1、文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。BACK GROUND Operative approaches to the treatment of chronic pancreatitis have undergone a dramatic transformation over the past few decades.The head of the pancreas has become universally appreciated as the nidus of chronic inflammation.Prospective,randomized
2、trials have repeatedly shown the superiority of surgical treatment over medical approaches to management2022-10-211文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。INDICATIONS FOR SURGERY1.Pain Ductal hypertension:some anatomic changes related with it such as：small cysts、foci of acinar cell necrosis、areas of
3、acute inflammation Peripancreatic sensory nerve damage：inflammatory damage 、neuron-specific proteinase activated receptor 2 activation、C fibers（a subpopulation of sensory neurons）contain peptides which can cause inflammatory changes2.The complications of chronic pancreatitis2022-10-212文档仅供参考，不能作为科学依
4、据，请勿模仿；如有不当之处，请联系网站或本人删除。Treatment1.The medical treatment of chronic pancreatitis-associated pain usually fails2.surgical treatment of chronic pancreatitis has been shown to eliminate pain and return patients to predisease employment and quality-of-life status.2022-10-213文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，
5、请联系网站或本人删除。Operative procedures Operative procedures about chronic pancreatitis have historically been classified into 3 categories：1.Decompression of diseased and obstructed pancreatic ducts2.Denervation of the pancreas3.Resection of the proximal,distal,or total pancreas.Within the past few years,h
6、owever,a category of hybrid procedures has been shown to be safe and effective.2022-10-214文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。DECOMPRESSION PROCEDURES1.Remove calculi from Wirsungs duct:transpancreatic route or transduodenally through the papilla of Vater(ERCP WITH OR WITHOUT prolonged pancreatic
7、 duct stenting)2.Decompressing the proximal pancreatic and distal bile ducts by sphincteroplasty to prevent recurrent pancreatitis which caused by biliary stone.2022-10-215文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。External drainage of the pancreatic duct to decompress obstruction caused by stricture or
8、 calculus(Fig.1)FIGURE 12022-10-216文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。4.Roux-en-Y,side-to-end,pancreaticojejunostomy5.The caudal,end-to-end,pancreaticojejunostomy as a drainage procedure for chronic pancreatitis(FIG 2.)FIGURE 2.2022-10-217文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。6.Longitudinal dec
9、ompre-ssion of the body and tail of the pancreas into a Roux limb of jejunum(Fig.3)FIGURE 3.2022-10-218文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。7.Side-to-side longitudinal pancreaticojejunostomy that became known as the“Puestow”procedure (Fig.4).FIGURE 42022-10-219文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删
10、除。For long-term relief of pain in chronic pancreatitis,techniques of focal decompression of the ductal system were found to fail as multiple points of obstruction due to calculi or strictures are the rule in patients with alcoholic,hereditary,tropical,and idiopathic pancreatitis.The effect of decomp
11、ression2022-10-2110文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。DENERVATION PROCEDURES1.Bilateral thoracolumbar sympathectomy2.The use of operative,endoscopic,and imageguided neurolysis of the celiac trunks and ganglia have been reported in the treatment of chronic pancreatitis.3.Vagotomy,with partial gas
12、trectomy or a drainage procedure(truncal vagotomy is not recommended as a mean to relieve the pain of chronic pancreatitis because it is the fundamental to pancreatic exocrine regulation)2022-10-2111文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The effect of denervation procedures Studies with follow-up ex
13、tending 2 years or more disclose that narcotic usag increases and pain typically returns to preoperative levels Howard et al found that patients who had had no prior operative or endoscopic intervention before bilateral splanchnicectomy and who likely had“small duct”disease remained improved2022-10-
14、2112文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。RESECTIONAL PROCEDURES1.Proximal PancreatectomyIt has proven to be an effective mean of managing pain and the complications of chronic pancreatitis In the 3 largest modern(circa 2000)series of the treatment,pain relief 4 to 6 years after operation ranged fr
15、om 71%to 89%of patients.The mortality rate of the operation has been reduced to less than 5%The morbidity stubbornly remains at about 40%.Without the high incidence of endocrine dysfunction2022-10-2113文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。2.Pylorus PreservationPresumed nutritional and physiologic b
16、enefits associated with retention of the pylorus.Now employed in 70%to 80%of all Whipple procedures.Physiologic gastric emptying is assumed with preservation of the pylorus Increased incidence of marginal ulcerationWithout the high incidence of endocrine dysfunction2022-10-2114文档仅供参考，不能作为科学依据，请勿模仿；如
17、有不当之处，请联系网站或本人删除。3.Total PancreatectomyThe operation produces no better pain relief for their patients than pancreaticoduodenectomy(about 80%85%)The metabolic consequences of total pancreatectomy in the absence of islet cell transplantation are profound and life threatening.Lethal episodes of hypogl
