目的 探讨胰管支架表面括约肌预切开(PPDS)在ERCP困难胆管插管中的应用效果.方法 回顾性统计分析2016年6月1日至2021年5月31日上海交通大学医学院附属瑞金医院北部院区所有ERCP术病例资料,将在ERCP操作过程中导丝意外进入胰管的困难胆管插管者,根据术中选择插管方法,分为两组:(1)PPDS组,(2)双导丝或经胰管括约肌切开(DGW/TPS)组.分析比较两组的胆管插管成功率、并发症发生率.结果 880例ERCP术中,共85例符合入选标准,其中PPDS组37例,DGW/TPS组48例.两组在年龄、性别、术前胆总管直径、血清总胆红素、病因构成等基本情况方面无统计学差异(P>0.05).PPDS组胆管插管成功率为94.6％(35/37),无ERCP术后胰腺炎(PEP)、出血、穿孔并发症发生.DGW/TPS组胆管插管成功率为83.3％(40/48);术后并发症发生率为20.8％(10/48),其中PEP 9例,出血2例(1例既有PEP又有出血),无穿孔病例.两组胆管插管成功率无统计学差异(χ2=2.55,P=0.18),但术后总并发症发生率有统计学差异(χ2=8.74,P=0.003).所有病例均治愈.结论 PPDS法成功率高,能显著降低ERCP相关并发症发生率,该法安全、简便.

胰腺癌是恶性程度极高的消化道肿瘤,手术是唯一可能的根治性治疗手段.胰十二指肠切除术后患者营养不良发生率较高,规范、合理、科学地使用肠内营养治疗,对胰腺癌患者术后恢复有着重大意义.本文基于近年来胰十二指肠切除术后肠内营养的现状和研究发展趋势做简要概述,为胰腺癌术后的肠内营养治疗提供参考.

ObjectivesThere are few reports about the survival rate of patients with pancreatic adenosquamous cancer (PASC). This study evaluated and analyzed prognostic factors of patients with resectable pancreatic adenosquamous cancer (rPASC), which might fulfill the blank in the research of PASC.MethodsIn this study, we identified and analyzed 55 patients who were diagnosed with rPASC from January 2013 to May 2019 at the Pancreatic Disease Center of the Shanghai Ruijin Hospital affiliated with Shanghai Jiaotong University School of Medicine. Age, sex, BMI, tumor position, and other important demographic data were collected and analyzed. The follow-up was updated by December 31th, 2019 with a median follow-up of nine months.ResultsAmong the 55 patients, 23 (41.8%) patients were female, and the mean age was 62.0 ± 10.3 years. The median overall survival (OS) time was 10 ± 2.1 months, and the median disease-free survival (DFS) time was 4 ± 0.9 months. The 1-year, 3-year, and 5-year survival rates were 40.9, 17.5, and 11.6%, respectively. The multivariate analysis showed that normal serum level of Ca199 (HR = 0.464, 95% CI = 0.222–0.970, P = 0.041) and Ca125 (HR = 0.441, 95% CI = 0.233–0.835, P = 0.012) were independent favorable prognostic factors.ConclusionPatients with rPASC had poor survival. The 5-year survival rate was only 11.6%. Normal serum levels of Ca199 and Ca125 were independent favorable prognostic factors that predicted prognosis.

Objective To analyze operative outcomes of endoscopic retrograde cholangiopancreatography (ERCP) rela-ted duodenal perforations. Methods Retrospective analysis was performed with the clinical data of 14 patients who had duodenal perforation during ERCP including 13 cases in Ruijin Hospital and one case in Ruijin Hospital North from Ja-nuary 2011 to May 2014. Surgical timing and procedure were analyzed. Duodenal perforations were classified into types according to Stapfer. Results There were type Ⅰ lesions in 2 cases, type Ⅱ lesions in 10 cases,and type Ⅲ lesions in 2 cases. The time to operation was during ERCP of type Ⅰ injuries, (2.0±1.1) (0-5.0) d of type Ⅱ injuries, and (6.0±2.8) (4.0-8.0) d of type Ⅲ injuries after ERCP with significant statistical difference (P<0.05), indicating different progress to abdominal infection from type Ⅰ, type Ⅱ, and type Ⅲ perforation. There were 3 cases of type Ⅱ perforation who had operation of duodenal diverticulation with two cases cured and one case died. No significant difference was present in hospital stay and mortality of the patients of type Ⅱ between 3 cases treated by duodenal diverticulation and 7 cases without duodenal diverticulation (P=0.451,P=0.300). Hospital stay of type Ⅰ, type Ⅱ, type Ⅲ was (49.0±32.5) d, (81.6±30.0) d, (51.0±22.6) d respectively without significant difference (P=0.239). Two cases 80 year and 86 year died had ampullary cancer, who were elder than cured cases (60~76) y with significant statistical difference (P<0.05). Conclusions Operation remains an important treatment for ERCP-related duodenal perforation. Optimal operation based on the type of ERCP related perforation and abdominal infection could be the key to affect efficacy. Elder patients with malignant tumor have poorer prognosis.

