慢性胰腺炎的外科治疗

慢性胰腺炎是各种病因引起胰腺组织和功能不可逆改变的慢性炎症性疾病。主要表现为反复发作的上腹部疼痛和胰腺内、外分泌功能不全。治疗原则是去除病因,控制症状,改善胰腺内、外分泌功能不全及防治并发症发生。常用治疗方法包括药物、内镜及手术等,其中外科治疗可去除病灶、改善症状、延缓胰腺功能损伤,在慢性胰腺炎治疗中起着重要作用。由于病因及发病机制不同,临床进展程度轻、重不一,对于外科干预时机     

慢性胰腺炎时胰腺内、外分泌功能不全的发生机制及处理

目的总结慢性胰腺炎时胰腺内、外分泌功能不全的发生机制及处理方法的研究进展。方法检索近年来国内外有关慢性胰腺炎时胰腺内、外分泌功能不全研究的相关文献并对其研究进展作一综述。结果近几年对慢性胰腺炎时出现胰腺内、外分泌功能不全有了很多新的研究和发现。慢性胰腺炎时胰腺外分泌功能不全的发生机制主要是因为患者胰酶分泌减少;胰腺内分泌功能不全的发生机制主要是由于慢性胰腺炎时胰腺外分泌腺体及胰岛组织的损伤导致胰腺内分泌细胞、其他内分泌细胞的破坏以及肠-胰岛轴紊乱,继而出现各种激素(胰岛素、胰高血糖素、胰多肽等)的紊乱,最终表现出糖耐量异常或显性糖尿病。当前的治疗方法胰腺外分泌功能不全包括针对病因治疗、饮食调节及胰酶替代治疗;胰腺内分泌功能不全应提倡使用动态血糖监测系统,2型糖尿病的管理治疗方案可以用于慢性胰腺炎糖尿病,强化胰岛素治疗方案仍是慢性胰腺炎糖尿病的首选。结论目前虽然对慢性胰腺炎时胰腺内、外分泌功能不全已经有了一定程度的了解,但其有关发病机制、诊疗方案尚无突破性的进展,缺乏大样本、多中心的临床对照研究的疗效,探索更加优化的检测手段,建立完善的治疗体系,是未来的发展趋势及研究的重点。     

慢性胰腺炎与骨质疏松相关性研究进展

慢性胰腺炎作为一种慢性进展性炎症疾病,可导致胰腺组织和胰腺功能不可逆的损害。流行病学发现,在慢性胰腺炎患者中骨质疏松和骨折的发生率高于正常人。慢性胰腺炎后骨质疏松的发生机制可能与胰腺外分泌及内分泌功能的损害有关。同时,多种因素诸如吸烟、疾病严重程度、患病时间、病因、体重指数(body mass index,BMI)、年龄及性别等都可影响慢性胰腺炎后骨质疏松的发生。笔者从流行病学研究、发生机制及影响因素等方面讨论慢性胰腺炎与骨质疏松的相关性,为临床工作者提供一定的参考。     

慢性胰腺炎的诊治策略

慢性胰腺炎临床并不少见,为各种病因引起的胰腺组织和功能不可逆的慢性炎症性疾病,其病理特征为胰腺腺泡萎缩、破坏和间质纤维化.其早期临床症状为反复发作的上腹部疼痛或胰腺炎,进展期可合并胰腺外、内分泌功能不全的症状.影像学上表现为胰腺实质钙化、胰管扩张、胰管结石和胰腺假性囊肿形成等.而大量流行病学研究表明,慢性胰腺炎是胰腺癌的高危因素.     

慢性胰腺炎的外科治疗

慢性胰腺炎（chronic pancreatitis，CP）是由多种因素引起的进行性胰腺组织破坏、间质纤维增生、钙化为基本病理改变，最终导致胰腺内、外分泌功能部分或完全丧失的胰腺慢性炎性疾病。主要发病因素与长期嗜酒、胆系结石、高血脂、反复发生急性胰腺炎等有关。发病机制还不很清楚。临床表现以腹痛和消化功能障碍为主。临床诊断主要依靠临床表现、实验室和现代影像学检查。治疗目的主要是缓解疼痛，解除胆、胰管梗阻，延缓病程进展，补充胰腺内、外分泌功能不足。治疗方法大致包括内科药物、内镜介入和外科手术治疗。     

慢性胰腺炎的内镜治疗

慢性胰腺炎（chronic pancreatitis，CP）是指由于不同病因引起胰腺局部或弥漫性组织损害，导致胰腺内、外分泌功能不全的疾病。病理特征为胰腺纤维化。临床以反复发作的上腹部疼痛，胰腺内、外分泌功能不全的各种表现为主要症状。在我国，CP的发病率较低，其病因主要是酒精性因素，胆道因素已降至第2位。随着人们的生活水平提高，饮食习惯改变，其发病率有上升趋势。近年来，内镜对胰腺疾病的治疗已经广泛开展．本文就CP的内镜治疗作一综述。     

