Partial distal duodenectomy in patient with adenocarcinoma / Duodenectomia distal parcial em paciente com adenocarcinoma

ABSTRACT BACKGROUND: Duodenal adenocarcinoma is a small percentage of gastrointestinal neoplasms, around 0.5%, and its treatment is based on resection of the tumor, classically by pancreaticoduodenectomy. In recent years, however, segmental resections of duodenal lesions, that do not involve the second portion or the periampullary region, have gained relevance with good surgical and oncological outcomes as well as the benefit of avoiding surgeries that can result in high morbidity and mortality. AIMS: To report a case of an elderly female patient with malignant neoplastic lesion in the third and fourth duodenal portion, non-obstructive, submitted to surgical treatment. METHODS: The technical option was the resection of the distal duodenum and proximal jejunum with preservation of the pancreas and reconstruction with side-to-side duodenojejunal anastomosis. RESULTS: The evolution was satisfactory and the surgical margins were free of neoplasia. CONCLUSIONS: Segmental resections of the duodenum are feasible and safe, offering the benefit of preventing complications of pancreaticoduodenectomies.

RESUMO RACIONAL: O adenocarcinoma duodenal é uma pequena porcentagem das neoplasias gastrointestinais, em torno de 0,5%, e seu tratamento baseia-se na ressecção da massa tumoral, classicamente por pancreatoduodenectomia. Nos últimos anos, porém, as ressecções segmentares de lesões duodenais que não envolvem a segunda porção ou a região periampular têm ganhado relevância com bons resultados cirúrgicos e oncológicos e com o benefício de evitar uma cirurgia que pode apresentar alta morbimortalidade. OBJETIVOS: Reportar o caso de uma paciente feminina, idosa, com lesão neoplásica maligna na terceira e quarta porção duodenal, não obstrutiva, submetida a tratamento cirúrgico. MÉTODOS: A opção técnica foi a ressecção do duodeno distal e jejuno proximal com preservação do pâncreas e reconstrução com anastomose duodenojejunal látero-lateral. RESULTADOS: A evolução foi satisfatória e as margens cirúrgicas foram livres de neoplasia. CONCLUSÕES: As ressecções segmentares do duodeno são factíveis e seguras, com os benefícios de evitar as complicações das pancreatoduodenectomias.

Correlation of the duration of preoperative biliary drainage and postoperative complications after pancreaticoduodenectomy / 肿瘤研究与临床