微创理念贯彻外科手术领域, 从疾病诊断到治疗,包括病因、病理生理和疾病的转归预后. 内镜技术相对于外科手术,亦属于微创理念,与腹腔镜技术同属微创外科. 目前胆胰疾病的诊治指南中,内镜逆行胰胆管造影术 (endoscopic retrograde cholangiopancreatography, ERCP) 已成为胆胰疾病的主要诊治方法.内镜器械的改进推动了ERCP的不断发展,也促使外科手术微创的进一步发展. 在ERCP领域,还建立了内科、外科之间的交流,通过多学科合作,对疾病诊治达成共识,使病人获益最大化.

在我国,急性胰腺炎(acute pancreatitis,AP)是常见的外科急腹症, 尤以急性胆源性胰腺炎(acute biliary pancreatitis,ABP)最常见,其起病急、进展快,发展成重症预后较差. 近年来随着对疾病的不断认识和重症监护水平的提高,急性胰腺炎的预后明显改善,并在腹腔镜、内镜及介入诊断和治疗方面取得很大进展.但在微创手段应用及具体外科介入时机上仍存在争议. 本文旨在阐述微创治疗AP及其并发症的方法,和存在的争议.

Objective To explore the impact of preoperative biliary drainage methods on perioperative complications. Methods Clinical data of 448 patients of malignant distal biliary obstruction with jaundice who underwent pancreaticoduodenectomy and received preoperative biliary drainage were collected from January 2012 to December 2019. Among them, 238 patients received percutaneous transhepatic cholangial drainage(PTCD) as PTCD group and 210 patients received endoscopic retrograde cholangiopancreatography (ERCP) as ERCP group, including 101 cases with endoscopic biliary sten-ting (EBS) as EBS group and 109 cases with endoscopic nasobiliary drainage. The intervention unsuccess rate and perio-perative complications of different biliary drainage methods were analyzed. Results Intervention unsuccess rate of ERCP was higher than that of PTCD (P=0.034). Postoperative pancreatic fistula rate and reoperation rate were higher in ERCP group than those in PTCD group, respectively (P=0.005 and P=0.025). In analysis of subgroup, overall postoperative complication rate in EBS group was higher than that in PTCD group (P=0.014), and pancreatic fistula rate and reoperation rate in EBS group were higher than those in PTCD group (P<0.001 and P=0.041). There was no statistical difference in other complications between groups. Conclusions PTCD could be used as biliary drainage method with greater advantage than ERCP for the patients of malignant distal biliary obstruction with jaundice before pancreaticoduodenectomy.

Objective To evaluate the use of clinical features, preoperative examination and imaging for predicting malignancy in pancreatic cystic neoplasm (PCN). Methods We included in the retrospective study 342 patients with PCN in our hospital from January 2003 to April 2015. Chi-square and t test were used to analyze the potential factors predicting in malignancy of PCN. Logistic regression of multivariable was applied with the factors P<0.20 for independent risk factors of malignancy. Results There were several factors which would be helpful to predict the malignant PCN including the pre-sent symptoms, male, older than 55, with history of diabetes mellitus or hypertension, very elevation of CA19-9 or CEA, the cyst located at the head, neck or uncinate process of the pancreas, pancreatic duct dilation, solid component and cyst diameter of 3 cm or more. The present symptoms, history of diabetes mellitus, elevation of CA19-9 or CEA, solid compo-nent of cyst and cyst diameter of 3 cm or more were all independent risk factors to predict malignancy of PCN. Cytological result of EUS-FNA helped the prediction of malignancy of PCN. Conclusions The patients with presence of symptoms, diabetes mellitus, elevation of CA19-9 or CEA, solid component of cyst and cyst diameter of 3 cm or more would be useful for preoperative prediction of malignant PCN. EUS-FNA is a valuable tool of preoperative prediction of malignant PCN.

