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Objective:After the propensity score matching method was used to balance the covariates between groups, the effects of pancreaticoduodenectomy (PD) and total pancreatectomy (TP) on the survival of patients with pancreatic head cancer and related prognostic factors were compared.Methods:The National Cancer Institute Surveillance, Epidemiology and Results (SEER) database were searched and 3 676 patients with pancreatic head cancer from 2010 to 2016 were selected, of whom 3 559 patients underwent PD (PD group) and 117 patients underwent TP (TP group) . Using propensity score matching to balance confounding factors, 117 pairs of cases from PD group and TP group were matched successfully. The Kaplan-Meier curve was used to observe the overall survival rate and cancer-specific survival rate of patients before and after matching. Log-rank test and Cox proportional hazard model were used to analyze and evaluate the impact of different clinicopathological characteristics on the prognosis of patients with pancreatic head cancer.Results:Before matching, the 1, 3, and 5-year cancer-specific survival rates of 3 559 patients in the PD group were 72.8%, 35.1% and 24.9%, and the median survival time was 23.89 months; the 1, 3, and 5-year cancer-specific survival rates of 117 patients in the TP group were 67.9%, 29.4% and 26.1%, and the median survival time was 21.51 months, and all the differences were not statistically significant (all P>0.05). After matching, the 1, 3, and 5-year cancer-specific survival rates of 117 patients in the PD group were 77.8%, 44.5% and 31.8%, and the median survival time was 31.50 months, which was significantly better than that of the TP group, and the differences were statistically significant (all P values <0.05). Cox regression analysis showed that surgical methods, tumor differentiation degree, N staging and pathological types were independent risk factors for overall survival and cancer-specific survival. Conclusions:Surgical methods, tumor differentiation degree, N stage and pathological type were independent risk factors affecting the overall survival rate and cancer-related survival rate. The survival benefit of PD was significantly better than that of TP, and the clinical choice of TP treatment for patients with pancreatic head cancer should be cautious.
ABSTRACT
Objective:To investigate the application value of choledochoscopy in the diagnosis of cholelithiasis related diseases.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 111 patients with cholelithiasis related diseases who were admitted to the Second Affiliated Hospital of Soochow University between January 2018 and April 2019 were collected. There were 45 males and 66 females, aged (55±16)years, with the range from 20 to 89 years. The mucosal course of biliary system and the submucosal vascular density of the 111 patients were observed by choledochoscopy during operation. Observation indicators: (1) patient examinations; (2) specific case analysis. Measurement data with normal distribution were represented as Mean± SD. Count data were described as absolute numbers or percentages. Results:(1) Patient examinations: 111 patients underwent intraoperative choledochoscopy examination, and 5 patients underwent pathological examination. Five of the 111 patients had the results of intraoperative choledochoscopy examination inconsistent with results of preoperative imaging examination. (2) Specific case analysis. Case 1: the patient was diagnosed with intrahepatic and extrahepatic bile duct stones preoperatively by computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) examination. Results of intraoperative choledochoscopy examination and electronic staining under choledochoscope showed abnormal mucosa at the opening of the original cholecyst duct in the common bile duct, thickened and disordered blood vessels, which indicated the possibility of malignant transformation. Results of intraoperative rapid frozen histopathological examination showed inflammatory cell infiltration in gallbladder neck and focal glandular epithelial high-grade intraepithelial neoplasia. Results of postoperative pathological examination showed high-grade intraepithelial neoplasia of the wall of gallbladder cervical ducts, focal infiltrating myowall carcinoma and strongly positive of Cytokeratin 7 diaminobenzine staining. Case 2: results of preoperative doppler ultrasonography and MRCP showed gallbladder polyps. Intraoperative choledochoscopy examination showed gallbladder polyps with adenoma and a blood vessel at polyp root, which was diagnosed as gallbladder polyp combined with adenoma. Results of electronic staining in narrow band imaging (NBI) showed gallbladder polyps with adenoma and thick blood vessels at polyp root. Results of intraoperative rapid frozen histopathological examination showed cholesterol polyps and focal adenomatous hyperplasia. Results of postoperative pathological examination showed chronic cholecystitis with cholesterol polyps and adenomatous hyperplasia of focal glands. Case 3: results of preoperative MRCP examination showed choledocholithiasis and intrahepatic bile duct stones. Results of intraoperative choledochoscopy examination showed intrahepatic bile duct stones of large size. The patient underwent holmium laser lithotripsy and mucosal hyperplasia with soft lesion and smooth mucous epithelium was found after the stone was broken. Results of NBI and methylene electron staining showed multiple submucosal tortuous vessels in proliferative lesions behind bile duct stone. Results of intraoperative rapid frozen histopathological examination showed adenoma with high-grade intraepithelial neoplasia. Case 4: results of preoperative MRCP examination showed intrahepatic and extrahepatic bile duct stones combined with dilatation of bile duct. Results of CT examination showed multiple soft tissue density shadows of intrahepatic and extrahepatic bile ducts, which was considered as biliary papillomatosis. Results of intraoperative choledochoscopy showed small stones in the lower common bile duct and multiple segmental proliferative flocculent hyperplasia lesions on the wall of the intrahepatic and extrahepatic bile ducts. Results of electronic staining in NBI showed multiple proliferative lesions in intrahepatic and extrahepatic bile ducts and multiple curved vascular shadows under the mucosa of the lesions. Results of intraoperative rapid frozen histopathological examination showed a denomatous hyperplasia with low-grade intraepithelial neoplasia. Results of postoperative pathological examination showed adenoma with low-grade intraepithelial neoplasia. Case 5: results of preoperative magnetic resonance imaging examination showed silt-like stones in the lower part of bile duct accompanied with dilatation of intrahepatic and extrahepatic bile ducts, neck of pancreatic duct was narrowed and the remaining areas were thickened. Results of CT examination showed multiple stones in the neck of the gallbladder and in the common bile duct, accompanied by dilatation of the intrahepatic and extrahepatic bile ducts and the main pancreatic duct, and the lower end of the common bile duct was slightly narrow which mean the possibility of ampulla space occupying could not be excluded. Results of preoperative endoscopic ultrasonography examination showed soft tissue occupation at the lower end of the common bile duct which considering as the possibility of entophytic adenoma, and small stones in the common bile duct. Results of preoperative endoscopic ultrasonography biopsy showed chronic inflammation of duodenal papilla. Results of intraoperative rapid frozen histopathological examination showed chronic inflammation of duodenal papilla. Results of intraoperative choledochoscopy examination and electronic staining under choledochoscope showed smooth mucosa of duodenal papilla, without lesion. Results of intraoperative choledochoscopy examination with endobronchial ultrasonography showed clear structure of mucosa and submucosal of duodenal papilla, without lesion.Conclusion:Choledochoscopy can be used in the auxiliary diagnosis of cholelithiasis related diseases.
ABSTRACT
Gallstone ileus is a rare mechanical ileus,which was caused by discharge of giant gall bladder stone to the intestine.Understanding the causes of ileus is the key factor for treatment,and surgical treatment is the treatment of choice.An old patient with gallstone ileus was admitted to the Second Affiliated Hospital of Soochow University in April 2013.Preoperative X ray detection and computed tomography showed gallbladder wall thickening,formation of a sinus tract between the gall bladder and the duodenum,and intestinal ileus in the left iliac region (the diameter of the stone was about 4 cm).The patient received medical treatment for 3 days and then exploratory laparotomy + lithotomy.Gall bladder stones were not detected during the operation,so the gall bladder was preserved.The patient was followed up till December 2013,the sinus tract was disappeared under B sonography,and the cholecystitis was cured.