Kuzindikira ndi chithandizo cha pancreatic pseudocyst

Pancreatic pseudocyst (PC) ndi gulu losakanikirana la kapamba wozunguliridwa ndi minofu ya granulation, yomwe ili mkati kapena kuzungulira kwa kapamba ndipo amayamba chifukwa cha kapamba kapena chifuwa cha kapamba. Ma pseudocysts amatha kukhala amodzi komanso angapo, akulu ndi ochepa, ndipo amatha kupanga mkati kapena kunja kwa kapamba. Ma pseudocysts ambiri amagwiritsidwa ntchito ndi pancreatic duct ndipo amakhala ndi michere yambiri. Makoma a pseudocyst amayimilidwa ndi zimakhala zapafupi monga m'mimba, colon yopingasa, ligament ya m'mimba, ndi kapamba. Kulumikizana kwamkati kwa PC kumayimiriridwa ndi granulation ndi fibrous minofu, kusakhalapo kwa epithelial akalozera kumasiyanitsa PC kuchokera ku mapangidwe owona a cystic a kapamba.

PC ikhoza kuchitika m'mikhalidwe itatu:

PC imatha kuukira pambuyo povulaza pachimake kapamba pafupifupi 10% ya milandu 1.2. Necrosis ya peripancreatic minofu imatha kufikira kuchuluka kwa liquefaction ndi gulu lotsatira ndikupanga ma pseudocysts, omwe amatha kulumikizana ndi pancreatic duct. Njira ina ndikuwonekera kwa ma pseudocysts chifukwa cha chachikulu necrosis ya parenchyma, yomwe ingayambitse kusokonezeka kwathunthu kwa pancreatic duct ndikukutulutsa kwakukulu kwa madzi a pancreatic.
Mwa odwala omwe ali ndi pancreatitis yodwala, yomwe nthawi zambiri imayamba chifukwa chomwa mowa kwambiri, mapangidwe a PC amatha kuchitika chifukwa cha kuchuluka kwa kapamba kapena kupitirira kwa kutsekeka kwa kapamba. Kutsekeka kumatha kuchitika mwina chifukwa cha kukakamiza kwa duct kapena kukhazikika kwapangidwe komwe kumapangidwa kuchokera kumapulogalamu apuloteni. Kuwonjezeka kwa kupanikizika kwa intraductal kungayambitse kutulutsa kwa pancreatic madzi ndi kudzikundikira kwake.
Kuvulala kofinya kapena kolowera kungawononge mwachindunji chimbudzi cha pancreatic chopita kumapangidwe a PC.

Ma PC ambiri ali asymptomatic, koma atha kukhala ndi mawonekedwe osiyanasiyana azachipatala kutengera kukula ndi malo.

Ma pseudocysts amakulitsa amatha kupweteka m'mimba, kutsekeka kwa duodenum, mitsempha yamagazi, kapena ndulu ya bile. Fistulas yokhala ndi ziwalo zoyandikana, the pleural patsekeke kapena pericardium imatha kupanga.
Matenda ofala ndi kupangika kwa kathumba.
Kudzimbidwa kwa ziwiya zapafupi kungapangitse mapangidwe a pseudo-aneurysm, omwe angayambitse kukula kwambiri kwa kukula kwa PK kapena magazi ochokera m'matumbo am'mimba chifukwa chakuwukha kwa magazi mu duct ya pancreatic.
Pancreatic ascites ndi pleurisy imatha kupangika ngati chimbudzi chikugundana ndikupanga fistula yokhala ndi m'mimba kapena chifuwa chamkati kapena PC ikang'ambika.

Kuzindikira kwa PC kumapangidwa nthawi zambiri ndi CT kapena ultrasound. Mukamapanga drainage (nthawi zambiri imatha kukhala yothandizirana kuposa njira zodziwira), kuwonjezeka kwakukulu kwa kuchuluka kwa amylase muzomwe zili mu PC, chifukwa cha kulumikizana kwake ndi kachitidwe kanyumba ka pancreatic, ndizodziwika ndi ma PC. Amylase okwera kwambiri, omwe nthawi zambiri amakhala pamwamba pa 1000, amapezeka m'madzi omwe amapezeka chifukwa cha laparocentesis kapena thoracocentesis mu pancreatic ascites kapena pleurisy.

Matenda ena

Funso loyamba ndilakuti ngati pali mwayi uliwonse kuti kuphatikiza kwa madzimadzi ndi cystic neoplasm kapena "pseudo-pseudocyst" wina. Masewera a cystic neoplasm omwe amathandizidwa ndi PC amatha kubweretsa zovuta zambiri ndipo zimapangitsa kuti zikhale zovuta kuchita pambuyo pake. Zotsatira zotsatirazi zikuyenera kudzutsa nkhawa kuti madzi omwe akonzedwa samakhala PC:

Palibe mbiri kapena zizindikiro za kapamba kapena kupweteka kwambiri kapena kupweteka kwambiri.
Kusakhalapo kwa kusintha kwokhudzana ndi kutupa mu CT.
Kupezeka kwa seta yamkati mkati mwa cyst.

