中断胆管扩张在胰腺癌和肿块型胰腺 1 胰头肿块型胰腺炎诊断炎鉴别诊断中有统计学差异但是目前没有大样本的临床研究证实某一影像表现具有高特异性胰头肿块型胰腺炎是节段性慢性胰腺炎中的特殊类型因炎性反应迁延不愈胰腺实质高敏感性 1.4 病理学检查 [2] 破坏纤维组织增生形成胰腺肿块近年来随着慢性胰腺炎发病率的逐年升高 [3] 针对临床表现肿瘤标志物以及影像学胰头肿检查仍然无法鉴别诊断的患者穿刺病理诊断是块型胰腺炎发病率也逐年升高其约占慢性胰腺较好选择内镜超声能克服传统超声 CT引导 [4] 炎的15%~30% 此外随着时间的延长约有 2%~16.5%的慢性胰腺炎患者将发展为胰腺癌 [5-7] 下穿刺诸多缺点如腹壁脂肪肠腔气体及胃前壁等干扰图像质量较长穿刺路径直接获得在西方国家慢性胰腺炎主要来自酒精性胰腺炎所需标本从而提高穿刺取材的成功率及阳性 [8] 在国内慢性胰腺炎主要来自胆源性和酒精性率 [17] 超声内镜穿刺活检诊断肿瘤的特异性高达胰腺炎 [9] 此外还有部分胰头肿块型胰腺炎缘于自 9 7 % ~ % 敏感性在 7 5 % ~ 9 5 % [18-20] 针对无法身免疫性胰腺炎 [10] 以下将从如下四个方面进行区分 1 5 % [21]炎性或恶性胰头肿块可选用特异性叙述胰头肿块型胰腺炎的诊断 100% 敏感性 98.8% 更高的术中Tru- 1.1 临床表现 Cut [22] 多点多组织穿刺活检甚至可以结合免疫蛋胰头肿块型胰腺炎的临床表现主要为腹痛白来区分自身免疫性胰腺炎 [23] 厌食恶心呕吐体质量减轻和梗阻性黄疸综上所述胰头肿块型胰腺炎多具有以下临肿块含有如下特征包括胰头钙化高龄胃出床及影像特征病程较长肿瘤标志物无明显升口梗阻突发腹痛梗阻性黄疸严重体质量丢高 <300 U/mL 无广泛侵犯转移周围组织胰失常提示恶性肿瘤可能 [11-12] 1.2 肿瘤标志物者可选择穿刺病理诊断方法针对疑难病例在血清的肿瘤标志物中 CA19-9被认为是目前胰腺癌诊断的最好指标腺广泛钙化萎缩针对临床和影像学鉴别困难 [13] 但是在部分胰头肿应选择诊断正确率高患者受益大的多学科诊疗模式 MDT [24-25] 块型胰腺炎患者中肿瘤标志物包括CA19-9 CEA 也有轻度至中度升高 20~300 U/mL [11,14-15] 2 胰头肿块型胰腺炎的外科治疗因此部分研究结论推荐鉴别肿块型胰腺炎与胰腺癌的CA19-9检测值阈值为300 U/mL [11,14-16] 此外大多数情况下尤其在疾病的早期慢性还有一些新兴蛋白标志物如TIMP1 ICAM1 胰腺炎多接受规范的内科保守治疗外科治疗指 AZGP1 [15] 1.3 影像学检查征主要包括常用于内科保守治疗失败重症疾病疼痛不可控制的胰腺炎压迫邻近组织结通过影像学检查超声 CT MRCP ERCP 构胆道主胰管十二指肠中重度梗阻不能等发现胰头肿块以及胰腺组织的异常表现肝排除胰腺癌 [26-27] 手术原则为缓解症状并最大限外胆管及胰管有无扩张与梗阻肝外胆管及胰管度地保留胰腺内外分泌功能但是也有一些研有无结石等临床医师通过此发现鉴别胰头肿块究者认为慢性胰腺炎行早期手术能够延缓疾病进型胰腺炎和胰腺癌慢性胰腺炎多有广泛的胰腺程保留更多正常细胞 [28-29] 希望现行的随机对钙化胰管扩张胰管结石但有些胰腺癌患者照试验 [30]能够给出较为确切的答案随科学的进则表现为胰腺组织局灶性钙化和胰腺结构紊乱步该手术也越来越多的被业界和社会所接受

3 436 第 25 卷究其原因有三点其一胰头肿块型胰腺炎有发大患者需行Beger术式或Berne术式Berne术式生癌变风险手术处理可预防或根治早期肿瘤与Beger术式和Frey术式相比该术式操作相对简其二解决压迫及内外分泌功能紊乱引起症状和单严重并发症较少在缓解疼痛保留内外体征效果确切其三近年来手术疗效和安全分泌功能等方面效果相近因此Berne作为胰头肿性不断提高手术病死率<3% [31] 其术式主要有胰十二指肠切除术保留幽门的胰十二指肠切除术保留十二指肠的胰头切除术等块型胰腺炎诊断明确或相对不明确时首选外科手术方案综上所述胰头肿块型胰腺炎行手术治疗利 2.1 诊断不明胰头肿块型胰腺炎大于弊诊断明确者以及肿块较小者保留十二胰十二指肠切除术和保留幽门胰十二指肠指肠的胰头切除术是被推荐的诊断不明确者或切除术较保留十二指肠的胰头切除术切除范围肿块较大者胰十二指肠切除术是被推荐的术广清创组织多针对早期肿瘤能做到彻底根式应按照如下顺序选择 Berne术式 Frey术式治而且既往研究 [32-33] 结论认为在绝大多数情况下针对诊断不明的胰头肿块尤其是恶性肿 Beger术式保留或不保留幽门的胰十二指肠切除瘤可能性大的胰头肿块行胰十二指肠切除术治总之针对胰头肿块型胰腺炎首先需通过疗手术是利大于弊的因其完成了早期肿瘤的临床表现肿瘤标志物影像检查病理检查等根治且术后胰腺内外分泌功能没有进一步减退联合考虑然后根据影像资料肿块大小和临床而生活质量得到明显改善因此我们建议对于术诊断选择合适手术方式从而最大限度降低并发前诊断不明确者可行胰十二指肠切除术症提高患者生活质量 2.2 诊断明确的胰头肿块型胰腺炎由于传统胰十二指肠切除术和保留幽门胰参考文献十二指肠切除术的创伤大并发症发生率高术后生活质量下降明显 [34] 所以针对诊断明确者行保留十二指肠的胰头切除术 DPPHR 是被推荐的 [35] 保留十二指肠的胰头切除术具有以下优点 [ ] ⑴ 由于保留了胃十二指肠及胆管生理功能术后生活质量疼痛缓解营养状态均较胰十二指肠切除术好 ⑵ 安全性较好术后病死率低 ⑶ 保留十二指肠的胰头切除术后胰腺内外分泌功能改变不明显经典的保留十二指肠的胰头切除术包括常见的Beger术式 Berne术式 [41] [39] Frey术式和不常见的Izbicki术式 [42] [40] 和等比较Beger术式与胰十二指肠切除术 Beger 术式除具有上述优点还有术中大出血几率低于 [43-44] [1] 苗毅, 吴峻立. 慢性胰腺炎的外科治疗[J]. 