抗生素(英文)-Pancreatic-Pseudocyst.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Pancreatic Pseudocyst,Kashaf Sherafgan,MD,Surgery IV Conference,May 5,th,2006,Pancreatic Pseudocyst,A fluid collection contained within a well-defined capsule of fibrous or granulation tissue or a combination of both,Does not possess an epithelial lining,Persists 4 weeks,May develop in the setting of acute or chronic pancreatitis,Bradley III et al.A clinically based classification system for acute pancreatitis:summary of the International Symposium on Acute Pancreatitis,Arch Surg.,1993;128:586-590,Pancreatic Pseudocyst,Most common cystic lesions of the pancreas,accounting for 75-80%of such masses,Location,Lesser peritoneal sac in proximity to the pancreas,Large pseudocysts can extend into the paracolic gutters,pelvis,mediastinum,neck or scrotum,May be loculated,Composition,Thick fibrous capsule not a true epithelial lining,Pseudocyst fluid,Similar electrolyte concentrations to plasma,High concentration of amylase,lipase,and enterokinases such as trypsin,Presentation,Symptoms,Abdominal pain 3 weeks(80 90%),Nausea/vomiting,Early satiety,Bloating,indigestion,Signs,Tenderness,Abdominal fullness,Cohen et al:Pancreatic pseudocyst.In:Cameron JL,ed.Current Surgical Therapy.7th ed.;2001:543-7,Diagnosis,CT scan,MRI/MRCP,Ultrasonography,Endoscopic Ultrasonography(EUS),ERCP,Pseudocyst compressing the stomach wall posteriorly,EUS showing pseudocyst,Complications,Infection,S/S Fever,worsening abd pain,systemic signs of sepsis,CT Thickening of fibrous wall or air within the cavity,GI obstruction,Perforation,Hemorrhage,Thrombosis SV(most common),Pseudoaneurysm formation Splenic artery(most common),GDA,PDA,Intervention,Indications for drainage,Presence of symptoms (6 wks),Enlargement of pseudocyst(6 cm),Complications,Suspicion of malignancy,Intervention,Percutaneous drainage,Endoscopic drainage,Surgical drainage,Endoscopic Management,Indications,Mature cyst wall 1 cm thick,Adherent to the duodenum or posterior gastric wall,Previous abd surgery or significant comorbidities,Contraindications,Bleeding dyscrasias,Gastric varices,Acute inflammatory changes that may prevent cyst from adhering to the enteric wall,CT findings,Thick debris,Multiloculated pseudocysts,Endoscopic Drainage,Transenteric drainage,Cystogastrostomy,Cystoduodenostomy,Transpapillary drainage,40-70%of pseudocysts communicate with pancreatic duct,ERCP with sphincterotomy,balloon dilatation of pancreatic duct strictures,and stent placement beyond strictures,Laparoscopic Management,The interface b/w the cyst and the enteric lumen must be,5 cm for adequate drainage,Approaches,Pancreatitis 2,to biliary etiology,extraluminal approach w/concurrent laparoscopic cholecystectomy,Non-biliary origin intraluminal(combined laparoscopic/endoscopic)approach,Enucleation of Pseudocyst,Surgical management of complications a/w percutaneous and/or endoscopic management of pseudocyst of the pancreas,Nealon et al,Ann Surg,.2005 Jun;241(6):948-57,Methods,10-year prospective study examining complications of endoscopic,percutaneous and surgical drainage and their operative management,Collected data,ICU monitoring,Hemorrhage,Shock(SBP 6 cm,symptomatic patients,Use ductal anatomy to guide choice of modality,Types V,VI,and VII ductal injuries are all managed operatively,Types I and II are always managed nonoperatively,Types III and IV are still under debate,Significant complications are likely to occur should nonoperative measures be used in patients most likely to sustain complications,References,Swayer et al.Pancreatic pseudocyst.,Bradley III et al.A clinically based classification system for acute pancreatitis:summary of the International Symposium on Acute Pancreatitis,Arch Surg.,1993;128:586-590,Cohen et al.Pancreatic pseudocyst.In:Cameron JL,ed.,Current Surgical Therapy,.7th ed.;2001:543-7,Gumaste et al:Pancreatic pseudocyst.,Gastroenterologist,1996 Mar;4(1):33-43,Nealon et al,Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis.,Ann Surg,.2001;233:793800,Nealon et al.Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas.,Ann Surg,.2005 Jun;241(6):948-57,