Ngakhale kuchuluka kwambiri kwa amylase pazomwe zili ndi PC chifukwa cha mayanjano ake ndi pancreatic flow kumawonetsa PC yotupa, kukayikira kwakukulu kuyenera kukhalabe kuyambira palibe mayeso amodzi okha omwe angalepheretse cystic neoplasm. Matenda ena ambiri osavulaza amatha kusilira PC, chifukwa cha izi, chisamaliro chofunikira ndikofunikira kuti mupewe zolakwika pakupezeka kwa 2.8.

Kupezeka kwa pseudo-aneurysm

Funso lotsatira ndiloti pseudo-aneurysm ilipo, zovuta zomwe zimachitika pafupifupi 10% ya odwala omwe ali ndi PC 9-11. Kukha kwambiri kapena ngakhale kupha kumene kumachitika pambuyo pa kukoka kwa endoscopic ngati wodwala sanayikiridwe ndi pseudo-aneurysm. Pokhapokha ngati embolization wa arterial yoyamba kuchitidwa, ndiye kuti pseudo-aneurysm ndikutsutsana kwathunthu ndi kulowerera kwa endoscopic. Zizindikiro zitatu zamankhwala zingasonyeze kukhalapo kwa pseudo-aneurysm:

Kutulutsa magazi m'matumbo osadziwika.
Kukula kosayembekezereka kwa PC.
Kutsika kosagawika mu hematocrit.

Tikukhulupirira kuti chosimbidwa bwino, cholimba, champhamvu cha CT chokhala ndi kuyerekezera koyambirira m'magawo oyambirirako chiyenera kukhala chizolowezi chofufuza kwa odwala onse omwe amawaganizira omwe akufuna kuti azitsatira pang'onopang'ono kuti adziwe pseudo-aneurysm. Kuwunika kwa m'mimba kumatha kukhala kothandiza, koma kumakhala ndi chidwi chochepa. Angiography ndi njira yofufuzira yoyesera ndipo ikugwiritsidwa ntchito kwambiri kuphatikiza ma pseudo-aneurysms okhala ndi chitho cha radiopaque kapena chithovu. Mwa odwala 57 oyamba omwe adatchulidwa kuti amathandizira endicopic pseudocysts ku malo athu, tidatha kuzindikira ma pseudo-aneurysms Asanachitike kukhetsa. Odwala awa ankawathandizira kudzera munjira zosiyanasiyana, kuphatikizapo embolization kapena resection. Posachedwa, tidapanga ngalande mosamala atatha kudziwa njira yabwino kwa odwala omwe sanayenerere opareshoni.

Udindo wa chithandizo chamankhwala

Maphunziro achikhalidwe opangira opaleshoni amatengera kafukufuku wakale yemwe ma PC omwe amapezekapo kwa masabata opitilira 6 samasinthidwa kawirikawiri ndipo, pambuyo pakuwona, apereka zovuta mu 50% ya milandu. Pambuyo pa masabata 13 palibe lingaliro lina lomwe linawonedwa ndipo kuchuluka kwa zovuta kunachuluka kwambiri. Opaleshoni idalimbikitsidwa atatha kuwunika kwa milungu 6 kuwonetsetsa kuti kudziletsa sikunachitike komanso kupereka nthawi yosinthasintha malinga a PC kulola mwachindunji cystic enterostomy mwa kusenda. Njirayi imavomerezedwa kwambiri ndi madokotala ochita opaleshoni ndipo imakonda kutchulidwa 15-18. Ndemanga zina ziwiri, komabe, zikulimbikitsa njira yodikira ndi kuwona wodwala yemwe ali ndi vuto losakhazikika la cystic neoplasm, pseudo-aneurysm, kapena wokhala ndi zizindikiro zochepa. Kuunikanso mwachidwi kwa odwala 68 omwe adagwidwa ndi PC adawonetsetsa kuti zovuta zazikulu zimachitika mu 9% ya milandu, yambiri imachitika masabata 8 oyambilira atazindikira. Mavuto anaphatikizidwa ndi mapangidwe a pseudo-aneurysms mu 3x, kupaka mafuta mu freex yam'mimba mu 2x komanso mapangidwe okhazikika a abscess mu 1st wodwalayo. Kuphatikiza apo, 1/3 ya odwala adachitidwa opaleshoni yosankhidwa chifukwa cha ululu womwe umakhudzana ndi kukulira cysts. Komabe, 43 odwala (63%) adawonetsa kuwongolera mosavomerezeka kapena kusowa kwa zizindikiro ndi zovuta zake pakutsatiridwa kwapafupifupi kwa miyezi 51. Zowonera zofananazi zidawonekanso pakafukufuku wina wa odwala 75. Kuchita opaleshoni kunachitika kokha chifukwa cha ululu wam'mimba kwambiri, zovuta kapena kuwonjezeka kwapang'onopang'ono kukula kwa cyst. 52% ya omwe adachitidwa opareshoni molingana ndi zomwe tafotokozazi, odwala omwe adatsalawo anali okhazikika. Mwa odwala a gulu lomalizali, 60% idasintha kwathunthu kwa cyst mpaka chaka 1, ndipo m'modzi yekha anali ndi zovuta zomwe zimakhudzana ndi PK. Odwala ena pagululi lazizindikiro analibe, ndipo PK mwina inalimbikira kapena kuchepa pang'ono pang'onopang'ono. Ndizosatheka kuneneratu, pamaziko a etiology kapena CT, momwe odwala azisankha kwathunthu kwa PC kudzachitika, koma kwakukulu, PC mu odwala omwe ali m'gulu lachipatala chokhazikika anali ochepa kukula kuposa omwe amafunikira opaleshoni. Kufotokozera mwatsatanetsatane kwa anatomy of pancreatic duct, komwe kungathandize kulosera kukula kwa matendawa, sikunaperekedwe mu maphunziro aliwonsewa.