外科理论与实践, 2015, 20(6): Miao Y, Wu JL. Surgical treatment of chronic pancreatitis[j]. Journal of Surgery Concepts & Practice, 2015, 20(6): [2] Yamaguchi K, Tanaka M. Groove pancreatitis masquerading as pancreatic carcinoma[j]. Am J Surg, 1992, 163(3): [3] Cavallini G, Frulloni L, Pederzoli P, et al. Long-term follow-up of patients with chronic pancreatitis in Italy[J]. Scand J Gastroenterol, 1998, 33(8): [4] Falconi M, Bassi C, Casetti L, et al. Long-term results of Frey's procedure for chronic pancreatitis: a longitudinal prospective study on 40 patients[j]. J Gastrointest Surg, 2006, 10(4): [5] Beger HG, Schlosser W, Friess HM, et al. Duodenum-preserving 究其原因可能为离断胰 head resection in chronic pancreatitis changes the natural course of 腺颈部时损伤门静脉Frey术式和Berne术式可 the disease: a single-center 26-year experience[j]. Ann Surg, 1999, 避免这种可能因此可根据肿块大小和影像学资 230(4): 胰十二指肠切除术料评估是否需要离断胰颈部若不需离断可选择Frey术式或Berne术式,否则选择Beger术式此外 Beger术式能延缓胰腺组织内腺体损伤但不能阻断 [45-46] 虽然Frey术式具有上述优点 [47] 但是 Frey术式中胰头切除范围较小术后仍有癌变可能 [47-48] 因此若术前考虑恶性肿瘤可能性相对较 [6] Lowenfels AB, Maisonneuve P, Cavallini G, et al. Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group[J]. N Engl J Med, 1993, 328(20): [7] Falconi M, Valerio A, Caldiron E, et al. Changes in pancreatic resection for chronic pancreatitis over 28 years in a single institution[j]. Br J Surg, 2000, 87(4): [8] Pezzilli R. Etiology of chronic pancreatitis: has it changed in the

4 第3期孙爱学等胰头肿块型胰腺炎诊断和外科治疗进展 last decade[j]. World J Gastroenterol, 2009, 15(38): [9] 王洛伟, 李兆申, 李淑德, 等. 慢性胰腺炎全国多中心流行病学调 437 Arabian experience[j]. Acta Cytol, 2011, 55(1): [21] Chen J, Yang R, Lu Y, et al. Diagnostic accuracy of endoscopic 查[J]. 胰腺病学, 2007, 7(1):1-5. ultrasound-guided fine-needle aspiration for solid pancreatic Wang LW, Li ZS, Li SD, et al. A multi-center survey on chronic lesion: a systematic review[j]. J Cancer Res Clin Oncol, 2012, pancreatitis in China[J]. Chinese JOurnal of Pancreatology, 2007, 138(9): (1):1-5. [10] Finkelberg DL, Sahani D, Deshpande V, et al. Autoimmune pancreatitis[j]. N Engl J Med, 2006, 355(25): [11] Perumal S, Palaniappan R, Pillai SA, et al. Predictors of malignancy in chronic calcific pancreatitis with head mass[j]. World J Gastrointest Surg, 2013, 5(4): [12] 郑恩典, 邹多武, 李淑德. 肿块型慢性胰腺炎39例临床分析[J]. 中华消化杂志, 2009, 29(3): [22] 夏菁, 陈坚, 徐天放. 胰头部肿块术中组织芯活检临床价值[J]. 