慢性胰腺炎专题知识

慢性胰腺炎专题知识BACKGROUNDOperativeapproachestothetreatmentofchronicpancreatitishaveundergoneadramatictransformationoverthepastfewdecades.Theheadofthepancreashasbecomeuniversallyappreciatedasthenidusofchronicinflammation.Prospective,randomizedtrialshaverepeatedlyshownthesuperiorityofsurgicaltreatmentovermedicalapproachestomanagement2025/3/182INDICATIONSFORSURGERYPain

Ductalhypertension:someanatomicchangesrelatedwithitsuchas：smallcysts、fociofacinarcellnecrosis、areasofacuteinflammationPeripancreaticsensorynervedamage：inflammatorydamage、neuron-specificproteinaseactivatedreceptor2activation、Cfibers（asubpopulationofsensoryneurons）containpeptideswhichcancauseinflammatorychanges2.Thecomplicationsofchronicpancreatitis2025/3/183TreatmentThemedicaltreatmentofchronicpancreatitis-associatedpainusuallyfailssurgicaltreatmentofchronicpancreatitishasbeenshowntoeliminatepainandreturnpatientstoprediseaseemploymentandquality-of-lifestatus.2025/3/184Operativeprocedures

Operativeproceduresaboutchronicpancreatitishavehistoricallybeenclassifiedinto3categories：DecompressionofdiseasedandobstructedpancreaticductsDenervationofthepancreasResectionoftheproximal,distal,ortotalpancreas.Withinthepastfewyears,however,acategoryofhybridprocedureshasbeenshowntobesafeandeffective.2025/3/185DECOMPRESSIONPROCEDURESRemovecalculifromWirsung’sduct:transpancreaticrouteortransduodenallythroughthepapillaofVater(ERCPWITHORWITHOUTprolongedpancreaticductstenting)Decompressingtheproximalpancreaticanddistalbileductsbysphincteroplastytopreventrecurrentpancreatitiswhichcausedbybiliarystone.2025/3/186Externaldrainageofthepancreaticducttodecompressobstructioncausedbystrictureorcalculus(Fig.1)FIGURE12025/3/187Roux-en-Y,side-to-end,pancreaticojejunostomyThecaudal,end-to-end,pancreaticojejunostomyasadrainageprocedureforchronicpancreatitis(FIG2.)FIGURE2.2025/3/188Longitudinaldecompre-ssionofthebodyandtailofthepancreasintoaRouxlimbofjejunum(Fig.3)FIGURE3.2025/3/189Side-to-sidelongitudinalpancreaticojejunostomythatbecameknownasthe“Puestow”procedure(Fig.4).FIGURE42025/3/1810

Forlong-termreliefofpaininchronicpancreatitis,techniquesoffocaldecompressionoftheductalsystemwerefoundtofailasmultiplepointsofobstructionduetocalculiorstricturesaretheruleinpatientswithalcoholic,hereditary,tropical,andidiopathicpancreatitis.Theeffectofdecompression