Njira zamakola

M'mbuyomu, pamene ngalande zidayamba kukhala zofunikira chifukwa chovuta chifukwa cha zovuta zina kapena mawonekedwe osapezekanso omwe adalumikizana ndi PC, drainage adangokhala chithandizo chokhacho. Pakadali pano, pali njira zina ziwiri zamankhwala zomwe zatchuka kwambiri: ngalande zodutsa ndi ma endoscopic. Kutsutsana komwe kumatsalabe funso loti ndi njira ziti zomwe zimayenera kuperekedwa kwa wodwala ngati mtundu woyamba wa chithandizo. Pakadali pano palibe kafukufuku wosiyanasiyananso wa njira ziwirizi, ndipo madokotala amagwiritsa ntchito yomwe amudziwa bwino. Zovuta zamadzimadzi zokhazikika ndizomwe zimakhalapo kwa catheter komanso kupangidwa kwa fistula yakunja.
Kukhetsa kwa mkati. Madokotala ambiri opaleshoni, ngati kuli kotheka, amagwiritsa ntchito njira yodulira madzi mkati, momwe mungakhalire atengera pseudocysts:

Cysto-gastro kapena duodenostomy pamene kugulitsa cyst ndi m'mimba kapena duodenum.
Cystejunostomy ikhoza kugwiritsidwa ntchito ndi mitundu ina ya anatomical.
Pancreatic mchira PK ikhoza kuchotsedwa ndi resection; papillosphincterotomy nthawi zambiri ndizofunikira pansi pamikhalidweyi.