Objective:To investigate the effect of the duration of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy.Methods:The clinical data of 102 patients with benign and malignant hepatopancreatic ductal periampullary tumors who underwent pancreaticoduodenectomy and preoperative biliary drainage in Beijing Friendship Hospital, Capital Medical University from January 2016 to July 2020 were retrospectively analyzed. According to the median duration of preoperative biliary drainage, the patients were divided into short-term drainage group (≤ the median duration of biliary drainage) and long-term drainage group (> the median duration of biliary drainage). The general data, the effect of biliary drainage, inflammation-related indicators and postoperative complications were compared between the two groups. Multivariate logistic regression was used to screen the risk factors related to the postoperative severe complications.Results:Of the 102 patients, 68 (66.7%) were males and 34 (33.3%) were females, with a median age of 63 years (43-80 years). The median duration of preoperative biliary drainage was 14 d. There were 68 patients in short-term drainage group and 34 patients in long-term drainage group. There were no statistically significant differences in age, gender, body mass index (BMI), hypertension, diabetes mellitus, surgery history of upper abdominal, American Society of Anesthesiologists (ASA) grade, carcinoembryonic antigen, carbohydrate antigen 125, alpha-fetoprotein, prothrombin time, pancreaticojejunostomy method, operation time, and pathological type between the two groups (all P > 0.05). However, patients in long-term drainage group had higher conversion rate, more blood loss and longer hospital stay compared with those in short-term drainage group (all P < 0.05). Before biliary drainage, alanine aminotransferase (ALT) level in short-term drainage group was higher than that in long-term drainage group ( Z = -2.59, P = 0.009), and there were no statistically significant differences in aspartate aminotransferase (AST), albumin (ALB), total bilirubin (TB) and direct bilirubin (DB) levels between the two groups before biliary drainage (all P > 0.05). After biliary drainage, DB in short-term drainage group was higher than that in long-term drainage group ( Z = -3.34, P = 0.001), and there was no statistically significant difference in ALT, AST, ALB, TB levels between the two groups (all P > 0.05). There were no statistically significant differences in the levels of white blood cells, neutrophils, lymphocytes and the ratio of neutrophils to lymphocytes between the two groups on the 1st and 3rd day after the operation (all P > 0.05). The total incidence of postoperative related complications in short-term drainage group and long-term drainage group was 63.2% (43/68), 70.6% (24/34), respectively, and the difference was statistically significant ( χ2 = 0.54, P = 0.461); the incidences of bile leakage, abdominal or gastrointestinal bleeding, intra-abdominal infection, delayed gastric emptying, all grades of pancreatic leakage, grade B and C pancreatic leakage were not statistically different between the two groups (all P > 0.05); the incidence of severe postoperative related complications in short-term drainage group was higher than that in long-term drainage group [27.9% (19/68) vs. 8.8% (3/34), χ2 = 4.90, P = 0.027]. Multivariate logistic regression analysis showed that the long-term preoperative biliary drainage was an independent protective factor for postoperative severe complications (long-term drainage vs. short-term drainage: OR = 0.253, 95% CI 0.066-0.975, P = 0.046), while BMI ( OR = 1.174, 95% CI 0.986-1.398, P = 0.071) and pathological type (benign or borderline vs. malignant tumor: OR = 0.247, 95% CI 0.043-1.419, P = 0.117) were not independent influencing factors for postoperative severe complications. Conclusions:Short-term biliary drainage (≤14 d) is a risk factor for postoperative severe complications in patients with hepatopancreatic ductal periampullary tumor undergoing preoperative biliary drainage. Preoperative biliary drainage time is not associated with postoperative total complications, pancreatic leakage, bile leakage, abdominal or gastrointestinal bleeding, intra-abdominal infection, delayed gastric emptying.

Progress of diagnosis and treatment for gastrointestinal neuroendocrine neoplasms / 肿瘤研究与临床

Gastrointestinal neuroendocrine neoplasm (GI-NEN) is an important part of digestive system tumor. With the progress of diagnosis and the further understanding of GI-NEN, the diagnostic rate is increasing. However, GI-NEN is a rare tumor, thus clinicians are not familiar with the diagnosis and treatment. Misdiagnosis and missed diagnosis of GI-NEN often occur, and the treatment regimen is not standardized. In recent years, some progresses of the diagnosis and treatment have been made in GI-NEN, especially in the aspects of pathology, imaging diagnosis, radionuclide therapy, targeted therapy and immunotherapy, which have improved the diagnosis rate and efficacy for GI-NEN. This paper reviews recent literatures of GI-NEN, summarizes its epidemiology, pathological diagnosis, image diagnosis, surgery, targeted therapy, radionuclide therapy, chemotherapy, immunotherapy, and separates GI-NEN into metastatic and non-metastatic groups for detailed review to provide a reference for guiding clinical diagnosis and treatment as well as exploring the new treatment regimens of GI-NEN.

Clinicopathological features and prognostic analysis of primary duodenal adenocarcinoma / 中华普通外科杂志

Objective:By analyzing the clinical data of patients with primary duodenal adenocarcinoma (PDA), the risk factors affecting the postoperative prognosis of PDA patients were discussed.Methods:The clinical data of 191 patients diagnosed with PDA in Peking University First Hospital from Jan 2009 to Dec 2022 were collected. The survival rate was calculated and the survival curve was plotted by Kaplan-Meier method. Univariate analysis was performed by Log-Rank test, and multivariate analysis was performed by COX proportional hazards regression model to obtain independent risk factors.Results:The median age of onset in patients with PDA is 65 years old, and the most common symptoms are abdominal pain and abdominal distension. Prognostic analysis showed that the survival rates at 1, 3 and 5 years were 73.8%, 44.6%, and 23.0%. The analysis of Cox risk proportional regression model showed that preoperative CA19-9 level, depth of tumor invasion, degree of differentiation, TNM stage, and surgical mode were independent risk factors for the prognosis of PDA (all P<0.01). Conclusion:The overall incidence of PDA is low, but the prognosis is rather poor. Multvariable factors are associated with its prognosis and surgery is still the mainstay for hope of cure.

