The surgery of chronic pancreatitis, pancreas peseudocysts Szentkereszty Zs. MD. PhD., Med. habil. UD MHSC Inst. Of Surgery

Chronic pancreatitis 1.Sclerosis of the pancreas 2.Gland atrophy - Focal - segmental - diffuse Protein extraction – calcification Duct dilatation– intraductal hypertension

Localisation -Mosttly in the head of the pancreas( Guillemin, Traverso és Longmire, Beger) -A „Rinnen” és „groove” pancreatitis-In the head ( Stolte, Becker) -The predilective localisation of the tumours are also in the head of the pancreas ( Cubilla és Fitzgerald, Hertzberg, Nakase és mtsai, Spohn és mtsai)

Etiology - Alimentaion: fatty foods, abundant meals alcoholism - Developement of diagnosis pancreas functional tests imagies

Complaints - Pain - Dypepsia - Weigh loss - Jaundice - Ascites - Duodenal obstraction - Diabetes

Imagies -Gastrio-duodenal passage -Pancreas ultrasonography -Pancreas scintigraphy -CT, MRI -ERCP -MRCP

NORMAL ERCP VIEW

VATER PAPILLA OBSTURCTION

„CHAIN OF LAKES”

CALIBER IRREGULARITY, PSEUDOCYS

PSEUDOCYS, CONNECTION WITH THE PANCREATIC DUCT

PSEUDOCYST

PSEUDOCYST, SEGMENTAL DUCTECTASY

PSEUDOCYST IN THE HEAD

INDICATION OF SURGERY IN CHR. PANCREATITIS Pain Acute exacerbations Complications: Jaundice duodenal obstraction pseudocysts pancreas fistule Suspition of cancer x

SOME WORDS ABOUT THE SURGICAL TREATMENT -It is symptomatic treatment -The stop of etiology does not prevent the progression - The alcohol free lifestyle is needed for the surgery

CHOICE OF TYPE OF THE SURGICAL PROCEDURE The duct morphology is important In general: 1. in case of dilatated duct decompressive surgery is needed 2. In cese of segmental, or focal inflammation resection is needed Imagies: US CT ERCP MRCP

CHOICE OF SURGICAL PROCEDURES -There is no generally used gold standard -Organ save methods are better? -The resections have a 5% of mortality rate -The decompressive operations have lower rate of mortality

DRAINAGE OPERATIONS - The drainage of the pancreatic juice -Decrease of the intraductal pressure Types of decompressive operations -longitudinal pancreaticojejunostomy -longitudinal pancreaticogastrostomy -Cyst drainage with the aboves -Pancreas head partzial resection and pancreat(ic)o- jejunostomy

A LONGITUDINAL PANCREATO CYSTO- GASTROSTOMIA

RESECTIONS -Resection of the advanced local destruction - Resection of the duct destructions -Treatment of the local compresive complaints Types of resections - Whipple pancreatoduodenectomy - Pylorus – preserving pancreatoduodenectomy (PPPD) - Duodenum preserving pancreas head resection

PANCREAS-CYSTS Definition true cyst pseudocyst Pathológic forms: 1. Genetic abnormalities pl. fibrocystic pancreas, dermoid cyst 2. retentional cysts 3. parasitic cysts (hydatid) 4. neoplastic cysts ( cystadenoma, cystadenocarcinoma, teratoma) 5. pseudocysts

PANCREAS-CYSTS

PANCREAS-PSEUDOCYSTS Localisation: pancreas head pancreas body pancreas tail Complaint: dullness Pain duodenal obstruction Diagnosis: US CT Surgery: 1. decompression: cysto-duodenostomy cysto-gastrostomy cysto-jejunostomy 2. resection 3. External drainage 4. Internal drainage (ERCP)

PANCREAS-PSEUDOCYSTS

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