Kuchuluka kwa zovuta zamakina amkati ndi pafupifupi 15% yokhala ndi anthu osakwana 5%. Mlingo wa kubwezeretsanso kwa postoperative uli pafupifupi 10% 22-26. Ngati pali cholepheretsa chachikulu cha pancreatic duct pansipa ya anastomosis, madokotala ena amathandizira kuyambiranso PC, m'malo mokhetsa mkati kuti ayesetse kuyambiranso.
Kukhetsa kwina kunja kungakhale kofunikira ngati sikutheka kupanga anastomosis yamkati. Fistulas zakunja ndizotsatira zamtunduwu.
Transdermal catheter ngalande. Mtsinje wa Transdermal catheter ndiwothandizadi ngati thambo la opaleshoni mu madzi ndikutsekeka kwa onse osabala ndi omwe ali ndi cysts 28-30. Ndikofunikira kusamalira patency ya catheter mwa kuthirira mosamala. The catheter imasiyidwa mpaka mulingo wa kutulutsa umachepetsedwa kukhala 5-10 ml. patsiku. Pakufufuza kumodzi kwa odwala 52, nthawi yayitali yonyamula inali masiku 42. Ngati kuchepa kotereku kumachitika, ndiye kuti octreotide (50-200 mg. Subcutaneally, maola 8 aliwonse) akhoza kukhala othandiza. Kuwongolera kwa CT kuyenera kuchitidwa ndikumachepetsa kuchuluka kwa zotulutsa kuti zitsimikizike kuti catheter sichichotsedwa mu PC patsekeke. Chovuta chachikulu cha njirayi ndikulowerera kudzera mu catheter ya matenda, omwe kafukufuku wina anachitika theka la odwala. Sizikudziwika ngati kutsekeka kwa dambo lalikulu la pancreatic kuyenera kupewedwa kuti muchite ngalande zowonongeka.
Njira ya Endoscopic. Malipoti ambiri amatsimikizira kuchuluka kwakukulu kwa endoscopic cysto-gastro (ECG) ndi cystic duodenostomy (ECD). ECD ndiyo njira yosankhira chifukwa chotetezeka kwambiri, kusavuta kwa njira yolumikizana ndi cyst panthawi ya kukhetsa, komanso chidwi chachikulu cha duodenum kuposa m'mimba nthawi zambiri za PC. Mlingo wa PC wogwiritsa ntchito endoscopic umasiyana 65 mpaka 89%. Mavuto akulu am'madzi am'madzi akutha magazi (omwe mu mphamvu yake imafunika chithandizo cha opaleshoni mpaka 5% ya milandu), kubwezeretsa, kupatsirana, kulephera komanso kukwaniritsa cholinga cha PC. Imfa zomwe zimagwirizanitsidwa ndi njirayi sizikupezeka paliponse ndi 6-18%. Chiwerengero cha milandu ya kufafaniza kapena magazi ingachepetsedwe ndikuzindikira PC musanaperekedwe kwa endoscopic. Timakonda kuzindikira PC ndikumangirira ma endoscopic, ngakhale kuchulukitsa kutchuka kwa endoscopic ultrasound kungapangitse njirayi kukhala njira yovomerezeka.

Udindo wa endoscopic ultrasound

Kutchuka kwa endoscopic ultrasound pakuzindikira pancreatic pseudocysts kukukula pompano chifukwa njirayi imakupatsani mwayi wodziwa zovuta za makoma ndi zomwe zili mu PC. Kuphatikiza ndi kushupika kwa biopsy, kumatha kuthandizira pakuwunika kwa PC ndi cystic neoplasm. Kupezeka kwa kusiyanasiyana kwa phala, echogenic mucin, ndi mawonekedwe a volumetric kumawonetsa cystic neoplasm yomwe ikufuna kuyambiranso osati kutulutsa. Monga tafotokozera pamwambapa, endoscopic ultrasound imatha kuthandiza posankha malo opangira ma pseudocysts - kupatula kukhalapo kwa mitsempha yayikulu kapena mitsempha yotayidwa m'deralo. Chifukwa chake, m'lingaliro, njirayi ikhoza kukhala ndi mwayi wochepetsera chiopsezo cha kukhetsa magazi ndi kufukiza, ngakhale izi sizinawonetsedwe pazoyesedwa zowongoleredwa.

Kukhalapo kwa pancreatic necrosis

Tikukhulupirira kuti nkhani yofunikira kwambiri yomwe chisankho chogwiritsa ntchito endoscopic, opaleshoni kapena ma radiology imadalira ngati pali zizindikiro za PC zomwe zimagwirizanitsidwa ndi pancreatic necrosis, yomwe imatsimikiziridwa ndi CT mosiyana ndi zina. Kukhalapo kwa wandiweyani inclusions, dendrite, ndi kukhalapo kwa madera a necrotic a pancreatic parenchyma kungasonyeze kuti gawo lalikulu la minofu yakufa ikhoza kukhalapo. Chisankho chogwiritsa ntchito njira ya transmural zimatengera momwe necrosis imawonekera bwino. Mavuto opatsirana amatengera pafupipafupi ndikugwiritsa ntchito ma endoscopic komanso radiological drainage mu izi. Ngakhale zovuta zambiri zomwe zimadza chifukwa cha kukoka kwa endoscopic zitha kuthandizidwa ndi katswiri wodziwa bwino ntchito, kulephera kuzindikira necrosis, chifukwa chokwanira, kutulutsa kapena kuyinya kwa chidwi cha necrotic, kumatha kudzetsa zovuta zambiri mpaka kufa. Chifukwa chake, kukhalapo kwa pancreatic necrosis kuyenera kukhala chifukwa chachikulu chokayikira pakukhazikitsa ngalulu yotsiriza ya endoscopic, ngakhale sizipatula zoyesayesa zake. Kukhetsa kwazitsulo kumalola PC kufunafuna kuti ichotse dendritis ya necrotic ndikwaniritse kutuluka kwathunthu kwazinthuzo asanakhazikitse anastomosis. Njira ya endoscopic yokhala ndi kupunthwa kwa transmural imalola kuphukira kwa nasogastric, kutsika kwa dzenje ndi kukhazikitsidwa kwa mitundu ingapo, ndipo kungakhale njira ina yothandizira opaleshoni odwala osankhidwa mosamalitsa m'malo apadera. Mavuto omwe angabuke akuwonetsedwa mu lipoti la odwala 11 omwe adatsekereza ngalande yamtundu wamtunduwu wa cyst (yofotokozedwa ngati "organised pancreatic necrosis"). Pogwiritsa ntchito njira zaukali za endoscopic, kupambana kunatheka mwa odwala 9. Njira zingapo zimafunika ndi kuchuluka kwa 50%, ngakhale ambiri a iwo ankalandira chithandizo mosiyanasiyana.

