慢性胰腺炎專題知識(shí)課件

1、BACK GROUNDOperative approaches to the treatment of chronic pancreatitis have undergone a dramatic transformation over the past few decades.The head of the pancreas has become universally appreciated as the nidus of chronic inammation. Prospective, randomized trials have repeatedly shown the superio

2、rity of surgical treatment over medical approaches to management2022/10/41BACK GROUNDOperative approacheINDICATIONS FOR SURGERY Pain Ductal hypertension: some anatomic changes related with it such as ：small cysts、foci of acinar cell necrosis、areas of acute inammation Peripancreatic sensory nerve dam

3、age： inammatory damage 、neuron-specic proteinase activated receptor 2 activation、C bers （a subpopulation of sensory neurons）contain peptides which can cause inammatory changes2. The complications of chronic pancreatitis2022/10/42INDICATIONS FOR SURGERY Pain2TreatmentThe medical treatment of chronic

4、pancreatitis-associated pain usually failssurgical treatment of chronic pancreatitis has been shown to eliminate pain and return patients to predisease employment and quality-of-life status.2022/10/43TreatmentThe medical treatmentOperative procedures Operative procedures about chronic pancreatitis h

5、ave historically been classied into 3 categories：Decompression of diseased and obstructed pancreatic ductsDenervation of the pancreasResection of the proximal, distal, or total pancreas. Within the past few years, however, a category of hybrid procedures has been shown to be safe and effective.2022/

6、10/44Operative procedures OperatiDECOMPRESSION PROCEDURESRemove calculi from Wirsungs duct: transpancreatic route or transduodenally through the papilla of Vater (ERCP WITH OR WITHOUT prolonged pancreatic duct stenting)Decompressing the proximal pancreatic and distal bile ducts by sphincteroplasty t

7、o prevent recurrent pancreatitis which caused by biliary stone.2022/10/45DECOMPRESSION PROCEDURESRemoveExternal drainage of the pancreatic duct to decompress obstruction caused by stricture or calculus(Fig. 1)FIGURE 12022/10/46External drainage of the panRoux-en-Y, side-to-end, pancreaticojejunostom

8、y The caudal, end-to-end, pancreaticojejunostomy as a drainage procedure for chronic pancreatitis (FIG 2.)FIGURE 2.2022/10/47Roux-en-Y, side-to-end, panLongitudinal decompre-ssion of the body and tail of the pancreas into a Roux limb of jejunum (Fig. 3)FIGURE 3.2022/10/48Longitudinal decompre-ssioSi

9、de-to-side longitudinal pancreaticojejunostomy that became known as the“Puestow”procedure ( Fig. 4).FIGURE 42022/10/49Side-to-side longitudinalFIGUR For long-term relief of pain in chronic pancreatitis, techniques of focal decompression of the ductal system were found to fail as multiple points of o

10、bstruction due to calculi or strictures are the rule in patients with alcoholic, hereditary, tropical, and idiopathic pancreatitis.The effect of decompression2022/10/410 For long-term relief DENERVATION PROCEDURESBilateral thoracolumbar sympathectomyThe use of operative, endoscopic, and imageguided

11、neurolysis of the celiac trunks and ganglia have been reported in the treatment of chronic pancreatitis.Vagotomy, with partial gastrectomy or a drainage procedure(truncal vagotomy is not recommended as a mean to relieve the pain of chronic pancreatitis because it is the fundamental to pancreatic exo

12、crine regulation)2022/10/411DENERVATION PROCEDURESBilateraThe effect of denervation procedures Studies with follow-up extending 2 years or more disclose that narcotic usag increases and pain typically returns to preoperative levelsHoward et al found that patients who had had no prior operative or en

13、doscopic intervention before bilateral splanchnicectomy and who likely had “small duct” disease remained improved2022/10/412The effect of denervation proRESECTIONAL PROCEDURESProximal PancreatectomyIt has proven to be an effective mean of managing pain and the complications of chronic pancreatitis I

14、n the 3 largest modern (circa 2000) series of the treatment , pain relief 4 to 6 years after operation ranged from 71% to 89% of patients. The mortality rate of the operation has been reduced to less than 5% The morbidity stubbornly remains at about 40%.Without the high incidence of endocrine dysfun

15、ction2022/10/413RESECTIONAL PROCEDURESProximalPylorus PreservationPresumed nutritional and physiologic benefits associated with retention of the pylorus.Now employed in 70% to 80% of all Whipple procedures.Physiologic gastric emptying is assumed with preservation of the pylorus Increased incidence o

