Surgical treatment of chronic pancreatitis and quality of life after operation.

In conclusion, surgical therapy in patients with chronic pancreatitis may be characterized as follows: 1. Independently, several investigators have found intraductal and intraparenchymatous hypertension in patients with chronic pancreatitis. Decompression of the ductal system as the main principle of surgical therapy achieves clinical pain relief in most patients with chronic pancreatitis. The precondition is a consequent drainage of the main pancreatic duct and tributary ducts of second and third order up to the prepapillary region. The presence of an inflammatory tumor in the head of the pancreas or ductal abnormalities in the prepapillary region or a pancreas divisum requires performance of an extended drainage operation (LPJ-LPHE) to achieve pain relief and an improved quality of life. An extended drainage operation effectively manages complications arising from adjacent organs, such as distal common bile duct stenosis, segmental duodenal stenosis, and internal pancreatic fistulas. The extent of decompression has to be tailored to the anatomic and morphologic situation of the patient. 2. In patients with chronic pancreatitis, the main pancreatic duct is usually dilated. A small duct (3-5 mm) is only small for the surgeon. For the sclerosing entity of chronic pancreatitis with a truly small duct, that is, less than 3 mm in diameter ("small duct disease"), a longitudinal V-shaped excision of the ventral pancreas, as opposed to left resection, provides a new perspective for a sufficient drainage. 3. In the presence of segmental portal hypertension, a simple or extended drainage operation does not result in a normalization of the portal venous blood flow; however, how often relevant upper gastrointestinal hemorrhage develops from segmental portal hypertension is unclear. Therefore, the clinical relevance of this special problem needs further evaluation. 4. Postoperative morbidity of LPJ-LPHE is significantly lower in comparison to resectional procedures, such as PD, PPPD, and DPRHP. A lower perioperative mortality rate is not justified anymore as a relevant criterion in favor of drainage procedures because resectional procedures are burdened by a minimal or no mortality in experienced centers; however, PD and PPPD are greatly hampered by a significantly decreased postoperative global quality of life as opposed to the LPJ-LPHE. This is reflected by a significantly lower rate of social and professional rehabilitation. 5. The incidence of exocrine and endocrine organ dysfunction is lower after LPJ-LPHE compared with PD or PPPD, but not compared with DPRHP. Preservation of the gastroduodenal passage and the continuity of the bile duct with its associated feedback mechanisms of exocrine pancreatic secretion and glucose metabolism seem to be responsible for this phenomenon. 6. An early surgical or endoscopic interventional drainage of the hypertensive pancreatic duct system possibly offers the chance to favorably manipulate the natural course of chronic pancreatitis with regard to a delayed onset of exocrine or endocrine insufficiency. 7. Late mortality reflects continued alcohol abuse rather than the effect of an operative procedure.     

Laterale Anastomosentechniken

Characteristic symptoms of chronic pancreatitis are difficult to manage conservatively. They include severe pain and endocrine and exocrine insufficiency. Surgical treatment with simple and extended draining procedures addresses pain relief and the management of chronic pancreatitis-associated complications of adjacent organs. Following the assumption that pancreatic duct changes with intraductal hypertension are the reason for pain, simple drainage procedures have reduced pain in up to 80% of patients, with low morbidity and mortality. In case of complications involving adjacent organs with inflammatory pancreatic head tumor and stenosis of the distal bile duct, extended drainage procedures with limited pancreatic head resection according to Frey and V-shaped excision of the ventral aspect of the pancreas have been performed successfully.     