Clinical characteristics and prognosis of duodenal neuroendocrine neoplasms / 中华普通外科杂志

Objective:To investigate the clinical characteristics and prognosis of duodenal neuroendocrine neoplasms.Methods:The clinical data of 35 patients with duodenal neuroendocrine neoplasms admitted to Union Hospital, Tongji Medical College, Huazhong University of Science & Technology from Jan 2012 to Dec 2021 were retrospectively analyzed. The differences of clinical characteristics between periampullary and non-periampullary duodenal neuroendocrine neoplasms were analyzed. Kaplan-Meier curve was used for survival analysis, and the clinical factors affecting the prognosis were analyzed.Results:Of the 35 patients, 30 underwent tumor resection, 7 (23%) developed different degree of complications after operation and were improved and discharged after intervention. A total of 5 patients died during the follow-up period. Only 1 of 30 patients who underwent tumor resection died 30 months after operation due to disease progression, and the others had no recurrence or metastasis. Univariate analysis showed that tumor size, tumor grade, and tumor location were associated with the prognosis of patients (all P<0.05), and multivariate analysis showed that patients with tumors located.Away from the ampulla had a significantly better prognosis than those located around the duodenal ampulla ( P<0.01). Conclusions:Patients with duodenal neuroendocrine neoplasms have a good prognosis after complete resection; patients with duodenal neuroendocrine neoplasms located around the ampulla of Vater have a relatively poor prognosis compared with those away from the area of ampulla.

Efficacy of endoscopy for early nonampullary duodenal cancer / 中华消化内镜杂志

Objective:To evaluate the clinical efficacy of endoscopic treatment for early nonampullary duodenal cancer.Methods:Data of patients with early nonampullary duodenal cancer, who underwent endoscopic treatment from January 2015 to January 2021 at Beijing Friendship Hospital were retrospectively analyzed. Baseline data, endoscopic treatment methods, wound closure, pathology, the occurrence and outcome of complications of patients were studied.Results:A total of 47 patients who successfully went through endoscopic treatment were enrolled. Seventeen cases received endoscopic mucosal resection (EMR), 5 cases received endoscopic submucosal dissection (ESD), and 7 cases received ESD+EMR (hybrid ESD). Six cases were converted to hybrid ESD due to difficulty in ESD. Four cases received full-thickness resection with over-the-scope clip system (OTSC), and 8 cases received endoscopic piecemeal mucosal resection (EPMR). Among the 47 cases of early cancer, the en bloc resection rate was 83.0% (39/47), and the complete resection rate was 85.1% (40/47). Four patients (8.5%) had perforation which occurred at the duodenal descending part during the perioperative period, among whom, 2 patients (4.3%) recovered after endoscopic treatment, 2 others (4.3%) recovered after surgical intervention. There were no complications such as postoperative bleeding or infection during the perioperative period.Conclusion:Endoscopic treatment for early nonampullary duodenal cancer is safe and effective. A specific treatment plan can be selected according to the location, size and specific conditions of the lesion. For the operation of the descending part, it is necessary to be more vigilant to against the occurrence of perforation complications.

Clinical diagnosis and treatment progress of duodenal neuroendocrine neoplasms / 肿瘤研究与临床

Duodenal neuroendocrine neoplasms (D-NEN) is a kind of heterogeneous tumor originated from neuroendocrine cells. With the continuous progress of diagnostic technology, more and more examination methods and treatment methods are applied. This article reviews the characteristics, classification, imaging applications, biochemical markers' monitoring and treatment of D-NEN.