Objective To investigate the pathogenesis and intervention of portal vein cannulation during endoscopic retrograde cholangiopancreatography (ERCP). Methods We present the clinical data of the case with an extremely rare complication during ERCP in which portal vein cannulation occurred combined with placement of a plastic endoscopic biliary stent in portal vein. A literature review was done and the data of this case combined with the other 4 cases reported between 2005 and 2015 were analyzed. To our knowledge, this is the first documented patient with stent in portal vein. Results Except the case with biliary portal vein fistula, catheter-induced and guidewire-induced portal vein cannulation occurred in other 4 cases. The catheter and guidewire were removed intra-operatively in 2 cases. Endoscopic nasobiliary drainage tube-induced portal vein cannulation occurred in 1 case and was removed after biliary drainage by PTCD 3 days. Plastic endoscopic biliary stent-induced portal vein cannulation occurred in 1 case. The case with advanced tumor and obstructive jaundice who was found biliary portal vein fistula during ERCP died 2 months later. The other 4 cases underwent secondary treatment after 1-7 d including 1 case with PTCD. One case was treated by ERCP gallstone removal and 1 case with bile duct stricture expanded by Balloon-associated ERCP. The case in this report was treated by open abdominal surgery and removing the plastic endoscopic biliary stent simultaneously. Conclusions Portal vein cannulation with or without endoscopic biliary stent is an extremely rare complication during ERCP. It is important to be awareness of this complication, careful operation, correct diagnosis and treatment based on different situations. Surgery should be performed timely if necessary.

Objective To assess the optimal timing of laparoscopic cholecystectomy ( LC ) in mild acute gallstone pancreatitis ( mAGP) .Methods From May 1, 2012 to August 30, 2015, consecutive patients with mAGP were prospectively assessed.Each patient underwent abdominal computed tomography scan within 48 h after mAGP onset to assess the presence of peripancreatitc fluid collection, and Marshall score was used to assess if there was organ failure.Patients with neither peripancreatic fluid collection by CT ( classified as grade A, B or C based on the Balthazar CT grading system) nor organ failure by clinical data (Marshall score <2) were randomized according to simple randomization into early laparoscopic cholecystectomy ( ELC; LC performed within 7 days after a pancreatitis attack, without waiting for symptom resolution) or late laparoscopic cholecystectomy ( LLC; LC performed ≥7 days following an attack, with complete remission of AGP symptoms) group.The mean LC operation time, bleeding during LC, post-LC complications and lengths of hospital stay between the ELC group and LLC group were compered.Results The study enrolled 102 patients with mAGP.A total of 49 and 53 patients were assigned to ELC and LLC group, respectively.The mean LC operation time and lengths of hospital stay were significantly shorter in the ELC group than in the LLC group [(19.9 ±5.3) vs(31.1 ±8.4) min;(7.9 ±1.8) vs (16.8 ±5.3) d, P<0.05], while there were no significant difference on bleeding during LC and post-LC complications.Conclusions LC for patients with mAGP who had neither peripancreatic fluid collection nor organ failure within 7 days after the onset was safe and feasible.

Objective To investigate the expression of genes involving in hepatic lipid metabolism in mice fed with lithogenic diet and the regulation of hepatic scavenger receptor B type 1 (SRB1) by PDZ domain-containing 1 (PDZK1) protein. Methods Male C57BL/6J mice were fed with lithogenic diet and the differences in the expression of hepatic genes were studied. PDZK1-overexpressing lentivirus vector and small interfering RNA adenovirus vector were constructed and were used to infect C57BL/6J mice fed with lithogenic diet. mRNA expression of the genes involved in lipid metabolism in liver was quantified by real-time PCR. The protein levels of PDZK1 and SRB1 were determined by Western blot. Results The mRNA expression of 3-hydroxy-3-methylglutaryl coenzyme A reductase, the key enzyme in cholesterol synthesis, in-creased (P<0.01) in the mice fed with lithogenic diet for 4 weeks. However the expression of cholesterol 7-αhydroxylase, the rate-limiting enzyme of bile acid synthesis, decreased significantly (P<0.001). Both the mRNA expression of SRB1 and PDZK1 decreased under lithogenic diet (P<0.001). Intraperitoneal injection to mice with PDZK1-overexpressing lentivirus increased the hepatic PDZK1 protein 37% (P<0.01) after 4 weeks fed with lithogenic diet. The increased expression of SRB1 protein was found in the liver plasma membrane (+136%, P<0.05) but not in the whole liver lysates. On contrary, the intraperitoneal injection to the mice with SiPDZK1 adnovirus after feeding with lithogenic diet 2 weeks reduced PDZK1 protein 49%(P<0.05). In accompany, the total SRB1 protein of liver increased 60%(P<0.05) and SRB1 protein in hepatic membrane decreased 14%. Conclusions Lithogenic diet changed the expression of hepatic genes in lipids metabolism in mice. The down-regulation of SRB1 might be due to the suppression of PDZK1 expression. Intervention of hepatic PDZK1 expression could affect the expression of SRB1 protein in the membrane of hepatocytes.