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??Rationality of surgical managements according to the pathological anatomy of chronic pancreatitis GAO Hong-qiao, CAI Meng-shan, MA Yong-su, et al. Department of General Surgery, Peking University First Hospital, Beijing 100034, China
Corresponding author: YANG Yin-mo, E-mail: yangyinmo@263.net
Abstract Objective To investigate the outcome after surgery directed by pathological anatomy of chronic pancreatitis and provide evidence for surgical procedures. Methods The clinical material of 60 patients with chronic pancreatitis who underwent surgical treatment between 2000 and 2010 were investigated retrospectively. Result 43 cases (71.7%) presented with abdominal pain, Perioperative mortality was 1.7% (1 case). Forty-two patients with abdominal pain were all relieved after surgery, but long-term recurrence occered in 17 cases (40.5%). Modified Puestow procedure was performed on 21 patients with dilatation of pancreatic duct and/or lithiasis, long-term pain recurrence occered in 8 cases (38.1%); Six patients undergoing pancreatic head resection had no recurrence in the long-term follow-up; Pain recurrence rate of 11 cases with only cholangioenterostomy was 81.2% (9 cases) within 2 years. Chronic pancreatitis with common bile duct obstruction occurred in 33 cases(55%), cholangioenterostomy alone or combined with partly pancreatic resection or pancreatic duct drainage procedures could alleviate symptoms of biliary obstruction, 4(33.3%) cases after pure biliary drainage emerged abdominal pain, 5 cases of pancreatic head resection had no recurrence of jaundice and abdominal pain after long-term follow-up. Conclusion Surgical procedures should be selected according to the pathological anatomy of chronic pancreatitis. Reasonable pancreatic head resection and adequate bile and/or pancreatic drainage could significantly improve the long-term outcomes.     

Indications and outcomes of surgical management of chronic pancreatitis: literature review

Surgical management of chronic pancreatitis remains a challenge for surgeons. Last decades, the improvement of knowledge regarding to pathophysiology of chronic pancreatitis, improved results of major pancreatic resections, and new diagnostic techniques in clinical practice resulted in significant changes in the surgical approach of this condition. Intractable pain, suspicion of malignancy, and involvement of adjacent organs are the main indications for surgery, while the improvement of patient's quality of life is the main purpose of surgical treatment. The surgical approach to chronic pancreatitis should be individualized based on pancreatic anatomy, pain characteristics, exocrine and endocrine function, and medical co-morbidity. The surgical treatment approach usually involves pancreatic duct drainage procedures and resectional procedures including longitudinal pancreatojejunostomy, pancreatoduodenectomy, pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger's procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey's procedure). Recently, non-pancreatic and endoscopic management of pain have also been described (splancnicectomy). Surgical procedures provide long-term pain relief, improve the patients? quality of life with preservation of endocrine and exocrine pancreatic function, and are associated with low mortality and morbidity rates. However, new studies are needed to determine which procedure is safe and effective for the surgical management of patients with chronic pancreatitis.     

慢性胰腺炎伴胰管结石外科治疗体会

目的 探讨慢性胰腺炎伴胰管结石外科治疗的术式选择.方法 对1991年6月至2006年6月收治的17例慢性胰腺炎伴胰管结石手术治疗的患者进行回顾性分析,总结不同类型的胰管结石的手术方式及结果.结果 本组17例中胰头部胰管结石13例,胰体尾部胰管结石4例,合并胆石症6例,其中6例行胰管切开取石胰管空肠吻合术(Partington法);4例行胰管胃吻合术(Warren法);3例行保留十二指肠胰头次全切除术(Beger法);3例行胰尾切除胰腺空肠吻合术(Duval法);1例行胰尾、脾切除胰腺空肠吻合术.17例临床治愈,其中上腹部顽固性疼痛完全缓解15例,血糖控制2例,胰漏2例,1例术后11个月死于胰腺癌.结论 针对慢性胰腺炎合并胰管结石患者的不同状况采取的手术方式应高度个体化,有主胰管扩张者采取引流术,无胰管扩张及局部胰腺病变者采取胰腺部分切除联合内引流术,同时注意尽量保存胰腺组织功能,可明显改善患者生活质量.     