Value of endoscopic papillectomy combined with endobiliary radio frequency ablation for duodenal papilla tumor with intraductal biliary infiltration / 中华消化内镜杂志

Objective:To evaluate the efficacy and safety of endoscopic papillectomy (EP) combined with endobiliary radio frequency ablation (RFA) for duodenal papilla tumor with intraductal biliary infiltration.Methods:Data of 12 patients with histologically confirmed duodenal papilla tumor combined with intraductal biliary infiltration treated by EP with RFA from February 2013 to February 2019 were retrospectively analyzed. Clinical characteristics,endoscopic features, treatment efficacy and postoperative complications of patients were reviewed and recurrence was followed up.Results:The median diameter of lesions measured by endoscopic ultrasound was 18.5 mm×15.5 mm, and the length of intrabiliary invasion was 14.1±5.8 mm. EP combined with RFA was successfully performed in all patients with a technical success rate of 100%. Postoperative pathology showed adenocarcinoma in 5 patients, adenoma with high-grade intraepithelial neoplasia in 6 patients, and adenoma with low-grade intraepithelial neoplasia in 1 patient. Patients received mean 4.1±1.6 times of ERCP with intraductal biopsy during a mean follow-up period of 28.5±10.4 months. Recurrence occurred in 2 patients at 14 and 20 months respectively, both were adenocarcinoma.Conclusion:EP combined with RFA is effective and safe for duodenal papilla tumor with intraductal biliary infiltration. However, given the risk of recurrence, close surveillance is recommended.

Safety and efficacy of endoscopic resection for early primary non-ampullary duodenal cancer / 中华普通外科杂志

Objective:To evaluate the safety and efficacy of endoscopic resection in the treatment of patients with primary non-ampullary duodenal early cancer.Methods:A total of 20 cases with primary non-ampullary duodenal early cancer receiving endoscopic resection were collected from Jan 2015 to Dec 2019 at the Department of Endoscopy, the First Affiliated Hospital of Shandong First Medical University.Results:The size of lesions ranged from 0.3-2.5 cm (0.9±0.5)cm.The size of removed membrane samples ranged from 1.5-3.5 cm (2.5±0.7)cm. The edges were all negatiue pathologically. Duodenal perforation occurred in 2 cases, and all were successfully clipped by endoscopy. The follow-up time was from 4-42 months (20.4±11.4)m and no recurrence was found.Conclusion:Endoscopic resection is a safe and effective method for primary non-ampullary duodenal early cancer.

Clinical analysis on diagnosis and treatment of 116 patients with primary duodenal malignant tumor / 中国医师进修杂志

Objective:To explore the diagnosis, surgical methods and therapeutic effect of primary duodenal malignant tumor.Methods:The clinical data of 116 patients with primary duodenal malignant tumor from January 2010 to December 2018 were retrospectively analyzed.Results:Among 116 patients, adenocarcinoma was in 74 cases, interstitial tumor was in 25 cases, carcinoid was in 9 cases, the others was in 8 cases. Before operation, duodenoscopy was performed in 107 cases, and CT examination was performed in 76 cases. There were 57 cases of pancreaticoduodenectomy, 15 cases of duodenal segmental resection, 13 cases of subtotal gastrectomy and duodenal bulbar resection, 13 cases of duodenal partial resection, and 18 cases of palliative short circuit operation. The total incidence of postoperative complication was 31.9% (37/116), including pancreatic fistula in 8 cases (grade B 5 cases, grade C 3 cases), biliary fistula in 6 cases, abdominal infection in 5 cases, pulmonary infection in 4 cases, intestinal fistula in 3 cases, delayed gastric emptying in 3 cases, and hemorrhage in 8 cases. Four cases (3.4%) died during the perioperative period. Single factor Cox regression analysis result showed that the postoperative survival time was related to the tumor differentiation degree, operation method, tumor infiltration degree and lymphatic metastasis ( P<0.05 or <0.01); multi-factor Cox regression analysis results showed that the operation method, tumor infiltration degree and lymphatic metastasis were the independent risk factors for the postoperative survival time of patients with primary duodenal malignant tumor ( P<0.05). The patients were followed up until June 2021, and 9 cases were lost to follow-up. Kaplan-Meier survival curve analysis result showed that the postoperative overall 1-,3- and 5-year survival rates were 82.11%, 57.56% and 33.11%, respectively. Conclusions:Adenocarcinoma is the main primary malignant tumor of duodenum. Duodenoscopy and CT are the main examination methods. Radical resection is the most effective treatment for primary duodenal malignant tumor, and pancreaticoduodenectomy is the first choice. Surgical method, tumor infiltration degree and lymphatic metastasis are the independent risk factors affecting the prognosis of patients.