16、f marginal ulcerationWithout the high incidence of endocrine dysfunction2022/10/414Pylorus Preservation2022/10/21Total PancreatectomyThe operation produces no better pain relief for their patients than pancreaticoduodenectomy (about 80%85%)The metabolic consequences of total pancreatectomy in the ab

17、sence of islet cell transplantation are profound and life threatening.Lethal episodes of hypoglycemia are common in severe apancreatic diabetes due to the absence of pancreatic glucagon, and to hypoglycemia unawarenessPrevention of the physiological consequences of total pancreatectomy remains an un

18、fullled goal2022/10/415Total Pancreatectomy2022/10/21Pancreatectomy With Islet AutoTransplan-tationMethods of harvesting and gland preservation Islets are infused into the portal venous circuit for intrahepatic engraftment Some degree of insulin dependence is still present in two-third of patients 2

19、 to 3 million islets are required for successful engraftment in an allogeneic recipientAuto-transplant recipient can achieve longterm, insulin independent status after engraftment of only 300,000 to 400,000 islets2022/10/416Pancreatectomy With Islet Auto25% to 30% of patients with chronic pancreatit

20、is are already diabetic so islet auto-transplantation is not an option in those patients.Islet transplant recipients who become euglycemic initially, their islet cell function remains impaired,and after 2 years most require insulin.2022/10/41725% to 30% of patients with chDistal PancreatectomyIn a s

21、mall percentage of cases the body and tail may be the portions of the pancreas most diseased due to isolated duct stricture, pseudocyst disease, or bothFor these patients the technique of partial (40%80%) distal pancreatectomy has been advocatedThe operation leaves untreated a major portion of the g

22、land, and is therefore associated with a signicant risk of symptomatic recurrenceLongterm outcomes reveal good pain relief in only 60% of patients, however, with completion pancreatectomy required for pain relief in 13% of patients2022/10/418Distal Pancreatectomy2022/10/2Distal Pancreatectomy (95%)A

23、void a pancreaticoduodenectomy and preserving the distal stomach, the entire duodenum and normal choledochoduodenal junction.A small cuff of the head of the pancreas which is preserved as the functional portion. This lines the lesser curvature of the duodenum and is estimated to be no more than 5% o

24、f the entire glandPain relief was excellent and achieved in about 80% of patients followed on average 6 years.2022/10/419Distal Pancreatectomy (95%)202The incidence of postopera-tive diabetes following 95% pancreatectomy rose to an unacceptable 72%. Exocrine insufciency deteriorated as well40% of pa

25、tients experienced abscesses or shortlived stulas in the region of the head resection2022/10/420The incidence of postopera-tiHybrid proceduresDenervated splenopancreatic apDividing the neck of the pancreas over the portal veinThe majority of the head of the pancreas was resectedLeaving a small cuff

26、of pancreatic tissue along the inner aspect of the duodenum2022/10/421Hybrid proceduresDenervated sThe splenic artery was divided at its origin and the splenic vein at its junction with the superior mesenteric vein.The body and tail of the pancreas was then freed from the retroperitoneal tissue unti

27、l the pancreas is attached only to the vessels at the splenic hilus.Severs somatic nerve bers as well as autonomic afferent bers along the splenic arteryThe transected neck of the pancreas was then anastomosed to a Roux-en-Y limb2022/10/422The splenic artery was dividedPain control was reportedly go

28、od.It is likely that the long-term effects on pain relief were ascribable to the pancreatic head resection 2022/10/423Pain control was reportedly goDuodenum Preserving Pancreatic Head Resection (Fig. 8)Identifying and preserving the posterior branch of the gastroduodenal artery which provides blood

29、ow to the duodenum, intrapancreatic common bile duct, and pancreaticoduodenal grooveThe neck of the pancreas overlying the portal and superior mesenteric vein is dividedA small amount of pancreatic tissue along the inner aspect of the duodenum is resected2022/10/424Duodenum Preserving PancreaticReco

30、nstruction consists of an end-to-end pancreatico-jejunostomy to the distal pancreas, and end-to-side pancreatico-jejunostomy to the remnant of pancreatic tissue on the inner aspect of the duodenum.The body and tail of the pancreas can be drained with a longitudinal pancreaticojejunostomy if the main

