胰腺手术后并发症的防治

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,The prevention and management of postoperative complications in pancreatic surgery,Introduction:,classification,Hemorrhage,Pancreatic fistula,Intraabdominal abscess,Delayed gastric emptying,Wound infection,Diabetes,Pancreatic exocrine insufficiency,Gastric/biliary fistula,Organ failure(heart,liver,lung etc.),Pancreatitis,Marginal ulceration,Splenic vein thrombosis,Introduction:,definition,1960s to 1970s,operative mortality:20%to 40%,Postoperative morbidity:40%to 60%,During the last decade,operative mortality:2%to 3%,Some centers:excess of 100 patients no perioperative death,Unfortunately,complication rates remain high,usually in excess of,25%to 35%,Introduction,To trace the evolution of pancreaticoduodenectomy from the decade of the 1960s through the first decade of the new Millenium,through the experience of,one surgeon,doing,1000 consecutive,operations,Operative time,:8.8 hours in the 1970s and 5.5 hours during the 2000s.,Postoperative length of stay,:17 days in the 1980s to 9 days in the 2000s.,Mortality,:1%,Morbidity,:20%to 30%,Incidence:,America,Cameron JL,Incidence:,Germany,Current practice patterns in pancreatic surgery:results of a multi-institutional analysis of seven large surgical departments in Germany with 1454 pancreatic head resections,1999 to 2004(German Advanced Surgical Treatment study group),Department of Surgery,University of Freiburg,Germany,Mortality,was between,1.1%and 4.8%,Morbidity,was between,24%and 46%,Pancreatic leakage,was between,9%and 20%,Incidence:,China,&,Japan,Morbidity:12.3%to 45%,A series of 3,610 patients collected,From 57 major Japanese institutions,In China,Morbidity:10%to 40%,In Japan,Hemorrhage,Early and delayed hemorrhage,Incidence:0.5%to 6.8%,Hemorrhage within the first 24 hours after surgery is generally caused by a,technical failure,and needs immediate adequate hemostasis through a,relaparotomy,Hemorrhage,Early hemorrhage,Hemorrhage in the late postoperative phase may originate from the,gastrointestinal tract such as,peptic ulceration,or ulceration from the anastomosis,but can also be from an intraabdominal site such as an,eroded vessel,or,dehiscence,of an anastomotic suture line,Sepsis,:50%to 74%,Anastomotic leakage,:23%to 65%,Sentinel bleeding,:78%to 100%,Relaparotomy,:14%to 30%,Hemorrhage,Delayed hemorrhage,Septic DH,Gastroduodenal A.,Hepatic A.,Mesentery A.,Pancreatic parenchyma A.,PJHJGEEE,Arterial DH,Pancreatic parenchyma A.,Splenic&hepatic A.,Suture-line DH,GEEEPJ,Hemorrhage,Delayed hemorrhage,ultrasonography and computed tomography play a supplementary role in detecting intraabdominal inflammation,Hemorrhage,Conservative,Embolization,Sclerotherapy,Surgical hemostasis,Mortality,:22%to 27%,Causes of death,:Fulminant sepsis and uncontrollable bleeding,Hemorrhage,Hemorrhage,Hemorrhage,Hemorrhage originating from,a false aneurysm of the common,hepatic artery after,pancreatoduodenectomy.,(B)Covered stent successfully,placed over the false aneurysm,(black arrows),Covered stent-grafts are particularly,useful in the emergency setting,when hemorrhage occurs from focal,point in a vessel where preservation,of vessel patency and end-organ,perfusion is desirable,Pancreatic fistula,Localised complications,Incidence(%),General complications,Incidence(%),Pancreatic fistula,23.4,Sepsis,3.6,Fluid collection,8.8,Respiratory failure,3.3,Anastomosis leakage,4.0,Death,3.3,Bleeding,4.3,Shock,2.4,Abscess,3.1,Renal failure,1.5,Postoperative pancreatitis,2.9,Pancreatic fistula,Fluid collection,Anastomosis leakage,Pancreatic fistula,Definition of leakage related complications,Trial,Pancreatic fistula,Abdominal abscess,Intra-abdominal fluid collection,Bchler 1992,26,Concentration of amylase and lipase in the drainage fluid g3 days postoperatively of g3 times the normal serum value and a drainage volume of g10 ml/24 hours,Collection of pus or infected fluid confirmed by ultrasound or CT guided aspiration and culture,or second laparotomy,Fluid collection(sterile)of at least 5X5 cm in diameter by ultrasound or CT,Pederzoli 1994,1,Drain output with amylase content g3 times the maximum normal value exceeding 10 ml/24 hours for 4 days from day 4 after the operation,Collection of pus or infected fluid confirmed by ultrasound or CT guided aspiration and culture,or second laparotomy,Fluid collection(sterile)of at least 5x5 cm in diameter by ultrasound or CT,Montorsi 1995,27,Concentration of amylase and lipase in the drainage fluid g3 days postoperatively of g3 times the normal serum value and a drainage volume of g10 ml/24 hours,Collection of infected fluid with normal amylase concentration,with or without pus,confirmed by ultrasound or CT guided aspiration and culture,or second laparotomy,An intraperitoneal sac containing sterile fluid,with or without amylase,Friess 1995,28,Complications were defined and recorded as previously reported,1,29,35,36,CT,computed tomography.,Output 10ml/24h,Amylase 3 times,Pancreatic fistula,3 days postoperation,Associa