摘要:

The indications of endoscopic management for chronic pancreatitis are strictly related to the classification of severe types and to the particular anatomy of the ducts. (1) Impacted or distal calculi without stricture: ESWL followed by EPS and extraction of fragments. (2) Stone(s) and stricture: ESWL, EPS, NPC, and then 10-french plastic stenting. (3) Relapsing strictures (with upward dilatation) after 6-12 months’ stenting: coated self-expanding stent (in a prospective trial), versus surgical laterolateral pancreaticojejunostomy (Partington-Ro-chelle operation). (4) Paraduodenal cyst bulging into the duodenum: ECD ± stenting. (5) Retrogastric pseudocyst: ECG and stenting. (6) Jaundice and/or cholestasis due to stricture of the intrapancreatic CBD: 10-french single or multiple plastic stents for calibration during 3 months. For relapsing cholestasis and stricture, 30-french metal mesh stent versus surgical hepaticojejunostomy. Due to the tremendous variations of the ducts’ anatomy, the method includes drainage through the minor papilla for patients with a dominant Santorini or dorsal duct (table 6). The indications of endoscopic management for chronic pancreatitis are specific and require complete imaging and functional check-up (ERCP, CT scanner, endosonography, pancreatic function tests). The technique is quite difficult and requires high-definition fluoroscopy, appropriate devices and experienced gastrointestinal assistents and radiologists. On these conditions, the complication rate is very low and can usually be medically controlled. Treatment does not compromise any further surgery. Endoscopy makes it possible to avoid or to postpone surgery, the indication for which might become better defined and the patients more carefully selected in the fu

ISSN:0253-4886    

DOI:10.1159/000172269

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Pain and malabsorption are the major clinical problems to manage in patients with chronic pancreatitis. To successfully manage pain requires knowledge of the natural history of chronic pancreatitis; to manage malabsorption requires some information regarding the pathophysiology of pancreatic insufficiency and the behavior of enzymes within the intestinal lumen. Surprisingly, all too often this knowledge is lacking and leads to inappropriate and ill-advised or improper treatments. Herein is reviewed the author’s current opinion regarding treatment of these problems, based on natural history and pathophysiologic studie

ISSN:0253-4886    

DOI:10.1159/000172270

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

The indications for surgery in chronic pancreatitis can be grouped as follows: suspicion of carcinoma, operations on organs remote from the pancreas, local complications of chronic pancreatitis (the most common complication being the choledochal stenosis), and intractable pain. Almost all local complications are best treated surgically, with each operation adapted to the type of complication. In the case of intractable pain, the choice of the procedure depends on the morphology of the altered gland. In symptom-free patients an operation is never indicated, not even with the goal of preserving the exocrine function.

ISSN:0253-4886    

DOI:10.1159/000172306

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Drainage procedures are conceived to treat the sequels of disruption or dilatation of the pancreatic ductal system. The most common consequence of duct disruption is a pseudocyst which must be distinguished from a pseudopseudocyst. Pseudopseudocysts have no communication with the ductal system and tend to resolve spontaneously. Healing of true pseudocysts requires drainage in the majority of cases. This may be achieved by surgical or nonsurgical methods, the respective merits of which are sill under debate. Pain in chronic pancreatitis which is due to pseudocysts or ductal hypertension and duct dilatation with or without intraductal calculi is relieved by drainage in most patients. The most widely used method of ductal drainage is a longitudinal pancreaticojejunostomy. Caudal pancreaticojejunostomy is nowadays mainly used as a complementary measure to distal pancreatectomy for pseudocysts. Longitudinal pancreaticojejunostomy may fail to relieve pain in patients with an inflammatory mass in the pancreatic head. It must then be combined with resection which can be achieved by using the techniques of duodenum-preserving resection of the pancreatic head. The difference between the two techniques is not as big as it might appear at first sight.

ISSN:0253-4886    

DOI:10.1159/000172276

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

The records of 25 patients with chronic pancreatitis who underwent pylorus-preserving pancreatoduodenectomy (PPPD) were reviewed. A comparison was made with the clinical results obtained from 20 patients with side-to-side pancreatojejunostomy and from 33 patients with distal resection. 88% of the patients treated with PPPD and 93% of the patients treated with distal resection reported complete improvement in pain; after side-to-side pancreatojejunostomy 10% patients had partial improvement in pain and 20% needed narcotics. Diabetes developed in 10% of patients following side-to-side pancreatojejunostomy and in 24% of patients following distal resection. Exocrine dysfunction developed in 64% after PPPD, in 15% after side-to-side pancreatojejunostomy and in 8% after distal resection. PPPD is very effective in relieving pain and preserving endocrine function, but precipitates exocrine dysfunction early on after the operation.

ISSN:0253-4886    

DOI:10.1159/000172277

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

In a randomized unicenter clinical study duodenum-preserving pancreatic head resection and pylorus-preserving Whipple operation were prospectively compared in patients with chronic pancreatitis. Preoperatively, 10 days and 6 months postoperatively the patients were investigated with regard to glucose tolerance, pain relief, weight gain, hospital readmission, professional rehabilitation and postoperative complications. In the 6 months’ follow-up, patients who underwent the duodenum-preserving pancreatic head resection had less pain, greater weight gain, a better glucose tolerance and a higher insulin secretion capacity than patients with the pylorus-preserving Whipple resection. The postoperative mortality was zero and the postoperative morbidity was comparable in both groups (duodenum-preserving pancreatic head resection: 3/20 patients (15%), pylorus-preserving Whipple operation 4/20 patients (20%)). Duodenum-preserving pancreatic head resection provides a better postoperative outcome than the pylorus-preserving Whipple resection. Therefore, it should be considered as a new standard operation in patients with chronic pancreatitis and pancreatic head-related complication