Kukhalapo kwa katemera wa pancreatic

Kukhazikika kochepa kwa mafinya mkati kapena pafupi ndi kapamba kale amati ndikovuta kwa pseudocyst, komwe kumafunika kutseguka mwachangu ndi madzi.Posachedwa, ngalande za endoscopic zimagwiritsidwa ntchito pagulu la odwala omwe ali ndi chiopsezo chogwira ntchito kwambiri chifukwa cha kukhalapo kwa zovuta za pancreatitis. Zofunikira ndizakumwa zokwanira, kufunikira kochotsa zotchinga ndi kuyesetsa mwachangu ndi kuwona kwa wodwalayo. Timakonda njira yopita kumayiko ena kukachotsa chimbudzi kuyambira pamenepo imalowetsanso ngalande ya cystenterostomy ngalande, kuyikapo catheter yothirira ya nasogastric ndi stents zingapo kuti tipewe zovuta zomwe zimagwiritsidwa ntchito posakwanira catheter ntchito komanso zotsalira.

Njira Yotsimikizika

Pakadali pano, tikulimbikitsa njira zamavuto odwala omwe ali ndi PC omwe adapezeka ngati vuto la kapamba kapena kupweteka kwambiri kwa pancreatitis komanso kukhalapo kwa masabata osachepera anayi. Timachita HRCP tikamaganiza kuti wodwala ndiwowayesera kuti ayesere kutaya kwa endoscopic. Pa endoscopy, matenda oopsa a portal komanso kutulutsa kovuta m'mimba sayenera kuphatikizidwa. RCP imapangidwa kuti iwone mawonekedwe a mtengo wapanja, makamaka spruce, hepatic indices. Pancreatography ndiyofunikira mwa odwala onse kuti azindikire zomwe zimayambitsa kupindika kwa pancreatic duct. Zovuta zosadziwika ndi kuwonongeka kwa pancreatic duct nthawi zambiri zimapezeka, zovuta zomwe zimayambitsidwa ndi chotupa chowopsa chitha kuchitika. Chifukwa ngalande za endoscopic zitha kuchitidwa zonse kudzera pakupyoza kwaposachedwa ndikuwonjezerapo papillary stent; pancreatogram ndiyofunikira posankha pakati pa izi. Endoscopic ultrasound itha kukhala yothandiza pakuwunika matenda osiyanasiyana ndi zotupa za pancreatic ndi zotupa za PC, ngakhale sizigwiritsidwa ntchito pafupipafupi. Odwala omwe ali ndi ma PC akulu, opitilira, kapena ochulukitsa nthawi zambiri amawonetsa kuwonongeka kwakukulu kwa pancreatic duct, komwe kumatsimikizira kufunika ndi mtundu wa chithandizo chomwe chikugwiritsidwa ntchito. Pazomwe takumana nazo, kutsekeka kwa kapamba wa pancreatic ndi ma stamptures ake athunthu amakhala pafupipafupi mgululi la odwala ndipo samathetseka atatha kuthetsa pseudocyst. Mosiyana ndi izi, kutayikira kochokera ku nthambi zotumphukira kumatseka pambuyo pa chithandizo cha endoscopic chopita kutsogolo kwa cyst.

