Periampullary cancer

　　First, Etiology

　　The etiology of VPC is not fully clear at present and may be related to factors such as diet, alcohol consumption, environment, bile duct stones, or chronic inflammation. It may also be due to the malignant transformation of benign tumors in this location.

　　Second, Pathogenesis

　　VPC is generally small in size, with a diameter of 1-2 cm, rarely more than 3.5 cm. The tumor originates from the ampulla, is usually soft,呈息肉样, and the surface may be eroded, congested, and prone to ischemic necrosis, therefore, it often causes intermittent obstruction and rarely reaches complete obstruction. The tumor originating from the single-layer columnar epithelium of the papilla is small and papillary, prone to ischemia, necrosis, shedding, and bleeding; those from the mucosa at the distal end of the pancreatic duct and bile duct are mostly nodular or mass-like, with significant infiltration and hardness, which can form ulcers; those from the mucosa of the descending part of the duodenum are mostly ulcerative; those from the acinar cells of the pancreatic head often present as infiltrative growth, hard and mass-like, often compressing adjacent tissues. The main mode of VPC spread is along the bile duct, pancreatic duct, or duodenal mucosa. Due to the low malignancy of the tumor, there is less metastasis, and the course of the disease is relatively long.

　　The gross specimen of the tumor presents as polypoid, nodular, mass-like, or ulcerative. Most are well-differentiated adenocarcinoma, with poorly differentiated adenocarcinoma accounting for about 15%, and if symptoms appear, 3/4 of the tumor has invaded the main pancreatic duct. The histological classification, in addition to adenocarcinoma, includes papillary carcinoma, mucinous carcinoma, undifferentiated carcinoma, reticulum cell sarcoma, leiomyosarcoma, and carcinoid. Due to the special location of the tumor, it is easy to block the common bile duct and the main pancreatic duct, leading to poor drainage of bile and pancreatic juice, resulting in obstruction, causing obstructive jaundice and dyspepsia. It can also directly infiltrate the intestinal wall to form a mass or ulcer. In addition to the mechanical injury of digestive juices and food, it can cause duodenal obstruction and upper gastrointestinal bleeding. The modes of metastasis include:

　　1. Direct spread to the pancreatic head, portal vein, and mesenteric blood vessels.

　　2. Regional lymph node metastasis, such as lymph node metastasis at the posterior duodenum, the hepatoduodenal ligament, and the upper and lower parts of the pancreatic head.

　　3. Liver metastasis, and there may be more extensive metastasis in the late stage.

　　1. Jaundice:It appears earlier, occurs simultaneously or先后出现 with abdominal pain, and progresses in severity. It belongs to obstructive jaundice, and the yellowing of the skin and mucous membranes is more obvious, can be dark green, and is often accompanied by skin itching.

　　2. Intermittent chills:Fever is often caused by tumor ulceration, bile stasis, and biliary tract infection.

　　3. Liver and gallbladder enlargement:It is caused by bile duct obstruction and bile stasis. A few patients may develop biliary cirrhosis and splenomegaly due to long-term jaundice.

　　Common surgical complications include: wound infection, intra-abdominal abscess, intra-abdominal hemorrhage, sepsis, liver failure, bile duct anastomotic leakage, gastric jejunostomy leakage, renal failure, diffuse intravascular hemorrhage.

　　The age of onset is mostly between 40-70 years old, with more males affected. It is extremely similar to the clinical manifestations of pancreatic head cancer, mainly manifested as jaundice, upper abdominal pain, fever, weight loss, liver enlargement, gallbladder enlargement, etc. 70% of pancreatic cancer occurs in the pancreatic head, half of the patients seek medical attention 3 months after the onset of symptoms, and 10% seek medical attention more than a year after the onset.

　　1. Jaundice:It appears earlier, occurs simultaneously or先后出现 with abdominal pain, and progresses in severity. However, in a few patients, jaundice may subside or decrease due to tumor necrosis, recanalization of the bile duct, but it may deepen again later, presenting fluctuating jaundice, which belongs to obstructive jaundice. The yellowing of the skin and mucous membranes is more obvious, can be dark green, and is often accompanied by skin itching. Jaundice is usually persistent, and in a few patients, jaundice may subside or decrease due to tumor necrosis and recanalization of the bile duct, but it may deepen again later, presenting fluctuating jaundice. The progressive increase of jaundice is a manifestation of the late stage, and attention should be paid not to misdiagnose it as cholelithiasis or hepatocellular jaundice. There may be dark urine, light feces, and bile salts deposited in the skin to stimulate the nerve endings, causing skin itching.