2025/3/1811DENERVATIONPROCEDURESBilateralthoracolumbarsympathectomyTheuseofoperative,endoscopic,andimageguidedneurolysisoftheceliactrunksandgangliahavebeenreportedinthetreatmentofchronicpancreatitis.Vagotomy,withpartialgastrectomyoradrainageprocedure(truncalvagotomyisnotrecommendedasameantorelievethepainofchronicpancreatitisbecauseitisthefundamentaltopancreaticexocrineregulation)2025/3/1812TheeffectofdenervationproceduresStudieswithfollow-upextending2yearsormoredisclosethatnarcoticusagincreasesandpaintypicallyreturnstopreoperativelevelsHowardetalfoundthatpatientswhohadhadnoprioroperativeorendoscopicinterventionbeforebilateralsplanchnicectomyandwholikelyhad“smallduct”diseaseremainedimproved2025/3/1813RESECTIONALPROCEDURESProximalPancreatectomyIthasproventobeaneffectivemeanofmanagingpainandthecomplicationsofchronicpancreatitisInthe3largestmodern(circa2023)seriesofthetreatment,painrelief4to6yearsafteroperationrangedfrom71%to89%ofpatients.Themortalityrateoftheoperationhasbeenreducedtolessthan5%Themorbiditystubbornlyremainsatabout40%.Withoutthehighincidenceofendocrinedysfunction2025/3/1814PylorusPreservationPresumednutritionalandphysiologicbenefitsassociatedwithretentionofthepylorus.Nowemployedin70%to80%ofallWhippleprocedures.PhysiologicgastricemptyingisassumedwithpreservationofthepylorusIncreasedincidenceofmarginalulcerationWithoutthehighincidenceofendocrinedysfunction2025/3/1815TotalPancreatectomyTheoperationproducesnobetterpainrelieffortheirpatientsthanpancreaticoduodenectomy(about80%–85%)Themetabolicconsequencesoftotalpancreatectomyintheabsenceofisletcelltransplantationareprofoundandlifethreatening.Lethalepisodesofhypoglycemiaarecommoninsevereapancreaticdiabetesduetotheabsenceofpancreaticglucagon,andtohypoglycemiaunawarenessPreventionofthephysiologicalconsequencesoftotalpancreatectomyremainsanunfulfilledgoal2025/3/1816PancreatectomyWithIsletAutoTransplan-tationMethodsofharvestingandglandpreservationIsletsareinfusedintotheportalvenouscircuitforintrahepaticengraftmentSomedegreeofinsulindependenceisstillpresentintwo-thirdofpatients2to3millionisletsarerequiredforsuccessfulengraftmentinanallogeneicrecipientAuto-transplantrecipientcanachievelongterm,insulinindependentstatusafterengraftmentofonly300,000to400,000islets2025/3/181725%to30%ofpatientswithchronicpancreatitisarealreadydiabeticsoisletauto-transplantationisnotanoptioninthosepatients.Islettransplantrecipientswhobecomeeuglycemicinitially,theirisletcellfunctionremainsimpaired,andafter2yearsmostrequireinsulin.2025/3/1818DistalPancreatectomyInasmallpercentageofcasesthebodyandtailmaybetheportionsofthepancreasmostdiseasedduetoisolatedductstricture,pseudocystdisease,orbothForthesepatientsthetechniqueofpartial(40%–80%)distalpancreatectomyhasbeenadvocatedTheoperationleavesuntreatedamajorportionofthegland,and

is

therefore

associatedwith

a

significant

risk

ofsymptomaticrecurrenceLongtermoutcomesrevealgoodpainreliefinonly60%ofpatients,however,withcompletionpancreatectomyrequiredforpainreliefin13%ofpatients2025/3/1819DistalPancreatectomy(95%)Avoidapancreaticoduodenectomyandpreservingthedistalstomach,theentireduodenumandnormalcholedochoduodenaljunction.Asmallcuffoftheheadofthepancreaswhichispreservedasthefunctionalportion.Thislinesthelessercurvatureoftheduodenumandisestimatedtobenomorethan5%oftheentireglandPainreliefwasexcellentandachievedinabout80%ofpatientsfollowedonaverage6years.2025/3/1820Theincidenceofpostopera-tivediabetesfollowing95%pancreatectomyrosetoanunacceptable72%.Exocrineinsufficiencydeterioratedaswell40%ofpatientsexperiencedabscessesorshortlivedfistulasintheregionoftheheadresection2025/3/1821HybridproceduresDenervatedsplenopancreaticflapDividingtheneckofthepancreasovertheportalveinThemajorityoftheheadofthepancreaswasresectedLeavingasmallcuffofpancreatictissuealongtheinneraspectoftheduodenum2025/3/1822Thesplenicarterywasdividedatitsoriginandthesplenicveinatitsjunctionwiththesuperiormesentericvein.Thebodyandtailofthepancreaswasthenfreedfromtheretroperitonealtissueuntilthepancreasisattachedonlytothevesselsatthesplenichilus.SeverssomaticnervefibersaswellasautonomicafferentfibersalongthesplenicarteryThetransectedneckofthepancreaswasthenanastomosedtoaRoux-en-Ylimb2025/3/1823Paincontrolwasreportedlygood.Itislikelythatthelong-termeffectsonpainreliefwereascribabletothepancreaticheadresection2025/3/1824DuodenumPreservingPancreaticHeadResection(Fig.8)Identifyingandpreservingtheposteriorbranchofthegastroduodenal