Caracterización de lesiones duodenales y su sobrevida / Characterization of duodenal lesions and their survival

Resumen Introducción: Las lesiones duodenales son infrecuentes. Objetivo: Caracterizar a los pacientes con lesiones duodenales observados entre enero de 2008 y diciembre de 2013 en el Servicio de Salud Metropolitano Sur, en Santiago de Chile. Materiales y Método: Se obtuvieron los datos de los registros del Hospital Barros Luco Trudeau y Hospital El Pino. Los pacientes incluidos fueron los observados entre enero de 2008 y diciembre de 2013. Se analizaron edad, género, características clínicas, localización, métodos diagnósticos, hallazgos anatomopatológicos y tratamiento. El 24 de abril de 2019 se obtuvo la fecha de fallecimiento de todos los pacientes del Registro Civil. El análisis estadístico se realizó con el software STATA 15.1. Resultados: Se encontraron 157 pacientes con lesiones duodenales, 65 presentaron adenocarcinoma duodenal y 71 pacientes pólipos duodenales, 25 de ellos fueron adenomas. Análisis univariado de sobrevida evidenció que los pacientes con pólipos asociado a carcinoma y los adenocarcinomas duodenales, presentaron una sobrevida inferior (p = 0,013, HR 6,584 y p < 0,001, HR 7,604, respectivamente). En los pacientes con adenocarcinoma duodenal, aquellos que se sometieron a una cirugía con intención curativa, y aquellos que recibieron quimioterapia tuvieron una sobrevida global mejor que aquellos que no recibieron terapia (p < 0,001, HR 0,351 y p = 0,001, HR 0,276, respectivamente. Discusión: La incidencia estimada del adenocarcinoma duodenal en nuestra población es de 1,1 por cada 100.000 habitantes, la que es más alta que otras publicadas. Proponemos estudio endoscópico en poblaciones de riesgo y tratamiento con intención curativa para los pacientes con adenocarcinoma duodenal sin metástasis a distancia.

Introduction: Duodenal lesions are infrequent. Aim: To characterize patients with duodenal lesions observed between January 2008 and December 2013 at the Southern Metropolitan Health Service, in Santiago, Chile. Materials and Method: Data were obtained from the Barros Luco Trudeau Hospital and El Pino Hospital records. The patients included were those observed between January 2008 and December 2013. Age, gender, clinical characteristics, location, diagnostic methods, anatomopathological findings and treatment were analyzed. On April 24th 2019 was obtained the date of death of all patients at the National Civil Registry. The statistical analysis was performed with the software STATA 15.1. Results: 157 patients with duodenal lesions were found, 65 presented duodenal adenocarcinoma and 71 patients had duodenal polyps, 25 of them were adenomas. Univariate analysis of survival showed that patients with polyps associated with carcinoma and duodenal adenocarcinomas had a lower survival rate (p = 0.013, HR 6.584 y p < 0.001, HR 7.604, respectively). In patients with duodenal adenocarcinoma, those who underwent surgery with curative intent, and those who receive chemotherapy had a better overall survival than those who did not received therapy (p < 0.001, HR 0.351 y p = 0.001, HR 0.276, respectively). Discussion: We propose endoscopic study in at-risk populations and treatment with curative intent for patients with duodenal adenocarcinoma without distant metastases. The estimated incidence of duodenal adenocarcinoma in our population is 1.1 per 100,000 inhabitants and seem to be higher than other published.

Carcinoma adenoneuroendocrino mixto de la ampolla de Vater: reporte de caso / Mixed adenoneuroendocrine carcinoma of the ampulla of Vater: case report

