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1、The prevention and management of postoperative complications in pancreatic surgery,The Department of Hepato-biliary-pancreatic Surgery in Chang Hai Hospital,Introduction:classification,HemorrhagePancreatic fistulaIntraabdominal abscessDelayed gastric emptyingWound infectionDiabetesPancreatic exocrin
2、e insufficiency,Gastric/biliary fistula Organ failure(heart,liver,lung etc.)Pancreatitis Marginal ulceration Splenic vein thrombosis,Introduction:definition,1960s to 1970soperative mortality:20%to 40%Postoperative morbidity:40%to 60%During the last decadeoperative mortality:2%to 3%Some centers:exces
3、s of 100 patients no perioperative deathUnfortunately,complication rates remain highusually in excess of 25%to 35%,Introduction,To 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 100
4、0 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:America,Cameron JL,Incidence:Germany,Current practice patterns in pancreatic surgery:result
5、s 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%P
6、ancreatic leakage was between 9%and 20%,Incidence:China&Japan,Morbidity:12.3%to 45%,A series of 3,610 patients collected From 57 major Japanese institutions,In China,Morbidity:10%to 40%,In Japan,Hemorrhage,Early and delayed hemorrhageIncidence:0.5%to 6.8%,Hemorrhage within the first 24 hours after s
7、urgery is generally caused by a technical failure and needs immediate adequate hemostasis through a relaparotomy,Hemorrhage Early hemorrhage,Hemorrhage in the late postoperative phase may originate from the gastrointestinal tract such as peptic ulceration or ulceration from the anastomosis,but can a
8、lso 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 hemorrhage,Septic DH Gastroduodenal A.Hepatic A.Mesentery A.Pancreatic parenchyma
9、 A.PJHJGEEEArterial DH Pancreatic parenchyma A.Splenic&hepatic A.Suture-line DH GEEEPJ,Hemorrhage Delayed hemorrhage,ultrasonography and computed tomography play a supplementary role in detecting intraabdominal inflammation,Hemorrhage,ConservativeEmbolizationSclerotherapySurgical hemostasisMortality
10、:22%to 27%Causes of death:Fulminant sepsis and uncontrollable bleeding,Hemorrhage,Hemorrhage,Hemorrhage,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-graft
11、s 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 fistula,Pancreatic fistula,Fluid collection,Anastomosis leakage,Pancreatic fistula,Output 10ml/24h,Amylase 3 tim
12、es,Pancreatic fistula,3 days postoperation,Associated 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 serious postoperative complications in the PF versus no PF group were mortal
13、ity(P=.03)intraabdominal abscess(P/=.001)wound infection(P/=.001)hemorrhage(P=.01)cardiac(P/=.001)bile leak(P/=.001)reoperation(P=.02),Pancreatic fistula,Surgery.2006 Oct;140(4):561-8;discussion 568-9,Risk factors associated with postoperative complications:pancreatic fistula Soft pancreatic parench
14、yma Chronic pancreatitis or tumours The site of the tumour The surgical technique experienceBlood loss in operationNutritional status General health condition,Pancreatic fistula,Conservative therapy:TPN(or EN)+somatostatin+GHInterventional endoscopic managementSurgical procedures,Pancreatic fistula,
15、The majority of patients with pancreatic fistula can be managed conservatively with either maintenance of oral diet or parenteral nutrition until closure of the pancreatic fistula,Pancreatic fistula,Incidence Abdominal abscess:3%to 5%Wound infection:6%to 8%Sepsis:3%to 5%Etiology General condition Ja
16、undice Bile infection Antibiotic used Surgical procedure,Infection,Ultrasonography and computed tomography play a supplementary role in detecting intraabdominal inflammation,Infection,Diagnosis,Clinical manifestation,Examinations,The overall rate of wound infection was 6.8%of the 2266 patients for w
17、hom data were available Eighty-five(78.7%)of the 108 eligible institutions chose a first-or second-generation cephalosporin for antibiotic prophylaxis given for a mean duration of 4.3 days the first dose was administered prior to surgical incision of the skin At 42%of the institutions,an additional
18、antibiotic was administered during surgery,Infection,J Hepatobiliary Pancreat Surg.2005;12(4):304-9,Some data show that infected bile is found more often after preoperative biliary drainage proceduresIcteric patients with biliary infections are at high risk for postoperative morbidities and need car
19、eful monitoring after surgery,Infection,Peritoneal dialysis/closed lavagePancreatic drainage and debridementWide debridement and packing,frequent debridement,Infection,DGE has been reported to occur in 9%to 37%of patients The average incidence of DGE after PD in the literature has been reported to b
20、e 13.9%The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%Both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associate
21、d with lower rates of DGE,Delayed gastric emptying,Delayed gastric emptying,Delayed gastric emptying,Local ischemia of the antrumAbsence of duodenal hormonesInflammation from pancreaticoenterostomyEdema from duodenojejunostomyGastric atony caused by vagotomyThe length of the preserved proximal porti
22、on of the duodenumVolume of gastric juiceDuration of gastric tube placementAdministration of cisapride THE TRUE MECHANISM OF DGE IS STILL UNCLEAR,Delayed gastric emptying,most studies seem to support the use of metoclopromide or erythromycin which has not gained wide acceptance Reoperations for mana
23、ging severe DGE were very rarely reported Standardization of the operative technique,as well as centralizing pancreatic resections in high-volume centers,should aid to improve the occurrence of this bothersome postoperative complication,Delayed gastric emptying,Incidence:50%to 90%,Pancreatic exocrin
24、e insufficiency,Pancreatic exocrine insufficiency,HISTORYOperationAlcoholSmoking,SYMPTOMSDistensionMalabsorptionSteatorrhoea,SIGNSWeight lossEdemaAnemia,Laboratory examination,Pancreatic exocrine insufficiency,Pancreatic enzyme supplements,Pancreatic exocrine insufficiency,Pancreatic enzyme suppleme
25、nts,Pancreatic exocrine insufficiency,Pancreatic insufficiency,Pancreatic microspherea(lipase 20-40 kU/meal),Increase dosage2-3times,Reevaluation of diagnosis,Give H2-blocker orProton pump inhibitor,Decrease fat intake,treat,These dramatic improvements might be attributed to More experienced surgeon
26、s performing the operation more frequently,taking less time and with less blood loss Improved preoperative and postoperative care Better anesthetic management Concentration of these patients in high volume centers,Challenges and problems,But what would we do to decline the morbidity of pancreatic operations?,THANK YOU,
