The Role of Surgery in Pancreatic Pseudocyst

外科手術在胰臟假性囊腫所扮演的角色

尹文耀(Wen-Yao Yin) ； 陳華宗(Hwa-Tzong Chen) ； 黃士銘(Shih-Ming Huang) ； 林志文(Chih-Wen Lin) ； 林世彬(Shih-Pin Lin) ； 徐大聞(Dah-Wen Shyu) ； 魏昌國(Chang-Kuo Wei) ； 李明哲(Ming-Che Lee) ； 周安良(An-Liang Chou) ； 曾國枝(Kuo-Chih Tseng) ； 張耀仁(Yao-Jen)

《慈濟醫學雜誌》 16卷6期 (2004/12) Pp. 359-369

https://doi.org/10.6440/TZUCMJ.200412.0359

摘要

目的：許多年來，外科手術一直是對胰臟假性囊腫唯一的有效撰擇。但近年來，有了新的治療方式，如經皮膚引流、內視鏡引流和經華達壺腹引流等。但我們必須承認，並沒有任何一種單獨的治療方式可以達到100%的成功且無併發症的產生。本文提供過去14年，我們在外科手術上的經驗，來跟大家一起分享。病人與方法:在過去的14年(1989-2003)中，大林慈濟外科和花蓮慈濟外科一共診斷並外科治療22位胰臟假性囊腫病患。直到目前為止，他們接受持續追蹤。結果：其中男性14人(63.6%)，女性8人(36.4%)，年齡為15-79歲之間（平均年齡38.2歲）。病患出現主要的症狀為：上腹部疼痛、硬塊、噁心、嘔吐、發燒和和持續升高的血清澱粉酵素。影像檢查，例如：超音波、電腦斷層掃描、膽胰管內視鏡，對於臨床診斷是很有幫助。手術適應症包含了持續增大的假性囊腫合併腹脹及腹痛、感染、腸胃道阻塞、穿孔、出血、腹膜炎、腹內出血和胰臟性腹水。有效的方式包含腹腔外引流(external drainage, ED : 9位)、腹腔內引流胰囊腫空腸吻合術(cystojejunostomy,CJ:4位)與胰囊腫胃造口吻合銜(cystogastrostomy,CG:8位)及遠端胰切除術(1位)。十例併發症(45.5%)包括囊腫復發(1 in ED and 1 in CJ)、胰胸腔瘻管(l in ED)、結腸穿孔(1 in ED)、延遲性大量出血(1 in CG)、胰臟瘻管(3 in ED)、胰臟膿傷 (1 in CJ)和持續性腹痛(1 in CG)。術後三位病患需再次進行手術以減緩術後出血(1 in GD)及施行結腸造口術來處理結腸穿孔併發症(1 in ED)，及術後九年復發胰臟假性囊腫亦以手術治療(l in CJ)。另有兩位再復發病患使用非手術治療方式，其一以較大的管徑進行經皮穿刺引流胰腫囊腫，一復發至呼吸衰竭的病患則使用支架經華壺腹引流，均能有效處理。在這個研究中並無死亡病例。結論：我們相信外科手術在治療各種不同胰臟假性囊腫扮演一涸很重要的角色。但我們也發現在臨床上需要非外科手術來彌補用手術無法改善的缺點。所以適當的應用上述各種非手術方法並和外科手術相輔相成，以達到最好療效才是最重要的。

關鍵字

胰臓假性囊腫 ； 腹腔內引流 ； 腹腔外引流 ； 經皮穿刺引流 ； 經華達壺腹引流

並列摘要

Objective: Surgery was the only option available for management of pancreatic pseudocyst (PP) for many years. Recently, new methods, such as percutaneous drainage, endoscopic transenteric drainage and transpapaillary drainage, have been used for treatment of a pseudocyst. However, no single technique offers the desired combination of 100% success and no complications. We present our surgical experience with PP over the past 14 years. Patients and Methods: A total of 22 patients were treated for PP in our departments in Dalin and Hualien Tzu Chi General Hospitals within the last 14 years. They were retrospectively reviewed and followed up. Results: There were 14 (63.6%) men and 8 (36.4%) women between 15 and 79-years-old (mean age 38.2 years). Dominating symptoms in most patients were epigastric pain, palpable mass, nausea, vomiting, fever and leukocytosis, and persistent elevation of serum amylase. Imaging studies, such as ultrasound, computed tomography scan, and endoscopic retrograde cholangiopancreaticography, were helpful in establishing the diagnosis. In addition to symptomatic persistent large (＞6 cm) pseudocysts, various complications, including infection, GI obstruction, rupture into the GI tract, peritonitis, GI bleeding, internal bleeding, and pancreatic ascites were indications for surgery in our cases. Operative procedures consisted of external drainage (ED, 9 cases), internal drainage using cystojejunostomy (CJ, 4 cases )and cystogastrostomy (CG, 8 cases), and distal pancreatectomy (1 case). There were ten complications (45.5%) including recurrence of cyst (1 patient with ED and 1 with CJ), recurrence with pancreaticopleural fistula (1 with ED), colon perforation (1 with ED), delayed massive bleeding (1 with CG), pancreatic fistula (3 with ED), pancreatic abscess (1 with CJ) and persistent pain (1 with CG). Repeat surgery was needed to stop bleeding (1 patient with CG) and to construct a proximal colostomy for a colon injury (1 with ED). One patient had a CJ for recurrence of pseudocyst 9 years after the first surgery. Percutaneous drainage with a wide bore tube was effective for pancreatic abscess (1 with CJ) and transpapillary drainage with a stent was used to relieve pleural effusion with respiratory failure (1 with ED). No deaths occurred in this series. Conclusion: Although complications do occur in surgical treatment, we believe that it is still important in the management of selected cases of pseudocyst of the pancreas. Surgical intervention, endoscopic drainage, and percutaneous drainage are complementary rather than competing alternatives both for simple and complicated pseudocysts.

並列關鍵字

pancreatic pseudocyst ； internal drainage ； external drainage ； percutaneous drainage ； transpapillary drainage