The surgery of chronic pancreatitis, pancreas The surgery of chronic pancreatitis, pancreas peseudocystspeseudocysts

Szentkereszty Zs. MD. PhD., Med. habil.

UD MHSC Inst. Of Surgery

Chronic pancreatitisChronic pancreatitis

1. Sclerosis of the pancreas

2. Gland atrophy - Focal

- segmental

- diffuse

Protein extraction – calcification

Duct dilatation– intraductal hypertension

LocalisationLocalisation

- Mosttly in the head of the pancreas( Guillemin, Traverso és Longmire, Beger)

- A „Rinnen” és „groove” pancreatitis-In the head

( Stolte, Becker)

- The predilective localisation of the tumours are also in the head of the pancreas

( Cubilla és Fitzgerald, Hertzberg, Nakase és mtsai, Spohn és mtsai)

EtiologyEtiology

- Alimentaion:fatty foods, abundant mealsalcoholism

- Developement of diagnosispancreas functional

testsimagies

ComplaintsComplaints

- Pain- Dypepsia- Weigh loss- Jaundice- Ascites- Duodenal obstraction- Diabetes

ImagiesImagies

- Gastrio-duodenal passage- Pancreas ultrasonography- Pancreas scintigraphy- CT, MRI- ERCP- MRCP

NORMAL ERCP VIEWNORMAL ERCP VIEW

VATER PAPILLA OBSTURCTIONVATER PAPILLA OBSTURCTION

„„CHAIN OF LAKES”CHAIN OF LAKES”

CALIBER IRREGULARITY, CALIBER IRREGULARITY, PSEUDOCYSPSEUDOCYS

PSEUDOCYS, CONNECTION WITH PSEUDOCYS, CONNECTION WITH THE PANCREATIC DUCTTHE PANCREATIC DUCT

PSEUDOCYSTPSEUDOCYST

PSEUDOCYST, SEGMENTAL PSEUDOCYST, SEGMENTAL DUCTECTASYDUCTECTASY

PSEUDOCYST IN THE HEADPSEUDOCYST IN THE HEAD

INDICATION OF SURGERY IN CHR. INDICATION OF SURGERY IN CHR. PANCREATITISPANCREATITIS

PainAcute exacerbationsComplications:

Jaundiceduodenal obstractionpseudocystspancreas

fistuleSuspition of cancer

x

SOME WORDS ABOUT THE SOME WORDS ABOUT THE SURGICAL TREATMENTSURGICAL TREATMENT

- It is symptomatic treatment

- The stop of etiology does not prevent the progression

- The alcohol free lifestyle is needed for the surgery

CHOICE OF TYPE OF THE SURGICAL CHOICE OF TYPE OF THE SURGICAL PROCEDUREPROCEDURE

The duct morphology is important

In general:

1. in case of dilatated duct decompressive surgery is needed

2. In cese of segmental, or focal inflammation resection is needed

Imagies:

US

CT

ERCP

MRCP

CHOICE OF SURGICAL PROCEDURES

- There is no generally used gold standard

- Organ save methods are better?

- The resections have a 5% of mortality rate

- The decompressive operations have lower rate of mortality

DRAINAGE OPERATIONS

- The drainage of the pancreatic juice- Decrease of the intraductal pressure

Types of decompressive operations

- longitudinal pancreaticojejunostomy- longitudinal pancreaticogastrostomy - Cyst drainage with the aboves- Pancreas head partzial resection and pancreat(ic)o-

jejunostomy

A LONGITUDINAL PANCREATO CYSTO-A LONGITUDINAL PANCREATO CYSTO-GASTROSTOMIAGASTROSTOMIA

RESECTIONSRESECTIONS

- Resection of the advanced local destruction- Resection of the duct destructions- Treatment of the local compresive complaints

Types of resectionsTypes of resections

- Whipple pancreatoduodenectomy- Pylorus – preserving pancreatoduodenectomy (PPPD)- Duodenum preserving pancreas head resection

PANCREAS-CYSTSPANCREAS-CYSTS

Definition true cyst

pseudocyst

Pathológic forms: 1. Genetic abnormalities

pl. fibrocystic pancreas, dermoid cyst

2. retentional cysts

3. parasitic cysts (hydatid)

4. neoplastic cysts

( cystadenoma, cystadenocarcinoma, teratoma)

5. pseudocysts

PANCREAS-CYSTSPANCREAS-CYSTS

PANCREAS-PSEUDOCYSTSPANCREAS-PSEUDOCYSTS

Localisation: pancreas headpancreas body pancreas tail

Complaint: dullnessPainduodenal obstruction

Diagnosis: USCT

Surgery: 1. decompression: cysto-duodenostomycysto-gastrostomycysto-jejunostomy2. resection3. External drainage4. Internal drainage (ERCP)

PANCREAS-PSEUDOCYSTSPANCREAS-PSEUDOCYSTS

Thank You for your attention!Thank You for your attention!