十二指腸乳頭部旁惡性腫瘤以胰十二指腸切除術治療之過去與現在

Pancreatico-Duodenectomy for Periampullary Malignancy: Past and Present

將胰十二指腸切除術(pancreatico-duodenectomy)應用於旁乳頭壺腹部惡性腫瘤(periampullary malignancy)是由惠浦爾(Whipple)醫師於1935年首先提出，而直到1961年台灣才開始進行此項手術。從我們接受此項手術方式，移動胰臟頭、十二指腸（亦稱寇克式技巧）以及謹慎觸摸壺腹區以鑒別腫瘤部位，至今已過了三十五個歲月。在這段期間，診斷方法、術前準備以及手術技術均不斷在進步，而手術死亡率也由起初的大約50%下降到5%。除了對胰頭部癌腫以外，病人五年存活率也進步到50%，因此，胰十二指腸切除術在現今已是一種安全而普遍的手術。目前所期望的目標是增加存活率以及減少大範圍不必要的手術，如幽門保存式十二指腸切除術(pylorus-preserving pancreatico-duodenectomy)以及局部乳突切除術(local papillary resection)。目前的問題在於希望能夠早期診斷出病灶，此也是增加旁壺腹區惡性腫瘤存活率最短的捷徑。對於早期的腫瘤以及華特乳頭部腫瘤(cancer of papilla Vater)而言，侵襲性較小的手術，如幽門保存式胰十二指腸切除術以及局部乳突切除術，可能在不久的將來，會被認為是處理此種腫瘤合宜的方法。此外，對於血液生化檢查值，如r-GT、ALK-P以及膽紅素不正常的病人也要特別小心，在進行內視鏡檢查時必須進一步小心的檢查十二指腸乳頭區，而此項檢查也可應用於旁壺腹區惡性腫瘤而沒有出現黃膽的病人。

Whipple described pancreatico-duodenectomy (PD) for periampullary malignancy in 1935. This operation had not been performed in Taiwan until 1961. Thirty-five years have passed since we adopted the PD with mobilization of pancreatic head and duodenum (so called Kocher's maneuver) and meticulous palpation of the ampullar area to differentiate the lesion during operation. During this period, the diagnostic methods, preoperative preparations, and operative technigue have improved gradually, and operative mortality has dropped from about 25% to 5%. The 5-year survival rate has also improved to 50%, except in patients with involvement of the pancreatic head. Pancreatico-duodenectomy is now a relatively safe and common operation. The current goals are to improve the survival rate and to minimize operation such as pylorus-preserving pancreatico-duodenectomy and local papillary resection. The current problem is to detect the lesion in early stage. Which is the shortest way to improve the surgical survival rate of periampullary malignancy For early stage of malignancy and for the cancer of papuilla of Vater, the less invasive surgical procedure such as PpPD or local papillary resection may be accepted as a rational method of treatment in the future. More attention should be paid to patients with abnormal blood chemistry values, such as r-GT, ALK-P, and bilirubin. When performing panendoscopic examination, the scope should always be extended for careful examination of the duodenal papilla. This should also be used for the detection of periampullary malignancy without jaundice.