Muzochita zathu, timapitiliza chithandizo chosasamala, ngati kuli kotheka, ndi chida chachikulu cha pancreatic mpaka mchira komanso kusalankhulana ndi PC. Ngati wodwalayo ali wokhazikika, ndiye kuti kukula kwa PC kungathe kuwongoleredwa pakatha miyezi 3-6 yolumikizidwa ndi CT ya m'mimba. Zizindikiro zatsopano monga kupweteka pamimba, kuzizira, ndi kutentha zimayenera kuwunikira nthawi yomweyo. Zowongolera zowononga zachilengedwe ziyenera kukhala zotetezeka pansi pa izi. fancula kapamba suwoneka. Komabe, zovuta zake ndizokhalitsa ndikuwongolera.
Kuchita chowotchera muulamuliro wama radiology kuyenera kupewedwa ndi kutsekeka kwa duct, angapo cysts ndi necrosis.
Pseudocyst yomwe imalumikizidwa ndi dancipondic, makamaka ngati ili kutali ndi khoma lam'mimba kapena duodenum ndi ochepera 6 mm, imathandizidwa bwino ndi drapapillary drainage.
Kutulutsira kwa Transmural kumachitika ndikutsekeka kwathunthu kwa kapamba kapenanso kukula kwa PC kuposa 6 mm, komwe kumapangitsa kutsimikiza kwake pogwiritsa ntchito ngalande za trans-capillary zokha. Mankhwala a Endoscopic ndi otheka kuchepetsedwa ndi PC ndi matumbo lumen, omwe amatsimikiziridwa ndi CT kapena endoscopic ultrasound.
Kuwonongeka kwakukulu kwa pancreatic duct komwe kumabweretsa kusadzaza kwa mchira wa pancreatic kumatha kuyankha ndikutulutsa kwa capillary drainage, ngakhale drainage dragege iyenera kuchitidwa ndi cyst yayikulu.
Njira yankhanza, yochita opaleshoni yokhala ndi kufalikira kapena kukoka kwakukulu kwa endoscopic ndikutsuka kwambiri ikuyenera kugwiritsidwa ntchito pamaso pa necrosis.

Abstract of the science nkhani zamankhwala ndi zamankhwala, wolemba pepala lasayansi - Schastny A. T.

Nkhaniyi ikuwunikira za matenda a miliri, etiology, kuzindikira ndi kuchiza kwa pseudocysts a kapamba, imafotokoza za matenda. Zinatsimikizika kuti pulogalamu yodziwitsa za matenda amtunduwu iyenera kuphatikizapo kugwiritsa ntchito njira zamakono zofufuzira (ultrasound, complication tomography, imagonance imaging, cholangiopancreatography, endoscopic retrograde papillocholangiography, komanso biochemical ndi cytological kusanthula zomwe zili mu cyst). Chidwi chachikulu chimaperekedwa pa njira zochizira, makamaka zamakono zowukira. Kutengera ndi zowerengera zamabuku komanso zomwe takumana nazo pothandiza odwala 300, zopindulitsa ndi zoyipa zosiyanasiyana zomwe zimachitika mwanjira imeneyi zimatsimikizika, zisonyezo zamankhwala opaleshoni zimapangidwa. Amawonetsedwa kuti opaleshoni ya laparoscopic ndiwowongolera popereka chithandizo cha odwala omwe ali ndi pancreatitis yokhala ndi pseudocysts.

Mafunso a epidemiology, etiology, diagnostics ndi chithandizo cha pseudocysts a kapamba akuwonetsedwa, amagwiritsidwa ntchito pogawa matendawa. Zapezeka kuti pulogalamu yodziwunika ngati matenda amtendawa akuyenera kupereka njira zamakono zofufuzira (kufufuza kwazinthu za pakompyuta, kulinganiza kwa makompyuta, kuwunika kwa mapangidwe apamwamba, kusindikiza kwa zinthu zakale, kupenda kosatha ndi kusanthula kwazinthu zokhudzana ndi ma cystological ndi cytological). Tawunikiridwa kwambiri njira zogwiritsira ntchito pochizira, makamaka zamatekinoloje othandizira. Kuyika pazomwe mabuku ndi chidziwitso cha odwala opaleshoni 300, zabwino ndi zovuta za kuchitapo kanthu pakagwiritsidwa ntchito ndi matenda awa. Mankhwala othandizira amapangidwa.Laparoscopies adawonetsedwa kuti ndi njira yochizira odwala omwe ali ndi pancreatitis yosagwirizana ndi pseudocysts.

Zolemba pazaka yasayansi pamutu wakuti "Pseudocysts of the pancreas: diagnostic, chithandizo"

MTHANDI WOTHANDIZA Dongosolo

Matenda a kapamba: Kudziwitsa,

UE "Vitebsk State Medical University", Regional Science Science and Practical Center "Opaleshoni yamatenda a chiwindi ndi kapamba",

Nkhaniyi ikuwunikira za matenda a miliri, etiology, kuzindikira ndi kuchiza kwa pseudocysts a kapamba, imafotokoza za matenda. Zinatsimikizika kuti pulogalamu yodziwitsa za matenda amtunduwu iyenera kuphatikizapo kugwiritsa ntchito njira zamakono zofufuzira (ultrasound, complication tomography, imagonance imaging, cholangiopancreatography, endoscopic retrograde papillocholangiography, komanso biochemical ndi cytological kusanthula zomwe zili mu cyst). Chidwi chachikulu chimalandira njira zakuchipatala, makamaka zamakono zowukira. Kutengera ndi zowerengera zamabuku komanso zomwe takumana nazo pothandiza odwala 300, zopindulitsa ndi zoyipa zosiyanasiyana zomwe zimachitika mwanjira imeneyi zimatsimikizika, zisonyezo zamankhwala opaleshoni zimapangidwa. Amawonetsedwa kuti opaleshoni ya laparoscopic ndiwowongolera popereka chithandizo cha odwala omwe ali ndi pancreatitis yokhala ndi pseudocysts.