INTRODUCCIÓN: Los carcinomas adenoneuroendocrinos mixtos (MANEC) son tipos de tumores bifásicos, reconocidos morfológicamente ante la presencia de una formación neoplásica constituida de manera simultánea por epitelio glandular y células neuroendocrinas. Dentro del tracto gastrointestinal, estas neoplasias predominan en el estómago o el colon. Solo 19 casos localizados en la ampolla de Vater han sido reportados por la literatura. OBJETIVO: Reportar un caso de MANEC; revisar la epidemiología, pronóstico y tratamiento de estos tumores. MATERIALES Y MÉTODO: Presentación de caso clínico de una paciente con diagnóstico de adenocarcinoma neuroendocrino mixto de la región ampular. DISCUSIÓN: La presentación clínica, el manejo y el pronóstico son similares al del adenocarcinoma ampular. Se diagnostican con el examen histopatológico de la muestra resecada. Ambos componentes deben ser histológicamente malignos, y cada uno de ellos debe representar al menos el 30% de la lesión. CONCLUSIÓN: Los MANEC ampulares son tumores poco comunes a nivel mundial, siendo éste el primer caso reportado en nuestro instituto.

INTRODUCTION: Mixed adenoneuroendocrine carcinomas (MANEC) are types of biphasic tumors, morphologically recognized in the presence of a neoplastic formation constituted simultaneously by glandular epithelium and neuroendocrine cells. Only 19 cases located in the ampulla of Vater have been reported in the literature. Within the gastrointestinal tract, these neoplasms predominate in the stomach or colon. AIM: Report a case of MANEC; review of the epidemiology, prognosis and treatment of these tumors. MATERIALS AND METHOD: Case presentation of a patient diagnosed with mixed adeno-neuroendocrine carcinoma of the ampullary region. DISCUSSION: The clinical presentation, management and prognosis are similar to ampullary adenocarcinoma. These tumors are diagnosed with a histopathological examination of the resected specimen. Both components must be histologically malignant, and each of them must represent at least 30% of the lesion. CONCLUSION: MANEC of the ampulla are rare tumors worldwide, being this case the first reported in our institute.

Prognostic factors of survival for patients with duodenal papilla carcinoma after pancreaticoduodenectomy / 中华普通外科杂志

Objective To investigate the prognostic factors of survival for patients with duodenal papilla carcinoma (DPC) after pancreaticoduodenectomy.Methods 98 DPC patients undergoing pancreaticoduodenectomy with follow-up from Jan 2010 to Dec 2017 at Renji Hospital,School of Medicine,Shanghai Jiao Tong University were analyzed retrospectively.Results 80 Cases were followed up.The 1,3,and 5 year survival rates of 80 patients were 89.9％,72.4％,and 66.6％,respectively.Univariate analysis showed tumor size,T stage,N stage,TNM stage,tissue differentiation degree were related to postoperative survival(all P ＜0.05).Multivariate analysis showed that tumor size,N stage,TNM stage,and tissue differentiation degree were independent factors influencing postoperative prognosis(all P ＜ 0.05).Conclusions Tumor size,N stage,TNM stage and tumor tissue differentiation degree were independent factors influencing the prognosis of DPC after pancreaticoduodenectomy,suggesting that early diagnosis,early treatment and radical resection were the key to improve the postoperative prognosis of DPC.

Clinical application value of modified invagination for pancreaticojejunostomy in pancreaticoduodenectomy / 中华消化外科杂志