Chirurgisches Vorgehen bei chronischer Pankreatitis

The major aims of surgical therapy in chronic pancreatitis (CP) are pain relief and good long-term quality of life with preservation of endocrine and exocrine organ function. The surgical approach is therefore focused on drainage of the congested pancreatic (and bile) duct as well as resection of fibrotic and calcified tissue. Draining procedures alone are adequate for drainage of pseudocysts (cystojejunostomy) and the pancreatic duct (Partington) if no inflammatory tumor is present in the organ. Most CP patients present with unclear head mass and subsequent duct dilation. In these patients the different modifications of duodenum-preserving pancreatic head resections (e.g. Beger, Bern) offer a preferable option. Partial duodenopancreatectomy is an alternative but may be difficult to perform due to inflammatory changes around the portal vein and venous collaterals. Segmental resection and V-shaped excision may be appropriate in special situations (segmental fibrosis, small duct disease) and are performed less frequently (approximately 5 %) in the entire surgical CP population. In cases of suspected CP-related malignancy, formal resections (partial, distal or total pancreaticoduodenectomy) must be the surgical procedures of choice and be performed according to oncological principles.     

Early versus late surgical drainage for obstructive pancreatitis in an experimental model

BACKGROUND: Chronic pancreatitis (CP) is characterized by intractable abdominal pain, and pancreatic exocrine and endocrine dysfunction. This study investigated whether early surgical drainage of pancreatic duct obstruction leads to improved recovery of pancreatic function compared with late surgical drainage in an experimental model of chronic obstructive pancreatitis. METHODS: Twenty-one piglets underwent pancreatic duct ligation and subsequent longitudinal pancreaticojejunostomy after 3 weeks (early drainage) or 6 weeks (late drainage), and drainage continued for 6 weeks. In controls with CP pancreatic duct ligation was continued for 12 weeks without a drainage procedure. RESULTS: Histological pancreatitis scores decreased with early drainage (P = 0.005), but not with late drainage. Pancreatic secretion of amylase and lipase was restored after early but not late drainage (P = 0.003 and P = 0.048 respectively). Excretion levels of lipase were restored to near-baseline preligation levels after early drainage. Pancreatic endocrine function (glucose tolerance test) showed no insufficiency in either group. CONCLUSION: In this model of early versus late surgical drainage of obstructive pancreatitis, histology grades and pancreatic exocrine function showed improvement in the early drainage group but no recovery in the late drainage group.     

慢性胰腺炎的手术方式选择

目的探讨慢性胰腺炎外科治疗的手术方式选择。方法回顾性分析2000年1月至2013年8月北京大学第一医院收治的80例慢性胰腺炎患者的临床资料,其中胰管扩张〉7mm、伴或不伴胰管结石者38例,胆总管扩张者44例,伴有胰头部炎性肿块者32例,脾大伴食管胃底静脉曲张3例。根据患者临床症状及影像学表现综合判断手术指征及选择手术方式。根据VAS疼痛分级标准评估患者术后疼痛缓解及复发。通过门诊复查、信件或电话访谈方式随访,随访时间截至2013年12月。结果胆肠吻合术27例,Partington—Rochelle术24例,Partington—Rochelle术＋胆肠吻合术6例,胰十二指肠切除术7例,胰体尾切除术4例,Beger术3例,脾切除术3例,Frey术＋胰头内胆管开窗术3例,Frey术2例,胆总管探查＋T管引流术1例。63例以腹痛为主要表现的患者术后腹痛缓解率达95．2％（60／63）。围手术期1例患者因腹腔感染并发MODS死亡。围手术期并发症7例,包括腹腔感染3例、胰瘘2例、胆瘘1例、腹腔出血1例,所有并发症经保守治疗治愈。79例患者获得随访,平均随访时间为58．6个月（4～156个月）。30例腹痛复发或出现新发腹痛症状,总复发率为38．O％（30／79）。32例胰头部炎性肿块患者中,17例因胆管扩张合并梗阻性黄疸仅行胆肠吻合术,术后腹痛复发率达9／17;另15例分别行胰十二指肠切除术、Beger术或Frey术,术后腹痛复发率为1／15。41例胰腺萎缩或弥漫炎性改变患者中,10例仅行胆肠吻合术者腹痛复发率达7／10;30例Partington-Rochelle术患者腹痛复发率为33．3％（10／30）。结论对胰管扩张的慢性胰腺炎患者,充分引流可有效缓解症状;对于胰头部炎性肿块慢性胰腺炎患者,应选择手术切除或联合术式。     

Customized surgical strategy in chronic pancreatitis.

