课件：壶腹部肿瘤治疗进展.ppt

壶腹部肿瘤手术治疗进展,概念：,壶腹部：十二指肠乳头，Vater壶腹、胆总管第4段（十二指肠壁内段）、胰管终末段及其周围的括约肌。 壶腹部肿瘤是指胆总管第4段、 Vater壶腹(胆总管末端斜行进入十二指肠后壁内与主胰管形成的共同通道）及十二指肠乳头的肿瘤。,概述（Introduction）,1.壶腹部肿瘤良性少见（10%）1-2； 2.与遗传性息肉病综合征关系密切，如FAP； 3.确诊壶腹癌年龄一般在60-70岁； 4.一些证据表明：生物学行为更接近于肠道而非胰胆管肿瘤。 1 Park SH, Kim YI, Park YH, 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 Vater. Yonsei Med J. 2000 Apr;41(2):213-8,壶腹癌治疗（Treatment）：,局部切除 胰十二指肠根治切除（PD）及改良（保留幽门）（PPPD） 微创非手术疗法（Minimally-invasive nonsurgical therapies）,局部切除（Local resection） 自1899年Halsted开展，未广泛接受（患者生存6个月，复发率高，疗效差） 发病年龄较大，并存疾病多 目前此种方法的文献报道较少，之间对比缺少标准（eg, “ampullectomy“ versus “local resection“),解剖学依据1： *十二指肠内段胆总管长1.5-2.0cm *进入十二指肠前1-2cm紧贴肠壁 *46.7%胆胰管汇合形成Vater壶腹2 *50%胆胰管并行 1、Gassler N1, Knchel R. Tumors of Vaters ampulla Pathologe. 2012 Feb;33(1):17-23. doi: 10.1007/s00292-011-1546-8 2、Funabiki T1, Matsubara T, Miyakawa S, Ishihara S. Pancreaticobiliary maljunction and carcinogenesis to biliary and pancreatic malignancy. Langenbecks Arch Surg. 2009 Jan;394(1):159-69. doi: 10.1007/s00423-0 08-0336-0. Epub 2008 May 24.,理论依据,解剖学依据 病理依据1-2： *壶腹癌以腺癌多见，分化程度高， *恶性程度低 1、Beger HG1, Treitschke F, Gansauge F, Harada N, Hiki N, Mattfeldt T. Tumor of the ampulla of Vater: experience with local or radical resection in 171 consecutively treated patients. Arch Surg. 1999 May;134(5):526-32 2、Gassler N1, Knchel R. Tumors of Vaters ampulla Pathologe. 2012 Feb;33(1):17-23. doi: 10.1007/s00292-011-1546-8,理论依据,解剖学依据 病理依据 肿瘤生物学依据1：*生长缓慢、转移较晚 *常沿十二指肠或胆总管粘膜 *少侵及肠壁外 1、Beger HG1, Treitschke F, Gansauge F, Harada N, Hiki N, Mattfeldt T. Tumor of the ampulla of Vater: experience with local or radical resection in 171 consecutively treated patients. Arch Surg. 1999 May;134(5):526-32,理论依据,解剖学依据 病理依据 肿瘤生物学依据 其他1：Whipple可以清扫淋巴结， 但不能减少血行转移 1、Topal B, Fieuws S, Aerts R, Weerts J, Feryn T, Roeyen G, Bertrand C, Hubert C, Janssens M。Pancreaticojejunostomy versus pancreaticogastro- stomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial. Lancet Oncol. 2013 Jun;14(7):655-62.,理论依据,手术范围,文献报道不尽相同 包括：不涉及胆胰管末端的单纯十二指肠黏膜切除 广泛的乳头区域切除：乳头、壶腹胆胰管末端和相应的十二指肠后壁，以及胆胰管末端再植 技术难度大 精细操作 切缘快速冰冻,优缺点,并发症少 恢复快 手术时间短 术后生活质量高 手术死亡率低 高复发率 低生存率,适用范围：,高风险病人 早期高分化、不穿透肌层（Tis,T1期) 超声内镜下直径6mm（国内文献报道直径2.0/2.5cm） 【UpToDate】：We suggest local ampullary excision rather than pancreaticoduodenectomy for patients with noninvasive ampullary tumors (pTis) (Grade 2B).,展望,1.术前病理诊断假阴性率较高 2.肿瘤的组织类型区分 3.术前淋巴结情况难判定 总之，尚有待临床大规模RCT研究,PD/PPPD,PD（Whipple operation）被认为是治疗壶腹癌的标准方法 PPPD( pylorus-preserving pancreaticoduodenectomy)（保留幽门） 尽管有报道1PPPD手术时间短，术中出血少，然而，二者对术后长期生存无明显差异，亦有报道PPPD更易产生胃排空延迟。 1Diener MK, Knaebel HP, Heukaufer C, Antes G, Bchler MW, Seiler CM. A systematic 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.,优缺点1-3,根治性切除率可达到80-90% 长期生存率高，即便是对于淋巴结转移或T3期病人 围手术期死亡率较高（最近文献表明，对经验丰富大夫可控制在0-5%） 围手术期并发症发生率高20-40%（肺炎、腹腔内感染、吻合口瘘、胃排空延迟等） 手术创伤大 与术者水平和术后护理关系密切,推荐级别,【UpToDate】We recommend pancreaticoduodenectomy rather than local resection for most patients with invasive ampullary carcinomas (Grade 1B),文献回顾：Roggin KK等 Limitations of ampullectomy in the treatment of nonfamilial ampullary neoplasms. Ann Surg Oncol. 2005,Memorial Sloan-Kettering Cancer Center（纪念斯隆-凯特琳癌症中心美） 99例浸润性壶腹癌患者，其中8例行AMP（ampullectomy）， 91例行PD(pancreaticoduodenectomy) 幸存者中位随访期18个月 比较：复发率和生存率 术前病理准确性 结论,微创非手术疗法,包括：内镜下圈套切除术（Endoscopic snare resection ） 射频消融（Laser ablation） 光动力疗法（photodynamic therapy，PDT） 姑息性治疗 仅适用于不适合手术或拒绝手术者,PROGNOSIS,Stage I 84 percent Stage II 70 percent Stage III 27 percent Stage IV 0 percent（one retrospective single-institution series） the National Cancer Institute SEER database between 1988 and 2003 Five-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,资料来源,/contents/ampullary-carcinoma-treatment-and-prognosis?source=search_result&search=Periampullary+tumors+AND+local+resection&selectedTitle=1150#H11 /contents/treatment-of-ampullary-adenomas?source=see_link#H24 /contents/ampullary-carcinoma-epidemiology-clinical-manifestations-diagnosis-and-staging?source=see_link,Thanks,,PEKING UNION MEDICAL COLLEGE HOSPITAL PEKING UNION MEDICAL COLLEGE HOSPITAL,参考文献,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. 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: 10.1002/jso.21390.,Overall, pre