外科-胰腺疾病課件

PANCREASThechapterincludes:Summaryofanatomy&physiologyAcutepancreatitisChronicpancreatitisPancreaticcystPancreaticcancer/Periampullarycarcinoma

PancreaticendocrinetumorsLocation®ionAnatomy&physiologyLength:12-20cmWidth:3-4cmWeight:75-125gBloodsupplyHead：Gastroduodenala.→Ant.andpost.sup.pancreaticoduodenala.

Sup.mesenterica.→Ant.andpost.inf.pancreaticoduodenala.

Body&tail:Splenica.，Dorsalpancreatica.→Transversepancreatica.

Venous&lymphdrainageLymphdrainagebymultiplenodegroups,mainlyceliacnodes&sup.mesentericnodes

Splenicv.Pancreaticv. Portalv.

Sup.andinf.pancreaticoduodenalv.Sup.mesentericv.

Ducts:

theductofWirsung/mainduct

theductofSantorini/accessoryductPhysiologyexocrinepancreas:pancreaticjuice,750-1500ml/d---bicarbonate&digestiveenzymes/proenzymesendocrinepancreas:1.7-2.0millionsofislets---4majorcelltypes&someminortypes

Acells–glucagonsBcells–insulinDcells–somatostatin

PPcells–pancreaticpolypeptideGcells–gastrin

D1–vasoactiveintestinalpolypeptideAcutepancraetitis

Acommonacuteabdomen,includingmild&severetypesWhatisit?benigndisease,malignantprognosisCausesBiliarytractstonesEthanolabuseHyperlipidemiaDietaryfactorsTrauma,Surgery,ERCP/ESTInfectionDrugs:thiazidediuretics,oralcontraceptivesMetabolicabnormalitiesBiliarytractstones/obstructionBilerefluxtheory---CommonchanneltheorystoneEthanolabuseIncreasingductalpressureIncreasingpancreaticenzymesecretionDirectinjurytopancreaticacinarcellsSIRSsystemicinflammatoryresponsesyndromeMODSmultipleorgandysfunctionsyndromePresentationacuteabdominalpainnausea,vomitingabdominaldistension/abdominalcompartmentsyndrome(ACS)fever/hyperthermiajaundiceshock,MODSPresentationGreyTurnersign–flankbluishecchymoses

Cullensign–umbilicalbluishecchymoses

ARDS

acuterespiratorydistresssyndrome

SIRSsystemicinflammatoryresponsesyndromeMODSmultipleorgandysfunctionsyndromeLaboratoryFindingsSerumamylaseandlipaselevelsSerumcalciumbloodglucosearterialbloodgaswhitebloodcellcountImagingstudiesChest/abdominalradiographsUltrasoundCTMRIMRCPcontrastCTmildpancreatitisbleedingandnecroticfocuseshemorrhagicfocuspseudocyst

AdmissionAge>55yrWBC>16000/mm3Glucose>200mg/dLLDH>350IU/LAST>250IU/L

Initial48hrsHct

fall>10%BUNelevation>5mg/dLCa2+<2mmol/LPaO2<60mmHgBasedeficit>4mmol/LFluidsequestration>6L3or4signsmortality15%,7or8signsmortality90%Ranson’sPrognosticSignsDifferentialdiagnosisacutecholangitis/cholecystitisperforatedhollowviscusbowelobstructionmesentericischemia/infarctionacutegastroenteritisacutemyocardialinfarction

Thestagesofcoursestageofacutereaction–--within2wstageofsystemicinfection–--2w-2mstageofresidualinfection---laterthan2-3musuallybutnotalwaysLocalcomplicationsacutefluidcollectionpancreaticandperipancreaticnecrosispancreaticpseudocystpancreaticabscessTreatment

Medicaltherapyfastingdiet,gastricsuctioninhibitionofpancreaticjuicesecreting--somatostatin

(Sandostatin，Stilamin，Uinastatin)paregorics&spasmolysisfluid&electrolytemanagementAntacids(Ranitidine，Losec)prophylacticantibioticstraditionalChinesemedicineTreatment

MedicaltherapyNutritionalsupport/totalparenteralnutritionInsulinOxygenprovidedThoracentesisDialysisTreatment

SurgicaltherapyEndoscopic

sphincterotomy,ESTGallbladderremovalPeritonealirrigating（nolongerwidelyused）CT-guidedneedleaspirationDebridementTreatmentofseverepancreatitis

stageofacutereaction–--nonoperative→surgicalstageofsystemicinfection–--antibiotics→(ultrasoundorCT-guided)needleaspiration→surgicaldrainagestageofresidualinfection---nutritionalsupport→surgeryTreatmentofacutebiliary

pancreatitisThegroupwithoutbileductobstructionorcholangitis---nonoperativetherapythencholecystectomyThegroupwithbileductobstructionorcholangitis---earlyoperationorEST,ENBDERCP

stoneextractionTreatmentoflocalcomplicationsacutefluidcollection---spontaneouslyresolvepancreaticandperipancreaticnecrosis---debridementanddrainage

pancreaticpseudocyst---<6cmwithoutsymptom,notreatment;theothersorexistingmorethan3-6m,surgicaldrainagepancreaticabscess---surgicaldrainageChronicPancreatitis

PancreaticCystPeriampullaryCarcinoma

carcinomaofheadofpancreas

ampullarycarcinoma

duodenalpapillarycarcinomacarcinomaofdistalcommonbileduct

carcinomaofVater's

ampulla

Symptomsandsignsupperabdominalpain(vague→severe,backpain)70％jaundice(painless)80%weightloss75％Trousseau’ssyndrome,Courvoisier’ssignothers:nausea,v