Mawu osakira: kapamba, kapamba, pseudocyst, opaleshoni ya endoscopic

Mafunso a epidemiology, etiology, diagnostics ndi chithandizo cha pseudocysts a kapamba akuwonetsedwa, amagwiritsidwa ntchito pogawa matendawa. Zapezeka kuti pulogalamu yodziwunika ngati matenda amtendawa akuyenera kupereka njira zamakono zofufuzira (kufufuza kwazinthu za pakompyuta, kulinganiza kwa makompyuta, kuwunika kwa mapangidwe apamwamba, kusindikiza kwa zinthu zakale, kupenda kosatha ndi kusanthula kwazinthu zokhudzana ndi ma cystological ndi cytological). Tawunika chidwi ndi njira zogwiritsira ntchito pochizira, makamaka zamatekinoloje othandizira. Kuyika pazomwe zalembedwa komanso chidziwitso cha odwala 300 othandizira chithandizo, zabwino ndi zoyipa zosiyanasiyana polimbana ndi matenda awa. mankhwalawa adapangidwa.Liposcopies yasonyezedwa kuti ndi njira yochizira odwala omwe ali ndi pancreatitis yosagwirizana ndi pseudocysts.

Mawu osakira: kapamba, kapamba, pseudocyst, mankhwala a pseudocysts, opaleshoni ya endoscopic

Pancreatic cysts ndi gulu lalikulu komanso losiyanasiyana la matenda a kapamba ndipo ndi zovuta za chifuwa chachikulu kapena chovuta cha kapamba. Pafupipafupi kupezeka kwa pseudocysts mu papoid ndi pancreatitis yovuta kwambiri taphunzira m'maphunziro ambiri. Wachibale

Gawo lalikulu la ma pseudocysts limatengera njira zodziwira matenda. Pancreatitis pachimake imapanikizika ndi cyst mu 5-19.4% ya milandu, mu mitundu yoopsa yowononga kapamba - mpaka 50% ya milandu. Pankhani ya kuvulala kwa pancreatic, cysts imachitika mu 20-30% ya ozunzidwa, ndipo pancreatic pseudocysts mu mawonekedwe a zovuta za chifuwa cham'mimba zimachitika mu 20 mpaka 40% ya milandu. Ntchito zina

Zotsatira zake zidawonetsa kuti pancreatitis yayikulu yosatha yoledzera imayambira kukula kwa pancreatic pseudocysts mu 56-70% ya odwala. Kuphatikiza apo, mu 6-36% ya milandu, cysts imachitika ndi biliary pancreatitis, 3-8% atatha kuchitira opaleshoni kapena kuvulala, ndipo mu 6-20%, chifukwa chawo sichinapezeke. Pseudocysts, iwonso imatha kuyambitsa zovuta zambiri (kutulutsa magazi, kukhathamiritsa, kukongoletsa), komwe kumayamba mu 25% ya odwala. Ngakhale kusinthika kwa maukadaulo opangira opaleshoni, kukhazikitsa njira zamakono zamankhwala othandizira kuchitira ntchito, kufa kwa pancreatic cysts ndi 27-42%, ndipo ngati sepsis, magazi, ndi mafuta odzola umafikira 40-60% 2, 3.

Pakadali pano, pakuwonjezereka kwa chiwopsezo chachikulu cha pancreatitis yovuta kwambiri, komanso chifukwa cha kukonza ndi kufalikira kwa njira zamakono zamakono zodziwitsira, kuchuluka kwa ma pseudocysts kukukula pang'onopang'ono. Njira zopangira opaleshoni ndi kusankha kwa njira ya chithandizo ndi nkhani yomwe mukukambirana. Chifukwa chake, kusaka njira yolumikizira pancreatic cysts ndikwachilengedwe, kutengera chikhalidwe chawo, kuthekera kwawoko, kulumikizana ndi pancreatic duct system, komanso kukhalapo kwa zovuta. Popeza izi, nkhani za chithandizo cha opaleshoni yamankhwala othandizira pancreatic cysts zimafunanso kafukufuku kuti apange njira zoyenera kwambiri ndikusankha kuchitapo kanthu koyenera, komwe kumatsimikizira kufunikira kwa vutoli.

