Pancreatic calculus disease

　　1. The etiology of pancreatic calculi is not yet fully understood. The results of a large amount of statistical data show that pancreatic calculi are related to alcohol consumption, and those with long-term and heavy alcohol consumption are more prone to develop pancreatic calculi. The age of onset of the cases is mostly between 30 and 50 years old, with an average daily alcohol intake of, protein intake of 100g, and fat intake of 90g. Kimura reported 45 cases of pancreatic calculi, of which 43 cases had been drinking for more than 10 years. In addition, there are also reports that pancreatic calculi are related to family history, with more than 10 families in Japan suffering from this disease. Other factors such as biliary tract diseases and hyperparathyroidism are also related. Long-term protein deficiency can also cause cellular变性 and fibrosis in the pancreas, similar to pancreatic calculi.

　　2. Long-term alcohol consumption leads to a significant increase in the concentration of proteins in pancreatic juice, forming protein deposits. The protein thrombi precipitated in the pancreatic ducts calcify to form calculi. There is a pancreatic stone protein (Pancreatic Stone Protein, PSP) in the blood of normal people and patients with chronic pancreatitis. PSP blocks the activity of calcium carbonate by binding, thereby inhibiting the precipitation of calcium carbonate. When long-term alcohol consumption or malnutrition and other factors occur, PSP secretion decreases, and the supersaturated calcium carbonate in pancreatic juice is no longer inhibited and forms crystalline precipitation. These calcium carbonate crystalline precipitates are deposited on the reticular structures of shed epithelial cells, mucosa, pancreatic enzymes, and non-enzymatic pancreatic ferritin, etc. In addition, these crystals have high surface potential activity and a large surface area of the reticular structure, so some metal ions are absorbed and precipitated on the network. After a certain period of precipitation, calculi are formed. Pancreatic calculi contain about 95.5% calcium carbonate, and the surface layer also contains calcium, chromium, magnesium, and other elements.

　　Since the pancreatic damage caused by pancreatic calculi is relatively obvious, it is easy to cause a series of complications, such as diabetes and pancreatic cancer. The most common complications include the following aspects.

　　1. Benign complications of pancreatic calculi:Diabetes is the most common, as well as myocardial lesions, renal lesions, retinopathy, occlusive arteriosclerosis, and other conditions caused by diabetes. Liver lesions and peptic ulcers may also occur.

　　2. Symptoms of pancreatic calculi involving surrounding organs:The hard nodules of pancreatic enlargement or fibrosis compress the common bile duct and splenic vein, or lead to the formation of splenic-portal vein thrombosis, resulting in secondary portal hypertension, which can be regional hypertension or systemic, depending on the scope of thrombosis.

　　3. Malignant complications:Pancreatic calculi have two types of malignant complications: one is the pancreas itself, and the other is malignant tumors outside the pancreas. The relationship between pancreatic calculi and pancreatic cancer is extremely close. Generally, pancreatic calculi occur first, followed by pancreatic cancer. Patients with concurrent pancreatic cancer are mostly large calculi, about half of which are located in the head of the pancreas. The incidence of combined pancreatic cancer varies among different reports. Western and European literature records it as 3.6-25%, and Mr. Osamu Ogata of Japan reported 31 cases of pancreatic calculi with concurrent pancreatic cancer (accounting for 14.8%). The general report in Japan is 5.3% to 10%.

　　The diagnosis of pancreolithiasis is not too difficult. Based on a long history of alcohol abuse, abdominal pain symptoms, and some with varying degrees of diabetes, a preliminary judgment can be made. Then, further experimental tests such as X-ray plain film, ultrasound, CT, and ERCP can be performed to make a definitive diagnosis.

　　The symptoms of pancreolithiasis can be divided into two types of manifestations: early and late.

　　1. Early Symptoms

　　1. Abdominal Pain:It is the most common symptom, with varying degrees of severity, mainly due to the obstruction of pancreatic ducts and the result of pancreatic fibrosis. It often manifests as upper abdominal pain, if it is alcoholic pancreolithiasis, it often manifests as severe pain, with frequent recurrence and a long duration. In cases with unknown etiology, severe pain is rare, and it is mostly upper abdominal dull pain or ache.

