磁共振胆胰管成像对阻塞性黄疸的诊断价值研究

目的评价磁共振胆胰管成像在阻塞性黄疸中的诊断价值。方法采用ＧｙｒｏｓｃａｎＴ５Ⅱ型超导磁共振成像系统、二维傅立叶转换,冠状成像技术及ＭＩＰ重建术对３６例临床拟诊阻塞性黄疸病人进行检查,根据手术及病理检查结果评估该法的诊断率。结果３６例受检者均未发生特殊异常反应。良性疾患的２３例中ＭＲＣＰ定位诊断率为９６％（２２／２３）,定性诊断符合率为８７％（２０／２３）,恶性疾患的１３例定位诊断率为１００％（１３／１３）,定性诊断符合率为８５％（１１／１３）。结论磁共振胆胰管成像对阻塞性黄疸的诊断、鉴别诊断具有重要的价值。     

MRCP联合BTFE序列对肝外胆管梗阻性疾病的诊断价值

目的 探讨磁共振胆胰管成像（MRCP）联合平衡梯度回波（BTFE）序列对肝外胆管梗阻性疾病的诊断价值。方法 回顾性分析我科经临床病理确诊的70例胆管梗阻性疾病患者的磁共振影像资料,分别比较MRCP以及MRCP联合BTFE的诊断阳性率。结果 70 例患者中胆管结石34 例、胆管炎性狭窄5 例、胆管癌16例、壶腹癌9例、胰头癌6例,MRCP诊断肝外胆管梗阻性疾病的阳性率为84.2%,MRCP联合BTFE的阳性率为95.7%,高于MRCP,差异有统计学意义（P=0.023）。结论 MRCP联合BTFE可较好地显示胆管梗阻的部位、形态,对梗阻性胆管扩张的定性诊断具有重要价值。     

MR动态增强结合 MRCP对 64例壶腹周围癌的诊断及鉴别分析

目的:探讨MR 动态增强结合磁共振胰胆管成像(MRCP)对壶腹周围癌的诊断及鉴别诊断价值。方法:回顾性分析64 例经病理学证实壶腹周围癌的MRI 资料,并复习相关文献。结果:64 例中胰头癌35 例,胆总管下段腺癌11 例,壶腹癌8 例,十二指肠腺癌10 例。58 例表现为壶腹区域大小不等的软组织信号结节或肿块,3 例胆总管下段癌及3 例十二指肠腺癌表现局部管壁增厚,61 例伴有程度不等的低位胆管和/ 或胰管梗阻。不同类别肿瘤的MR 表现既有共同之处,又各有特点。结论:MR 动态增强结合MRCP 对壶腹周围癌的诊断及鉴别具有较大价值。     

MR/MRCP/MRA对胆胰管恶性阻塞性疾病术前诊断及治疗抉择的评价

目的 探讨现代影像学检查对胆胰管恶性阻塞性疾病术前诊断的准确性及临床应用价值。方法 对４４例胆胰管恶性阻塞性疾病患者进行磁共振成像（ＭＲ）、磁共振胆胰管造影（ＭＲＣＰ）以及磁共振动态增强血管显影（ＭＲＡ）检查,并与同期进行Ｂ超（Ｂ－us）、内窥镜逆行性胰胆管造影（ＥＲＣＰ）以及电子计算机断层扫描（ＣＴ）等检查结果对照。结果 ４４例患者中诊断为胰头部和壶腹周围癌者２８例,胰体尾部癌５例,肝胆管癌１１例,其定位准确率为８２％,定性准确率为７６％。Ｂ-us定位准确率、定性准确率分别为７３％和６８５,ＥＲＣＰ定位准确率、定性准确率分别为９６％和８４％。结论 ＭＲ／ＭＲＣＰ／ＭＲＡ对胆胰管恶性阻塞性疾病术前诊断的准确性优于Ｂ超、ＣＴ和ＥＲＣＰ,对胰胆管肿瘤转移和周围组织浸润,尤其是对肿瘤血管浸润可明确显示,其影像学结果对病变程度估计及指导临床治疗抉择有重要价值。     

壶腹部癌的临床病理分析(附41例报告)

目的 探讨壶腹部癌的临床病理特点，提高对壶腹部癌的临床诊治水平。方法 回顾性分析41例经手术及病理确诊为壶腹部癌患者的临床病理资料，寻找其特点及联系。结果 41例壶腹部癌以梗阻性黄疸和上腹部不适、疼痛为突出的临床表现；影像学检查主要表现为壶腹部肿物及胆、胰管扩张、狭窄、中断；内镜对十二指肠乳头及附近粘膜病变发现率高，活检阳性达83％；病理上以腺癌多见，呈浸润性生长，易侵犯胰头和十二指肠。结论 上腹部不适、疼痛是壶腹部癌的早期症状，对早期诊断有重要的提示作用；超声及内镜，尤其是内镜和活检对壶腹部癌的发现和诊断具有重要的作用。     

