壺腹部腫瘤治療進(jìn)展課件

1、壺腹部腫瘤手術(shù)治療進(jìn)展壺腹部腫瘤手術(shù)治療進(jìn)展概念：壺腹部：十二指腸乳頭，Vater壺腹、膽總管第4段（十二指腸壁內(nèi)段）、胰管終末段及其周?chē)睦s肌。壺腹部腫瘤是指膽總管第4段、 Vater壺腹(膽總管末端斜行進(jìn)入十二指腸后壁內(nèi)與主胰管形成的共同通道）及十二指腸乳頭的腫瘤。概念：壺腹部：十二指腸乳頭，Vater壺腹、膽總管第4段（十 概述（Introduction）1.壺腹部腫瘤良性少見(jiàn)（10%）1-2；2.與遺傳性息肉病綜合征關(guān)系密切，如FAP；3.確診壺腹癌年齡一般在60-70歲；4.一些證據(jù)表明：生物學(xué)行為更接近于腸道而非胰膽管腫瘤。1 Park SH, Kim YI, Park YH,

2、Kim SW, Kim KW, Kim YT, Kim WH. Clinicopathologic correlation of p53 protein overexpression in adenoma and carcinoma of the ampulla of Vater. World J Surg. 2000 Jan;24(1):54-9.2Park SW, Song SY, Chung JB, Lee SK, Moon YM, Kang JK, Park IS. Endoscopic snare resection for tumors of the ampulla of Vate

3、r. Yonsei Med J. 2000 Apr;41(2):213-8 概述（Introduction）1.壺腹部腫瘤良性少見(jiàn)壺腹癌治療（Treatment）：局部切除胰十二指腸根治切除（PD）及改良（保留幽門(mén)）（PPPD）微創(chuàng)非手術(shù)療法（Minimally-invasive nonsurgical therapies）壺腹癌治療（Treatment）：局部切除局部切除（Local resection）自1899年Halsted開(kāi)展，未廣泛接受（患者生存6個(gè)月，復(fù)發(fā)率高，療效差）發(fā)病年齡較大，并存疾病多目前此種方法的文獻(xiàn)報(bào)道較少，之間對(duì)比缺少標(biāo)準(zhǔn)（eg, ampullectomy vers

4、us local resection)局部切除（Local resection）解剖學(xué)依據(jù)1：*十二指腸內(nèi)段膽總管長(zhǎng)1.5-2.0cm*進(jìn)入十二指腸前1-2cm緊貼腸壁*46.7%膽胰管匯合形成Vater壺腹2*50%膽胰管并行1、Gassler N1,Knchel R. Tumors ofVaters ampulla Pathologe.2012 Feb;33(1):17-23. doi: 10.1007/s00292-011-1546-82、Funabiki T1,Matsubara T,Miyakawa S,Ishihara S. Pancreaticobiliarymaljunctio

5、nandcarcinogenesistobiliaryandpancreaticmalignancy.Langenbecks Arch Surg.2009 Jan;394(1):159-69. doi: 10.1007/s00423-008-0336-0. Epub 2008 May 24.理論依據(jù)解剖學(xué)依據(jù)1：理論依據(jù)解剖學(xué)依據(jù)病理依據(jù)1-2：*壺腹癌以腺癌多見(jiàn)，分化程度高，*惡性程度低1、Beger HG1,Treitschke F,Gansauge F,Harada N,Hiki N,Mattfeldt T. Tumorof theampulla of Vater:experiencew

6、ithlocalorradicalresection in 171 consecutively treated patients. Arch Surg.1999 May;134(5):526-322、Gassler N1,Knchel R. Tumors ofVaters ampulla Pathologe.2012 Feb;33(1):17-23. doi: 10.1007/s00292-011-1546-8理論依據(jù)解剖學(xué)依據(jù)理論依據(jù)解剖學(xué)依據(jù)病理依據(jù)腫瘤生物學(xué)依據(jù)1：*生長(zhǎng)緩慢、轉(zhuǎn)移較晚*常沿十二指腸或膽總管粘膜*少侵及腸壁外1、Beger HG1,Treitschke F,Gansaug

7、e F,Harada N,Hiki N,Mattfeldt T. Tumorof theampulla of Vater:experiencewithlocalorradicalresection in 171 consecutively treated patients. Arch Surg.1999 May;134(5):526-32理論依據(jù)解剖學(xué)依據(jù)理論依據(jù)解剖學(xué)依據(jù)病理依據(jù)腫瘤生物學(xué)依據(jù)其他1：Whipple可以清掃淋巴結(jié)，但不能減少血行轉(zhuǎn)移1、Topal B, Fieuws S, Aerts R, Weerts J, Feryn T, Roeyen G, Bertrand C, Hu

8、bert C, Janssens M。Pancreaticojejunostomy versus pancreaticogastro-stomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullarytumours: a multicentre randomised trial. Lancet Oncol. 2013 Jun;14(7):655-62.理論依據(jù)解剖學(xué)依據(jù)理論依據(jù)手術(shù)范圍文獻(xiàn)報(bào)道不盡相同包括：不涉及膽胰管末端的單純十二指腸黏膜切除 廣泛的乳頭區(qū)域切除：乳頭、壺腹膽胰管末端和相應(yīng)的十二

