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首页 英文原版胰腺

英文原版胰腺.PDF

英文原版胰腺

bachdong1
2011-09-23 0人阅读 举报 0 0 暂无简介

简介:本文档为《英文原版胰腺pdf》,可适用于自然科学领域

CHAPTERPancreasWilliamEFisher,DanaKAndersen,RichardHBellJr,AshokKSaluja,andFCharlesBrunicardiAnatomyandPhysiologyGrossAnatomyRegionsofthePancreasPancreaticDuctAnatomyVascularandLymphaticAnatomyNeuroanatomyHistologyandPhysiologyExocrinePancreasEndocrinePancreasIntraisletRegulationAcutePancreatitisDefinitionandIncidenceEtiologyBiliaryTractDiseaseAlcoholTumorsIatrogenicPancreatitisDrugsInfectionsHyperlipidemiaMiscellaneousCausesPathophysiologyInitialEventsLeadingtotheOnsetofPancreatitisFactorsDeterminingtheSeverityofPancreatitisDiagnosisSerumMarkersUltrasoundAssessmentofSeverityEarlyPrognosticSignsBiochemicalMarkersComputedTomographyScanTreatmentMildPancreatitisSeverePancreatitisInfectionsSterileNecrosisPancreaticAbscessNutritionalSupportTreatmentofBiliaryPancreatitisChronicPancreatitisDefinition,Incidence,andPrevalenceEtiologyAlcoholHyperparathyroidismHyperlipidemiaClassificationChronicCalcifying(Lithogenic)PancreatitisChronicObstructivePancreatitisChronicInflammatoryPancreatitisChronicAutoimmunePancreatitisTropical(Nutritional)PancreatitisHereditaryPancreatitisAsymptomaticPancreaticFibrosisIdiopathicPancreatitisPathologyHistologyFibrosisStoneFormationDuctDistortionRadiologyPresentation,NaturalHistory,andComplicationsPresentingSignsandSymptomsMalabsorptionandWeightLossApancreaticDiabetesLaboratoryStudiesPrognosisandNaturalHistoryComplicationsPseudocystPancreaticAscitesPancreaticEntericFistulaHeadofPancreasMassSplenicandPortalVeinThrombosisTreatmentMedicalTherapyAnalgesiaEnzymeTherapyAntisecretoryTherapyNeurolyticTherapyEndoscopicManagementSurgicalTherapyPancreasCHAPTERANATOMYANDPHYSIOLOGYThepancreasisperhapsthemostunforgivingorganinthehumanbody,leadingmostsurgeonstoavoidevenpalpatingitunlessnecessarySituateddeepinthecenteroftheabdomen,thepancreasissurroundedbynumerousimportantstructuresandmajorbloodvesselsSeeminglyminortraumatothepancreascanresultinthereleaseofpancreaticenzymesandcauselifethreateningpancreatitisSurgeonsthatchoosetoundertakesurgeryonthepancreasrequireathoroughknowledgeofitsanatomyHowever,knowledgeoftherelationshipsofthepancreasandsurroundingstructuresisalsocriticallyimportantforallsurgeonstoensurethatpancreaticinjuryisavoidedduringsurgeryonotherstructuresGrossAnatomyThepancreasisaretroperitonealorganthatliesinanobliqueposition,slopingupwardfromtheCloopoftheduodenumtothesplenichilum(Fig)Inanadult,thepancreasweighstogandisabouttocmlongThefactthatthepancreasissituatedsodeeplyintheabdomenandissealedintheretroperitoneumexplainsthepoorlylocalizedandsometimesilldefinednaturewithwhichpancreaticpathologypresentsPatientswithpancreaticcancerwithoutbileductobstructionusuallypresentaftermonthsofvagueupperabdominaldiscomfort,ornoantecedentsymptomsatallDuetoitsretroperitoneallocation,painassociatedwithpancreatitisoftenischaracterizedaspenetratingthroughtothebackRegionsofthePancreasSurgeonstypicallydescribethelocationofpathologywithinthepancreasinrelationtofourregions:thehead,neck,body,andtailTheheadofthepancreasisnestledintheCloopoftheduodenumandisposteriortothetransversemesocolonJustbehindtheheadofthepancreasliethevenacava,therightrenalartery,andbothrenalveinsTheneckofthepancreasliesdirectlyovertheportalveinAttheinferiorborderoftheneckofthepancreas,thesuperiormesentericveinjoinsthesplenicveinandthencontinuestowardtheportahepatisastheportalveinTheinferiormesentericveinoftenjoinsthesplenicveinnearitsjunctionwiththeportalveinSometimes,theinferiormesentericveinjoinsthesuperiormesentericveinormergeswiththesuperiormesentericportalvenousjunctiontoformatrifurcation(Fig)ThesuperiormesentericarteryliesparalleltoandjusttotheleftofthesuperiormesentericveinTheuncinateprocessandtheheadofthepancreaswraparoundtherightsideoftheportalveinandendposteriorlynearthespacebetweenthesuperiormesentericveinandsuperiormesentericarteryVenousbranchesdrainingthepancreaticheadanduncinateprocessenteralongtherightlateralandposteriorsidesoftheportalveinThereareusuallynoanteriorvenoustributaries,andaplanecanusuallybedevelopedbetweentheneckofthepancreasandtheportalandsuperiormesentericveinsduringpancreaticresection,unlessthetumorisinvadingtheveinanteriorlyThecommonbileductrunsinadeepgrooveontheposterioraspectofthepancreaticheaduntilitpassesthroughthepancreaticparenchymatojointhemainpancreaticductattheampullaofVaterThebodyandtailofthepancreasliejustanteriortothesplenicarteryandveinTheveinrunsinagrooveonthebackofthepancreasandisfedbymultiplefragilevenousbranchesfromthepancreaticparenchymaThesebranchesmustbeligatedtoperformaspleensparingdistalpancreatectomyThesplenicarteryrunsparallelandjustsuperiortotheveinalongtheposteriorsuperioredgeofthebodyandtailofthepancreasThesplenicarteryoftenistortuousTheanteriorsurfaceofthebodyofthepancreasiscoveredbyperitoneumOncethegastrocolicomentumisdivided,thebodyandtailofthepancreascanbeseenalongthefloorofthelessersac,justposteriortothestomachPancreaticpseudocystscommonlydevelopinthisarea,andtheposterioraspectofthestomachcanformtheanteriorwallofthepseudocyst,allowingdrainageintothestomachThebaseofthetransversemesocolonattachestotheinferiormarginofthebodyandtailofthepancreasThetransversemesocolonoftenformstheinferiorwallofpancreaticpseudocystsorinflammatoryprocesses,allowingsurgicaldrainagethroughthetransversemesocolonThebodyofthepancreasoverliestheaortaattheoriginofthesuperiormesentericarteryTheneckofthepancreasoverliesthevertebralbodyofLandL,andbluntanteroposteriortraumacancompresstheneckofthepancreasagainstthespine,causingparenchymaland,sometimes,ductalinjuryTheneckdividesthepancreasintoapproximatelytwoequalhalvesThesmallportionofthepancreasanteriortotheleftkidneyisreferredtoasthetailandisnestledinthehilumofthespleennearthesplenicflexureoftheleftcolonAwarenessoftheseanatomicrelationshipsisimportanttoavoidinjurytothepancreatictailduringleftcolectomyorsplenectomyPancreaticDuctAnatomyAnunderstandingofembryologyisrequiredtoappreciatethecommonvariationsinpancreaticductanatomyThepancreasisformedbythefusionofaventralanddorsalbudTheductfromthesmallerventralbud,whicharisesfromthehepaticdiverticulum,connectsdirectlytothecommonbileductTheductfromthelargerdorsalbud,whicharisesfromtheduodenum,drainsdirectlyintoPancreaticNeoplasmsNeoplasmsoftheEndocrinePancreasInsulinomaGastrinomaVasoactiveIntestinalPeptideSecretingTumorGlucagonomaSomatostatinomaNonfunctioningIsletCellTumorsNeoplasmsoftheExocrinePancreasEpidemiologyandRiskFactorsGeneticsofPancreaticCancerPathologyDiagnosisandStagingPalliativeSurgeryandEndoscopyPalliativeChemotherapyandRadiationSurgicalResection:PancreaticoduodenectomyVariationsandControversiesComplicationsofPancreaticoduodenectomyOutcomeandValueofPancreaticoduodenectomyforCancerAdjuvantChemotherapyandRadiationNeoadjuvantTreatmentPostoperativeSurveillanceFutureTherapyAmpullaryandPeriampullaryCancerManagementofPeriampullaryAdenomasCysticNeoplasmsofthePancreasPseudocystsCystadenomaMucinousCystadenomaandCystadenocarcinomaIntraductalPapillaryMucinousNeoplasmSolidPseudopapillaryTumorOtherCysticNeoplasmsPancreaticLymphomaPancreasCHAPTERtheduodenumTheductoftheventralanlagebecomestheductofWirsung,andtheductfromthedorsalanlagebecomestheductofSantoriniWithgutrotation,theventralanlagerotatestotherightandaroundtheposteriorsideoftheduodenumtofusewiththedorsalbudTheventralanlagebecomestheinferiorportionofthepancreaticheadandtheuncinateprocess,whilethedorsalanlagebecomesthebodyandtailofthepancreasTheductsfromeachanlageusuallyfusetogetherinthepancreaticheadsuchthatmostofthepancreasdrainsthroughtheductofWirsung,ormainpancreaticduct,intothecommonchannelformedfromthebileductandpancreaticductThelengthofthecommonchannelisvariableInaboutonethirdofpatients,thebileductandpancreaticductremaindistincttotheendofthepapilla,thetwoductsmergeattheendofthepapillainanotheronethird,andintheremainingonethird,atruecommonchannelispresentforadistanceofseveralmillimetersCommonly,theductfromthedorsalanlage,theductofSantorini,persistsasthelesserpancreaticduct,andsometimesdrainsdirectlyintotheduodenumthroughthelesserpapillajustproximaltothemajorpapillaInapproximatelyofpatients,theductofSantoriniendsasablindaccessoryductanddoesnotemptyKEYPOINTSIncompletefusionofthedorsalandventralpancreaticductsresultsinpancreasdivisum,butavarietyofductalanomaliescanbeseenMagneticresonancecholangiopancreatographyaswellasendoscopicretrogradecholangiopancreatographycanidentifytheseductalanomalies,andclarificationoftheductalpatternofthepancreasisimportantbeforeattemptsatinterventionsThe“replacedrighthepaticartery”occursinofpatientsandneedstobeidentifiedpreoperativelytopreventinadvertentinjurywithresultinghepaticnecrosisAnomaloushepaticarterialanatomycanresultinhepaticischemiaduringdissectionoftheportahepatisaswell“Thincut”multidetectorcomputedtomographicimagesareusuallyabletoidentifytherelevantarterialandvenouspatternsaroundthepancreasRegardlessoftheetiology,themanagementoftheearlyphaseofacutepancreatitisiscriticaltoachieveasuccessfuloutcome“Restingthepancreas”meanseliminatingoralnutrients,andresumptionofdietshouldbelimitedtoliquidsandlowfatlowproteinfoodsPatientswhodonotimprovespontaneouslywithintohoursareatriskfordevelopingseverediseasewithitsriskoflifethreateningsepsisSurgicalinterventioninacutepancreatitisisreservedforpatientswithinfectedcollectionsorinfectednecrosisonly,ortorelieveanimpactedgallstoneintheampullaifendoscopicorradiologictreatmentsareunavailableorunsuccessfulInfectionisusuallyconfirmedbyapatternofairintheretroperitoneumoncomputedtomographicscan,orbydocumentationofbacteriaonGram’sstainorculturefromfineneedleaspirationofasuspectedinfectedfluidcollectionFineneedleaspirationofsuspiciousfluidcollectionsshouldnotbeconvertedtopercutaneousdrainageunlessinfectionisconfirmed,andtheconsensusdecisionhasbeenmadethatpercutaneousdrainageisappropriatefortheindividualpatientTheappearanceofchronicpancreatitisoncomputedtomographicscanvariesdramatically,andmultiplediagnosticstudiesareusuallyneededtoestablishtheextentofdiseaseCalcificpancreatitisisnotamarkerofalcoholicpancreatitisalone,andrarelyindicatesautoimmunepancreatitisEndoscopicultrasoundprovidesabetterassessmentofthediseasethancomputedtomographyandisusefultodiscloseindolentorunsuspectedcancer,whichcanoccurinuptoofpatientsThenidusofinflammationinchronicpancreatitisduetoanycauseistheheadoftheglandTherefore,treatmentapproachesthataddressthediseaseintheheadhavethebestlongtermresultsTheWhippleprocedure,theBegerprocedure,andtheFreyprocedure,withorwithoutlongitudinalductdrainage,arethebestsurgicaloptions,asallthreeapproachesremoveallormostofthediseaseintheheadoftheglandTheprecursorlesionthatprobablyleadstomostcasesofductularadenocarcinomaistheductalepithelialhyperplasiadysplasiaprocessdescribedbythepancreaticintraepithelialneoplasiaclassificationsystemPancreaticintraepithelialneoplasiaandpancreaticintraepithelialneoplasialesionsmaybeassociatedwithother,nonspecificchangesinpancreaticmorphologyseenonimagingstudies,ormayonlybeseenhistologicallyResectionmarginsforpancreaticneoplasmsshouldbeexaminedforadvancedpancreaticintraepithelialneoplasiastagepatternsofductalhyperplasiatoensureadequateresectionstatusIntraductalpapillarymucinousneoplasmsaresmallmacroscopicpolypoidorplaquelikeadenomasthatdevelopinthemainpancreaticductorinsidebranchducts,andsecretemucinTheyareoftensilentsymptomatically,butcausecharacteristicappearancesofsmallcystlikecollectionsofmucus,ordiffusedilatationofthemainpancreaticductwithmucusThesepremalignantlesionsmaybemultifocalorsingleandcanevolveintoinvasiveadenocarcinomainasimilarpatternaswithotheradenomatouspolypoidlesionsofthegastrointestinaltractTheyhavebeendiagnosedwithincreasingfrequency,andaccountformorethanonethirdofpancreaticresectionsatsomecentersMainductintraductalpapillarymucinousneoplasmsareanindicationforresectionsidebranchintraductalpapillarymucinousneoplasmshavealowerincidenceofmalignancyandaresometimesfollowedwithserialimagingsurveillancePancreasCHAPTERFIGPancreaticanatomyasseenoncomputedtomographyKnowledgeoftherelationshipofthepancreaswithsurroundingstructuresisimportanttoensurethatinjuryisavoidedduringabdominalsurgeryIMV=inferiormesentericveinSMA=superiormesentericarterySMV=superiormesentericveinFIGVariationsinportalvenousanatomyThesuperiormesentericveinjoinsthesplenicveinandthencontinuestowardtheportahepatisastheportalveinTheinferiormesentericveinoftenjoinsthesplenicveinnearitsjunctionwiththeportalvein,butsometimesjoinsthesuperiormesentericveinorthethreeveinsmergeasatrifurcationtoformtheportalveinPortalveinSplenicveinInferiormesentericveinSuperiormesentericveinSuperiormesentericveinSuperiormesentericveinInferiormesentericveinInferiormesentericveinSplenicveinSplenicveinPortalveinPortalveinPancreasCHAPTERintotheduodenumInofpatients,theductsofWirsungandSantorinifailtofuseThisresultsinthemajorityofthepancreasdrainingthroughtheductofSantoriniandthelesserpapilla,whiletheinferiorportionofthepancreaticheadanduncinateprocessdrainsthroughtheductofWirsungandmajorpapillaThisnormalanatomicvariant,whichoccursinoneoutofpatients,isreferredtoaspancreasdivisum(Fig)Inaminorityofthesepatients,theminorpapillacanbeinadequatetohandletheflowofpancreaticjuicesfromthemajorityoftheglandThisrelativeolowobstructioncanresultinpancreatitisandissometimestreatedbysphincteroplastyoftheminorpapillaThemainpancreaticductisusuallyonlytommindiameterandrunsmidwaybetweenthesuperiorandinferiorbordersofthepancreas,usuallyclosertotheposteriorthantotheanteriorsurfacePressureinsidethepancreaticductisabouttwicethatinthecommonbileduct,whichisthoughttopreventrefluxofbileintothepancreaticductThemainpancreaticductjoinswiththecommonbileductandemptiesattheampullaofVaterormajorpapilla,whichislocatedonthemedialaspectofthesecondportionoftheduodenumThemusclefibersaroundtheampullaformthesphincterofOddi,whichcontrolstheflowofpancreaticandbiliarysecretionsintotheduodenumContractionandrelaxationofthesphincterisregulatedbycomplexneuralandhormonalfactorsWhentheaccessorypancreaticductorlesserductdrainsintotheduodenum,alesserpapillacanbeidentifiedapproximatelycmproximaltotheampullaofVaterVascularandLymphaticAnatomyThebloodsupplytothepancreascomesfrommultiplebranchesfromtheceliacandsuperiormesentericarteries(Fig)ThecommonhepaticarterygivesrisetothegastroduodenalarterybeforecontinuingtowardtheportahepatisastheproperhepaticarteryThegastroduodenalarterybecomesthesuperiorpancreaticoduodenalarteryasitpassesbehindthefirstportionoftheduodenumandbranchesintotheanteriorandposteriorsuperiorpancreaticoduodenalarteriesAsthesuperiormesentericarterypassesbehindtheneckofthepancreas,itgivesofftheinferiorpancreaticoduodenalarteryattheinferiormarginoftheneckofthepancreasThisvesselquicklydividesintotheanteriorandposteriorinferiorpancreaticoduodenalarteriesThesuperiorandinferiorpancreaticoduodenalarteriesjointogetherwithintheparenchymaoftheanteriorandposteriorsidesoftheheadofthepancreasalongthemedialaspectoftheCloopoftheduodenumtoformarcadesthatgiveoffnumerousbranchestotheduodenumandheadofthepancreasTherefore,itisimpossibletoresecttheheadofthepancreaswithoutdevascularizingtheduodenum,unlessarimofpancreascontainingthepancreaticoduodenalarcadeispreservedVariationsinthearterialanatomyoccurinoneoutoffivepatientsTherighthepaticartery,commonhepaticartery,orgastroduodenalarteriescanarisefromthesuperiormesentericarteryIntoofpatients,therighthepaticarterywillaris

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英文原版胰腺

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