Despite major advances in the management of patients with chronic pancreatitis, yet the disease remains an enigmatic process of uncertain pathogenesis, unpredictable clinical course, and unclear treatment. In most of the cases intractable pain is the main indication for surgical intervention. Furthermore complications related to adjacent organs, endoscopically not permanently controlled pancreatic pseudocysts, ductal pathology, conservatively intractable internal pancreatic fistula or suspected malignancy also require surgery. The ideal surgical approach should address all these problems--tailoring the various therapeutic options to meet the individual patient's needs. In our opinion, the ideal procedure for chronic pancreatitis is the duodenum preserving pancreatic head resection in terms of an extended drainage procedure, were the extent of the pancreatic head resection may be tailored to the morphology of the pancreatic gland, thus allowing a tailored concept (to resect and/or drain as much as necessary but as little as possible). Looking at the present data, there is no need to transsect the pancreatic axis above the portal vein. If portal vein thrombosis is present, an extended drainage procedure is mandatory without transsection of the neck of the pancreas.     

Surgical treatment of chronic pancreatitis

Debilitating abdominal or back pain remains the most common indication for surgery in patients with chronic pancreatitis. The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. No single approach is ideal for all patients with chronic pancreatitis. Pancreatic ductal drainage with pancreaticojejunostomy targets patients with a dilated pancreatic duct and produces good early postoperative pain relief; however, 30%–50% of patients experience recurrent symptoms at 5 years. Resection for chronic pancreatitis should be considered (1) when the main pancreatic duct is not dilated, (2) when the pancreatic head is enlarged, (3) when there is suspicion of a malignancy, or (4) when previous pancreaticojejunostomy has failed. Re-sectional strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure). Superior results are obtained when the pancreatic head is resected, either completely (pancreaticoduodenectomy) or partially (Beger or Frey procedure). Although pylorus-preserving pancreaticoduodenectomy remains the gold standard resection procedure, there is evidence that newer operations, such as the Beger resection, may be as effective in regard to pain relief and better in respect to nutritional repletion and preservation of endocrine and exocrine function. Received: April 20, 2002 / Accepted: May 13, 2002 Offprint requests to: H.A. Reber     

Surgical management of chronic pancreatitis

The management of chronic pancreatitis continues to achieve only limited success. A lack of understanding of the basic pathogenic mechanism of this disease limits our therapy to treatment of symptoms, sequelae, and complications. The diagnosis of chronic pancreatitis usually is based on a history of classic pain plus some objective findings of pancreatic disease. Imaging techniques, such as ultrasonography or CT, are helpful in defining the size of the gland and the presence of masses and collections of fluid. Endoscopic pancreatography, however, remains the most helpful tool for diagnosis. The information that it provides about the pancreatic ductal system can help in selecting a procedure that achieves the best result with the lowest morbidity and mortality. The principle to follow in the surgical management of this condition is to tailor the procedure in each patient to preoperative clinical information, information provided by pancreatography, operative findings, exocrine and endocrine status of the patient, presence or absence of drug addiction and alcoholism, and the personality of the patient as well as his or her ability to manage the possible metabolic complications of surgery. Although management of pain is the main goal, the morbidity and late mortality that can result from different procedures must be a major consideration in selecting therapy. Pancreaticojejunostomy is the procedure of choice at this time for patients with a dilated pancreatic duct sphincterotomy or sphincteroplasty for the occasional patient with proved ampullary obstruction of the pancreatic duct, and internal drainage for pseudocyst. Different degrees of pancreatic resection are indicated for patients with severe disease and small pancreatic ducts, in patients in whom decompressive operations have failed, in patients with lateralized disease to the head or tail of the gland, in some instances of pseudocyst or pancreatic fistulas, and for some patients when cancer cannot be ruled out. Attempts are being made to improve the limited results of our current therapy. Endoscopic occlusion of the pancreatic duct, pancreatic segmental autotransplantation, islet cell autoimplantation, use of the pyloric-preserving operation, and use of continuous subcutaneous insulin infusion are being tried. Further experience with these techniques is required to determine their value in the management of patients with chronic pancreatitis.     