18、ycemia are common in severe apancreatic diabetes due to the absence of pancreatic glucagon,and to hypoglycemia unawarenessPrevention of the physiological consequences of total pancreatectomy remains an unfulfilled goal2022-10-2115文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。4.Pancreatectomy With Islet Aut
19、oTransplan-tationMethods of harvesting and gland preservation Islets are infused into the portal venous circuit for intrahepatic engraftment Some degree of insulin dependence is still present in two-third of patients 2 to 3 million islets are required for successful engraftment in an allogeneic reci
20、pientAuto-transplant recipient can achieve longterm,insulin independent status after engraftment of only 300,000 to 400,000 islets2022-10-2116文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。25%to 30%of patients with chronic pancreatitis are already diabetic so islet auto-transplantation is not an option in t
21、hose patients.Islet transplant recipients who become euglycemic initially,their islet cell function remains impaired,and after 2 years most require insulin.2022-10-2117文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。5.Distal PancreatectomyIn a small percentage of cases the body and tail may be the portions o
22、f the pancreas most diseased due to isolated duct stricture,pseudocyst disease,or bothFor these patients the technique of partial(40%80%)distal pancreatectomy has been advocatedThe operation leaves untreated a major portion of the gland,and is therefore associated with a significant risk of symptoma
23、tic recurrenceLongterm outcomes reveal good pain relief in only 60%of patients,however,with completion pancreatectomy required for pain relief in 13%of patients2022-10-2118文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。6.Distal Pancreatectomy(95%)Avoid a pancreaticoduodenectomy and preserving the distal s t
24、 o m a c h,t h e e n t i r e d u o d e n u m a n d n o r m a l choledochoduodenal junction.A small cuff of the head of the pancreas which is preserved as the functional portion.This lines the lesser curvature of the duodenum and is estimated to be no more than 5%of the entire glandPain relief was ex
25、cellent and achieved in about 80%of patients followed on average 6 years.2022-10-2119文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The incidence of postopera-tive diabetes following 95%pancreatectomy rose to an unacceptable 72%.Exocrine insufficiency deteriorated as well40%of patients experienced abscesses
26、 or shortlived fistulas in the region of the head resection2022-10-2120文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Hybrid procedures1.Denervated splenopancreatic flapDividing the neck of the pancreas over the portal veinThe majority of the head of the pancreas was resectedLeaving a small cuff of pancreat
27、ic tissue along the inner aspect of the duodenum2022-10-2121文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The splenic artery was divided at its origin and the splenic vein at its junction with the superior mesenteric vein.The body and tail of the pancreas was then freed from the retroperitoneal tissue unti
28、l the pancreas is attached only to the vessels at the splenic hilus.Severs somatic nerve fibers as well as autonomic afferent fibers along the splenic arteryThe transected neck of the pancreas was then anastomosed to a Roux-en-Y limb2022-10-2122文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Pain control was
29、 reportedly good.It is likely that the long-term effects on pain relief were ascribable to the pancreatic head resection 2022-10-2123文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。2.Duodenum Preserving Pancreatic Head Resection(Fig.8)Identifying and preserving the posterior branch of the gastroduodenal arte
30、ry which provides blood flow to the duodenum,intrapancreatic common bile duct,and pancreaticoduodenal grooveThe neck of the pancreas overlying the portal and superior mesenteric vein is dividedA small amount of pancreatic tissue along the inner aspect of the duodenum is resected2022-10-2124文档仅供参考，不能
31、作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Reconstruction consists of an end-to-end pancreatico-jejunostomy to the distal pancreas,and end-to-side pancreatico-jejunostomy to the remnant of pancreatic tissue on the inner aspect of the duodenum.The body and tail of the pancreas can be drained with a longitudinal p
32、ancreaticojejunostomy if the main duct in the body and tail of the pancreas is obstructed.A common bile duct stricture,if present,should be relieved by decompression into the same Roux limb through a separate choledochojejunostomy.Performing a choledochopancreatos-tomy into the excavated pancreatic
33、head has been associated with late recurrences of bile duct strictures2022-10-2125文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Relieved pain in 80%or more of patients and preserved endocrine and exocrine function.incidence of new diabetes after the DPPHR procedure ranges from 8%to 21%This appears to be du