无痛内镜下胆道金属支架联合胰管支架治疗壶腹周围癌

目的 探讨胆道金属支架联合胰管支架置入治疗壶腹周围癌的临床价值。方法 3例患者经临床或病理诊断为壶腹周围癌,其中1例经病理学诊断为（十二指肠乳头）腺癌,2例临床诊断为胰头癌。影像学表现为胰管和胆管均有狭窄,经内镜先在胰管内置入塑料胰管支架,后胆道内置入可膨胀式金属支架,观察支架置放前后患者的临床表现及胆红素、血尿淀粉酶等生化指标变化。结果 3例均顺利置入胆道金属支架及胰管支架,支架置放后总胆红素、血尿淀粉酶均有明显的下降,症状缓解。结论 胆道金属支架联合胰管支架可以解除壶腹周围癌患者的胆、胰管恶性狭窄与梗阻,安全有效。     

壶腹部癌的诊断和治疗

<正>壶腹部癌包括Vater壶腹周围2 cm范围以内的恶性肿瘤,可起源于十二指肠乳头及乳头附近的黏膜、壶腹内的黏膜、胰管及胆总管十二指肠壁间部黏膜上皮,主要包括壶腹癌、十二指肠乳头癌及胆总管下端癌~([1-4])。壶腹部癌较少见,约占胃肠道恶性肿瘤的0.5%。壶腹部癌因起源不明、发病率低、周围解剖结构复杂,加之在生物学特性、生存率等方面存在较大差异,所以一直是临床和病理学研究的难点。在临床实践中,壶腹部癌的诊疗关键在于鉴别诊断、     

MRCP对胆囊切除术后问题病因的诊断价值

目的: 评价磁共振胆胰管成像（MRCP）在胆囊切除术后问题（ PCP）病因诊断中的价值。方法: 采用快速自旋回波水成像技术对33例PCP病人进行MRCP检查,并根据手术及病理情况评估其诊断符合率。结果: 33例病人均获得了满意的MRCP图像,且无特殊异常反应,在 27例胆胰相关病因的诊断中,MRCP的诊断符合率为88.9%（24/27）;而在6例非胆胰相关病因的诊断中,其诊断符合率为0。结论: MRCP对PCP病人胆胰相关病因的诊断和鉴别诊断有重要价值,它不仅为临床提供了丰富的形态学信息,还能指导外科手术和介入性治疗方法的实施。     

乏特壶腹癌的诊断和治疗

乏特壶腹部癌(carcinoma of the ampulla of Vater)是指十二指肠乳头内胆管、乳头内胰管、胆胰管壶腹、十二指肠大乳头区的一种比较少见的恶性肿瘤.乏特壶腹部癌的症状及其诊治措施均与胰头癌很相似,有时甚至于手术中也很难区别,故临床上将两者统称之为壶腹周围癌(periampullary carcinoma);     

磁共振胆胰管成像在阻塞性黄疸中的应用研究

目的探讨磁共振胆胰管成像(MRCP)在阻塞性黄疸中的应用价值。方法对3126例阻塞性黄疸患者进行MRCP检查,将MRCP诊断与临床诊断或手术和病理结果综合分析对比。结果1324例获清晰胆管树影像,1038例胰管显示,2例图像模糊。MRCP对阻塞性黄的定位,定性诊准确率分别为99.8%、92.3%。结论MRCP图像清晰,不用造影剂,无并发症,对阻塞性黄疸的诊断是一种有效、安全、可靠的方法。     

影像学检查技术在壶腹周围癌诊断上的合理应用

目的：探讨影像学检查技术在壶腹周围诊断上的合理应用。方法：对我院185例壶腹周围癌（包括胰头癌119例、十二指肠乳头癌41例、Vater壶腹癌13例、胆总管下段癌12例）的临床特点和各种影像学检查资料进行回顾性分析。结果：本组CT诊断胰头癌的准确率为90．9％；ERCP对十二指肠乳头癌的确诊率为100％；ERCP和MRCP对壶腹癌和胆总管下段癌的诊断价值优于其他检查。78％的病人上腹饱胀／隐痛出现时间早于黄疸1－3月。血清CA19－9值在3／4以上的胰头癌、壶腹癌和胆总管下段癌病人超过正常值。结论：凡有中上腹部饱胀、隐痛、血清CA19－9值升高、胆总管和（或）胰管扩张的病人应有步骤地进行各种影像学检查。超声检查发现胰头部有肿块，宜行CT检查。如未发现肿块，则行ERCP。凡ERCP检查时观察到有肿瘤征象的病人，不宜作胰胆管造影而仅作活检。MRCP可用于胰胆管造影失败的壶腹癌和胆总管下段癌。超声内镜对壶腹周围癌的诊断和鉴别诊断也起重要作用。     

