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

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

3. 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)

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

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

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

7. NORMAL ERCP VIEW

8. VATER PAPILLA OBSTURCTION

9. „CHAIN OF LAKES”

10. CALIBER IRREGULARITY, PSEUDOCYS

11. PSEUDOCYS, CONNECTION WITH THE PANCREATIC DUCT

12. PSEUDOCYST

13. PSEUDOCYST, SEGMENTAL DUCTECTASY

14. PSEUDOCYST IN THE HEAD

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

16. 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

17. 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

18. 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

19. 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

20. A LONGITUDINAL PANCREATO CYSTO- GASTROSTOMIA

21. 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

22. 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

23. PANCREAS-CYSTS

24. 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)

25. PANCREAS-PSEUDOCYSTS

26. Thank You for your attention!