慢性胰腺炎的外科治疗

目的 改善慢性胰腺炎的外科治疗效果。方法 回顾性分析我院外科1983－2000年收治的34例慢性胰腺炎病人的临床资料，并将其分为慢性钙化性胰腺炎及慢性梗阻性胰腺炎两组。结果 男性23例（68％），女性11例（32％），平均年龄52.89岁。嗜酒者23例（67.65%），合并胆石症者13例（38.24%），继往有急性胰腺炎发作者11例（32.35%）。主诉腹痛者28例（82.35%），合并黄疸者17例（50％），慢性钙化性胰腺炎与慢性梗阻性胰腺炎在某些临床表现间存在显著性差异，提示二者可能存在不同的发病机制。34 病人分别采用9种不同的手术方式，无围手术期死亡。Puestow手术及胰十二指肠切除可有效地缓解疼痛，并可改善胰外分泌功能，对胰内分泌的影响不大。Puestow手术并行胆肠吻合适于合并胆道狭窄的慢性胰腺炎病人，而仅行胆道引流效果不佳。结论 慢性胰腺炎的外科治疗应采用个体化原则，如合并胰管扩张可行Puestow引流手术，胰头炎性包块病人应行切除手术。     

Pancreatectomy for chronic pancreatitis.

Of one hundred and forty-nine patients (101 male and 48 female) 4-67 years of age, 117 were alcoholics and underwent pancreatectomy because of episodic or continuous abdominal pain or complications or chronic pancreatitis. Nineteen patients underwent pancreaticoduodenectomy, seventy-seven 80-95% distal resection, anf fifty-three 40-80% distal pancreatic resection. There were 3 operative death and 30 late deaths 6 months to 11 years post pancreatectomy. Twenty-one patients were lost to followup, 1 to 11 years post pancreatectomy. Ninety-five patients are known to be alive, 4 of whom are institutionalized. Indications for pancreatectomy in addition to abdominal pain include recurrent or multiple pseudocysts, failure to relieve pain after decompression of a pseudocyst, pseudoaneurysm of the visceral arteries associated with a pseudocyst, recurrent attacks of pancreatitis unrelived by non-resective operations, duodenal stenosis and left side portal hypertension. The choice between pancreaticoduodenectomy or distal resection of 40-80% or 80-95% of the pancreas should be based on the principle site of inflammation whether proximal or distal in the gland, the size of the common bile duct, the ability to rule out carcinoma, and the anticipated deficits in exocrine and endocrine function. The risk of diabetes is very significant after 80-95% distal resection and of steatorrhea after pancreaticoduodenectomy. When the disease process can be encompassed by 40-80% distal pancreatectomy this is the procedure of choice.     

Combined pancreatic duct and upper gastrointestinal and biliary tract drainage in chronic pancreatitis

In 55 patients undergoing pancreaticojejunostomy for intractable abdominal pain, common bile duct obstruction occurred in 29% (16/55) and duodenal obstruction occurred in 15% (8/55). Serum alkaline phosphatase and total and direct serum bilirubin levels were significantly higher in patients with intrapancreatic common bile duct stenosis. Transient upper gastrointestinal (UGI) tract obstruction was common with chronic pancreatitis; however, if symptoms persisted beyond 2 weeks, fixed duodenal obstruction was likely. Endoscopic retrograde cholangiopancreatography and UGI roentgenograms and endoscopy were useful in confirming mechanical obstruction to the biliary and UGI tracts, respectively. There was no difference in operative mortality and morbidity from combined drainage procedures compared with pancreaticojejunostomy alone. The biliary and UGI tracts should be investigated in symptomatic patients both before and after pancreaticojejunostomy. Combined drainage of the pancreatic duct and UGI and biliary tract is safe and effective treatment for obstructing complications of chronic pancreatitis.     