磁共振血管造影和胰胆管造影在胰头癌外科中的价值

目的探讨磁共振成像（MRI）联合磁共振血管造影（MRA）和胰胆管造影（MRCP）对胰头癌诊断的价值。方法对42例胰头癌患者进行MRI、MRA和MRCP检查,并与术中探查结果及手术方式行对比分析。结果42例胰头癌患者中MRCP和MRA显示癌肿未侵犯邻近组织、血管者24例,癌肿压迫邻近门静脉、肠系膜上静脉者5例,侵犯或浸润邻近血管者10例,远处器官转移者3例。与术中探查结果相符者35例,准确率达89．7％（35／39）。行胰十二指肠切除术者28例,行内引流术者11例,3例行介入治疗,手术切除率为66．7％（28／42）。结论MRCP和MRA对胰头癌患者术前肿瘤转移和周围组织浸润,尤其是对肿瘤血管浸润可明确显示,其影像学结果对病变程度的估计及指导临床治疗决策有重要价值。     

Magnetic resonance imaging with magnetic resonance cholangiopancreatography accurately predicts resectability of pancreatic carcinoma

Accurate preoperative staging of pancreatic malignancy aids in directing appropriate therapy and avoids unnecessary invasive procedures. We evaluated the accuracy of magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) in determining resectability of pancreatic malignancy. Twenty-one patients with suspected pancreatic malignancy underwent dynamic, contrast-en-hanced breath-hold MRI with MRCP prior to surgical evaluation. Results of this study were correlated with operative results and pathologic findings. The sensitivity, specificity, and accuracy of MRI with MRCP in detecting a mass, determining the nature of the mass, and predicting lymph node involvement and resectability were determined. MRI with MRCP correctly identified the presence of a pancreatic mass in all 21 of these patients. Following pathologic correlation, it was determined that MRI with MRCP was 81 % accurate in determining the benign or malignant nature of the pancreatic mass and 43% accurate in predicting lymph node involvement. In predicting resectability, MRI with MRCP had a sensitivity of 100%, specificity of 83%, positive predictive value of 94%, negative predictive value of 100%, and accuracy of 95%. MRI with MRCP is an accurate, noninvasive technique in the preoperative evaluation of pancreatic malignancy. Information obtained from MRI with MRCP including identification of a mass and predicting tumor resectability may be of value in staging and avoiding unnecessary invasive diagnostic procedures in patients with pancreatic cancer. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Adenocarcinoma of the ampulla of Vater. A 28-year experience.

OBJECTIVE: The aim of this study were to review the experience with adenocarcinoma of the ampulla of Vater at The Johns Hopkins Hospital and to determine what factors influenced the long-term outcome in these patients. SUMMARY BACKGROUND DATA: Adenocarcinoma of the ampulla of Vater is the second most common periampullary malignancy. However, most series have relatively small numbers. As a result, analysis of factors influencing outcome has been limited. METHODS: From 1969 to 1996, 120 patients with adenocarcinoma of the ampulla of Vater were managed at The Johns Hopkins Hospital. Clinical, operative, and pathologic factors were correlated with morbidity and long-term survival. Factors influencing outcome were evaluated by univariate and multivariate analyses. RESULTS: Resection was performed in 106 patients (88%), and 105 of these patients (99%) underwent either pancreatoduodenal resection (n = 103) or total pancreatectomy (n = 2). Resection rate increased from 62% in the 1970s to 82% in the 1980s to 96% in the 1990s (p < 0.05). Overall mortality after resection was 3.8% with no mortality in the 45 consecutive patients resected in the past 5 years. Morbidity also decreased significantly (p < 0.05) from 70% before to 38% after December 1992. Five-year survival for resected patient was 38%. Factors favorably influencing long-term outcome were resection (p < 0.001), no perioperative blood transfusions (p < 0.05), negative lymph node status (p = 0.05), and moderate or well-differentiated tumors (p < 0.05). In a multivariate analysis, the best predictor of prolonged survival was absence of intraoperative transfusion (p = 0.06, relative risk = 1.90, 95% confidence limits = 0.95-3.78). CONCLUSIONS: Compared to carcinoma of the pancreas, carcinoma of the ampulla of Vater has a higher resectability rate and a better prognosis. Early diagnosis is important because lymph node status influences survival. Careful operative dissection and avoidance of transfusions also improves long-term survival.     

常规MRI结合MR胰胆管成像诊断原发性胆囊癌

目的探讨常规MRI结合MR胰胆管成像（MRCP）诊断原发性胆囊癌的价值。方法回顾性分析经病理证实的29例原发性胆囊癌患者的MR平扫、动态增强与MRCP资料。结果 MRI诊断厚壁型原发性胆囊癌12例,肿块型9例,腔内结节型5例。术前常规MRI诊断原发性胆囊癌的正确率为89.66%（26/29）,MRI结合MRCP诊断原发性胆囊癌正确率为100%（29/29）。结论常规MRI结合MRCP对诊断原发性胆囊癌有重要意义。     

Report of two cases of large cell neuroendocrine carcinoma of duodenal ampulla with contrasting outcomes following pancreaticoduodenectomy according to the use of adjuvant chemotherapy

IntroductionLarge-cell neuroendocrine carcinoma (LCNEC) in the duodenal ampulla of Vater is a rare malignant tumor, with frequent postoperative recurrence and poor prognosis even following complete resection. Effective adjuvant chemotherapy is expected to offer longer survival.Presentation of caseWe present two patients with LCNEC accompanied by components of tubular adenocarcinoma/adenoma in the duodenal ampulla of Vater who underwent pancreaticoduodenectomy (PD), resulting in longer survival of 1 patient. The first patient was an 81-year-old man in whom a 14-mm protruding solid tumor of the ampulla was observed. Pylorus-preserving PD (PPPD) was performed for the diagnosis of adenocarcinoma of the ampulla, and the final histological diagnosis of the resected specimen was LCNEC with an adenoma component. The patient showed a liver metastasis 4 months after surgery and died of carcinoma after 11 months. The second patient was a 72-year-old man with a 24-mm ulcerative solid tumor of the ampulla. PPPD was also performed in this patient, and the final histological diagnosis was LCNEC with mixed adenocarcinoma component (21%). Adjuvant chemotherapy of cisplatin and etoposide was administered, and the patient survived without tumor relapse for 24 months after surgery.ConclusionIn the surgical treatment of LCNEC of the ampulla showing malignant behaviour, an accurate preoperative diagnosis and effective adjuvant chemotherapy after curative resection are necessary for longer survival.     

Carcinoma of the ampulla of Vater.

Thirty-five consecutive cases of adenocarcinoma of the ampulla of Vater seen over the past 36 years were reviewed. The introduction of new diagnostic techniques over the course of this study improved the accuracy of preoperative diagnosis but did not lead to earlier diagnosis. The surgical resectability rate was 88%, and 53% of postoperative survivors were free of disease at 5 years. Of the 14 patients with metastases to regional lymph nodes, 27% survived disease-free for 5 years. Surgical mortality was 25% for the entire series but has been reduced to 6.6% over the past decade. Surgical mortality was primarily due to leakage of the pancreaticojejunostomy; the risk of pancreaticojejunostomy leak correlated inversely with the degree of chronic pancreatitis in the pancreatic remnant. In 35% of resected cases, a benign adenomatous component was contained within the cancer of the ampulla of Vater. Cure rates are good for this lesion. The most important factor in maximizing cure rate is careful attention to the technical details of pancreaticojejunostomy in order to minimize surgical mortality. Benign adenomas appear to be a frequent precursor of carcinoma of the ampulla of Vater.     

胰十二指肠切除术治疗胰头和壶腹部癌230例分析

了解胰十二指肠切除术治疗胰头和壶腹部癌的效果和影响病人生存的因素。方法:分析230例胰头和壶腹部癌的主要表现,辅助检查、手术并发症、手术死亡率,调查术后生存情况及影响病人长期生存的因素。结果:本组病人出现黄疽90.9％,腹痛56.1％,发热32.6％,白陶土样大便13.5％。B超、CT和ERCP检查准确率分别为68.3％、79.3％和66.6％。手术并发症72例(31.3％),死亡20例(8.7％)。术后1、3、5年存活率分别为46.7％,17.4％和52％。肿瘤直径、淋巴结转移和切缘状态是影响病人术后生存的因素,而肿瘤分化程度和病人年龄对生存率无明显影响。结论:胰头和壶腹部癌临床表现有多样性,B超和CT等辅助检查有局限性,手术有高并发症,5年生存率低下,手术治疗远近期效果都不理想。     

Large Cell Neuroendocrine Carcinoma of the Ampulla of Vater: Report of a Case

Large cell neuroendocrine carcinoma in the ampulla of Vater is rare and very different from the common ampullary adenocarcinoma. A 59-year-old man was admitted with obstructive jaundice. Gastroendoscopy showed a swollen ampulla of Vater and pathological examination of an ampullary biopsy revealed findings of a carcinoid tumor. After endoscopic biliary drainage, he underwent pancreaticoduodenectomy. A diagnosis of large cell neuroendocrine carcinoma was confirmed by immunohistochemical examination of the resected specimen. Despite adjuvant chemotherapy with cyclophosphamide and cisplatin, liver and peritoneal metastasis developed within 5 months and he survived for only 10 months after the operation. Thus, further investigations are needed to find a more effective postoperative adjuvant chemotherapy agent to treat patients with this aggressive tumor.