31、 duct in the body and tail of the pancreas is obstructed.A common bile duct stricture, if present, should be relieved by decompression into the same Roux limb through a separate choledochojejunostomy. Performing a choledochopancreatos-tomy into the excavated pancreatic head has been associated with

32、late recurrences of bile duct strictures2022/10/425Reconstruction consists of an Relieved pain in 80% or more of patients and preserved endocrine and exocrine function.incidence of new diabetes after the DPPHR procedure ranges from 8% to 21%This appears to be due to preservation of insulin and pancr

33、eatic polypeptide (PP) secretion.FIGURE 82022/10/426Relieved pain in 80% or more oLocal Resection of the Pancreatic Head With Longitudinal PancreaticojejunostomyThe rim of pancreatic tissue of the entire head is preserved，and is used to sew to the opened jejunumThe ducts of Wirsung and Santorini are

34、 excisedThe excavation is created in continuity with the longitudinal dochotomy of the dorsal ductPreservation of the pancreatic neck as well as the capsule of the posterior pancreatic head and avoids intraoperative problems with the venous structures lying posterior to the gland2022/10/427Local Res

35、ection of the PancreaThe posterior limit of resection be the back wall of the opened duct of Wirsung and duct to the uncinate.All intervening and overlying tissue in the pancreatic head including the duct of Santorini is excised.The locally excised head of the pancreas is covered with the opened Rou

36、x-en-Y limb of jejunum in continuity with the opened main pancreatic duct in the body and tail of the pancreas(Fig. 9)2022/10/428The posterior limit of resectiSome modification：A.excise the the ducts of Wirsung and Uncinate in the head rather than unroofing using the ultrasonic aspirator and dissect

37、or (Fig. 10) B.the central portion of the uncinate process is included in the excavation(Fig. 11) C.merely excavating the core of the pancreatic head and without any effort to include the duct of the body(Fig. 12) D.without division of the pancreatic neck compared to DPPHR(Fig. 13) 2022/10/429Some m

38、odification：A.excise theFIGURE 10.FIGURE 11.FIGURE 12.FIGURE 13.FIGURE 9.2022/10/430FIGURE 10.FIGURE 11.FIGURE 12.COMPLICATIONAnastomotic Leak: Pancreatic anastomotic leaks are less likely to occur in chronic pancreatitis because of the rmer consistency of the glandDorsal duct can be 2 to 3 mm or le

39、ss in a gland with diffuse sclerosis, and difculties with the anastomosis can occur.Techniques of anastomoses: end-to-side duct to mucosa technique, as well as the invaginating or intussuscepting methods of end-to-end anastomosis2022/10/431COMPLICATIONAnastomotic Leak: The duct-to-mucosa An-astomosi

40、s leak rate has been reported to be as low as 1%,considerably less than the 10% to 12% leak rate observed with the intussuscepting or invagina-ting techniqueEnd-to-side, duct-to-mucosa method ofpancreaticojejunostomy2022/10/432The duct-to-mucosa An-astomosiProspective, randomized trials of the use o

41、f octreotide administered postoperatively to prevent leak have both supported and refuted its valueThe use of brin glue appears ineffective.The use of the operating microscope and that the jejunum is secured around the pancreas with a purse string suture may reduce leak rate.A randomized prospective

42、 trial has demonstrated a reduced leak rate with stent use in a mixed group of patients2022/10/433Prospective, randomized trialsMajor Perioperative Complications : necrotizing pancreatitis and intraluminal bleedingLate Complications: A.stricturing of the anastomoses when the “stufng” or invaginating

43、 method is avoided B.the loss of exocrine and endocrine function：the late incidence of both exocrine and endocrine dysfunction after pancreatico-duodenectomy is about 50% which can be avoided altogether by performing a ligation of the pancreatic duct.C. Delayed gastric emptying which usually resolve

44、s spontaneously,or as a late complication associated with a retrocolic, as opposed to an antecolic, gastrojejunostomy.2022/10/434Major Perioperative ComplicThere is the risk of ischemia of the duodenum in theduodenum preserved cases2022/10/435There is the risk of ischemia COMPARISONS OF THE 3 OPERAT

45、IVEPROCEDURES: DPPHR AND LR-LPJ:there is no significant difference in global quality of life 、pain score、late mortality 、exocrine or endocrine insufciency . there is initial reduction in morbidity associated with the excavation procedureTHE BOTH WITH WHIP :there is fewer complications 、 a lower global quality of life scores 、 a lower short-term (3 year) incidence of new diabetes and exocrine dysfunction compared with the Whipple