Redrainage of the pancreatic duct in chronic pancreatitis

Recurrent pain after a drainage procedure for chronic pancreatitis is considered an indication for pancreatectomy. To evaluate whether redrainage might be a better alternative, 14 patients who underwent redrainage after a failed pancreaticojejunostomy were reviewed. Patients with previous pseudocyst drainage were excluded. Initial operations included five caudal, three longitudinal, and six side-to-side pancreaticojejunostomies. Nine patients treated since 1974 had ERCP, which showed obstructed segments of pancreatic duct in the head of the gland. Two caudal pancreaticojejunostomies and one longitudinal pancreaticojejunostomy were revised to longitudinal pancreaticojejunostomies. The other 11 were revised to side-to-side pancreaticojejunostomies. Operative findings confirmed undrained segments of the pancreatic duct in the pancreatic head. Postoperatively, one patient died from hemorrhage and four patients had complications. At most recent follow-up from 6 months to 20 years postoperatively, three patients were pain free and six had substantial relief from pain (71 percent). Of eight patients who were not diabetic before redrainage, diabetes developed in only two. Only one of seven patients without pancreatic exocrine insufficiency required pancreatic enzymes after redrainage. Patients with recurrent pain after pancreaticojejunostomy should undergo ERCP. If segments of the pancreatic duct are obstructed, redrainage can provide satisfactory pain relief with a minimal loss of endocrine and exocrine function. This problem is best avoided by initial complete drainage of the major and minor pancreatic ducts.     

Role of pancreaticojejunostomy in the treatment of chronic pancreatitis. A study of 105 operated patients]

105 patients with intractable pain due to chronic pancreatitis were selected for treatment by lateral pancreatico-jejunostomy (according to the procedure of Partington Rochelle) after pre operative endoscopy had revealed a dilatation of the main pancreatic duct (mean : 6 mm). Pancreatico-jejunostomy was the unique procedure in 59 patients; it was associated with a biliary or duodenal diversion in 46 others patients. 2 patients died post-operatively and 12 required a second operation some years subsequent to the pancreatic drainage, for biliary stenosis due to the progress of the sclerosis. 8 of the 22 late death were in direct relation with the persistence of alcohol intake and 4 others died from an extra pancreatic cancer. Peptic ulcer complicating pancreatico-jejunostomy appeared in three patients and two of them died from hemorrhage. Mean observation time was 65 years. Long term results were excellent or improved in 93.4% what pain relief concern, but the progression of exocrine or endocrine pancreatic insufficiency indicates that decompression of the dilated pancreatic duct does not prevent continuing destruction of pancreatic glandular tissue. In spite of these good results, the rational for duct drainage as a mean to decrease the intraductal pressure secondary to stricture is unclear. Neither the patency of the anastomosis, nor the presence or not of pancreatic lithiasis or the size of the dilated pancreatic duct seem to be crucial for pain relief after pancreatico-jejunostomy. Notwithstanding of the dubiousness of the mechanism of action of the drainage procedure, pancreato-jejunostomy remains the most effective procedure for relief of pain in chronic pancreatitis with dilated duct.     

胰管结石11例诊治体会

目的探讨胰管结石的诊断与治疗。方法对2001～2007年间11例胰管结石患者的临床资料进行回顾性分析。结果胰管结石患者均以上腹痛为主要首发症状且合并慢性胰腺炎,多数有内、外分泌功能障碍。B超、CT、ERCP及MRCP均可明确诊断。6例行胰管切开取石、胰管空肠Roux—en—Y吻合术,3例胰体尾部结石行胰体尾切除、胰断端套入空肠端Roux—en-Y吻合术;2例行胰十二指肠切除术,1例胰头部结石行胰管切开取石,主胰管内置T型管引流。结论：B超、CT及MRCP是诊断胰管结石最主要的手段。外科手术治疗仍是目前治疗胰管结石的主要方法。手术方式的选择主要取决于胰管结石的部位、主胰管有无狭窄及是否合并胰腺癌。     