慢性胰腺炎的病因和发病机理探讨

慢性胰腺炎(chronic pancreatitis,CP)是指由于各种不同原因引起的胰腺组织的进行性的慢性炎症性疾病,伴有以广泛纤维化为特征的基本结构的永久性改变,去除病因后仍然存在功能性障碍。临床上通常表现为反复发作的腹痛和内、外分泌功能不全[1]。慢性胰腺炎的发病机理十分复杂,大     

慢性胰腺炎的病因与发病机制

慢性胰腺炎的病因与发病机制第三军医大学西南医院肝胆外科中心（重庆，６３００３８）董家鸿与慢性胰腺炎发病有不同程度密切关系的因素很多。在不同的国家和地区，由于受地理环境、经济状况及生活习惯等多种因素的影响，其致病因素与发病率均有较大的差异。据国外多中心...     

肿块型慢性胰腺炎的治疗

慢性胰腺炎是一种进行性不可逆转地破坏胰腺并使胰腺组织被纤维组织替代的慢性炎症,而胰腺组织的破坏最终将导致腹泻、脂肪泻、糖尿病等胰腺外分泌、内分泌功能障碍和反复发作且难以控制的上腹部疼痛.慢性胰腺炎的病因较多,可分为:毒性代谢性因素(酗酒和吸烟是主要的原因)导致的慢性胰腺炎、特发性慢性胰腺炎、基因相关的慢性胰腺炎、自身免疫性慢性胰腺炎、复发性急性胰腺炎或梗阻因素导致的慢性胰腺炎.     

慢性胰腺炎的外科治疗

<正>慢性胰腺炎(chronic pancreatitis,CP)是由各种病因引起的胰腺组织和功能不可逆的慢性炎症性疾病,以胰腺腺泡萎缩、破坏和间质纤维化为主要病理表现,临床表现为反复发作的上腹部疼痛和(或)胰腺内、外分泌功能不全,可伴有胰腺实质钙化、胰管扩张、胰管结石和胰腺假性囊肿形成等[1-2]。由于CP是一个不可逆的炎症反应,因此,治疗以去除病因,控制症状,纠正和改善胰腺内外分泌功能不全及     

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??Etiology and pathogenesis of chronic pancreatitis WANG Xing-peng*, ZHANG Ru-ling. *Tenth People’s Hospital of Tongji University, Shanghai 200072, China
Corresponding author: WANG Xing-peng, E-mail: wangxp1965@yahoo.com.cn
Abstract Chronic pancreatitis (CP) is the progressive and permanent destruction of the pancreas resulting in exocrine and endocrine insufficiency. The typical pathological change of CP is pancreatic fibrosis, which could cause persistent or recurrent abdominal pain as well as loss of pancreatic endo- and exocrine function. The etiology and pathogenesis of CP are multifactorial, including cholelithiasis, alcoholism, genetic predisposition and autoimmune factors. However, the incidence of CP should be a result of multiple etiological factors, and the individual pathogenesis remains unclear. Further researches of individual etiology and pathogenesis of CP would be helpful to the prevention and treatment of this disease.     

CENTRAL PANCREATECTOMY FOR BENIGN PANCREATIC PATHOLOGY/TRAUMA: IS IT A REASONABLE PANCREAS‐PRESERVING CONSERVATIVE SURGICAL STRATEGY ALTERNATIVE TO STANDARD MAJOR PANCREATIC RESECTION?

BACKGROUND: The aim of this study was to assess the technical feasibility, safety and outcome of central pancreatectomy (CP) with pancreaticogastrostomy or pancreaticojejunostomy in appropriately selected patients with benign central pancreatic pathology/trauma. Benign lesions/trauma of the pancreatic neck and proximal body pose an interesting surgical challenge. CP is an operation that allows resection of benign tumours located in the pancreatic isthmus that are not suitable for enucleation. METHODS: Between January 2000 and December 2005, eight central pancreatectomies were carried out. There were six women and two men with a mean age of 35.7 years. The cephalic pancreatic stump is oversewn and the distal stump is anastomosed end-to-end with a Roux-en-Y jejunal loop in two and with the stomach in six patients. The indications for CP were: non-functional islet cell tumours in two patients, traumatic pancreatic neck transection in two and one each for insulinoma, solid pseudopapillary tumour, splenic artery pseudoaneurysm and pseudocyst. Pancreatic exocrine function was evaluated by a questionnaire method. Endocrine function was evaluated by blood glucose level. RESULTS: Morbidity rate was 37.5% with no operative mortality. Mean postoperative hospital stay was 10.5 days. Neither of the patients developed pancreatic fistula nor required reoperations or interventional radiological procedures. At a mean follow up of 26.4 months, no patient had evidence of endocrine or exocrine pancreatic insufficiency, all the patients were alive and well without clinical and imaging evidence of disease recurrence. CONCLUSION: When technically feasible, CP is a safe, pancreas-preserving pancreatectomy for non-enucleable benign pancreatic pathology/trauma confined to pancreatic isthmus that allows for cure of the disease without loss of substantial amount of normal pancreatic parenchyma with preservation of exocrine/endocrine function and without interruption of enteric continuity.     