Objective To explore the clinical application value of modified invagination for pancreaticojejunostomy in pancreaticoduodenectomy (PD).Methods The retrospective cohort study was conducted.The clinicopathological data of 39 patients who underwent PD in the Affiliated Hospital of Inner Mongolia Medical University from January 2014 to December 2017 were collected.There were 26 males and 13 females,aged (60±7)years,with a range of 41-75 years.All the 39 patients underwent PD,using Child method to reconstruct digestive tract.Of 39 patients,19 undergoing modified invagination for pancreaticojejunostomy and 20 undergoing mucosa-to-mucosa end-to-side pancreaticojejunostomy were allocated to innovative group and traditional group,respectively.Observation indicators:(1)surgical situations;(2) postoperative complications;(3) follow-up.Follow-up was performed by outpatient examination and telephone interview to detect postoperative tumor recurrence,main pancreatic duct dilatation,survival,and discomfort (abdominal pain,bloating,indigestion,etc.) of patients up to October 2018.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed by t test.Measurement data with skewed distribution were represented as M (P25,P75) or M (range),and comparison between groups was analyzed by Mann Whitney U test.Count data were expressed as absolute numbers,and comparison between groups was analyzed by chi-square test or Fisher exact probability.Results (1) Surgical situations:operation time,volume of intraoperative blood loss,cases with soft pancreas or hard pancreas (pancreatic texture),pancreatic duct diameter,time of pancreatic duct removal,cases using somatostatin,and duration of postoperative hospital stay of the innovative group were (342±47) minutes,400 mL (300 mL,400 mL),10,9,3.1 cm (2.9 cm,3.4 cm),37 days (32 days,63 days),17,18 days (15 days,22 days),respectively,versus (392±95)minutes,400 mL (300 mL,525 mL),6,14,3.6 cm (2.6 cm,4.2 cm),43 days (34 days,49 days),18,and 24 days (15 days,27days) of the traditional group;there was no significant difference in the volume of intraoperative blood loss,cases with soft pancreas or hard pancreas (pancreatic texture),pancreatic duct diameter,time of pancreatic duct removal,cases using somatostatin,and duration of postoperative hospital stay between the two groups (Z=-0.775,x2 =2.063,Z=-1.155,Z=-0.295,x2 =0.003,Z=-1.286,P＞0.05);but a significant difference in operation time between the two groups (t =-2.114,P＜0.05).(2) Postoperative complications:6 patients in the innovative group had complications,including 1 of delayed gastric emptying,1 of wound infection,1 of pulmonary infection,1 of acute respiratory failure,1 of perihepatic effusion,and 3 of grade A pancreatic leakage;11 patients in the traditional group had postoperative complications,including 1 of bile leakage,2 of delayed gastric emptying,4 of abdominal infection,4 of wound infection,2 of pulmonary infection,1 of ascites,1 of abdominal hemorrhage,1 of pleural effusion,2 of grade A pancreatic leakage,5 of grade B and C pancreatic leakage;the same patient had multiple complications.There was no significant difference in postoperative complications between the two groups (x2=2.174,P＞0.05),but there was a significant difference in postoperative grade B and C pancreatic leakage between the two groups (P＜O.05).Patients with postoperative complications were improved after symptomatic support treatment,and no patient died during the perioperative period.(3) Follow-up:of the 39 patients,33 (18 in the innovation group and 15 in the traditional group) were followed up for 3-57 months,with a median follow-up time of 17 months.Of the 18 patients receiving follow-up in the innovative group,5 died of tumor recurrence and metastasis,with a survival time of 5-24 months,1 had tumor recurrence at 34 months after operation,1 had main pancreatic duct dilatation and intermittent abdominal pain and abdominal distension,5 had indigestion,1 had back pain,and 5 had good recovery.Of 15 patients receiving follow-up in the traditional group,10 died of tumor recurrence and metastasis,with a survival time of 3-57 months,2 had main pancreatic duct dilatation and intermittent abdominal pain and abdominal distension,2 had indigestion,1 had good recovery.Conclusion Compared with the traditional mucosa-to-mucosa end-to-side pancreaticojejunostomy,modified invagination for pancreaticojejunostomy in the PD is safe and feasible,which can simplify the operation,reduce the requirements for the operator's operation skills,shorten the operation time,and reduce incidence of postoperative grade B and C pancreatic leakage.

Diagnosis and Treatment of Primary Duodenal Adenocarcinoma / 胃肠病学

Primary duodenal adenocarcinoma (PDA)is a rare but aggressive digestive tract malignancy,and its incidence is increasing in recent years. Early diagnosis of PDA is challenging due to nonspecific symptoms. Hence,it is often detected at an advanced stage. Treatment strategies tends to favor aggressive surgical resection. Adjuvant chemotherapy and radiation are important components of multi-modality treatment for patients with high risk of recurrence, and molecular targeted therapy is still in the exploratory stage. The best adjuvant therapy after operation is not yet clear. Early diagnosis and treatment is of great significance for prognosis. This article reviewed advances in epidemiology,risk factors,diagnosis,treatment and prognosis of PDA.

