不同类型胰腺囊性肿瘤的诊断与治疗

Diagnosis and treatment of various types of pancreatic cystic neoplasms

目的探讨不同类型胰腺囊性肿瘤(PCNs)的诊断与治疗。方法采用回顾性描述性研究方法。收集2009年1月至2018年12月中山大学附属第一医院收治的244例PCNs患者的临床病理资料;男70例,女174例;中位年龄为43岁,年龄范围为5~79岁。根据患者术前评估结果和术中探查结果确定手术方式。观察指标:(1)PCNs分类和临床病理学情况。(2)PCNs患者术前CA19⁃9水平情况。(3)影像学检查结果。(4)手术情况。(5)术后并发症情况。正态分布的计量资料以x±s表示。计数资料以绝对数或百分比表示,组间比较采用χ^2检验。结果(1)PCNs分类和临床病理学情况:244例PCNs患者中,浆液性囊性瘤(SCN)76例,黏液性囊性瘤(MCN)56例,实性假乳头状瘤(SPN)96例,导管内乳头状黏液性瘤(IPMN)16例。76例SCN患者中,男22例、女54例;年龄为(51±14)岁,年龄范围为22~78岁;32例术前有腹痛,44例术前无腹痛;47例肿瘤位于胰腺体尾部,29例肿瘤位于胰腺头颈部。76例SCN患者术后病理学检查结果均为良性。56例MCN患者中,男16例、女40例;年龄为(49±16)岁,年龄范围为20~79岁;34例术前有腹痛,22例术前无腹痛;35例肿瘤位于胰腺体尾部,21例肿瘤位于胰腺头颈部。56例MCN患者中,11例术后病理学检查结果为恶性。96例SPN患者中,男21例、女75例;年龄为(32±14)岁,年龄范围为5~68岁;42例术前有腹痛,54例术前无腹痛;58例肿瘤位于胰腺体尾部,38例肿瘤位于胰腺头颈部。96例SPN患者中,1例术后病理学检查结果为恶性。16例IPMN患者中,男11例、女5例;年龄为(56±10)岁,年龄范围为41~76岁;11例术前有腹痛,5例术前无腹痛;4例肿瘤位于胰腺体尾部,12例肿瘤位于胰腺头颈部。16例IPMN患者中,6例术后病理学检查结果为恶性。(2)PCNs患者术前CA19⁃9水平情况:76例SCN患者中,9例术前CA19⁃9水平升高;67例术前CA19⁃9水平正常。56例MCN患者中,7例术前CA19⁃9水平升高,49例术前CA19⁃9水平正常。96例SPN患者中,14例术前CA19⁃9水平升高,82例术前CA19⁃9水平正常。16例IPMN患者中,4例术前CA19⁃9水平升高,12例术前CA19⁃9水平正常。244例PCNs患者中,226例为良性PCNs,18例为恶性PCNs。226例良性PCNs患者中,26例CA19⁃9水平升高;18例恶性PCNs患者中,8例CA19⁃9水平升高,两者术前CA19⁃9水平升高情况比较,差异有统计学意义(χ^2=15.084,P<0.05)。(3)影像学检查结果:244例患者中,163例行超声造影检查,其中SCN 59例,MCN 37例,SPN 55例,IPMN 12例。163例行超声造影检查患者中,82例检查结果与术后病理学检查结果一致,诊断符合率为50.3%(82/163)。其中,SCN、MCN、SPN、IPMN的诊断符合率分别为67.8%(40/59)、54.1%(20/37)、32.7%(18/55)、4/12。244例患者中,198例行CT检查,其中SCN 60例,MCN 44例,SPN 82例,IPMN 12例。198例行CT检查的患者中,135例检查结果与术后病理学检查结果一致,诊断符合率为68.2%(135/198),其中SCN、MCN、SPN、IPMN的诊断符合率分别为76.7%(46/60)、79.5%(35/44)、58.5%(48/82)、6/12。(4)手术情况:244例患者均根据术前评估结果和术中探查结果成功施行手术,术中无死亡病例。76例SCN患者中,20例行胰十二指肠切除术、20例行保留脾脏的胰体尾切除术、14例行胰体尾切除合并脾切除术、9例行肿瘤局部切除术、7例行保留十二指肠的胰头切除术、6例行胰腺中段切除术。56例MCN患者中,20例行胰体尾切除合并脾切除术、16例行胰十二指肠切除术、9例行保留脾脏的胰体尾切除术、8例行胰腺中段切除术、3例行肿瘤局部切除术。96例SPN患者中,34例行胰体尾切除合并脾切除术、23例行胰十二指肠切除术、15例行保留脾脏的胰体尾切除术、12例行肿瘤局部切除术、8例行胰腺中段切除术、3例行保留十二指肠的胰头切除术、1例行全胰腺切除术。16例IPMN患者中,9例行胰十二指肠切除术、3例行胰体尾切除合并脾切除术、3例行全胰腺切除术、1例行保留脾脏的胰体尾切除术。(5)术后并发症情况:76例SCN患者中,17例发生胰瘘(生化瘘12例、B级胰瘘5例),7例腹腔感染,1例胰十二指肠切除术后患者发生胃排空延迟,1例腹腔出血,1例乳糜瘘,1例胰腺中段切除术患者术后发生胰肠吻合口瘘。56例MCN患者中,7例发生胰瘘(生化瘘2例、B级胰瘘5例),3例腹腔感染,2例胆瘘,1例胰十二指肠切除术后患者发生胃排空延迟,1例消化道出血,1例术后门静脉血栓形成。96例SPN患者中,14例发生胰瘘(生化瘘5例、B级胰瘘8例、C级胰瘘1例),6例腹腔感染,4例胰十二指肠切除术后患者发生胃排空延迟,2例腹腔出血或消化道出血,1例胆瘘,1例术后门静脉血栓形成。16例IPMN患者中,3例发生胰瘘(生化瘘、B级胰瘘、C级胰瘘各1例),2例腹腔出血或消化道出血,1例腹腔感染,1例胆瘘,1例围术期死于肺栓塞。所有并发症根据病情的严重程度,选择保守治疗、经皮穿刺置管引流、介入治疗或二次手术,均好转出院。结论PCNs主要包括SCN、MCN、SPN、IPMN。各型PCNs缺乏典型的临床症状,实验室检查也缺乏特异性。术前CA19⁃9水平可对PCNs术前良恶性判断提供一定参考。影像学检查是PCNs主要的诊断依据。PCNs应严格把握手术指征,有手术指征时应积极手术治疗。

Objective To investigate the diagnosis and treatment of various types of pancreatic cystic neoplasms(PCNs).Methods The retrospective and descriptive study was conducted.The clinicopathological data of 244 PCNs patients who underwent surgical resection in the First Affiliated Hospital of Sun Yat⁃Sen University from January 2009 to December 2018 were collected.There were 70 males and 174 females,aged from 5 to 79 years,with a median age of 43 years.Patients received corresponding surgical methods according to the preoperative evaluation and intraoperative exploration.Observation indicators:(1)classification and clinicopathological features of PCNs;(2)preoperative CA19⁃9 levels of PCNs patients;(3)results of imaging examinations;(4)surgical situations;(5)postoperative complications.Measurement data with normal distribution were represented as Mean±SD.Count data were represented as absolute numbers or percentages,and comparison between groups was conducted using the chi⁃square test.Results(1)Classification and clinicopathological features of PCNs:in 244 PCNs patients,there were 76 cases of serous cystic neoplasm(SCN),56 cases of mucinous cystic neoplasm(MCN),96 cases of solid pseudopapillary neoplasm(SPN),and 16 cases of intraductal papillary mucinous neoplasm(IPMN).Among