胰腺手术后并发症的防治.ppt
The prevention and management of postoperative complications in pancreatic surgeryIntroduction:classificationHemorrhagePancreatic fistulaIntraabdominal abscessDelayed gastric emptyingWound infectionDiabetesPancreatic exocrine insufficiency Gastric/biliary fistula Organ failure(heart,liver,lung etc.)Pancreatitis Marginal ulceration Splenic vein thrombosis Introduction:definition1960s to 1970soperative mortality:20%to 40%Postoperative morbidity:40%to 60%During the last decadeoperative mortality:2%to 3%Some centers:excess of 100 patients no perioperative deathUnfortunately,complication rates remain highusually in excess of 25%to 35%IntroductionTo trace the evolution of pancreaticoduodenectomy from the decade of the 1960s through the first decade of the new Millenium,through the experience of one surgeon doing 1000 consecutive operations Operative time:8.8 hours in the 1970s and 5.5 hours during the 2000s.Postoperative length of stay:17 days in the 1980s to 9 days in the 2000s.Mortality:1%Morbidity:20%to 30%Incidence:AmericaCameron JLIncidence:Germany Current practice patterns in pancreatic surgery:results of a multi-institutional analysis of seven large surgical departments in Germany with 1454 pancreatic head resections,1999 to 2004(German Advanced Surgical Treatment study group)Department of Surgery,University of Freiburg,Germany Mortality was between 1.1%and 4.8%Morbidity was between 24%and 46%Pancreatic leakage was between 9%and 20%Incidence:China&JapanMorbidity:12.3%to 45%A series of 3,610 patients collected From 57 major Japanese institutionsIn ChinaMorbidity:10%to 40%In JapanHemorrhageEarly and delayed hemorrhageIncidence:0.5%to 6.8%Hemorrhage within the first 24 hours after surgery is generally caused by a technical failure and needs immediate adequate hemostasis through a relaparotomy Hemorrhage Early hemorrhageHemorrhage in the late postoperative phase may originate from the gastrointestinal tract such as peptic ulceration or ulceration from the anastomosis,but can also be from an intraabdominal site such as an eroded vessel or dehiscence of an anastomotic suture line Sepsis:50%to 74%Anastomotic leakage:23%to 65%Sentinel bleeding:78%to 100%Relaparotomy:14%to 30%Hemorrhage Delayed hemorrhageSeptic DH Gastroduodenal A.Hepatic A.Mesentery A.Pancreatic parenchyma A.PJHJGEEEArterial DH Pancreatic parenchyma A.Splenic&hepatic A.Suture-line DH GEEEPJHemorrhage Delayed hemorrhage ultrasonography and computed tomography play a supplementary role in detecting intraabdominal inflammation HemorrhageConservativeEmbolizationSclerotherapySurgical hemostasisMortality:22%to 27%Causes of death:Fulminant sepsis and uncontrollable bleedingHemorrhageHemorrhageHemorrhage(A)Hemorrhage originating from a false aneurysm of the common hepatic artery after pancreatoduodenectomy.(B)Covered stent successfully placed over the false aneurysm (black arrows)Covered stent-grafts are particularly useful in the emergency setting when hemorrhage occurs from focal point in a vessel where preservation of vessel patency and end-organ perfusion is desirable Pancreatic fistulaLocalised complicationsIncidence(%)General complicationsIncidence(%)Pancreatic fistula23.4Sepsis3.6Fluid collection8.8Respiratory failure3.3Anastomosis leakage4.0Death3.3Bleeding4.3Shock2.4Abscess3.1Renal failure1.5Postoperative pancreatitis2.9 Pancreatic fistulaFluid collectionAnastomosis leakagePancreatic fistula Definition of leakage related complicationsTrialPancreatic fistulaAbdominal abscessIntra-abdominal fluid collectionBchler 199226Concentration of amylase and lipase in the drainage fluid g3 days postoperatively of g3 times the normal serum value and a drainage volume of g10 ml/24 hoursCollection of pus or infected fluid confirmed by ultrasound or CT guided aspiration and culture,or second laparotomyFluid collection(sterile)of at least 5X5 cm in diameter by ultrasound or CTPederz o l i 19941Drain output with amylase content g3 times the maximum normal value exceeding 10 ml/24 hours for 4 days from day 4 after the operationCollection of pus or infected fluid confirmed by ultrasound or CT guided aspiration and culture,or second laparotomyFluid collection(sterile)of at least 5x5 cm in diameter by ultrasound or CTMonto r s i 199527Concentration of amylase and lipase in the drainage fluid g3 days postoperatively of g3 times the normal serum value and a drainage volume of g10 ml/24 hoursCollection of infected fluid with normal amylase concentration,with or without pus,confirmed by ultrasound or CT guided aspiration and culture,or second laparotomyAn intraperitoneal sac containing sterile fluid,with or without amylaseFriess 199528Complications were defined and recorded as previously reported1,29,35,36 CT,computed tomography.Output 10ml/24hAmylase 3 timesPancreatic fistula3 days postoperationAssociated complications:PF 51%;no PF 21%(P/=.001)Duration of hospital stay:16 days in PF;9 days in no PF(P/=.001)Intraoperative blood loss:greater in the PF;no PF(P=.01)Clinically
