胆胰管扩张的诊断与治疗

Diagnosis and treatment of biliary pancreatic duct dilatation

目的总结胆胰管扩张的诊断与治疗经验。方法采用回顾性描述性研究方法。收集2013年10月至2017年9月上海交通大学医学院附属仁济医院收治的22例胆胰管扩张患者的临床资料;男6例,女16例;平均年龄为66岁,年龄范围为33~82岁。根据患者临床症状、实验室检查和影像学检查结果决定是否行手术探查。手术探查占位性病变阳性者,根据病理学检查结果选择具体手术方式。未行手术探查者及手术探查占位性病变阴性者进行随访。观察指标:(1)手术探查情况。(2)临床症状及术前检查与手术探查占位性病变阳性的相关性。(3)手术治疗情况。(4)随访情况。采用门诊方式进行随访。手术探查占位性病变阳性患者了解术后并发症发生情况。影像学检查阳性、无黄疸、实验室检查正常或有轻度异常者,每个月复查肝功能、肿瘤标志物和B超,每3个月复查增强CT和磁共振成像(MRI),出现总胆红素(TBil)或肿瘤标志物进行性升高,及时行手术探查。影像学检查阴性、有黄疸、CA19⁃9轻度升高者,密切随访,每月复查TBil和CA19⁃9,若TBil和CA19⁃9进行性升高,改为手术探查。影像学检查阴性、无症状、实验室检查阴性者,每3个月复查肝功能、肿瘤标志物和B超,每半年复查增强CT和MRI,随访1年无异常,第2年起每半年随访1次,以后每年随访1次。随访时间截至2018年10月。正态分布的计量资料以x􀭰±s表示,组间比较采用t检验,计数资料以绝对数标示,采用R×C列表的χ^2检验和Fisher确切概率法。结果(1)手术探查情况:22例患者中,行手术探查11例,随访11例。11例行手术探查患者中,4例占位性病变阳性(包括假阴性1例),7例占位性病变阴性。(2)临床症状及术前检查与手术探查占位性病变阳性的相关性。①临床症状和实验室检查与手术探查占位性病变阳性的相关性:黄疸与胆胰管扩张患者手术探查占位性病变阳性显著相关(P<0.05),TBil升高、DBil升高与胆胰管扩张患者手术探查占位性病变阳性显著相关(χ^2=0,0,P<0.05),灵敏度均为75.0%,特异度均为100.0%。②影像学检查与手术探查占位性病变阳性的相关性:CT、MRI、内镜逆行胰胆管成像、超声内镜、PET⁃CT单项检查及联合检查结果与胆胰管扩张患者手术探查占位性病变阳性无显著相关(χ^2=0,0.77,0,0,1.00,0,0,0,0,P>0.05)。PET⁃CT单项检查与胆胰管扩张患者手术探查占位性病变阳性无显著相关(P>0.05)。③影像学检查联合实验室检查与手术探查占位性病变阳性的相关性:影像学检查阳性+TBil升高+CA19⁃9升高与胆胰管扩张患者手术探查占位性病变阳性显著相关(P<0.05),灵敏度为50.0%,特异度为100.0%。④术前胆管和胰管直径与手术探查占位性病变阳性的相关性:22例患者中,手术探查阳性患者术前胆管直径和胰管直径分别为(13.8±4.3)mm和(4.6±1.5)mm,手术探查阴性患者上述指标分别为(13.0±2.8)mm和(3.5±0.5)mm,随访患者上述指标分别为(11.6±2.4)mm和(3.2±0.4)mm,三者比较,差异均无统计学意义(t=0.22,0.36,P>0.05)。(3)手术治疗情况:11例行手术探查患者中,9例按照标准流程进行探查,其中4例术中探查发现胆胰肠结合部占位性病变(3例行胰十二指肠切除术、1例行十二指肠乳头局部切除术),5例手术探查占位性病变阴性患者行胆总管切开T管外引流术(1例患者术后1个月T管无法夹管,造影显示胆管下端不通畅,术后3个月再次手术证实为胰头癌)。2例患者不符合探查流程,在无术中病理学检查前提下仅凭术前影像学表现行胰十二指肠切除术,术后病理学检查显示为壶腹部慢性炎症与慢性胰腺炎。(4)随访情况:22例患者均获得随访,随访时间为12~60个月,中位随访时间为36个月。11例行手术探查患者术后胃瘫2例,胆汁漏1例,伤口感染1例,均经对症治疗后好转。4例手术探查阳性行手术治疗患者随访期间无复发。5例手术探查阴性行胆总管切开T管外引流术患者中,1例3个月后被证实为胰头癌再行胰十二指肠切除术,4例术后2个月行T管造影示胆管远端通畅后均顺利拔除T管,随访期间实验室和影像学检查无阳性发现。2例慢性炎症行胰十二指肠切除术患者,实验室检查与影像学检查均无阳性发现。11例未行手术探查的随访患者中,10例有腹痛症状,随访期间3例仍有轻微腹痛,7例症状消失。11例患者随访期间实验室检查均无异常。结论影像学检查阳性+黄疸升高+CA19⁃9升高是胆胰管扩张施行手术探查的绝对指征,不符合此指征患者可行密切随访,术中未明确病理学检查为肿瘤,应终止手术转入随访,反对盲目行胆肠吻合术或胆道支架置入术.