9、指腸后壁，以及膽胰管末端再植技術(shù)難度大 精細(xì)操作 切緣快速冰凍手術(shù)范圍文獻(xiàn)報(bào)道不盡相同優(yōu)缺點(diǎn)并發(fā)癥少恢復(fù)快手術(shù)時(shí)間短術(shù)后生活質(zhì)量高手術(shù)死亡率低高復(fù)發(fā)率低生存率優(yōu)缺點(diǎn)并發(fā)癥少適用范圍：高風(fēng)險(xiǎn)病人早期高分化、不穿透肌層（Tis,T1期)超聲內(nèi)鏡下直徑6mm（國(guó)內(nèi)文獻(xiàn)報(bào)道直徑2.0/2.5cm）【UpToDate】：We suggest local ampullary excision rather than pancreaticoduodenectomy for patients with noninvasive ampullary tumors (pTis) (Grade 2B).適用范圍：高風(fēng)

10、險(xiǎn)病人展望1.術(shù)前病理診斷假陰性率較高2.腫瘤的組織類型區(qū)分3.術(shù)前淋巴結(jié)情況難判定總之，尚有待臨床大規(guī)模RCT研究展望1.術(shù)前病理診斷假陰性率較高PD/PPPDPD（Whipple operation）被認(rèn)為是治療壺腹癌的標(biāo)準(zhǔn)方法PPPD( pylorus-preserving pancreaticoduodenectomy)（保留幽門(mén)）盡管有報(bào)道1PPPD手術(shù)時(shí)間短，術(shù)中出血少，然而，二者對(duì)術(shù)后長(zhǎng)期生存無(wú)明顯差異，亦有報(bào)道PPPD更易產(chǎn)生胃排空延遲。1Diener MK, Knaebel HP, Heukaufer C, Antes G, Bchler MW, Seiler CM. A s

11、ystematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Ann Surg. 2007 Feb;245(2):187-200.PD/PPPDPD（Whipple operation）被認(rèn)優(yōu)缺點(diǎn)1-3根治性切除率可達(dá)到80-90%長(zhǎng)期生存率高，即便是對(duì)于淋巴結(jié)轉(zhuǎn)移或T3期病人圍手術(shù)期死亡率較高（最近文獻(xiàn)表明，對(duì)經(jīng)驗(yàn)豐富大夫可控制在

12、0-5%）圍手術(shù)期并發(fā)癥發(fā)生率高20-40%（肺炎、腹腔內(nèi)感染、吻合口瘺、胃排空延遲等）手術(shù)創(chuàng)傷大與術(shù)者水平和術(shù)后護(hù)理關(guān)系密切優(yōu)缺點(diǎn)1-3根治性切除率可達(dá)到80-90%推薦級(jí)別【UpToDate】We recommend pancreaticoduodenectomy rather than local resection for most patients with invasive ampullary carcinomas (Grade 1B)推薦級(jí)別【UpToDate】We recommend pan文獻(xiàn)回顧：Roggin KK等 Limitations of ampullectomy

13、in the treatment of nonfamilial ampullary neoplasms. Ann Surg Oncol. 2005 Memorial Sloan-Kettering Cancer Center（紀(jì)念斯隆-凱特琳癌癥中心美）99例浸潤(rùn)性壺腹癌患者，其中8例行AMP（ampullectomy），91例行PD(pancreaticoduodenectomy)幸存者中位隨訪期18個(gè)月比較：復(fù)發(fā)率和生存率術(shù)前病理準(zhǔn)確性結(jié)論文獻(xiàn)回顧：Roggin KK等 Limitations o微創(chuàng)非手術(shù)療法包括：內(nèi)鏡下圈套切除術(shù)（Endoscopic snare resection ）

14、射頻消融（Laser ablation）光動(dòng)力療法（photodynamic therapy，PDT）姑息性治療僅適用于不適合手術(shù)或拒絕手術(shù)者微創(chuàng)非手術(shù)療法包括：內(nèi)鏡下圈套切除術(shù)（Endoscopic PROGNOSISStage I 84 percentStage II 70 percentStage III 27 percentStage IV 0 percent（one retrospective single-institution series）the National Cancer Institute SEER database between 1988 and 2003 Five

15、-year survival rates following PD range from 64 to 80 percent for patients with node-negative disease, and from 17 to 50 percent for node-positive disease PROGNOSISStage I 84 percent資料來(lái)源/contents/ampullary-carcinoma-treatment-and-prognosis?source=search_result&search=Periampullary+tumors+AND+local+r

16、esection&selectedTitle=1150#H11/contents/treatment-of-ampullary-adenomas?source=see_link#H24/contents/ampullary-carcinoma-epidemiology-clinical-manifestations-diagnosis-and-staging?source=see_link資料來(lái)源/coThanksPEKING UNION MEDICAL COLLEGE HOSPITALPEKING UNION MEDICAL COLLEGE HOSPITALTPEKING UNION參考文獻(xiàn)

17、 1Allema JH, Reinders ME, van Gulik TM, van Leeuwen DJ, Verbeek PC, de Wit LT, Gouma DJ. Results of ancreaticoduodenectomy for ampullary carcinoma and analysis of rognostic factors for survival. Surgery. 1995 Mar;117(3):247-53. 2Bettschart V, Rahman MQ, Engelken FJ, Madhavan KK, Parks RW, Garden OJ.

18、 Presentation, treatment and outcome in patients with ampullary tumours. Br J Surg. 2004 Dec;91(12):1600-7. 3Sommerville CA, Limongelli P, Pai M, Ahmad R, Stamp G, Habib NA, Williamson RC, Jiao LR. Survival analysis after pancreatic resection for ampullary and pancreatic head carcinoma: an analysis of clinicopathological factors. J Surg Oncol. 2009 Dec 15;100(8):651-6. doi: 1