　　2. Abdominal pain:Upper abdominal pain is seen in 3/4 of the cases and is often the first symptom. In the early stage, some patients (about 40%) may experience dull pain under the sternum due to dilatation of the common bile duct or obstruction of pancreatic juice excretion, leading to increased intraluminal pressure. Abdominal pain can radiate to the back, usually worsens after meals, in the evening, at night, or after a fatty meal, but it is not as severe as that of pancreatic head cancer. Some patients may have dull pain under the sternum that can radiate to the back, which is more pronounced after eating and often goes unnoticed. In the later stage, due to the expansion of the cancer infiltration range or accompanied by inflammation, the pain may increase, and back pain may occur.

　　3. Intermittent chills:Fever is often caused by tumor ulceration, bile stasis, and biliary tract infection, characterized by recurrent sudden onset and sudden cessation, brief high fever with chills, elevated white blood cell count, and even toxic shock, which is often misdiagnosed as cholangitis, cholelithiasis, and treatment with antibiotics and hormones is ineffective.

　　4. Gastrointestinal symptoms:Due to the lack of bile and pancreatic juice in the intestines, it often causes dysfunctions of digestion and absorption, mainly manifested as anorexia, fullness, dyspepsia, fatigue, diarrhea or steatorrhea, pale stools, and weight loss, etc. Due to the chronic bleeding of partial necrosis of ampullary cancer, melena may occur, and the occult blood test in feces may be positive, and secondary anemia may occur. Peritoneal metastasis or portal vein metastasis of the tumor mass may cause ascites.

　　5. Liver and gallbladder enlargement:Due to bile duct obstruction and bile stasis, it is often possible to palpate an enlarged liver and gallbladder, with hard and smooth liver texture. In the late stage of pancreatic head cancer, irregular and fixed masses can often be palpated, and a few patients may develop biliary cirrhosis due to long-term jaundice, splenomegaly, etc.

　　Early detection, early diagnosis, and early treatment.

　　1. Disease prognosis

　　At a good pancreatic surgery center, the mortality rate of surgery is about 1-2%. Most patients die of tumor recurrence after surgery, often within three months after surgery, which often indicates poor prognosis. Tumor size, lymph node metastasis, involvement of large blood vessels, nerve involvement, tumor cell differentiation grade, tumor margin, blood transfusion during or after surgery are all related to prognosis. The prognosis of cholangiopancreatic type is worse than that of intestinal type. According to SEER statistics, the 5-year survival rates of local (local), regional (region), unknown (unknown), and distant metastasis (distant) periampullary cancer are 45%, 31%, 14%, and 4% respectively.

　　2. Disease care

　　For patients with familial adenomatous polyposis (FAP), the risk of developing periampullary cancer is significantly increased, and close observation and timely treatment are required.

　　1. Feces and urine examination:About 85% to 100% of patients have persistent positive occult blood test in feces, with mild anemia, positive urinary bilirubin and negative urinary bilirubin.

　　2. Blood examination:Serum bilirubin levels are usually between 256.5 and 342μmol/L, alkaline phosphatase, γ-glutamyl transferase, and transaminase levels are slightly to moderately elevated, and carcinoembryonic antigen, CA19-9, and CA125 can all be elevated.

　　3. Duodenal secretion examination:The duodenum can drain out hemorrhagic or dark brown fluid, with positive occult blood test, and microscopic examination can show a large number of red blood cells. Cytological examination of exfoliated cells shows that 60% to 95% of patients can find cancer cells.

　　4. Barium meal and duodenal hypotension imaging examination:Occasionally, a gallbladder indentation can be seen above the duodenum, with an enlarged duodenal papilla and irregularly chaotic mucosa or hypoplasia, in patients with pancreatic head cancer, the duodenal loop may expand, the inner wall of the duodenum may become 'stiff' and compressed, deformed or partially obstructed, showing an '∑' shape, but typical manifestations are rare.

　　5, B-ultrasound examination:Show dilation of the common bile duct or (and) intrahepatic bile ducts, enlargement of the gallbladder, but the diagnostic rate of壶腹cancer itself is low, which is due to the fact that there is often air and food accumulation in the duodenum and stomach at this location, which can provide early clues for further examination for those without jaundice. Experienced practitioners can sometimes observe local cancer masses.

　　6, CT, MRI examination:It is meaningful for distinguishing pancreatic head cancer and helpful for the diagnosis of the disease. It can show the location and contour of the tumor. Radiographically,壶腹cancer and bile duct cancer show similar manifestations. Both bile ducts and pancreatic ducts can be dilated or only bile ducts are dilated, which depends on the growth pattern of壶腹cancer; when pancreatic head cancer occurs, the pancreatic head is enlarged, there is a mass, the pancreatic duct is dilated, the annular shadow is suddenly interrupted and deformed, and double annular shadows appear, indicating that both the pancreatic head and bile ducts are involved. Sometimes, soft tissue shadows or abnormal signals can be seen inside the dilated bile duct.