Chronic pancreatitis: pathogenesis and molecular aspects

Chronic pancreatitis (CP) is characterized by irreversible morphological and functional alterations of the pancreas presenting clinically with upper abdominal pain as well as exocrine and endocrine insufficiencies. CP is morphologically characterized by pancreatic head enlargement, calcifications of the parenchyma, cysts, and pancreatic stones. The most common etiological factor of CP in Western industrialized countries is alcohol abuse; less common factors include hereditary pancreatitis, CP due to metabolic disturbances, CP due to pancreas divisum or duodenal wall cysts, and idiopathic CP. The molecular alterations leading to the chronic inflammatory process are nor completely understood. Research during the last years, however, has elucidated that a number of growth factors and their receptors are overexpressed in CP, which is thought to contribute to the high degree of pancreatic fibrosis and to the proliferative potential of ductular cells in this disorder. In addition, gene mutations have been detected in a subgroup of CP samples underscoring the pre-malignant potential of CP. In this review we will summarize our current knowledge about pathogenic and molecular aspects of CP.     

Chronic pancreatitis: modern surgical management

Introduction  

Chronic pancreatitis (CP) is a disease with enormous social and personal impact. It is most commonly caused by the abuse of alcohol combined with nicotine. CP is usually characterised by an inflammatory mass located in the pancreatic head. Its natural course is characterised by persistent or recurrent painful attacks as well as progressive loss of pancreatic function due to fibrosis of the parenchyma with consecutive endocrine and exocrine insufficiency.     

Pancreaticoduodenectomy Versus Frey's Procedure for Chronic Pancreatitis: Preliminary Data on Outcome and Pancreatic Function

Purpose Several surgical treatments have been proposed for treating chronic pancreatitis (CP), including standard pancreaticoduodenectomy (PD), pylorus-preserving PD, Beger's procedure, and Frey's procedure; however, few studies have compared pre- and postoperative pancreatic function in patients undergoing surgery for CP. Methods Between 1996 and 2003, 42 patients with CP underwent pancreatic head resection; as PD in 17 and as Frey's procedure in 25. Frey's procedure was chosen if the pancreatic duct was dilated more than 5 mm. We conducted this prospective, nonrandomized study to compare the pre- and postoperative status after PD or Frey's procedure by evaluating pancreatic function and symptom relief. Results The demographic features, surgical morbidity, and mortality were similar in the two groups. Pancreatic exocrine function improved, pain subsided, and complications of the adjacent organs resolved after surgery in both groups. Similar postoperative endocrine and exocrine functional results were observed in both groups. Frey's procedure was associated with a significantly shorter hospital stay than PD (10.6 versus 15.4 days, respectively; (P < 0.0001)). Conclusion There were no significant difference in operative time, surgical morbidity, or mortality rates between PD and Frey's procedure. Both procedures were equally effective in terms of pain relief, improvement of pancreatic exocrine function, and control of complications affecting the adjacent organs; however, Frey's procedure was associated with a significantly shorter hospital stay.     

