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Hosszú távú utánkövetés krónikus pancreatitis miatt végzett szervmegtartó pancreasfej-resectio után: 8 éves klinikai tapasztalat
Long-term follow-up after organ-preserving pancreatic head resection in patients with chronic pancreatitis: an 8-year clinical experience
Absztrakt
Krónikus pancreatitisben (CP) szenvedő betegek egyharmadában az inflammatoricus folyamat a pancreasfej gyulladásos tumorát idézi elő, mely a vezetékrendszerek obstructióját, fájdalmat és fogyást okoz. Egy biztonságos, szervmegtartó pancreasfej-resectiót (OPPHR) dolgoztunk ki. Közleményünkben az elmúlt 8 évben végzett 150 OPPHR műtéti és késői eredményeiről számolunk be. A sebészi beavatkozás magában foglalja a pancreasfejben kialakult gyulladásos tumor széles resectióját anélkül, hogy a pancreast a v. portae felett izolálnánk, illetve átvágnánk. A rekonstrukció, amely biztosítja a resecált pancreas secretióját az emésztőtraktus felé, a vékonybélből izolált Roux-kaccsal történik. A posztoperatív időszakban két reoperációra kényszerültünk, egyrészt anastomosisvérzés, másrészt vékonybél-adhaesiós ileus miatt, ugyanakkor halálos szövődmény nem jelentkezett. Az ápolási idő 7 és 12 nap között változott. Az áltagos utánkövetési idő 4,5 év volt (0,5–8 év). A késői mortalitás 4%-osnak bizonyult. A műtét után a betegek 89%-ában az életminőség javult, melyet EORTC Quality-of-Life kérdésekre adott válaszok bizonyítottak. A 8 éves klinikai megfigyeléseink egyértelműen alátámasztották, hogy az OPPHR műtét egy biztonságos és hatásos sebészi beavatkozás a CP komplikációinak megoldására, és javasolt műtétnek tekinthető a CP gyógyítására.
The aim of this article is to represent our new surgical technique and methods applied in the treatment of infected pancreatic necrosis, chronic pancreatitis, and islet transplantation from 1986.
Infected pancreatic necrosis (IPN), the most severe form of acute pancreatitis, is responsible for most cases of pancreatitis-related morbidity and high mortality. Since 1986, 224 patients with IPN have been treated. The surgical treatment consisted of wide-ranging necrosectomy, combined with widespread drainage and continuous lavage. Following surgery supportive therapy was applied. The overall hospital mortality was 7.7%. In our experience, IPN responds well to the complex treatment, consisting of adequate surgery, continuous, longstanding widespread drainage and lavage, together with supportive therapy.
In chronic pancreatitis (CP), enlargement of the head of the pancreas develops as a consequence of inflammatory alterations. A new safe procedure has been developed for duodenum and organ-preserving pancreatic head resection. The surgical procedure consisted of a local resection of the inflammatory tumour in the region of the pancreatic head, without division and cutting of the pancreas over the portal vein. This operation was performed on 196 patients. No mortality was detected in the postoperative period. The mean follow-up time was 6.3 years. The QoL improved in 89% of the cases. The results reveal that this organ-preserving pancreatic head resection is a safe and effective procedure for definitive control of the complications following the inflammatory alterations of CP.
The most common complication in distal pancreatectomy is the occurrence of a postoperative pancreatic fistula (POPF). The fistula rate of 30% in the multicenter trial demonstrated that the currently applied techniques for closure of the pancreas remnant do not always lead to perfect results. Staples made from PolysorbR, an absorbable lactomer, have been applied in our practice in 187 patients following distal resection to reduce these complications. The incidence of POPF was 0.6%. Our clinical results demonstrated that the application of absorbable lactomer staples is a safe alternative to the standard closure technique and can be applied in all cases when distal pancreatic resection is indicated.
Human foetal pancreatic islets has long been viewed as an attractive source of tissue for transplantation in diabetic patients. Foetal pancreas has a high ratio for endocrine tissue and a longer period of tissue culture allows the proliferation of islets. The organ culture also provides the opportunity for reducing the immunogenicity of islets. Unfortunately, this quantity of islets is not enough for a complete cure of the diabetic condition in one recipient, but in combination with cryopreserved islet tissues, it may provide an opportunity for the treatment of diabetes mellitus. In our clinical practice, long-term cultured and cryopreserved islets were applied for transplantations of 25 diabetic patients. After grafting the insulin requirement decreased significantly and the normoglycemic condition prevents, stabilizes, or reverses the secondary complications if it can be performed at a relatively early stage of the diabetes.
Absztrakt
A szerzők konzervatív módon sikeresen kezelt esetük kapcsán a pancreatopleuralis fistula (PPF) terápiás stratégiájának lehetőségeit foglalják össze. A PPF ritka szövődménye a krónikus pancreatitisnek. Többnyire alkoholos etiológiára visszavezethető, relapsusban levő pancreatitis talaján jön létre, és dominálóan dyspnoés tüneteket produkál. Diagnózishoz fizikális vizsgálat mellett a mellkasi folyadék laboratóriumi vizsgálatával, illetve képalkotó eljárások segítségével juthatunk. Az ERCP a legfontosabb lépés a PPF diagnózisának felállításában. Gyógyítása során a somatostatin analóg gyógyszeres, az endoscopos kezelés során végzett EST, illetve a ductus Wirsungianus stentelése és a folyamatos enteralis (jejunalis) táplálás együttes hatása vezethet eredményre. E komplex terápia melletti sikertelenség esetén a PPF műtéti megoldása javasolt.
A perifériás érbetegség ellátásának változásai a Szegedi Tudományegyetemen
Changes in the care of peripheral vascular disease at the University of Szeged
Introduction and aims
In recent decades health care changes have accelerated enormously. Previously, by learning an effective procedure, the doctor could guarantee his patients the highest level of care for many years. Nowadays, due to the dynamics of development, the renewal cycles of the methods have been shortened, without continuous learning and training, it is already inconceivable to provide the up-to-date care required by patients.
Patients and methods
Instead of vascular replacements with prosthetic grafts, which played an important role in vascular reconstructions, the primacy of endovascular techniques has become decisive. It can be significant for aortic aneurysms that can be operated with high invasiveness. The learning of catheter techniques by vascular surgeons made it possible to treat more successfully those limb-threatening cases, which are often associated with extensive vascular involvement, through the so-called hybrid operations. In addition to the increasing prevalence of diabetes worldwide, the higher proportion of critical limb ischemia and the highlighted pathogenic role of multi-resistant bacteria in the disease caused the marginaliation of the use of previously preferred prosthetic grafts. The effectiveness of the treatment of graft infections, which thus become less frequent, is improved by the use of homografts and negative pressure therapy. An effective method of preventing stroke is carotid endarterectomy, the morbidity of which is reduced by the introduction of locoregional anaesthesia allowing direct neuromonitoring.
Results/conclusions
Although the acquisition and implementation of new methods has posed a continuous challenge for our specialists and doctors over the past 10 years, our achievements have made our department one of the leading vascular surgery centres in the country.