　　7, ERCP:Can observe the inner wall of the duodenum and the papilla, and see the papilla enlargement, irregular surface, nodular,脆and easy to bleed, and can also perform biopsy for pathological diagnosis, which is of great help in the diagnosis of壶腹cancer and pancreatic head cancer (which may have stenosis of the pancreatic duct or no shadowing).

　　8, PTC examination:It is superior to ERCP because of the uneven height and roughness of the ampulla papilla, narrow lumen, and blockage. ERCP is often not successful, PTC can show expansion of bile ducts both inside and outside the liver, bile ducts show irregular filling defects or occlusion in the shape of 'V', which has the value of localization and differential diagnosis. There is a possibility of complications such as bile leakage and choleperitonitis, which need to be vigilant.

　　9, Selective celiac arteriography (SCA):Beneficial for the diagnosis of pancreatic head cancer, from the change in vascular position, it can indirectly determine the location of pancreatic cancer, which is beneficial for the diagnosis of pancreatic head cancer.

　　10, Radionuclide examination:Can understand the obstruction site, 75Se-methionine pancreatic scan shows radionuclide defect (cold area) at the site of pancreatic cancer mass.

　　First, therapeutic diet for per壶腹cancer

　　1, Zijuzi and Gouqizi porridge

　　Ingredients: 5-10 grams of Zijuzi, 6 grams of fresh lotus root (or 10-15 lotus root nodes), 30 grams of Baimaogen, 40 grams of Gouqizi, and 130 grams of cooked rice.

　　Preparation method: Place Zijuzi, Lujie, Baimaogen, and Gouqizi in a gauze bag and tie it tightly. Add water to boil and decoct the medicine juice. Add cooked rice to the pot, add the medicine juice and clear water, bring to a boil, and simmer over low heat until the porridge is soft, add an appropriate amount of honey for seasoning, and it is ready to serve.

　　Effects: Clear heat and promote diuresis, cool blood and stop bleeding, and relieve thirst.

　　Indications: Used for壶腹cancer, distension and pain in the hypochondriac region, abdominal mass, poor appetite, pale complexion, fatigue, low fever, epistaxis, and hemorrhage.

　　2, Shepherd's purse tofu soup

　　Ingredients: 120 grams of Fojia grass, 180 grams of shepherd's purse, 200 grams of tofu, 28 grams of clean asparagus, 750 grams of soybean sprout soup, and appropriate seasoning.

　　Preparation method: Cut Fojia grass into segments, place in a gauze bag, add an appropriate amount of water, decoct the medicine juice, and reserve it. Heat a wok, add soybean sprout juice, medicine juice, tofu cubes, asparagus slices, and salt, bring to a boil, add shepherd's purse, bring to a boil again, add monosodium glutamate and cooked peanut oil, and then remove from heat.

　　Effects: Clear heat and benefit the spleen, reduce swelling and detoxify.

　　Indications: Used for ampullary cancer, abdominal pain, loss of appetite, and abdominal mass.

　　3. Pork pancreas and kelp soup

　　Ingredients: 1 pork pancreas (about 100 grams), 30 grams of shiitake, 20 grams of kelp, 15 grams of肿节风, 3 grams of ginger juice, appropriate amount of seasoning.

　　Preparation method: Cut the肿节风 into sections, put it into a gauze bag, and boil the medicine juice. Wash the pork pancreas clean, blanch it in boiling water. Remove the hair from the shiitake, soak the kelp in warm water until it swells and wash it clean. Heat the pot, add peanut oil, stir-fry the pork pancreas slices, add ginger juice, add chicken broth, medicine juice, shiitake, kelp, cooking wine, salt, soy sauce, boil and then simmer over low heat until fully cooked, season with MSG, and it is ready.

　　Effects: Tonify deficiency and benefit the spleen, clear heat and detoxify, soften hardness and resolve nodules.

　　Indications: Used for ampullary cancer, loss of appetite, abdominal pain, fever, weight loss, and intra-abdominal mass.

　　4. Turtle plate and black date pill:Several pieces of turtle plate, appropriate amount of black date meat. The turtle plate is roasted yellow and ground into powder, the black date meat is pounded, and the two are mixed to make pills. Take once a day, 10 grams each time, taken with plain water, which has the effects of nourishing yin and benefiting the stomach.

　　5. Calabash powder:120 grams of calabash handle, appropriate amount of refined salt. After the calabash handle is soaked in salt water, it is dried and ground into powder. Take once a day, 10 grams each time, which can be taken with warm water. It has the effects of analgesia and resolving nodules.

