| Pancreatic ductal stones(PDS)is a secondary lesion of chronic pancreatitis(CP),and its diagnosis is relatively easy,while the early diagnosis of canceration in the context of CP and PDS is difficult.This series of studies firstly summarized the literature of PDS combined with PC reported in China in the past 30 years;then retrospectively analyzed the medical records of patients with PDS treated in Southwest Hospital in recent ten years,established the risk prediction model and simplified diagnostic scoring system for PDS complicated with canceration,and evaluated its effectiveness.Finally,we summarized the treatment experience and lessons of the patients with PDS complicated with canceration,and explored its surgical coping strategies according to the diagnostic scoring system.1.Pathogenesis,diagnosis and treatment of PDS combined with PC in China(1980-2010).Objective:To summarize the epidemiological characteristics,incidence,diagnosis,treatment and prognosis of PDS combined with PC in China in the past 30 years.Methods:By means of CNKI,Wanfang Data,CQVIP,PubMed,the literatures on PDS combined with PC reported in mainland China from 1980 to 2010 were retrieved,and 15literatures were summarized and analyzed according to the inclusion criteria.Results:94 cases of PDS combined with PC were reported.The ratio of male to female was 2:1.The average age was 46.8 years.The incidence of PC was 19.0%in PDS.Alcohol abuse was probably the most common cause of PDS and PC.PDS combined with PC lacked specific clinical manifestations.Comprehensive analysis of imaging features and serum tumor markers can improve the accuracy of preoperative clinical diagnosis.Invasive examinations such as ERCP or percutaneous pancreatic biopsy were helpful for preoperative diagnosis,but the incidence of preoperative missed diagnosis of PC was still as high as 29.9%.Pancreatic head was still the most common site of PC(53.2%)in the context of PDS,but PDS in the body and tail of pancreas can also be complicated with canceration(25.5%).Radical surgery was performed according to the treatment plan of PC after diagnosis.The overall survival rates of 1,3 and 5 years after operation were 62.8%,20.3%and 6.1%,respectively.The median survival time was 23.0 months(95%CI:16.0-30.0).Conclusion:PDS combined with PC often lacked specific clinical manifestations and detection methods.Early diagnosis was difficult and preoperative missed diagnosis rate was high.Even if radical surgery was adopted,the prognosis was still poor.2.Establishment and evaluation of diagnostic scoring system for PDS complicated with canceration.Objective:To establish a diagnostic scoring system for PDS complicated with canceration and evaluate its diagnostic efficacy.Methods:A retrospective analysis was made on the medical records of patients with PDS treated surgically in the hepatobiliary surgery department of Southwest Hospital from January 2005 to December 2017.The patients were grouped according to the pathological diagnosis after operation with or without canceration.The risk prediction model of PDS complicated with canceration was established by Logistic multiple regression,and the diagnostic scoring system was established according to the beta value of model variables.Receiver operating characteristic(ROC)curve analysis,Hosmer-Lemeshow test and leave-one-out cross-validation(LOOCV)method were used to evaluate the diagnostic efficiency of the model.Results:In the risk prediction model,significant pancreatic atrophy(OR=10.617,CI:2.830-38.827,P<0.001),common bile duct deformations(OR=12.189,CI:2.902-51.191,P=0.001),increased serum tumor markers(OR=7.502,CI:2.193-25.655,P=0.001)and large pancreatic ductal calculi(diameter<13 mm)(OR=4.302,CI:1.305-14.185,P=0.017)were independent predictors of the risk of PDS complicated with canceration.By calculating the area under ROC curve,AUC(95%CI)was 0.926(0.885,0.968)(P<0.001),and Hosmer-Lemeshow test showed that the model had good goodness of fit(~2=3.277,P>0.05).The sensitivity,specificity,accuracy,positive predictive value,negative predictive value,positive likelihood ratio and negative likelihood ratio of the model were calculated by using LOOCV,and the results were 71.43%,78.97%,7.05,respectively.8.24%,26.79%,96.25%,3.40,0.36.Four independent risk predictors were used to evaluate the risk score.The total score ranged from 0 to 6.A diagnostic scoring system for PDS complicated with canceration was established.The risk stratification was carried out by Youden’s index.However,patients with PDS were divided into low risk group(1-3 points)and high risk group(>3 points).The actual incidence of canceration in high risk group was significantly higher than that in low risk group(P<0.001).To verify the consistency between the predicted value and the actual value of the diagnostic scoring system,sensitivity,specificity,accuracy,positive predictive value,negative predictive value,positive likelihood ratio and negative likelihood ratio were 71.43%,89.74%,87.96%,42.86%,96.69%,6.96 and 0.32,respectively,which showed that the diagnostic sensitivity,specificity and accuracy of the diagnostic scoring system based on risk stratification were good.Conclusion:Preoperative diagnosis of PDS complicated with canceration was difficult.Significant atrophy of pancreas(parenchymal thickness<7mm),common bile duct deformation,large pancreatic ductal calculi(diameter≥13mm)and increased serum tumor markers(at least one of CA19-9,CA125 or CEA)were independent predictors of the risk of PDS complicated with carceration.The diagnostic scoring system established on this