肝胆胰外科杂志, 2011, 23(5): Xia Q, Chen J, Xu TF. Clinical application of core needle biopsy for pancreatic head mass[j]. Journal of Hepatopancreatobiliary Surgery, 2011, 23(5): [23] Lee LK, Sahani DV. Autoimmune pancreatitis in the context of IgG4-related disease: review of imaging findings[j]. World J Gastroenterol, 2014, 20(41): Zheng ED Zou DW Li SD. Clinical analysis of 39 cases of [24] Pawlik TM, Laheru D, Hruban RH, et al. Evaluating the impact of a chronic pancreatitis with mass[j]. Chinese Journal of Digestion, single-day multidisciplinary clinic on the management of pancreatic 2009, 29(3): cancer[j]. Ann Surg Oncol, 2008, 15(8): [13] Goonetilleke KS, Siriwardena AK. Systematic review of [25] Katz MH, Wang H, Fleming JB, et al. Long-term survival carbohydrate antigen (CA 19-9) as a biochemical marker in the after multidisciplinary management of resected pancreatic diagnosis of pancreatic cancer[j]. Eur J Surg Oncol, 33(3): adenocarcinoma[j]. Ann Surg Oncol, 2009, 16(4): [14] 石军, 夏峰, 李冠群, 等. 以胰腺肿块为特征的慢性胰腺炎的外科 [26] American Gastroenterological Association Medical Position 治疗[J]. 中华普通外科杂志, 2010, 25(8): Statement: treatment of pain in chronic pancreatitis[j]. Shi J, Xia F, Li GQ, et al. Surgical treatment for chronic pancreatitis Gastroenterology, 1998, 115(3): characterized by a pancreatic mass[j]. Zhong Hua Pu Tong Wai Ke Za Zhi, 2010, 25(8): [15] Pan S, Chen R, Crispin D A, et al. Protein alterations associated [27] van Esch AA, Wilder-Smith OH, Jansen JB, et al. Pharmacological management of pain in chronic pancreatitis[j]. Dig Liver Dis, 2006, 38: with pancreatic cancer and chronic pancreatitis found in human [28] Lamme B, Boermeester MA, Straatsburg IH, et al. Early versus late plasma using global quantitative proteomics proﬁling[j]. J Proteome surgical drainage for obstructive pancreatitis in an experimental Res, 2011, 10(5): model[j]. Br J Surg, 2007, 94(7): [16] Bedi MM, Gandhi MD, Jacob G, et al. CA 19-9 to differentiate [29] Ahmed Ali U, Pahlplatz JM, Nealon WH, et al. Endoscopic or benign and malignant masses in chronic pancreatitis: is there any surgical intervention for painful obstructive chronic pancreatitis[j]. beneﬁt[j]. Indian J Gastroenterol, 2009, 28(1): Cochrane Database Syst Rev, doi: / [17] Yusuf TE, Ho S, Pavey DA, et al. Retrospective analysis of the cd pub2 utility of endoscopic ultrasound-guided ﬁne-needle aspiration (EUS- [30] Ahmed Ali U, Issa Y, Bruno M J, et al. Early surgery versus optimal FNA) in pancreatic masses, using a 22-gauge or 25-gauge needle current step-up practice for chronic pancreatitis (ESCAPE): design system: a multicenter experience[j]. Endoscopy, 2009, 41(5):445- and rationale of a randomized trial[j]. BMC Gastroenterol, 2013, (1):49. [18] Fisher L, Segarajasingam DS, Stewart C, et al. Endoscopic [31] 赵玉沛.