慢性胰腺炎的分型与术式选择

目的 探讨慢性胰腺炎的分型与术式选择及其外科治疗效果。方法 回顾性分析我院外科1983-2004年收治的54例慢性胰腺炎患者的临床资料,并将其分为慢性钙化性胰腺炎及慢性梗阻性胰腺炎两组。结果男性41例(76％),女性13例(24％),平均年龄53．7岁。嗜酒者25例(46％),合并胆石症者21例(39％),原因不明特发性者2例(4％),既往有急性胰腺炎发作者18例(33％)。主诉腹痛者38例(70％),合并黄疸者27例(50％)。慢性钙化性胰腺炎与慢性梗阻性胰腺炎在某些临床表现问存在显著性差异,后者临床表现更趋复杂多样。34例患者分别采用9种不同的手术方式,无围手术期死亡。Puestow手术及胰十二指肠切除可有效地缓解疼痛,并可改善胰外分泌功能,对胰内分泌的影响不大。Puestow手术并行胆肠吻合适于合并胆道狭窄的慢性胰腺炎患者;胰头肿块型胰腺炎以黄疸为主要表现,应行胰十二指肠切除等切除术式,仅行胆道引流减黄效果良好,但胰头病变的演变尚待进一步观察。结论慢性梗阻性胰腺炎临床表现复杂,外科治疗应采用个体化原则。     

Chronic obstructive pancreatitis as a delayed complication of pancreatic trauma.

Increasing surgical experience with the immediate consequences of pancreatic injuries has resulted from parallel growth in the volume of motor vehicle accidents and societal violence. However, few surgeons are aware that complications may be considerably delayed following pancreatic trauma, occurring in some cases months to years after apparent recovery from the original injury. In four patients with blunt pancreatic trauma initially treated by non-operative means, stricture of the main pancreatic duct developed over a period of months as a result of progressive fibrosis at the site of ductal injury. Pancreatic duct hypertension was demonstrated to be present in the obstructed duct, and secondary changes of chronic pancreatitis developed in the obstructed segment of the gland ("upstream" chronic pancreatitis). Seven similar patients with delayed onset of chronic obstructive pancreatitis after pancreatic trauma were found in the literature. Symptoms related to these acquired ductal strictures are most commonly those of abdominal pain and recurrent episodes of acute pancreatitis. Recognition of post-traumatic chronic obstructive pancreatitis principally involves awareness that injuries to the pancreatic duct can produce remote complications. Pancreatoenteric drainage, or resection of the obstructed segment of pancreas, provides prompt and effective relief.     

Organ-preserving pancreatic head resection in chronic pancreatitis

BACKGROUND: Twenty to thirty per cent of patients with chronic pancreatitis develop inflammatory enlargement of the head of the pancreas. A safe procedure has been developed for duodenum-preserving pancreatic head resection; this report describes the preliminary results achieved. METHODS: Thirty patients, 27 men and three women of mean age 44 years, underwent surgical resection following the development of an inflammatory mass in the pancreatic head. All patients had weight loss and frequent abdominal pain. Jaundice was present in three and diabetes mellitus in ten patients. The diagnosis of chronic pancreatitis was made by a combination of endoscopic retrograde cholangiopancreatography, sonography and computed tomography. Pancreatic function was assessed by amylum tolerance test (ATT), oral glucose tolerance test and stool elastase measurement. The surgical procedure involved wide local resection of the inflammatory tumour in the pancreatic head, without division of the pancreas over the portal vein. Reconstruction involved drainage via a jejunal Roux-en-Y loop. In three icteric cases, prepapillary bile duct anastomosis was also performed using the same jejunal loop. RESULTS: There were no hospital deaths or major complications. After a median follow-up of 10 (range 6-14) months, all patients were symptom free. The mean increase in body-weight was 8.9 (range 4-20) kg. The ATT and stool elastase level demonstrated improved exocrine function but there was no change in endocrine function. CONCLUSION: This type of pancreatic head resection is a safe procedure that provides good short-term relief of symptoms associated with inflammatory changes in the head of the pancreas in chronic pancreatitis.