二階外科複習07: 胰臟

Reference: 二階老趙外科學

1. 急性胰臟炎

• 成因(臺灣)：結石>酒精>藥物
• 處置：NPO、NG decompression、fluid supplement、pain control、monitor hemodynamic status、prophylaxis for stress ulcer、antibiotics、(結石，不處理幾個禮拜內50~80% recurrence)住院中恢復後做LC or open cholecystectomy+ CBD explore+ T-tube或先做ERCP
• 壞死性胰臟炎(20%)
• 70%合併感染，則需wide debridement、continuous local lavage、multiple drainage
• 診斷by CT (necrosis tissue+ retroperitoneal air bubble or SIRS)--> FNA smear
• complications

• Prognosis: Ranson's criteria
  口訣：
• 住院前抽血-年齡/白two(AST/LDH)糖
• 住院後抽血+ABG-CHOBBS
• Ranson's for GB pancreatitis: age>70, WBC>18000, AST>250, LDH>400, Glu>220, PaO2不看, Base deficit>5, BUN>2, sequestration>4

2. 慢性胰臟炎

• 手術適應症：intractable pain, cannot rule out malignancy
• 手術方式：
• dilated pancreatic duct-->Puestow procedure(drainage via Y loop)

              --> side to side pancreaticojuojenostomy

• no dilated duct, distal inflammation-->Child procedure (distal pancreatectomy)
• inflammation at pancreatic head-->Whipple, DPPHR(duodenum preserved pancreas head resection)?
• pancreatectomy

3. 胰臟癌

• Peri-ampullary
• Incidence: pancreas>cholangio>duodenum>ampulla
• Prognosis: pancreas<cholangio<duodenum<ampulla
                  (但症狀較明顯、發現早，發現時較resectable)
• symptoms: obstructive jaundice(75%), 膽管炎(10%), GI bleeding(ampullary tumor)
• 最常見轉移：liver
• 處置：
  Whipple operation--> reconstruction by Y loop
  
  antrectomy+ vagotomy--> prevent stress ulcer
  cholecystectomy--> prevent GB stone
  
  pylorus-preserving pancreaticoduodenectomy(PPP)--> 延長胃排空時間、減少dumping syndrome、手術時間較短、marginal ulcer風險增加
  (參考TINYNOTE:
  https://thetinynotes.com/topic/388/%E5%82%BE%E9%A3%9F%E7%97%87%E5%80%99%E7%BE%A4-dumping-syndrome)
• Distal: Child procedure