| BackgroundPeriampillary carcinomas(PACs)refer to tumors digestive tract that originated within 2 cm around ampulla of Vater.The ampulla is the complex anatomical site where multiple duct systems converge.In addition,it is located in the retroperitoneum,the deep part of the abdominal cavity.Therefore PACs are not easily perceived when they are at an early stage,and are diagnosed mostly at a progressive stage.Palliative bilioenterostomy is the primary surgical intervention because most patients are unable to undergo radical pancreatoduodenectomy.However,approximately 27.8%of patients who underwent palliative bilioenterostomy appeared upper GI obstruction.Therefore should a prophylactic gastrojejunostomy be performed?Which patients are more in need?These draw significant attention from surgeons in related fields.ObjectiveTo estimate the hazard fators of upper gastrointestinal obstruction in patients with advaned periampullary carcinoma after palliative choleoenterostomy.MethodsOn the basis of the inclusive and exclusive standard,a total of 389 invalids with adenocarcinoma of advanced PACs were choosed.They all attended the Department of hepatobiliary pancreatic surgery in our hospital from January 2010 to December 2019.1.Invalids were segmented into obstruction set and matched one on the grounds of whether they were retreated due to obstruction of upper digestive tract after choleoenterostomy.The two independent sample t test or rank sum test method was suitable for the part of the clinical data between the two sets that belong to the quantitative data;the chi-square test comparison method was applied to the qualitative data.2.To find out whether the upper gastrointestinal obstruction occurred in patients with advanced PACs undergoing choleoenterostomy and lymphatic metastases,the preoperative mGPS,tumor primary position,and biopsy fingdings,postoperative therapy and other factors were related,we had used Kaplan-Meier method and Cox regression analysis in this research.Results1.In patients with obstructive jaundice caused by advanced PACs,94 cases of upper gastrointestinal obstruction(24.16%)after biliary anastomosis occurred,the shortest period was 1.3 months after the upper gastrointestinal obstruction,and the longest period was 25.1 months later symptom.Upper gastrointestinal obstruction symptoms occurred for an average of 11.8 months.These were considered a total of 21 due to tumor invasion,43 due to compression by lymph node enlargement,13 due to both,and 17 due to other tumor related factors.2.We had found obvious difference in preoperative serum carcinoembryonic antigen,preoperative mGPS between the obstructive set and the no obstruction set(P<0.05).We had discovered evident discrepancies(P<0.05)in the existence of lymphatic metastases,site of tumor initiation,no treatment after surgery,and biopsy findings between the obstructive set and the no obstruction set.We could not find obvious discrepancies in age,gender,tumor size,vascular invasion between obstructive set and no obstruction set(P>0.05).In terms of preoperative serum glutamic oxaloacetic transaminase,preoperative Tbil,and glycoprotein 19-9,we did not find evident discrepancy(P>0.05).3.Cox regression analysis showed that the presence of lymphatic metastases,preoperative mGPS score 2 points,site of tumorigenesis suggested the pancreatic head or the end of biliary ducts,no treatment after surgery,and biopsy findings were pancreatobiliary type PACs were associated with the existence of upper GI obstruction after bilioenterostomy in patients with advanced PACs.4.In the obstruction set,it can be found that the existence of lymphatic metastasis has a shorter time for obstruction of the upper digestive tract than patients without it.In the treated set,we found that invalids with an mGPS score of 2 had a shorter time to onset of obstruction of the upper digestive tract compared with invalids with an mGPS score of 1 or 0.In the obstructive group,we found that invalids with tumors suggestive of ampulla or duodenal papilla had a longer time to upper GI obstruction than those with tumors in pancreatic head or the end of biliary ducts.In the treated set,we could find biopsies suggestive of a shorter time to upper GI obstruction in invalids with pancreatobiliary type PACs compared with these with intestinal type PACs.In the obstructive set,patients who did not undergo treatment after surgery had a shorter period of time for upper digestive obstruction than those who received treatment.Conclusions1.The existence of lymphatic metastasis,mGPS score of 2 points before the operation,the location of the tumor indicates pancreatic head or the end of biliary ducts,and the biopsy findings indicated the pancreaticobiliary PACs and no treatment after surgery were related to upper GI obstruction after palliative cholangioenterostomy in invalids with cancer of the ampulla.They were hazard elements for upper GI obstruction after palliative cholangioenterostomy in invalids with PACs.2.In the obstruction group,patients with lymphatic metastasis were obvious more likely to have upper GI obstruction than patients without lymphatic metastasis.Patients with a mGPS score of 2 preoperatively had a significantly higher risk of upper digestive obstruction than those with a mGPS score of 1 or 0.The risk of upper digestive obstruction was significantly higher in patients whose tumor sites suggest pancreatic head or the end of biliary ducts than those whose tumor sites suggest duodenal papilla or ampulla.Biopsy results suggest that invalids with pancreaticobiliary type PACs had a significantly higher risk of upper digestive obstruction than invalids with intestinal PACs.The risk of upper gastrointestinal obstruction was significantly higher in patients who have not undergone treatment after surgery than those who have undergone treatment after surgery.3.Patients with advanced PACs who present with jaundice should be assessed which based on the patient’s general condition.And if the mGPS score is 2,the site of tumorigenesis is suggestive of pancreatic head or lower common bile duct,the biopsy results suggest pancreaticobiliary PACs,or auxiliary examinations suggest lymphatic metastasis,these patients should be treated with palliative bilioenteric anastomosis in combination with prophylactic palliative gastrojejunostomy. |
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