　　6. Guati powder:Appropriate amount of the base of the mature pumpkin. After the mature pumpkin is dried in the shade, the base is calcined with charcoal fire, and immediately covered with a magnetic bowl to prevent it from becoming charcoal. After 15 minutes, it is ground into fine powder. Take two pumpkin bases each day, taken in the morning with warm water, which has the effects of invigorating the spleen and detoxifying, and promoting blood circulation and removing stasis.

　　2. What kind of food should be eaten for periampullary cancer to be good for the body:

　　The diet should be mainly carbohydrates, with appropriate amounts of fat and protein. It is necessary to consume easily digestible proteins such as lean meat, eggs, and fish. Reasonable cooking methods should be adopted, such as boiling, stewing, simmering, steaming, stir-frying, and blanching.

　　(The above information is for reference only, for details please consult a doctor)

　　1. Treatment

　　Once the disease is diagnosed, a pancreaticoduodenectomy should be performed, which is currently the most effective treatment method. The scope of resection includes the distal part of 1/2 of the stomach, the entire duodenum, the head of the pancreas, the proximal part of the jejunum about 10.0 cm, and the lower part of the bile duct below the duodenal bulb. Subsequently, various methods of gastrointestinal reconstruction are performed. This operation has a wide range, significant trauma, and in addition to the patient's long-term jaundice, liver and kidney dysfunction, low digestive and absorptive function, malnutrition, it is necessary to do well the preoperative preparation, provide high sugar, high protein, high vitamin diet, and provide bile salts, pancreatic enzymes and other digestive aids, emphasize the administration of vitamin K (intramuscular or intravenous infusion), and if necessary, preoperative blood transfusion, plasma, albumin and other supportive measures to correct anemia and hypoproteinemia. If the tumor has invaded the portal vein, extensive retroperitoneal metastasis, liver metastasis, and cannot be resected, then an internal drainage operation should be performed to alleviate jaundice; if cholecystojejunostomy or choledochojejunostomy or choledocho-duodenostomy and other palliative bypass surgery; if duodenal stenosis occurs, a gastrojejunostomy should be performed to relieve duodenal obstruction.

　　Chemotherapy is generally not sensitive, commonly used 5-FU, mitomycin or in combination with arabinosylcytosine, vincristine, etc., and can be used for 1-2 courses after surgery. In addition, traditional Chinese medicine with anticancer or immune-enhancing effects can also be used for treatment.

　　Pancreatic head cancer is a common type of pancreatic cancer, accounting for about 70%, and adenocarcinoma is most common, while acinar cell carcinoma is less common. In addition, there are also pleomorphic adenocarcinoma, mucinous carcinoma, fibroblast carcinoma. The clinical manifestations are very similar to those of ampullary cancer, indicating that the tumor has reached a relatively advanced stage. There is often infiltration and metastasis of adjacent tissues and organs, so the resection rate of the tumor is low. The diagnosis and treatment of this disease are similar to those of ampullary cancer, but the resection rate and 5-year cure rate are low.

　　1. Surgical treatment

　　If the diagnosis is clear or highly suspected, and no metastasis is found in clinical examination, laparotomy should be performed. ① If there is no metastatic focus and the general condition allows, perform a first-stage pancreatoduodenectomy. For those with poor physical condition, consider PTCD or cholecystojejunostomy, and perform a second-stage pancreatoduodenectomy after jaundice subsides. ② For those with cancer infiltration into adjacent organs or distant metastasis, only perform cholecystojejunostomy or cholecystoduodenostomy to relieve jaundice.

　　2. Non-surgical treatment

　　① Symptomatic treatment. Oral multi-enzyme tablets, vitamins, protein. Blood transfusion, fluid replacement, pain relief. ② Chemotherapy. Used for comprehensive treatment before and after surgery or for those who cannot be removed. Fluorouracil 250-500mg/day, intravenous infusion, total dose 7.5-1.0g for one course, rest for 2-4 weeks after infusion and repeat. Combined chemotherapy, give mitomycin 4mg, arabinosylcytosine 100mg, fluorouracil 500mg, added to 10% glucose solution, twice a week, intravenous infusion, 10 times for one course. Check blood count every 5-7 days during medication, if white blood cells are below 3.5×10^9/L and platelets are below 8×10^9/L, discontinue medication. ③ Traditional Chinese medicine treatment. ④ Immunotherapy. Thymosin, interferon, transfer factor can be used.

　　2. Prognosis

　　The 5-year cure rate of this disease is 40% to 50%, and the prognosis is better than that of pancreatic head cancer.