胰腺手术后并发症的防治.ppt

thepreventionandmanagementofpostoperativecomplicationsinpancreaticsurgery thedepartmentofhepato biliary pancreaticsurgeryinchanghaihospital introduction classification hemorrhagepancreaticfistulaintraabdominalabscessdelayedgastricemptyingwoundinfectiondiabetespancreaticexocrineinsufficiency gastric biliaryfistulaorganfailure heart liver lungetc pancreatitismarginalulcerationsplenicveinthrombosis introduction definition 1960sto1970soperativemortality 20 to40 postoperativemorbidity 40 to60 duringthelastdecadeoperativemortality 2 to3 somecenters excessof100patientsnoperioperativedeathunfortunately complicationratesremainhighusuallyinexcessof25 to35 introduction totracetheevolutionofpancreaticoduodenectomyfromthedecadeofthe1960sthroughthefirstdecadeofthenewmillenium throughtheexperienceofonesurgeondoing1000consecutiveoperationsoperativetime 8 8hoursinthe1970sand5 5hoursduringthe2000s postoperativelengthofstay 17daysinthe1980sto9daysinthe2000s mortality 1 morbidity 20 to30 incidence america cameronjl incidence germany currentpracticepatternsinpancreaticsurgery resultsofamulti institutionalanalysisofsevenlargesurgicaldepartmentsingermanywith1454pancreaticheadresections 1999to2004 germanadvancedsurgicaltreatmentstudygroup departmentofsurgery universityoffreiburg germanymortalitywasbetween1 1 and4 8 morbiditywasbetween24 and46 pancreaticleakagewasbetween9 and20 incidence china japan morbidity 12 3 to45 aseriesof3 610patientscollectedfrom57majorjapaneseinstitutions inchina morbidity 10 to40 injapan hemorrhage earlyanddelayedhemorrhageincidence 0 5 to6 8 hemorrhagewithinthefirst24hoursaftersurgeryisgenerallycausedbyatechnicalfailureandneedsimmediateadequatehemostasisthrougharelaparotomy hemorrhageearlyhemorrhage hemorrhageinthelatepostoperativephasemayoriginatefromthegastrointestinaltractsuchaspepticulcerationorulcerationfromtheanastomosis butcanalsobefromanintraabdominalsitesuchasanerodedvesselordehiscenceofananastomoticsutureline sepsis 50 to74 anastomoticleakage 23 to65 sentinelbleeding 78 to100 relaparotomy 14 to30 hemorrhagedelayedhemorrhage septicdhgastroduodenala hepatica mesenterya pancreaticparenchymaa pj hj ge eearterialdhpancreaticparenchymaa splenic hepatica suture linedhge ee pj hemorrhagedelayedhemorrhage ultrasonographyandcomputedtomographyplayasupplementaryroleindetectingintraabdominalinflammation hemorrhage conservativeembolizationsclerotherapysurgicalhemostasismortality 22 to27 causesofdeath fulminantsepsisanduncontrollablebleeding hemorrhage hemorrhage hemorrhage hemorrhageoriginatingfromafalseaneurysmofthecommonhepaticarteryafterpancreatoduodenectomy b coveredstentsuccessfullyplacedoverthefalseaneurysm blackarrows coveredstent graftsareparticularlyusefulintheemergencysettingwhenhemorrhageoccursfromfocalpointinavesselwherepreservationofvesselpatencyandend organperfusionisdesirable pancreaticfistula pancreaticfistula fluidcollection anastomosisleakage pancreaticfistula output 10ml 24h amylase 3times pancreaticfistula 3dayspostoperation associatedcomplications pf51 nopf21 p 001 durationofhospitalstay 16daysinpf 9daysinnopf p 001 intraoperativebloodloss greaterinthepf nopf p 01 clinicallyseriouspostoperativecomplicationsinthepfversusnopfgroupweremortality p 03 intraabdominalabscess p 001 woundinfection p 001 hemorrhage p 01 cardiac p 001 bileleak p 001 reoperation p 02 pancreaticfistula surgery 2006oct 140 4 561 8 discussion568 9 riskfactorsassociatedwithpostoperativecomplications pancreaticfistulasoftpancreaticparenchymachronicpancreatitisortumoursthesiteofthetumourthesurgicaltechniqueexperiencebloodlossinoperationnutritionalstatusgeneralhealthcondition pancreaticfistula conservativetherapy tpn oren somatostatin ghinterventionalendoscopicmanagementsurgicalprocedures pancreaticfistula themajorityofpatientswithpancreaticfistulacanbemanagedconservativelywitheithermaintenanceoforaldietorparenteralnutritionuntilclosureofthepancreaticfistula pancreaticfistula incidenceabdominalabscess 3 to5 woundinfection 6 to8 sepsis 3 to5 etiologygeneralconditionjaundicebileinfectionantibioticusedsurgicalprocedure infection ultrasonographyandcomputedtomographyplayasupplementaryroleindetectingintraabdominalinflammation infection diagnosis clinicalmanifestation examinations theoverallrateofwoundinfectionwas6 8 ofthe2266patientsforwhomdatawereavailableeighty five 78 7 ofthe108eligibleinstitutionschoseafirst orsecond generationcephalosporinforantibioticprophylaxisgivenforameandurationof4 3daysthefirstdosewasadministeredpriortosurgicalincisionoftheskinat42 oftheinstitutions anadditionalantibioticwasadministeredduringsurgery infection jhepatobiliarypancreatsurg 2005 12 4 304 9 somedatashowthatinfectedbileisfoundmoreoftenafterpreoperativebiliarydrainageproceduresictericpatientswithbiliaryinfectionsareathighriskforpostoperativemorbiditiesandneedcarefulmonitoringaftersurgery infection peritonealdialysis closedlavagepancreaticdrainageanddebridementwidedebridementandpacking frequentdebridement infection dgehasbeenreportedtooccurin9 to37 ofpatientstheaverageincidenceofdgeafterpdintheliteraturehasbeenreportedtobe13 9 theincidenceofdgeinhigh volumecentersspecializedinpancreaticsurgeryiswellbelow20 bothstandardwhippleandpylorus preservingpancreaticresectioncarrysimilarratesofdgebillrothiitype likegastrointestinalreconstructionisthemostwidelyacceptedmethodandisassociatedwithlowerratesofdge delayedgastricemptying delayedgastricemptying delayedgastricemptying localischemiaoftheantrumabsenceofduodenalhormonesinflammationfrompancreaticoenterostomyedemafromduodenojejunostomygastricatonycausedbyvagotomythelengthofthepreservedproximalportionoftheduodenumvolumeofgastricjuicedurationofgastrictubeplacementadministrationofcisapridethetruemechanismofdgeisstillunclear delayedgastricemptying moststudiesseemtosupporttheuseofmetoclopromideorerythromycinwhichhasnotgainedwideacceptancereoperationsformanagingseveredgewereveryrarelyreportedstandardizationoftheoperativetechnique aswellas centralizing pancreaticresectionsinhigh volumecenters shouldaidtoimprovetheoccurrenceofthisbothersomepostoperativecomplication delayedgastricemptying incidence 50 to90 pancreaticexocrineinsufficiency pancreaticexocrineinsufficiency historyoperationalcoholsmoking symptomsdistensionmalabsorptionsteatorrhoea signsweightlossedem