Long-term Outcome After Resection for Chronic Pancreatitis in 224 Patients

Introduction Organ complications like biliary or duodenal stenosis as well as intractable pain are current indications for surgery in patients with chronic pancreatitis (CP). We present here our experience with pancreatic resection for CP and focus on the long-term outcome after surgery regarding pain, exocrine/endocrine pancreatic function, and the control of organ complications in 224 patients with a median postoperative follow-up period of 56 months. Methods During 11 years 272 pancreatic resections were performed in our institution for CP. Perioperative mortality was 1%. Follow-up data using at least standardized questionnaires were available in 224 patients. The types of resection in these 224 patients were Whipple (9%), pylorus-preserving pancreato-duodenectomy (PD) (PPPD; 40%), duodenum-preserving pancreatic head resection (DPPHR; 41%, 50 Frey, 42 Beger), distal (9%) and two central pancreatic resections. Eighty-six of the patients were part of a randomized study comparing PPPD and DPPHR. The perioperative and follow-up (f/up) data were prospectively documented. Exocrine insufficiency was regarded as the presence of steatorrhea and/or the need for oral enzyme supplementation. Multivariate analysis was performed using binary logistic regression. Results Perioperative surgical morbidity was 28% and did not differ between the types of resection. At last f/up 87% of the patients were pain-free (60%) or had pain less frequently than once per week (27%). Thirteen percent had frequent pain, at least once per week (no difference between the operative procedures). A concomitant exocrine insufficiency and former postoperative surgical complications were the strongest independent risk factors for pain and frequent pain at follow-up. At the last f/up 65% had exocrine insufficiency, half of them developed it during the postoperative course. The presence of regional or generalized portal hypertension, a low preoperative body mass index, and a longer preoperative duration of CP were independent risk factors for exocrine insufficiency. Thirty-seven percent of the patients without preoperative diabetes developed de novo diabetes during f/up (no risk factor identified). Both, exocrine and endocrine insufficiencies were independent of the type of surgery. Median weight gain was 2 kg and higher in patients with preoperative malnutrition and in patients without abdominal pain. After PPPD, 8% of the patients had peptic jejunal ulcers, whereas 4% presented with biliary complications after DPPHR. Late mortality was analyzed in 233 patients. Survival rates after pancreatic resection for CP were 86% after 5 years and 65% after 10 years. Conclusions Pancreatic resection leads to adequate pain control in the majority of patients with CP. Long-term outcome does not depend on the type of surgical procedure but is in part influenced by severe preoperative CP and by postoperative surgical complications (regarding pain). A few patients develop procedure-related late complications. Late mortality is high, probably because of the high comorbidity (alcohol, smoking) in many of these patients.     

中段胰腺切除术19例临床分析

背景与目的:胰十二指肠切除术(PD)和胰体尾切除术(DP)被认为是治疗胰腺肿瘤的标准术式.然而,它们应用于治疗良性或低度恶性肿瘤时可能导致的胰腺内外分泌功能不足需引起重视.本研究旨在探讨中段胰腺切除术(CP)治疗胰颈部或近端体部良性或低度恶性肿瘤的临床疗效.方法:回顾性分析南昌大学第一附属医院2009年6月—2020年...     

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.     

Islet cell dysfunction in patients with chronic pancreatitis

Chronic pancreatitis(CP) is characterized by progressive inflammation and fibrosis of the pancreas that eventually leads to pancreatic exocrine and endocrine insufficiency. Diabetes in the background of CP is very difficult to manage due to high glycemic variability and concomitant malabsorption. Progressive beta cell loss leading to insulin deficiency is the cardinal mechanism underlying diabetes development in CP. Alpha cell dysfunction leading to deranged glucagon secretion has been described in different studies using a variety of stimuli in CP. However, the emerging evidence is varied probably because of dependence on the study procedure, the study population as well as on the stage of the disease. The mechanism behind islet cell dysfunction in CP is multifactorial. The intra-islet alpha and beta cell regulation of each other is often lost. Moreover, secretion of the incretin hormones such as glucagon like peptide-1 and glucose-dependent insulinotropic polypeptide is dysregulated. This significantly contributes to islet cell disturbances. Persistent and progressive inflammation with changes in the function of other cells such as islet delta cells and pancreatic polypeptide cells are also implicated in CP. In addition, the different surgical procedures performed in patients with CP and antihyperglycemic drugs used to treat diabetes associated with CP also affect islet cell function. Hence, different factors such as chronic inflammation, dysregulated incretin axis, surgical interventions and anti-diabetic drugs all affect islet cell function in patients with CP. Newer therapies targeting alpha cell function and beta cell regeneration would be useful in the management of pancreatic diabetes in the near future.     

慢性胰腺炎的内科治疗

慢性胰腺炎（chronic pancreatitis,CP）是由于胰腺炎症导致胰腺组织不可逆的毁损, 最终将导致胰腺内、外分泌功能的部分或全部丧失。CP治疗目标是减轻疼痛,改善胰腺脂肪泻及营养不良,治疗糖尿病等并发症,保持或改善病人生活质量等。缓解疼痛是最常见的临床问题,补充胰酶和适当使用镇痛药物是常用治疗方法。胰酶制剂能显著改善脂肪泻,而其使用剂量和使用方法非常重要。近年来内镜治疗的进步令人鼓舞,方法包括胰腺括约肌切开术,支架置入术和体外震波碎石术等。内镜技术的进步为CP病人提供了新的治疗希望,但长期疗效仍有待随访。此外,在生活方式上,戒烟酒对CP病人很可能有益,而低脂饮食因为可能导致脂溶性维生素的缺乏而不被推荐。