the 76 SCN patients,there were 22 males and 54 females,aged(51±14)years,with a range from 22 to 78 years.Of 76 SCN patients,there were 32 cases with abdominal pain while 44 without abdominal pain before surgery,and there were 47 cases with tumor located in the body and tail of the pancreas while 29 cases with tumor located in the head and neck of the pancreas.The postoperative pathological examination of all 76 SCN patients were benign.Among the 56 MCN patients,there were 16 males and 40 females,aged(49±16)years,with a range from 20 to 79 years.Of 56 MCN patients,there were 34 cases with abdominal pain while 22 without abdominal pain before surgery,and there were 35 cases with tumor located in the body and tail of the pancreas while 21 cases with tumor located in the head and neck of the pancreas.Eleven of the 56 MCN patients were pathologically confirmed as malignant tumors after operation.Among the 96 SPN patients,there were 21 males and 75 females,aged(32±14)years,with a range from 5 to 68 years.Of 96 SPN patients,there were 42 cases with abdominal pain while 54 without abdominal pain before surgery,and there were 58 cases with tumor located in the body and tail of the pancreas while 38 cases with tumor located in the head and neck of the pancreas.One of the 96 SPN patients were pathologically confirmed as malignant tumors after operation.Among the 16 IPMN patients,there were 11 males and 5 females,aged(56±10)years,with a range from 41 to 76 years.Of 16 IPMN patients,there were 11 cases with abdominal pain while 5 without abdominal pain before surgery,and there were 4 cases with tumor located in the body and tail of the pancreas while 12 cases with tumor located in the head and neck of the pancreas.Six of the 16 IPMN patients were pathologically confirmed as malignant tumors after operation.(2)Preoperative CA19⁃9 levels of PCNs patients:of 76 SCN patients,there were 9 cases with elevated preoperative CA19⁃9 levels while 67 cases with normal preoperative CA19⁃9 levels.Of 56 MCN patients,there were 7 cases with elevated preoperative CA19⁃9 levels while 49 cases with normal preoperative CA19⁃9 levels.Of 96 SPN patients,there were 14 cases with elevated preoperative CA19⁃9 levels while 82 cases with normal preoperative CA19⁃9 levels.Of 16 IPMN patients,there were 4 cases with elevated preoperative CA19⁃9 levels while 12 cases with normal preoperative CA19⁃9 levels.Of 244 PCNs patients,there were 226 cases with benign PCNs and 18 cases with malignant PCNs.The cases with elevated preoperative CA19⁃9 levels in 226 benign PCNs patients and 18 malignant PCNs patients were 26 and 8,respectively,showing a significant difference(χ^2=15.084,P<0.05).(3)Results of imaging examinations:of 244 PCNs patients,163 cases underwent contrast⁃enhanced ultrasound examination,including 59 cases of SCN,37 cases of MCN,55 cases of SPN,and 12 cases of IPMN.Of 163 patients undergoing contrast⁃enhanced ultrasound examination,there were 82 cases who had the result of contrast⁃enhanced ultrasound examination consistent with the result postoperative pathological examination,and the diagnosis accuracy rate was 50.3%(82/163).The diagnosis accuracy rates of contrast⁃enhanced ultrasound examination for the SCN,MCN,SPN and IPMN patients were 67.8%(40/59),54.1%(20/37),32.7%(18/55)and 4/12,respectively.Of 244 PCNs patients,198 cases underwent computed tomography(CT)examination,including 60 cases of SCN,44 cases of MCN,82 cases of SPN,and 12 cases of IPMN.Of 198 patients undergoing CT examination,there were 135 cases who had the result of CT examination consistent with the result postoperative pathological examination,and the diagnosis accuracy rate was 68.2%(135/198).The diagnosis accuracy rates of CT examination for the SCN,MCN,SPN and IPMN patients were 76.7%(46/60),79.5%(35/44),58.5%(48/82)and 6/12,respectively.