1、2018/9/13,1,The Evolution of the Surgical Treatment of Chronic Pancreatitis,汇报人：柴大海 导师：刘杰 专业：普外,2018/9/13,2,BACK GROUND,Operative 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 ap
2、preciated as the nidus of chronic inammation. Prospective, randomized trials have repeatedly shown the superiority of surgical treatment over medical approaches to management,2018/9/13,3,INDICATIONS FOR SURGERY,PainDuctal hypertension: some anatomic changes related with it such as ：small cysts、foci
3、of acinar cell necrosis、areas of acute inammationPeripancreatic sensory nerve damage： inammatory damage 、neuron-specic proteinase activated receptor 2 activation、C bers （a subpopulation of sensory neurons）contain peptides which can cause inammatory changes 2. The complications of chronic pancreatiti
4、s,2018/9/13,4,Treatment,The medical treatment of chronic pancreatitis-associated pain usually fails surgical treatment of chronic pancreatitis has been shown to eliminate pain and return patients to predisease employment and quality-of-life status.,2018/9/13,5,Operative procedures,Operative procedur
5、es about chronic pancreatitis have historically been classied into 3 categories： Decompression of diseased and obstructed pancreatic ducts Denervation of the pancreas Resection of the proximal, distal, or total pancreas. Within the past few years, however, a category of hybrid procedures has been sh
6、own to be safe and effective.,2018/9/13,6,DECOMPRESSION PROCEDURES,Remove 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 sphinct
7、eroplasty to prevent recurrent pancreatitis which caused by biliary stone.,2018/9/13,7,External drainage of the pancreatic duct to decompress obstruction caused by stricture or calculus(Fig. 1),FIGURE 1,2018/9/13,8,Roux-en-Y, side-to-end, pancreaticojejunostomyThe caudal, end-to-end, pancreaticojeju
8、nostomy as a drainage procedure for chronic pancreatitis (FIG 2.),FIGURE 2.,2018/9/13,9,Longitudinal decompre-ssion of the body and tail of the pancreas into a Roux limb of jejunum (Fig. 3),FIGURE 3.,2018/9/13,10,Side-to-side longitudinalpancreaticojejunostomythat became known asthe“Puestow”procedur
9、e( Fig. 4).,FIGURE 4,2018/9/13,11,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 obstruction due to calculi or strictures are the rule in patients with alcoholic, hereditary, tropical, and idiopath
10、ic pancreatitis.,The effect of decompression,2018/9/13,12,DENERVATION PROCEDURES,Bilateral thoracolumbar sympathectomy The use of operative, endoscopic, and imageguided neurolysis of the celiac trunks and ganglia have been reported in the treatment of chronic pancreatitis. Vagotomy, with partial gas
11、trectomy 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 exocrine regulation),2018/9/13,13,The effect of denervation procedures,Studies with follow-up extending 2 years or more disclose that
12、 narcotic usag increases and pain typically returns to preoperative levels Howard et al found that patients who had had no prior operative or endoscopic intervention before bilateral splanchnicectomy and who likely had “small duct” disease remained improved,2018/9/13,14,RESECTIONAL PROCEDURES,Proxim
13、al Pancreatectomy It has proven to be an effective mean of managing pain and the complications of chronic pancreatitis In 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 b
14、een reduced to less than 5% The morbidity stubbornly remains at about 40%. Without the high incidence of endocrine dysfunction,2018/9/13,15,Pylorus Preservation Presumed nutritional and physiologic benefits associated with retention of the pylorus. Now employed in 70% to 80% of all Whipple procedure
15、s. Physiologic gastric emptying is assumed with preservation of the pylorusIncreased incidence of marginal ulceration Without the high incidence of endocrine dysfunction,2018/9/13,16,Total Pancreatectomy The operation produces no better pain relief for their patients than pancreaticoduodenectomy (ab
16、out 80%85%) The metabolic consequences of total pancreatectomy in the absence 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 unawareness Preventi
17、on of the physiological consequences of total pancreatectomy remains an unfullled goal,2018/9/13,17,Pancreatectomy With Islet AutoTransplan-tation Methods of harvesting and gland preservationIslets are infused into the portal venous circuit for intrahepatic engraftment Some degree of insulin depende
18、nce is still present in two-third of patients2 to 3 million islets are required for successful engraftment in an allogeneic recipient Auto-transplant recipient can achieve longterm, insulin independent status after engraftment of only 300,000 to 400,000 islets,2018/9/13,18,25% to 30% of patients wit
19、h chronic pancreatitis 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.,2018/9/13,19,Distal Pancreatectomy In a small
20、percentage of cases the body and tail may be the portions of the pancreas most diseased due to isolated duct stricture, pseudocyst disease, or both For these patients the technique of partial (40%80%) distal pancreatectomy has been advocated The operation leaves untreated a major portion of the glan
21、d, and is therefore associated with a signicant risk of symptomatic recurrence Longterm outcomes reveal good pain relief in only 60% of patients, however, with completion pancreatectomy required for pain relief in 13% of patients,2018/9/13,20,Distal Pancreatectomy (95%) Avoid a pancreaticoduodenecto
22、my 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% of the entire gland Pain rel
23、ief was excellent and achieved in about 80% of patients followed on average 6 years.,2018/9/13,21,The incidence of postopera-tive diabetes following 95% pancreatectomy rose to an unacceptable 72%. Exocrine insufciency deteriorated as well 40% of patients experienced abscesses or shortlived stulas in
24、 the region of the head resection,2018/9/13,22,Hybrid procedures,Denervated splenopancreatic ap Dividing the neck of the pancreas over the portal vein The majority of the head of the pancreas was resected Leaving a small cuff of pancreatic tissue along the inner aspect of the duodenum,2018/9/13,23,T