artery

which

provides

blood

flow

to

theduodenum,intrapancreaticcommonbileduct,andpancreaticoduodenalgrooveTheneckofthepancreasoverlyingtheportalandsuperiormesentericveinisdividedAsmallamountofpancreatictissuealongtheinneraspectoftheduodenumisresected2025/3/1825Reconstructionconsistsofanend-to-endpancreatico-jejunostomytothedistalpancreas,andend-to-sidepancreatico-jejunostomytotheremnantofpancreatictissueontheinneraspectoftheduodenum.Thebodyandtailofthepancreascanbedrainedwithalongitudinalpancreaticojejunostomyifthemainductinthebodyandtailofthepancreasisobstructed.Acommonbileductstricture,ifpresent,shouldberelievedbydecompressionintothesameRouxlimbthroughaseparatecholedochojejunostomy.Performingacholedochopancreatos-tomyintotheexcavatedpancreaticheadhasbeenassociatedwithlaterecurrencesofbileductstrictures2025/3/1826Relievedpainin80%ormoreofpatientsandpreservedendocrineandexocrinefunction.incidenceofnewdiabetesaftertheDPPHRprocedurerangesfrom8%to21%Thisappearstobeduetopreservationofinsulinandpancreaticpolypeptide(PP)secretion.FIGURE82025/3/1827LocalResectionofthePancreaticHeadWithLongitudinalPancreaticojejunostomyTherimofpancreatictissueoftheentireheadispreserved，andisusedtosewtotheopenedjejunumTheductsofWirsungandSantoriniareexcisedTheexcavationiscreatedincontinuitywiththelongitudinaldochotomyofthedorsalductPreservationofthepancreaticneckaswellasthecapsuleoftheposteriorpancreaticheadandavoidsintraoperativeproblemswiththevenousstructureslyingposteriortothegland2025/3/1828TheposteriorlimitofresectionbethebackwalloftheopenedductofWirsungandducttotheuncinate.AllinterveningandoverlyingtissueinthepancreaticheadincludingtheductofSantoriniisexcised.ThelocallyexcisedheadofthepancreasiscoveredwiththeopenedRoux-en-Ylimbofjejunumincontinuitywiththeopenedmainpancreaticductinthebodyandtailofthepancreas(Fig.9)2025/3/1829Somemodification：A.excisethetheductsofWirsungandUncinateintheheadratherthanunroofingusingtheultrasonicaspiratoranddissector(Fig.10)B.thecentralportionoftheuncinateprocessisincludedintheexcavation(Fig.11)C.merelyexcavatingthecoreofthepancreaticheadandwithoutanyefforttoincludetheductofthebody(Fig.12)D.withoutdivisionofthepancreaticneckcomparedtoDPPHR(Fig.13)2025/3/1830FIGURE10.FIGURE11.FIGURE12.FIGURE13.FIGURE9.2025/3/1831COMPLICATIONAnastomoticLeak:PancreaticanastomoticleaksarelesslikelytooccurinchronicpancreatitisbecauseofthefirmerconsistencyoftheglandDorsalductcanbe2to3mmorlessinaglandwithdiffusesclerosis,anddifficultieswiththeanastomosiscanoccur.Techniquesofanastomoses:end-to-sideducttomucosatechnique,aswellastheinvaginatingorintussusceptingmethodsofend-to-endanastomosis2025/3/1832Theduct-to-mucosaAn-astomosisleakratehasbeenreportedtobeaslowas1%,considerablylessthanthe10%to12%leakrateobservedwiththeintussusceptingorinvagina-tingtechniqueEnd-to-side,duct-to-mucosamethodofpancreaticojejunostomy2025/3/1833Prospective,randomizedtrialsoftheuseofoctreotideadministeredpostoperativelytopreventleakhavebothsupportedandrefuteditsvalueTheuseoffibringlueappearsineffective.Theuseoftheoperatingmicroscopeandthatthejejunumissecuredaroundthepancreaswithapursestringsuturemayreduceleakrate.Arandomizedprospectivetrialhasdemonstratedareducedleakratewithstentuseinamixedgroupofpatients2025/3/1834MajorPerioperativeComplications:necrotizingpancreatitisandintraluminalbleedingLateComplications:A.stricturingoftheanastomoseswhenthe“stuffing”orinvaginatingmethodisavoidedB.thelossofexocrineandendocrinefunction：thelateincidenceofbothexocrineandendocrinedysfunctionafterpancreatico-duodenectomyisabout50%whichcanbeavoidedaltogetherbyperformingaligationofthepancreaticduct.C.Delayedgastricemptyingwhichusuallyresolvesspontaneously,orasalatecomplicationassociatedwitharetrocolic,asopposedtoanantecolic,gastrojejunostomy.2025/3/1835Thereistheriskofischemiaoftheduodenumintheduodenumpreservedcases2025/3/1836COMPARISONSOFTHE3OPERATIVEPROCEDURES:DPPHRANDLR-LPJ:thereisnosignificantdifferenceinglobalqualityoflife、painscore、latemortality、exocrineorendocrineinsufficiency.thereisinitialreductioninmorbidityassociatedwiththeexcavationprocedureTHEBOTHWITHWHIP:thereisfewercomplications、alowerglobalqualityoflifescores、alowershort-term(3year)incidenceofnewdiabetesandexocri