　　2. Weight loss, steatorrhea:It is due to the decreased exocrine function of the pancreas caused by calculous chronic pancreatitis, and the condition of steatorrhea should vary with the degree of pancreatic damage.

　　Jaundice: About 1/4 of patients can develop jaundice, which is caused by fibrosis of the patient and the hard head of the pancreas compressing the lower end of the common bile duct. Jaundice can be persistent or intermittent, with the latter being more common.

　　2. Late Symptoms

　　The late symptoms of pancreolithiasis mainly manifest as complications caused by progressive chronic pancreatic damage.

　　Pancreolithiasis is related to alcohol consumption. Those with long drinking history and high alcohol intake are more prone to form pancreatic calculi, so it is necessary to reduce alcohol consumption and change bad living habits. This mainly includes the following points:

　　1. Quitting Smoking and Drinking

　　The occurrence of pancreolithiasis in clinical practice is mainly related to long-term and excessive alcohol consumption. Those with long drinking history and high alcohol intake are more prone to form pancreatic calculi. The incidence of pancreolithiasis in smokers is 2-3 times higher than that in non-smokers. Therefore, to prevent pancreolithiasis, it is necessary to quit smoking and drinking first. After quitting smoking and drinking, the abdominal pain of pancreolithiasis will be somewhat relieved. Postoperative patients still need to quit smoking and drinking, otherwise, recurrence is easy.

　　2. Adjusting the Diet

　　In addition to giving up alcohol, daily meals should be well-balanced, and try to eat less high-fat, high-oil, and high-salt foods. Grains, beans, sweet potatoes, and other coarse grains should be the mainstay of the diet. The intake of fat should be strictly limited, not exceeding 40 grams per day. More easily digestible sugars, such as brown sugar, sucrose, and honey, should be chosen. Since carbohydrates are the main source of energy, more than 300 grams can be provided daily. Eat fresh vegetables and fruits every day to increase the intake of fiber, carotenoids, vitamin E, and necessary minerals. More cooking methods such as boiling, simmering, and steaming should be used, and methods such as frying and stir-frying should not be used.

　　3. Physical Exercise

　　Engaging in moderate physical activity can help reduce the incidence of pancreolithiasis by avoiding overweight and obesity. Physical activities include running, walking, swimming, playing sports, dancing, climbing stairs, cleaning rooms, and more.

　　One, experimental examination

　　Detect serum GPT, GOT, cholesterol, triglycerides, etc., which may have slight abnormalities, and AKP can be elevated in a few patients.

　　To differentiate whether there is concurrent pancreatic cancer, cancer embryonic antigen (CEA) should be detected. The staining of cancer embryonic antigen in pancreatic cancer tissue is moderately positive, and the pancreatic duct epithelial cells are lightly to moderately positive.

　　Two, X-ray film

　　Pancreatic stones can be displayed on X-ray films in three types:

　　1. Diffuse type: Some stones of different sizes scattered on the pancreas.

　　2. Solitary type: One or more block-like stones, mostly in the main pancreatic duct.

　　3. Mixed type: Granular stones and block-like stones coexist on the same X-ray film.

　　Pancreatic stones are often most in the head of the pancreas, less in the tail, and in the middle of the body. Large stones block the main pancreatic duct more severely, and the vast majority are accompanied by pancreatic duct obstruction, and complications are also common.

　　Three, ultrasonic and CT examination

　　The sensitivity of pancreatic calculi is over 90%, and if combined with a positive rate of CT examination, it is especially high. CT examination can improve the positive detection rate for the diagnosis of pancreatic cancer. When pancreatic stones and concurrent pancreatic cancer are present, calcification of the pancreas, pseudocysts, dilatation of the pancreatic duct, irregular shape of the pancreas, localized enlargement of the pancreas, and disappearance of peripancreatic fat can be seen.

　　1. Reduce the intake of easily bloating foods such as radishes, onions, coarse grains, and dried beans, avoid刺激性 foods, and abstain from alcohol and animal internal organs.