目的 探讨胰腺囊腺瘤和囊腺癌的临床病理特点及其诊治方法.方法 对我院2002年1月至2012年9月收治的165例胰腺囊性肿瘤患者的临床及病理资料进行回顾性分析.结果 胰腺囊性肿瘤好发于中年女性,临床表现缺乏特异性,其中74例患者因体检时行B超或CT等影像学检查发现胰腺囊性占位来院就诊,影像学检查虽然是发现病灶的主要检查方法,但不能确定疾病病理类型.肿瘤位于胰腺头部40例,胰腺项部34例,胰腺体尾部91例;行不同术式的肿瘤切除160例,剖腹探查、肿瘤活检3例,行胃空肠转流术2例.患者术前免疫学指标糖链抗原125 (CA125)单项指标检测的特异度显著高于糖链抗原19-9 (CA19-9)单项指标检测以及联合检测的特异度(P＜ 0.05).结论 在鉴别诊治胰腺囊腺瘤和囊腺癌患者中,结合患者术前影像学检查结果和免疫学肿瘤指标检测结果,有助于提高术前预判的准确性.由于CA19-9在良性疾病中也有升高现象,所以CA125检测有助于减少这种假阳性的结果.手术切除是胰腺囊腺瘤和囊腺癌的主要治疗手段.

1968年，McCune 等[1]首次报道内镜逆行胰胆管造影术(endoscopic retrograde cholangio-pancre-atography, ERCP)，标志着这一新技术的诞生。ERCP是将十二指肠镜插至十二指肠降部，经活检管道插入造影导管至十二指肠乳头，注入造影剂后透视摄片，以显示胰胆管系统。从20世纪70年代起，随着以内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy, EST)为代表的各种十二指肠内镜治疗新技术的引入以及内镜和相关配件设备的完善， ERCP取得了长足的进步，迄今已发展为集诊断和治疗为一体的内镜诊治系统。许多疾病，如胆总管结石、梗阻性黄疸、创伤性胆漏、慢性胰腺炎、乳头括约肌疾病等以往需外科手术治疗的病例，现在绝大多数均可通过ERCP得到有效的治疗。不仅降低治疗风险，同时具有创伤小、恢复快等优点，有利于病人的康复。目前，ERCP已成为临床不可或缺的重要诊治手段。

Objective To determine the incidence of long-term complications post endoscopic retrograde cholan-giopancreatography (ERCP) combined with endoscopic sphincterotomy (EST), and to examine whether duodenal diverticu-lum or cholecystectomy before-ERCP would affect long-term complications. Methods We got access to the database of ER-CP from our hospital and recruited the patients who had successfully experienced ERCP+EST between 2009 and 2012. Patients were taken through a standard questionnaire via telephone interview , and the information whether biliary symp-toms recurred and whether any long-term complications occurred post-surgery was obtained. Results In 172 successful ERCP cases, recurrent choledocholithiasis was found in 43 (25%) cases 27-71 months post-surgery, while acute cholangitis in 14 (8.1%). No significant difference was observed in the incidence of complications when patients were grouped by age (P>0.05). Moreover, it was found that duodenal diverticulum diagnosed pre-surgery was not associated with post-ERCP long-term complications(P>0.05). Whether patients had cholecystectomy was not a significant contributor for long-term complication, either(P>0.05). Conclusions Recurrent choledocholithiasis and acute cholangitis are the main long-term com-plications following ERCP combined with EST.