ISSN:0253-4886    

DOI:10.1159/000172278

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (LR-LPJ) was performed in 50 patients, the results of which were reported at the American Surgical Association meeting in San Antonio, Tex., on April 8, 1994. The operation was not performed in patients where ducts were less than 3.5 mm in diameter. There were no operative deaths. Forty-seven patients were followed an average of 37 months. Forty-three of the 50 patients were alcoholic. Pseudocysts were present in 50% of the patients. Thirty-five intra-abdominal operations had previously been performed on 23 patients. Preoperatively, all patients underwent computed tomography. Endoscopic retrograde cholangiopancreatography was performed in 82% of patients and angiography in 64% of patients. Preoperatively, all patients had pain. Common bile duct obstruction was present in 8% of patients. The average length of hospital stay was 18.7 days. Postoperative complications occurred in 22% of patients. Pain relief was judged excellent in 74.5%, improved in 12.75%, and unimproved in 12.75%. The pain assessment included use of a pain scale and narcotic usage. Progression of diabetes occurred in patients in the immediate postoperative period and in 3 patients at 3, 16, and 22 months. Exocrine function based on presence of steatorrhea improved in 10 patients (22%) and deteriorated in 5 (11%). Weight gain was noted in 25 patients and weight loss in 13 patients. Few patients not working preoperatively returned to work postoperatively (15.9%). Aside from pain relief, the operation is also useful in the management of patients with stricture of the intrapancreatic portion of the common duct, pseudocysts, pancreatic ascites, and pancreatic fistulas. LR-LPJ is not indicated in patients in whom there is a suspicion of pancreatic cancer, nor in patients with splenic vein thrombosis and left-sided portal hypertension or pseudoaneurysm of the peripancreatic vessels in the absence of some additional procedure to correct these problems. Patients with a small main pancreatic duct < 3.5 mm having common duct and duodenal obstruction are best treated by pancreaticoduodenectomy. Patients with a small main pancreatic duct whose disease is limited to the body and tail of the pancreas are best treated by distal pancreatectomy.

ISSN:0253-4886    

DOI:10.1159/000172279

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Two techniques of duodenum-preserving resections of the head of the pancreas have been described by Beger and Frey for treatment of chronic pancreatitis. These techniques were compared in a prospective randomized trial following a pilot study. The course of 31 patients with chronic pancreatitis was prospectively documented with 25 patients having undergone Beger’s and 6 Frey’s procedure. Thereafter 38 patients were randomly allocated to either Beger’s or Frey’s group. The mean interval between symptoms and surgery was 5.4 years in the pilot study and 5.6 years in the randomized study. 17 adjacent organs (13 common bile duct stenoses, 4 duodenal stenoses) were affected in 13 patients in the pilot study, and 35 adjacent organs (28 common bile duct stenoses, 6 duodenal stenoses, 1 pancreatopleural fistula) in 28 patients in the randomized study. The mean follow-up was 4.8 years in the pilot study and 1.5 years in the randomized study (minimum 6 months). In both series there was no mortality. Morbidity was 26% in the pilot study (28% Beger, 17% Frey) and 16% in the randomized study (21 % Beger, 11 % Frey). In the pilot study complete pain relief was achieved in 92 and 83% of patients after Beger’s and Frey’s procedure, and in the randomized trial in 95 and 89% of patients after Beger’s and Frey’s procedure. Associated affection of adjacent organs was definitively resolved in 94% (16 of 17) in the pilot study (92% Beger, 100% Frey) and in 94% (33 of 35) in the randomized study (90% Beger, 100% Frey). Both techniques of duodenum-preserving pancreatic head resection are equally safe and effective with regard to pain relief and definitive control of complications affecting

ISSN:0253-4886    

DOI:10.1159/000172280

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Pancreatic cancers take their origin from exocrine and endocrine components of the gland, but about 95% occur within the exocrine portion. In this short review, emphasis is placed on malignant tumors of exocrine epithelia. Ductal adenocarcinoma and its variants are discussed in more detail, and the pathology of the clinically most relevant special types of pancreatic carcinoma is presented. In addition, recent criteria used to identify preneoplastic lesions of the exocrine pancreas are reviewed. Finally, aspects of neuroendocrine differentiation in pancreatic carcinomas are discussed.

ISSN:0253-4886    

DOI:10.1159/000172281

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

The prognosis of carcinoma of the pancreas remains dismal, with no recent appreciable improvement in overall survival. Prognostication in individual patients has become important in the selection of appropriate treatment, particularly in advanced disease with the option of non-operative stenting. Patients with a short life expectancy can be identified by a poor performance status (e.g. Karnofsky) or when metastatic disease is detected by imaging (ultrasonography or CT) or laparoscopy. The correlation between tumour staging and prognosis remains problematic. The anatomical location of the pancreas and lack of representative tissue sampling invariably result in understaging, which limits the value of tumour staging systems and hampers the interpretation of therapeutic trials. While it is generally agreed that pancreatic resection provides the only hope for cure, there is no consensus on how radical surgery should be. No convincing data have been produced to support radical (regional) pancreatectomy as a better cancer operation. Improved 5-year survival figures have been achieved after pancreatectomy irrespective of the extent of the resection. Lower operative mortality has contributed to these improved results.

ISSN:0253-4886    

DOI:10.1159/000172282

出版商:S. Karger AG    

年代:1994

数据来源: Karger