(4)Surgical situations:244 patients underwent surgery successfully according to the preoperative evaluation and intraoperative exploration,without death during operation.Of 76 SCN patients,there were 20 cases undergoing pancreatoduodenectomy,20 cases undergoing spleen⁃preserving distal pancreatectomy,14 cases undergoing distal pancreatectomy combined with splenectomy,9 cases undergoing local tumor resection,7 cases undergoing duodenum⁃preserving pancreatic head resection and 6 cases undergoing middle pancreatectomy,respectively.Of 56 MCN patients,there were 20 cases undergoing distal pancreatectomy combined with splenectomy,16 cases undergoing pancreatoduodenectomy,9 cases undergoing spleen⁃preserving distal pancreatectomy,8 cases undergoing middle pancreatectomy and 3 cases undergoing local tumor resection,respectively.Of 96 SPN patients,there were 34 cases undergoing distal pancreatectomy combined with splenectomy,23 cases undergoing pancreatoduodenectomy,15 cases undergoing spleen⁃preserving distal pancreatectomy,12 cases undergoing local tumor resection,8 cases undergoing middle pancreatectomy,3 cases undergoing duodenum⁃preserving pancreatic head resection and 1 case undergoing total pancreatectomy,respectively.Of 16 IPMN patients,there were 9 cases undergoing pancreatoduodenectomy,3 cases undergoing distal pancreatectomy combined with splenectomy,3 cases undergoing total pancreatectomy and 1 case undergoing spleen⁃preserving distal pancreatectomy,respectively.(5)Postoperative complications:of 76 SCN patients,17 cases had pancreatic fistula including 12 cases of biochemical fistula and 5 cases of grade B pancreatic fistula,7 cases had abdominal infection,1 case had delayed gastric emptying after pancreatoduodenectomy,1 case had abdominal hemorrhage,1 case had chyle fistula and 1 case had anastomotic fistula after middle pancreatectomy,respectively.Of 56 MCN patients,7 cases had pancreatic fistula including 2 cases of biochemical fistula and 5 cases of grade B pancreatic fistula,3 cases had abdominal infection,2 cases had biliary fistula,1 case had delayed gastric emptying after pancreatoduodenectomy,1 case had gastrointestinal bleeding and 1 case had postoperative portal vein thrombosis,respectively.Of 96 SPN patients,14 cases had pancreatic fistula including 5 cases of biochemical fistula,8 cases of grade B pancreatic fistula,and 1 case of grade C pancreatic fistula,6 cases had abdominal infection,4 cases had delayed gastric emptying after pancreatoduodenectomy,2 cases had abdominal hemorrhage or gastrointestinal bleeding,1 case had biliary fistula and 1 case had postoperative portal vein thrombosis,respectively.Of 16 IPMN patients,3 cases had pancreatic fistula including 1 case of biochemical fistula,1 case of grade B pancreatic fistula,and 1 case of grade C pancreatic fistula,2 cases had abdominal hemorrhage or gastrointestinal bleeding,1 case had abdominal infection,1 case had biliary fistula and 1 case had pulmonary embolism,respectively.The patient with pulmonary embolism died during the perioperative period,and the other patients with postoperative complications were discharged after conservative treatment,percutaneous drainage,interventional therapy or secondary surgery,respectively.Conclusions Patients with various types of PCNs including SCN,MCN,SPN and IPMN lack specific clinical symptoms and results of laboratory test.The CA19⁃9 levels has no significance for the classification of PCNs,but can be considered as a reference for distinguishing benign and malignant PCNs preoperatively.Imaging examination is the main diagnostic basis of PCNs.Surgical indications should be strictly controlled in patients with PCNs,and surgery should be actively performed in patients with indicators.