Objective To investigate the prognostic risk factors in unexpected gallbladder carcinoma by laparoscopic cholecystectomy. Methods The retrospective study enrolled 20 patients underwent laparoscopic cholecystectomy,and diagnosed gallbladder cancer postoperatively by pathology between January 2008 and January 2013. Results There were 6 men and 14 women,with a mean age of 65.1 years old. One patient was converted to an open procedure,9 patients accepted a secondary radical surgery and others underwent laparoscopic cholecystectomy. By the end of the follow-up period,only 2 patients died and the longest survival was 55 months. Postoperative Nevin staging:stage Ⅰ,0 case;stageⅡ ,11 cases;stage Ⅲ ,6 cases;stage Ⅳ ,1 case,stage Ⅴ ,2 cases. Conclusions It is still difficult to correctly diagnose an unexpected gallbladder carcinoma without a surgery. For cases of Nevin stage Ⅳ andⅤ,a radical surgery is indicated.

Objective To evaluate the indications,efficacy and safety of ERCP for nonagenarians and centenarians patients.Methods Data of nonagenarian or centenarian patients who went through ERCP in our hospital between January 1 st,2001 and March 31st,2014 were retrospectively analyzed.Their clinical characteristics,procedures of ERCP and complications after ERCP were also analyzed.Results A total of 97 nonagenarian or centenarian patients underwent 113 ERCP procedures,the success rate of cannulation was 96.5％,and the final success rate was 92.0％.Of the 97 patients,74 were diagnosed as having extrahepatic bile duct stones and/or bile duct infection,18 malignant obstructive jaundice,and 5 other benign pancreaticobiliary diseases.The overall ERCP related complication rate was 11.5％,mortality being 3.1％.Other complications were mild or moderate,and patients could recover in several days.Conclusion ERCP is both effective and safe for nonagenarian or centenarian patients,however,more research with larger samples is still needed to support it.

经过20多年的发展,随着技术及外科医生对肝脏解剖和生理特征的认识提高,腹腔镜肝切除术有了质的飞跃,报道日益增多,成功有效的断肝是腹腔镜肝脏切除术的关键.术前选择好适应证,术中注意出血栓塞,借助于手助腔镜或中转开腹,恰当行肝血流阻断已达到精准肝切除.特作一综述.

自身免疫性胰腺炎(autoimmune pancreatitis,AIP)是一类以胰腺弥漫性或节段性炎症改变为主的自身免疫性疾病.作为自身免疫性疾病家族的年轻成员,AIP是少数几类可治愈的胰腺疾病,也因此逐渐被人们所重视.组织学上AIP以胰腺导管淋巴浆细胞浸润和组织纤维化为特征,由于发病率低,且临床表现和影像学征象较难与胰腺癌鉴别,故目前对AIP的诊断和治疗仍存在困扰.现将AIP 1例报道如下.

<正>随着人们生活习惯及方式的改变,胆囊结石发病率有上升趋势。胆囊结石可继发炎症,引发急性胆囊炎、急性胰腺炎和急性胆管炎等外科常见急性病[1],临床上常需急诊手术。在症状性胆囊结石并发的疾病中,结石相关慢性炎症过程可引起一系列慢性炎症并发症,其中Mirizzi综合征(Mirizzisyndrome,MS)具有特殊的临床意义[2]。MS的类型及表现复杂,常使外科医师难以作出正确的诊治,片面的诊断和错误的处理可能导致严重的胆道损伤,甚至治疗失败。本文拟从病理生理、临床表现、分型和外科处理等方面对现阶段MS的研究和认识作一阐述。

Cholangiocarcinoma (CC) is an uncommon tumor that may arise anywhere from the biliary epithelium.Chinese CC patients account for more than 55% of CC cases in the world.Complete tumor resection has been recognized as the most effective therapy for CC.Unfortunately,only 10% of the patients are considered candidates for surgical resection.Long-term survival remains poor in these patients,and the5-year survival rate is about 5%.Median survival of patients with the tumor unresectable is only a few months.Although standard systemic chemotherapy approaches are emerging,the prognosis remains poor.Molecularly targeted therapies are a new treatment for advanced CC.The results of recent clinical trials of targeted therapies for CC appear promising.This article will review the molecular basis for targeted therapies for CC and evaluate recent clinical trials on targeted agents.