25、he 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 until the pancreas is attached only to the vessels at the splenic hilus. Severs somatic nerve bers as w
26、ell as autonomic afferent bers along the splenic artery The transected neck of the pancreas was then anastomosed to a Roux-en-Y limb,2018/9/13,24,Pain control was reportedly good.It is likely that the long-term effects on pain relief were ascribable to the pancreatic head resection,2018/9/13,25,Duod
27、enum Preserving Pancreatic Head Resection (Fig. 8) Identifying and preserving the posterior branch of the gastroduodenal artery which provides blood ow to the duodenum, intrapancreatic common bile duct, and pancreaticoduodenal groove The neck of the pancreas overlying the portal and superior mesente
28、ric vein is divided A small amount of pancreatic tissue along the inner aspect of the duodenum is resected,2018/9/13,26,Reconstruction 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 as
29、pect of the duodenum. The body and tail of the pancreas can be drained with a longitudinal pancreaticojejunostomy if the main 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 separ
30、ate choledochojejunostomy. Performing a choledochopancreatos-tomy into the excavated pancreatic head has been associated with late recurrences of bile duct strictures,2018/9/13,27,Relieved pain in 80% or more of patients and preserved endocrine and exocrine function.incidence of new diabetes after t
31、he DPPHR procedure ranges from 8% to 21%This appears to be due to preservation of insulin and pancreatic polypeptide (PP) secretion.,FIGURE 8,2018/9/13,28,Local Resection of the Pancreatic Head With Longitudinal Pancreaticojejunostomy The rim of pancreatic tissue of the entire head is preserved，and
32、is used to sew to the opened jejunum The ducts of Wirsung and Santorini are excised The excavation is created in continuity with the longitudinal dochotomy of the dorsal duct Preservation of the pancreatic neck as well as the capsule of the posterior pancreatic head and avoids intraoperative problem
33、s with the venous structures lying posterior to the gland,2018/9/13,29,The 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
34、head of the pancreas is covered with the opened Roux-en-Y limb of jejunum in continuity with the opened main pancreatic duct in the body and tail of the pancreas(Fig. 9),2018/9/13,30,Some modification：A.excise the the ducts of Wirsung and Uncinate in the head rather than unroofing using the ultrason
35、ic aspirator and dissector (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(Fi
36、g. 13),2018/9/13,31,FIGURE 10.,FIGURE 11.,FIGURE 12.,FIGURE 13.,FIGURE 9.,2018/9/13,32,COMPLICATION,Anastomotic Leak: Pancreatic anastomotic leaks are less likely to occur in chronic pancreatitis because of the rmer consistency of the gland Dorsal duct can be 2 to 3 mm or less in a gland with diffus
37、e 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 anastomosis,2018/9/13,33,The duct-to-mucosa An-astomosis leak rate has been reported to be as low as 1%,co
38、nsiderably less than the 10% to 12% leak rate observed with the intussuscepting or invagina-ting technique,End-to-side, duct-to-mucosa method of pancreaticojejunostomy,2018/9/13,34,Prospective, randomized trials of the use of octreotide administered postoperatively to prevent leak have both supporte
39、d and refuted its value The 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 trial has demonstrated a reduced leak rate with stent use in a mixed gro
40、up of patients,2018/9/13,35,Major Perioperative Complications : necrotizing pancreatitis and intraluminal bleeding Late Complications: A.stricturing of the anastomoses when the “stufng” or invaginating method is avoided B.the loss of exocrine and endocrine function：the late incidence of both exocrin
41、e 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 resolves spontaneously,or as a late complication associated with a retrocolic, as opposed to an antecolic,
42、 gastrojejunostomy.,2018/9/13,36,There is the risk of ischemia of the duodenum in theduodenum preserved cases,2018/9/13,37,COMPARISONS OF THE 3 OPERATIVEPROCEDURES:,DPPHR AND LR-LPJ:there is no significant difference in global quality of life 、pain score、late mortality 、exocrine or endocrine insufci
43、ency . there is initial reduction in morbidity associated with the excavation procedure THE 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 procedure. survi
44、val、pain relief 、the late incidence of diabetes and exocrine dysfunction appears similar,2018/9/13,38,2018/9/13,39,2018/9/13,40,CONCLUSION,The head of the pancreas is the locus of the disease in the overwhelming majority of patients with chronic pancreatitis The procedures that address disease in th
45、e head of the pancreas produce long lasting pain relief in about 80% of patients with chronic pancreatitis The combined elements of decompression of the distal pancreas and excision of the core of the pancreatic head are essential for successful long-term symptom relief in this disease. The extent o
46、f the longitudinal dochotomy appears less important than the excision of the central portion of the head of the gland.,2018/9/13,41,Excavation techniques are safer than techniques which require division of the neck of the pancreas, and are easier to perform. The early postoperative mortality and mor
47、bidity risk is highest with pancreaticoduodenectomy and lowest with the LR-LPJ procedure. Late results are nearly identical after the 3 procedures If the duct is uninammed and the duct diameter is no more than 3 to 4 mm:the dochotomy and anastomosis probably should be carried If the duct is large and the mucosa of the duct obviously inamed:a long longitudinal pancreaticojejunostomy is appropriate to prevent recurrent stricture,2018/9/13,42,THANKS FOR YOUR TIME,