胰头部肿块鉴别诊断和临床对策[J].中国实用外科杂志, ultrasound guided ﬁne needle aspiration of solid pancreatic lesions: 2009, 29(8): Performance and outcomes[j]. J Gastroenterol Hepatol, 2009, Zhao YP. Differential diagnosis and surgical strategies for 24(1): pancreatic head mass[j]. Chinese Journal of Practical Surgery, 2009, [19] Zhang S, Defrias DV, Alasadi R, et al. Endoscopic ultrasoundguided fine needle aspiration (EUS-FNA): experience of an academic centre in the USA[J]. Cytopathology, 2010, 21(1): [20] Raddaoui E. Clinical utility and diagnostic accuracy of endoscopic ultrasound-guided ﬁne needle aspiration of pancreatic lesions: Saudi 29(8): [32] Sonnenberg A, Rodriguez SA, Faigel DO. Diagnostic ascertainment of suspicious pancreatic mass: a threshold analysis[j]. Clin Gastroenterol Hepatol, 2008, 6(10): [33] Bachmann K, Tomkoetter L, Kutup A, et al. Is the Whipple

5 438 第 25 卷 Procedure Harmful for Long-term Outcome in Treatment of Chronic [43] Farkas G, Leindler L, Daróczi M, et al. Long-term follow-up after Pancreatitis? 15-Years Follow-up Comparing the Outcome after organ-preserving pancreatic head resection in patients with chronic Pylorus-Preserving Pancreatoduodenectomy and Frey Procedure in pancreatitis[j]. J Gastrointest Surg, 2008, 12(2): Chronic Pancreatitis[J]. Ann Surg, 2013, 258(5): [44] Farkas G, Leindler L, Daróczi M, et al. Prospective randomised [34] Karanicolas PJ, Davies E, Kunz R, et al. The pylorus: take it or comparison of organ-preserving pancreatic head resection with leave it? Systematic review and meta-analysis of pylorus-preserving pylorus-preserving pancreaticoduodenectomy[j]. Langenbecks Arch versus standard whipple pancreaticoduodenectomy for pancreatic or Surg, 2006, 391(4): periampullary cancer[j]. Ann Surg Oncol, 2007, 14(6): [35] Keck T, Marjanovic G, Fernandez-del Castillo C, et al. The inflammatory pancreatic head mass: significant differences in the [45] Zheng Z, Xiang G, Tan C, et al. Pancreaticoduodenectomy versus duodenum-preserving pancreatic head resection for the treatment of chronic pancreatitis[j]. Pancreas, 2012, 41(1): anatomic pathology of German and American patients with chronic [46] Müller MW, Friess H, Martin DJ, et al. Long-term follow-up of a pancreatitis determine very different surgical strategies[j]. Ann randomized clinical trial comparing Beger with pylorus-preserving Surg, 2009, 249: Whipple procedure for chronic pancreatitis[j]. Br J Surg, 2008, [36] Roch AM, Brachet D, Lermite E, et al. Frey procedure in patients with chronic pancreatitis: short and long-term outcome from a prospective study[j]. J Gastrointest Surg, 2012, 16(7): (3): [47] 谢思明, 陈拥华, 谭春露, 等. Frey手术治疗慢性胰腺炎的围手术期并发症及近期疗效[J]. 