　　2. Actively quit smoking and drinking. There are many carcinogenic substances in tobacco; excessive drinking for a long time increases the burden on the liver and is harmful to the recovery of the disease. Experts have pointed out that long-term drinking is the main factor causing pancreatic stones, therefore, it is necessary to make patients quit drinking in the process of nursing care.

　　The goal of treating pancreatic stones is to remove stones, relieve obstruction, prevent further damage to the pancreas and prevent malignancy, and alleviate pain.

　　1. Stone removal through endoscopy

　　This method is only used for pancreatic stones with no stricture in the pancreatic duct. If there is no stricture in the pancreatic duct, the sphincter can be incised to remove the stone. When the stone is large, it can be removed after undergoing ultrasonic lithotripsy or laser shock wave lithotripsy. After the stone has undergone ultrasonic lithotripsy, the stone fragments are smaller and can also be excreted spontaneously. If there is a stricture factor in the pancreatic duct, even though the stone has been fragmented and removed, the obstructive factor has not been relieved, and stones will still form in the future.

　　2. Partial resection of the pancreas

　　This refers to multiple stones localized in the body and tail of the pancreas, with severe damage to the part of the pancreas. After the resection of the body and tail of the pancreas, if there is no stricture at the proximal part of the pancreatic duct, it does not affect the excretion of pancreatic juice, and the residual end of the pancreas can be sutured. When there is a stricture factor at the proximal part of the pancreatic duct, the residual end of the pancreatic duct can be anastomosed with the jejunum in a sleeve or end-to-side Roux-y fashion. Since most of the islet cells are located in the tail and body of the pancreas, resecting too much of the body and tail of a pathologically altered pancreas will lead to severe deficiency in the endocrine function of the pancreas. Therefore, more of the body and tail of the pancreas should be preserved, and a pancreatojejunostomy can be performed when there is a stricture at the proximal end.

　　3. Pancreatic Duct Stones Complicated with Pancreatic Cyst

　　On the one hand, remove the stones, and on the other hand, perform an internal drainage operation between the cyst and the intestines.

　　4. Pancreatic Parenchyma Incision for Stone Removal

　　It is suitable for patients with stones in the head and body of the pancreas, and multiple stenoses in the pancreatic duct. For patients with solitary stones in the head and body of the pancreas without stenosis, the fibrotic pancreatic tissue at the stone location is incised to remove the stone, and the incised pancreatic duct and pancreas are sutured properly. However, such cases are rare. Generally, multiple stones in the pancreatic duct are accompanied by multiple stenoses and dilatations. To relieve obstruction, the pancreatic duct may be partially or nearly completely divided, the stones removed, and the divided pancreatic duct anastomosed with the jejunum. Since most of the pancreas has fibrotic, bleeding is not too much when dividing the pancreatic duct.

　　5. Whipple Surgery

　　It is suitable for patients with multiple stones in the head of the pancreas, pancreatic head destruction, or malignant transformation. The resection of the pancreas and duodenum is destructive and severely disrupts physiological function, so the indications should be strictly controlled. To reduce injury, if there are no signs of malignancy, a modified pancreatoduodenectomy (retaining the duodenum) can be adopted.

　　The treatment of pancreatic lithiasis has not yet formed a fixed surgical method. The reason is that the size, location, degree of stenosis of the pancreatic duct, and the extent of fibrosis of the pancreatic tissue are not uniform, which makes the treatment somewhat difficult. The specific surgical method to be adopted should be considered from multiple aspects before implementation.

　　6. Treatment for Pancreatic Stones Complicated with Pancreatic Cancer

　　If there is suspicion of malignancy during surgery, frozen section should be performed. After confirmation, the following treatment should be carried out:

　　If the lesion is localized within the pancreas and there is no surrounding metastasis, a total pancreatectomy can be performed. Postoperative inadequate endocrine and exocrine secretion requires substitution therapy.

　　When a tumor is localized within the capsule and compresses the inferior end of the common bile duct, perform an intraluminal biliary jejunostomy. When the tumor cannot be resected or resected incompletely, intraoperative radiotherapy can be performed. Arterial catheter perfusion of chemotherapy drugs can also be adopted. In recent years, some people have tried extracorporeal hyperthermia therapy, which has certain efficacy.