Analysis of clinical diagnosis,surgical management and prognosis in primary malignant tumor of the duo-denum / 实用医学杂志

Objective To evaluate the diagnosis,surgical treatment and prognosis of primary malignant tumor of the duodenum. Methods The clinical data of 118 cases with primary malignant tumor of the duodenum were collected and analyzed retrospectively during January 2005 to December 2015. Results Tumors located in the first,second,third and fourth parts in 7 cases,92 cases,12 cases,and 7 cases individually.The correct di-agnosis rate of endoscopy,duodenography,abdominal enhanced CT and ultrasound was 83.02%,79.42%,47.46% and 29.41% separately.Eighty cases underwent pancreaticoduodenectomy,18 cases received segmental duodenectom and 20 cases received bypass operation. Conclusions Tumors located in papillary region account for the majority of primary malignant tumors of the duodenum and are mainly of adenocarcinoma.Duodenography and endoscopy are the major methods for diagnosis of primary malignant tumor of the duodenum.Pancreaticoduodeneetomy is the first choice of therapy for primary malignant tumor in the duodenum.

Severe immune-related adverse events in the treatment with Pembrolizumab for a patient with ampullar carcinoma / 天津医药

Programmed death receptor-1 inhibitor pembrolizumab can restore the function of T cell activity and enhance the anti-tumor immune response by inhibiting the binding of PD-1 to its ligand PD-L1 and blocking the negative regulation of signal pathway. The activated T cells may cause immune-mediated adverse events in the process of anti-tumor. This article reported the severe immune related adverse effects induced by PD-1 inhibitor, pembrolizumab, in a patient with advanced ampullar carcinoma. The patient eventually died due to liver injury, leukocytosis,thrombocytopenia,and disseminated intravascular coagulation (DIC). This article reviewed the diagnosis and treatment of the patient, and reviewed the relevant literatures.

Clinical effect and safety of surgical operation in treating benign tumor of the stomach and duodenum by laparoscopic combined gastroscope positioning / 中国现代普通外科进展

Objective:To analyze the clinical effect and safety of surgical operation in treating benign tumor of the stomach and duodenum by laparoscopic combined gastroscope positioning.Methods:47 cases of stomach and duodenum patients with benign tumorour in the hospital from September 2013 to December 2015 were chosen,32 cases were only used laparoscopy to treat gastric and duodenal benign tumor,the other 15 patients were difficult to locate by laparoscopy.Results:The operation time,blood loss,length of hospital stay,the rate of conversion to abdominal surgery and the incidence of postoperative complications were lower in the combined group than in the laparoscopic group,the difference was statistically significant(P＜0.05).All patients were followed up for 6～18 months,no recurrence occurred in the combined group,7 cases of recurrence in the laparoscopic group,the recurrence rate of the comparison between the two groups,the difference was statistically significant (x 2=0.049,P＜0.05).Conclusion:The laparoscopic combined gastroscope to treat gastric and duodenal tumor can be accurately and quickly locate,significantly shorten the operation time,reduces the operation caused by trauma,and has the advantage of less postoperative pain and recover rapidly,which has good clinical application value.

CEA, CA19-9 in predicting the clinicopathologic characteristics and prognosis of primary duodenal carcinoma / 中华普通外科杂志

Objective To investigate the significance of tumor markers CEA and CA19-9 in predicting the clinicopathologic characteristics and prognosis of primary duodenal carcinoma.Methods A retrospective analysis of 110 cases with primary duodenal carcinoma treated in our hospital from January 1999 to December 2016 was conducted.ROC analysis,univariate and multivariate analysiswere performed to investigate the relationship between CEA,CA19-9 and the clinicopathologic characteristics of primary duodenal carcinoma.Kaplain-Meier method was used to analyze the relationship between CEA and CA19-9 and the prognosis of primary duodenal carcinoma.Results CEA level was of value for predicting the depth of infiltration,lymphatic involvement,metastasis and TNM stage.The receiver operating characteristic was 0.629,0.672,0.749,0.692 respectively.Univariate analysis showed serum CA19-9 lever was related to the depth of infiltration and serum CEA lever were related to tumor differentiation,lymphatic invasion,metastasis and TNM stage.Logistic analysis showed that CEA value was only associated with metastasis (OR:9.853,P ＜ 0.01).Patients with elevated serum CEA level had a significant worse prognosis than patients with normal serum CEA level (P ＜ 0.05).Conclusion Serum CEA level was closely associated with the clinicopathologic characteristics and prognosis of primary duodenal carcinoma.