中华外科杂志, 2014, 52(3): [37] McClaine RJ, Lowy AM, Matthews JB, et al. A comparison of Xie SM, Chen YH, Tan CL, et al. Perioperative complications pancreaticoduodenectomy and duodenum-preserving head resection and recent results of Frey procedure in the treatment of chronic for the treatment of chronic pancreatitis[j]. HPB (Oxford), 2009, pancreatitis[j]. Chinese Journal of surgery, 2014, 52(3): (8): [38] Keck T, Adam U, Makowiec F, et al. Short- and long-term results [48] 贺舜民, 李志强, 余枭, 等. 胰十二指肠切除术与保留十二指肠胰头次全切除术治疗胰头肿块型慢性胰腺炎的临床疗效[J]. 中华 of duodenum preservation versus resection for the management of 消化外科杂志, 2015, 14(8): chronic pancreatitis: a prospective, randomized study[j]. Surgery, H e S M, L i Z Q, Yu X, e t a l. C l i n i c a l e f f i c a c y o f 2012, 152(3 Suppl 1):S pancreaticoduodenectomy and duodenum-preserving pancreatic [39] Beger HG, Büchler M. Duodenum-preserving resection of the head head resection for the treatment of chronic pancreatitis with mass in of the pancreas in chronic pancreatitis with inﬂammatory mass in the head of the pancreas[j]. Chinese Journal of Digestive Surgery, the head[j]. World J Surg, 1990, 14(1): , 14(8): [40] Roch A, Teyssedou J, Mutter D, et al. Chronic pancreatitis: A surgical disease? Role of the Frey procedure[j]. World J Gastrointest 本文编辑宋涛 Surg, 2014, 6(7): [41] Müller MW, Friess H, Leitzbach S, et al. Perioperative and follow- 本文引用格式孙爱学, 赵成功. 胰头肿块型胰腺炎诊断和外科 up results after central pancreatic head resection (Berne technique) 治疗进展[J]., 2016, 25(3): doi: / in a consecutive series of patients with chronic pancreatitis[j]. Am J Surg, 2008, 196(3): [42] Izbicki JR, Bloechle C, Broering DC, et al. Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe j.issn Cite this article as: Sun AX, Zhao CG, et al. Progress in diagnosis and surgical treatment for pancreatic head mass due to chronic pancreatitis[j]. Chin J Gen Surg, 2016, 25(3): doi: / j.issn chronic pancreatitis: prospective evaluation of a new surgical procedure[j]. Ann Surg, 1998, 227(2):

J Clin Hepatol Vol.31 No.3 Mar R576 B Guidelines for the management of chronic pancreatitis 2014

J Clin Hepatol Vol.31 No.3 Mar R576 B Guidelines for the management of chronic pancreatitis 2014 322 2014 R576 B 1001-5256 2015 03-0322 - 05 Guidelines for the management of chronic pancreatitis 2014 Group of Pancreas Surgery Chinese Society of Surgery Chinese Medical Association. Key words pancreatitis