Objective To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.Methods The retrospective and descriptive study was conducted.The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected.There were 6 males and 16 females,aged from 33 to 82 years,with an average age of 66 years.Surgical exploration was decided according to clinical symptoms,results of laboratory test and imaging examinations.For patients with space occupying lesions,surgical procedure was selected based on results of pathological examination.Patients without surgical exploration or space occupying lesions were allocated into follow⁃up.Observation indicators:(1)surgical exploration;(2)relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions;(3)surgical treatment;(4)follow⁃up.Follow⁃up using outpatient examination was performed on patients up to October 2018.Follow⁃up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations,no jaundice,normal laboratory indicators or mild abnormality,liver function,tumor markers and B⁃ultrasound were re⁃examined each month,and computed tomography(CT)and magnetic resonance imaging(MRI)was performed once every 3 months.Surgical exploration was performed when total bilirubin(TBil)or tumor markers showed a progressive increase.Follow⁃up was performed on patients with negative results of imaging examination,jaundice,and mildly elevated CA19⁃9.TBil and CA19⁃9 were re⁃examined monthly,and if they were progressively elevated,patients were transferred to surgical exploration.For patients with negative results of imaging examination,no symptoms,and negative laboratory test,liver function,tumor markers,and B⁃ultrasound were re⁃examined once every 3 months,and enhanced CT and MRI were re⁃examined once every 6 months within one year.Follow⁃up was performed once every 6 months during the second year,and once a year after two years.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were descibed as absolute numbers,and they were analyzed using the chi⁃square test under R×C chart or Fisher exact probability.Results(1)Surgical exploration:of 22 patients,11 underwent surgical exploration,and 11 underwent follow⁃up.Of the 11 patients with surgical exploration,4 were positive for space occupying lesions including 1 of false negative,and 7 were negative for space occupying lesions.(2)Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions.①Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions:juandice was significantly associated with surgical exploration positive for space occupying lesions(P<0.05),and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions(χ^2=0,0,P<0.05),with a sensitivity of 75.0%and specificity of 100.0%.②Relationship between imaging examination and surgical exploration positive for space occupying lesions:results of CT,MRI,endoscopic retrograde cholangio⁃pancreatography,endoscopic ultrasonography,PET⁃CT,and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions(χ^2=0,0.77,0,0,1.00,0,0,0,0,P>0.05).PET⁃CT had no significant association with surgical exploration positive for space occupying lesions(P>0.05).③Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions:positive imaging examination combined with elevated TBil and CA19⁃9 was significantly associated with surgical exploration positive for space occupying lesions(P<0.05),with a sensitivity of 50.0%and specificity of 100.0%.④Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions:of 22 patients,the diameters of biliary ducts and pancreatic ducts were(13.8±4.3)mm and(4.6±1.5)mm for patients with positive surgical exploration,(13.0±2.8)mm and(3.5±0.5)mm for patients with negative surgical exploration,(11.6±2.4)mm and(3.2±0.4)mm for patients with follow⁃up,respectively,showing no significant difference b0.05).(3)Surgical treatment:9 of 11 patients with surgical exploration followed the standard procedure.Of the 9 patients,4 were found space⁃occupying lesions at the choledocho⁃pancreatico⁃duodenal junction(3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection),5 with negative exploration underwent common bile duct incision and T⁃tube drainage(one patient was unable to pinch the T⁃tube one month after operation and detected obstruction at the lower end of the bile duct by radiography,and was confirmed pancreatic head cancer by reoperation 3 months after the first operation).Two patients didn′t follow the exploratory procedure,and underwent the child operation only based on the preoperative imaging findings,without intraoperative pathological examination.Postoperative pathological examination showed chronic ampulla and chronic pancreatitis,respectively.(4)Follow⁃up:22 patients were followed up for 12-60 months,with a median follow⁃up time of 36 months.Two of 11 patients with surgical exploration had postoperative gastroplegia,1 had bile leakage,1 had incisional infection,and they were improved after symptomatic treatment.Four patients undergoing surgeries for positive exploration had no recurrence during follow⁃up.Of 5 patients with negative exploration undergoing common bile duct incision and T⁃tube drainage,1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy,4 were removed T⁃tube after by T⁃tube cholangiography at 2 months after surgery.During the follow⁃up,no positive signs showed in laboratory test or imaging examination.No recurrence occurred in the two patients undergoing pancreaticoduodenectomy.Of 11 patients with follow⁃up,10 had abdominal pain before surgery,including 3 with pain during follow⁃up and 7 with symptoms disappeared.There was no abnormalities in the laboratory test.Conclusions The positive imaging examinations combined with jaundice and elevated CA19⁃9 is an absolute indication for surgical exploration in patients with biliary duct dilatation.Those patients who do not meet this criteria should be distributed into the follow⁃up.If no positive pathological results were obtained during the operation,the surgery should be terminated and the patients should be transferred into follow⁃up.The reckless biliary anastomosis or biliary stents placement is opposed.