basis could improve the diagnostic efficiency of PDS complicated with canceration,which had certain clinical value.3.Analysis of high risk factors for PDS complicated with pancreatic intraepithelial neoplasias.Objective:To analyze the high risk factors of PDS complicated with precancerous lesions(pancreatic intraepithelial neoplasias,PanINs).Methods:The clinical data of patients with PDS treated surgically in the author’s hospital from January 2005 to December 2017 were retrospectively analyzed.The risk factors of PDS complicated with PanINs were analyzed by Logistic regression model.Results:Three potential risk factors of PDS complicated with PanINs were screened out by single factor analysis:enlarged pancreatic head,common bile duct deformations and increased serum tumor markers.Multiple regression analysis showed that enlarged pancreatic head(OR=3.250,CI:1.371~7.706,P=0.007)was the only independent predictor of PDS complicated with PanINs.Conclusion:Although the enlargement of the pancreatic head was not included in the diagnostic scoring system of canceration,it was the only independent predictor of PDS complicated with precancerous lesions.Therefore,it should be paid more attention in early prevention and treatment of canceration.4.Surgical coping strategies for PDS complicated with canceration.Objective:To retrospectively analyze and summarize the experience and lessons in surgical management of PDS complicated with canceration,and to explore its surgical strategies.Methods:Data of patients with PDS complicated with canceration treated in the author’s hospital from January 2005 to December 2017 were collected.The clinical features of patients and the experience and lessons of surgical treatment were summarized.Results:(1)Clinical features,diagnosis,treatment and prognosis:The incidence of canceration in patients with PDS was 7.3%,and the average age of patients was 54.3±12.5years.Type-I PDS were the main features.In addition to the direct signs of cancerous tumors,the four characteristics of pancreas atrophy,common bile duct deformations,increased serum tumor markers and large pancreatic ductal calculi were particularly common.The missed diagnosis rate of preoperative canceration was 39.4%(12 cases).The diagnostic scoring system can improve the accuracy of imaging diagnosis and reduce the missed diagnosis before operation.Another 23.8%(5 cases)of patients missed diagnosis of cancer during operation.Postoperative delayed canceration(11 cases)occurred within 2years after the first operation,and 54.5%of the patients underwent pancreatic duct drainage and did not undergo biopsy during the initial operation.In 15 patients with canceration who underwent surgical resection,the overall survival rates of 1,3 and 5 years after operation were 46.2%,6.7%and 0,respectively,and the median survival time was 12 months(95%CI:3.2-20.8).(2)Surgical coping strategies:In the face of patients with PDS,a comprehensive preoperative examination is the premise to reduce missed diagnosis of canceration.The core of surgical strategy is to recommend pancreatic resection as the first choice for patients with suspected cancerous mass,or enlarged head of pancreas,or with high risk of canceration.For patients with low risk,pancreatectomy,pancreatic duct drainage or combined procedures can be selected according to the pancreatic morphology and characteristics of calculi.Routine biopsy and rapid frozen pathological examination should be performed during the operation to further clarify the diagnosis and determine the final surgical procedure.The outpatient follow-up should be at least 2 years for patients without concurrent canceration.Conclusion:The key to prevent and treat PDS complicated with canceration lies in improving the preoperative diagnostic efficiency and reducing the missed diagnosis of canceration before and during operation.By preoperative evaluation of patients with PDS whether there is a mass of cancer or enlarged head of pancreas,and whether they belong to high-risk canceration group,individual surgical strategies are adopted to improve the effectiveness of the treatment.5.The efficacy and prognosis of pancreatectomy and pancreatic duct drainage in the treatment of PDS.Objective:To compare the efficacy and prognosis of two surgical treatments for PDS,and to evaluate the feasibility of cancer coping strategies.Methods:The clinical data and follow-up data of patients with PDS treated surgically in the author’s hospital from January 2008 to June 2017 were collected.A case-control study was conducted to compare the efficacy and prognosis of pancreatic ductal stones treated by pancreatectomy and pancreatic duct drainage.Results:136 patients with PDS were divided into pancreatic duct drainage group(44cases)and resection group(92 cases).Both procedures were safe and effective in the treatment of PDS.Compared with the drainage group,the resection group had longer operation time,more intraoperative bleeding and longer hospital stay(P<0.05),but lower residual stone rate(P<0.05),and did not increase the incidence of complications and mortality(P>0.05).There was no significant difference in long-term pain relief rate between the two groups(P>0.05).Conclusion:Pancreactomy is an active intervention strategy in the surgical management of PDS complicated with canceration.It is as safe and effective as pancreatic duct drainage in the treatment of PDS.Its reasonable application will not bring obvious negative effects on patients with PDS misdiagnosed as cancerous by the scoring system. |
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