34、e to preservation of insulin and pancreatic polypeptide(PP)secretion.FIGURE 82022-10-2126文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。3.Local Resection of the Pancreatic Head With Longitudinal PancreaticojejunostomyThe rim of pancreatic tissue of the entire head is preserved，and is used to sew to the open
35、ed jejunumThe ducts of Wirsung and Santorini are excisedThe excavation is created in continuity with the longitudinal dochotomy of the dorsal ductPreservation of the pancreatic neck as well as the capsule of the posterior pancreatic head and avoids intraoperative problems with the venous structures
36、lying posterior to the gland2022-10-2127文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The posterior limit of resection be the back wall of the opened duct of Wirsung and duct to the uncinate.All intervening and overlying tissue in the pancreatic head including the duct of Santorini is excised.The locally e
37、xcised head of the pancreas is covered with the opened Roux-en-Y limb of jejunum in continuity with the opened main pancreatic duct in the body and tail of the pancreas(Fig.9)2022-10-2128文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Some modification：A.excise the the ducts of Wirsung and Uncinate in the he
38、ad rather than unroofing using the ultrasonic aspirator and dissector(Fig.10)B.the central portion of the uncinate process is included in the excavation(Fig.11)C.merely excavating the core of the pancreatic head and without any effort to include the duct of the body(Fig.12)D.without division of the
39、pancreatic neck compared to DPPHR(Fig.13)2022-10-2129文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。FIGURE 10.FIGURE 11.FIGURE 12.FIGURE 13.FIGURE 9.2022-10-2130文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。COMPLICATION1.Anastomotic Leak:Pancreatic anastomotic leaks are less likely to occur in chronic pancreatitis
40、 because of the firmer consistency of the glandDorsal duct can be 2 to 3 mm or less in a gland with diffuse sclerosis,and difficulties with the anastomosis can occur.Techniques of anastomoses:end-to-side duct to mucosa technique,as well as the invaginating or intussuscepting methods of end-to-end an
41、astomosis2022-10-2131文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The duct-to-mucosa An-astomosis leak rate has been reported to be as low as 1%,considerably less than the 10%to 12%leak rate observed with the intussuscepting or invagina-ting techniqueEnd-to-side,duct-to-mucosa method ofpancreaticojejunost
42、omy2022-10-2132文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Prospective,randomized trials of the use of octreotide administered postoperatively to prevent leak have both supported and refuted its valueThe use of fibrin glue appears ineffective.The use of the operating microscope and that the jejunum is se
43、cured around the pancreas with a purse string suture may reduce leak rate.A randomized prospective trial has demonstrated a reduced leak rate with stent use in a mixed group of patients2022-10-2133文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。2.Major Perioperative Complications:necrotizing pancreatitis and
44、 intraluminal bleeding3.Late Complications:A.stricturing of the anastomoses when the “stuffing”or invaginating method is avoided B.the loss of exocrine and endocrine function：the late incidence of both exocrine and endocrine dysfunction after pancreatico-duodenectomy is about 50%which can be avoided
45、 altogether by performing a ligation of the pancreatic duct.C.Delayed gastric emptying which usually resolves spontaneously,or as a late complication associated with a retrocolic,as opposed to an antecolic,gastrojejunostomy.2022-10-2134文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。4.There is the risk of is
46、chemia of the duodenum in theduodenum preserved cases2022-10-2135文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。COMPARISONS OF THE 3 OPERATIVEPROCEDURES:DPPHR AND LR-LPJ:there is no significant difference in global quality of life、pain score、late mortality、exocrine or endocrine insufficiency.there is initia
47、l reduction in morbidity associated with the excavation procedureTHE BOTH WITH WHIP:there is fewer complications、a lower global quality of life scores、a lower short-term(3 year)incidence of new diabetes and exocrine dysfunction compared with the Whipple procedure.survival、pain relief、the late incide
48、nce of diabetes and exocrine dysfunction appears similar2022-10-2136文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。2022-10-2137文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。2022-10-2138文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。CONCLUSION The head of the pancreas is the locus of the disease in the overwhelming majorit
49、y of patients with chronic pancreatitis The procedures that address disease in the head of the pancreas produce long lasting pain relief in about 80%of patients with chronic pancreatitis The combined elements of decompression of the distal pancreas and excision of the core of the pancreatic head are
50、 essential for successful long-term symptom relief in this disease.The extent of the longitudinal dochotomy appears less important than the excision of the central portion of the head of the gland.2022-10-2139文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Excavation techniques are safer than techniques whic
