lecturePC.ppt

Typical Case of Modified Appleby operation-2 患者70岁，背部持续性疼痛，厌食消瘦2个月，CA199:1000, CT示胰颈肿块侵犯腹腔干，SMA移位，PV与肿块临近 骨骼化分离腹腔干，保留肝总A及胃左A，结扎脾A行胰颈体尾并脾切除术less invasive operation than standard Appleby operation Total Pancreatectomy Indications massive adenocarcioma or cystoadenocarcinomas Local advanced cancers at head and neck of the pancreas with positive margin and already diabetes mellitus No Impatient Mortality Morbidity Much less often seen than that in Whipple operation all 8 cases, including one old patient aged 80 were discharged within 2 weeks Lower cost Blood glucose is easily in control perioperatively Nutrition status post operation Insulin Chronic diarrhea survival The prognosis of cystoadenocarcinomas is better than adenocarcinoma Mean survival time 14 month Typical case of total Pancreatectomy 患者女性，34岁；背部持续疼痛伴消瘦6个月；入院B超和CT示胰管结石、弥漫性胰腺囊肿及钙化，CA199正常，术前诊断，慢性胰腺炎，全胰癌待排。 手术探查发现结节样肿块侵及全胰，多处穿刺活检证实全胰癌行全胰切除术 术后无并发症，血糖控制良好，12天出院。 Extended Whipple operation 标准和扩大 Whipple手术并发症比较 ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- * * * Langenbecks Arch Surg. 2003; 388:101~106 腹腔干切除范围 浸润腹腔干的胰腺癌－Appleby 手术 Appleby与姑息性胰腺癌切除术 腹腔干切除 姑息性手术 腹腔干切除是安全可行的，可以提高手术切除率，同时有效控制癌痛症状 Hospital volume and mortality Pancreatic resection 住院死亡率与医院床位数的关系 本院胰腺癌手术的必威体育精装版进展情况 采用Appleby或改良 Appleby手术治疗侵犯腹腔干的胰腺癌 全胰腺切除治疗合并胰岛素依赖型的胰腺巨大恶性肿瘤 扩大胰腺癌根治术 Appleby Operation 腹腔干动脉侵犯 CA 典型病例 –改良 Appleby手术 男性,50岁,糖尿病2年（胰岛素依赖型）, 上腹巨大肿块伴腹胀, 气急1周。 CA199正常，B超和CT提示后腹膜来源巨大肿块,侵及胰颈、体、尾及胃,腹腔干完全包裹 患者由于严重压迫症状（气急、极度腹胀）要求剖腹探查减瘤 术后病理提示胰腺来源间皮肉瘤 CA   术中发现肿块完全侵犯腹腔干，累及肝总A，分离和保留GDA困难，胰头颈间难以确定阴性 切缘，由于PV和SMV可游离，根据肝癌病人结扎肝固有A的经验，决定行较Appleby 切除范围更大的全胰、全胃、脾并腹腔干切除以达减瘤目的，由于横结肠也累及，故一并切除。 术后一周肝功能出现一过性变化 CT示肝脏出现散在性局灶梗塞， 随后肝功能恢复正。 男性，70岁，背部持续性疼痛伴厌食消瘦2个月。 CA199:100