Malinga ndi kunena kwa a M. Calley ndi W. Meyers, zomwe zikugwirizana ndi malingaliro a akatswiri ambiri, "Opaleshoni

"akupitiliza kukhala muyezo wazithandizo zamankhwala ndikusokonekera kwamadzi amadzimadzi, ma pancreatic pseudocysts ndi abscesses." Maluso opangira opaleshoni amapangidwa pamaziko a matendawa, omwe nawonso amawonetsedwa ndi a M. Sarner. " ayankhe mafunso atatu: cholakwika ndi chiyani? zomwe zinachitika chingachitike ndi chiyani? ” Magawo angapo a pancreatic pseudocysts afunsidwa.

Gulu la Atlanta limasiyanitsa mitundu inayi yazomwe zimayambira:

1) kudzikundikira kwamadzi pachimake pa nthawi ya pachimake kapamba ndi kuchepa kwa khoma la granulomatous kapena fibrous minofu.

2) pseudocysts pachimake - khola lazunguliridwa ndi minyewa ya fibrous kapena granulomatous, zomwe ndi zotsatira za kapamba kapena kuvulala,

3) pseudocysts oyamba chifukwa cha chifuwa cham'mimba komanso popanda chifukwa cham'mbuyomu cha kapamba,

4) chithuza, chimbudzi cham'mimba chokhudzana ndi mafinya pafupi ndi kapamba kapena popanda necrosis chifukwa cha pancreatitis yovuta kapena yopweteka.

Njira ina yogawa, yomwe inavomerezedwa mu 1991 ndi A. D'Egidio ndi M. Schein, idakhazikitsidwa ndipo imaganizira kupezeka komanso kuchuluka kwa kulumikizana kwa dongosolo la pancreatic duct ndi patseudocyst patsekeke

1) cysts pachimake pa pancreatic duct yayikulu,

2) cysts yomwe ikubwera potengera maziko a chifuwa chachikulu chokhala ndi mauthenga a protocococystic, koma osaletseka m'mphepete mwa mapaipi akuluakulu,

3) cysts aakulu kuphatikiza

Kusintha kwakukuru mu pancreatic duct, makamaka, ndi kupindika m'mphepete mwa pancreatic duct.

W. Nealon ndi E. Walser amatchulanso ma pancreatic pseudocysts malinga ndi duct anatomy ndi kukhalapo kapena kusapezeka kwa kulumikizana ndi patseudocyst patsekeke. Cholinga cha gawoli chinali kupangira mfundo zoyenera zochizira pancreatic pseudocysts.

The diagnostic algorithm ya pancudic pseudocysts imaphatikizapo ultrasound, yowerengera tomography, maginidwe oyesa a micron, cholangiopancreatography, endoscopic retrograde papillocholangiography ndi kafukufuku wazomwe zili mu cyst biochemically ndi cytologically. Malinga ndi gulu la Atlantean, pseudocyst imadziwika ndi kukhalapo kwa khoma la zotupa kapena ma granulomatous, pomwe kudzikundikira kwamadzi kumachitika. Koma kukhalapo kwa zizindikiritso za kutalikirana, madera a necrosis, sequesters amachititsa kuti kuwunika kwa ma morphological kusakhale kothandiza nthawi zonse, chifukwa chake, kuwunika kuyenera kuyenderana ndi momwe wodwalayo alili 9, 10.

Mwa njira zodziwitsira matenda, ultrasound ndiyotsika mtengo kwambiri, yotsika mtengo komanso yosavulaza. Kafukufukuyu akuyenera kuchitidwa ngati gawo loyamba pakupezeka pysreatic cysts. Kuzindikira kwa njirayo ndi 88-100% ndipo kutsimikizika kwake ndi 92-100%, koma zotsatira zake zimadalira luso ndi udokotala. Moyang'aniridwa ndi ultrasound, ma punctic a cystic formations amachitidwa poyesedwa pambuyo pake pazomwe zili, komabe, mpaka

Mkuyu. 1. Ultrasound. Pancreatic cyst

Njira zowonongera, ndikofunikira kugwiritsa ntchito dopplerography kuti muwone m'mitsempha yamagazi yomwe ili pafupi ndi pseudocyst kapena khoma lake.

Amakhulupilira kuti compression tomography ndiyowumiriza maphunziro pakudziwitsa za pseudocysts. Njira imakuthandizani kudziwa komwe pseudocyst, makulidwe ake khoma, kukhalapo kwa necrosis, sequesters, septa mkati mwa foci komanso kuchuluka kwa pseudocyst kumitsempha yamagazi. Tomography yophatikizidwa imakhala ndi kukhudzika kwapamwamba - 82-100%, kutchulidwa - 98% ndi kulondola - 88-94% 11, 12.

Njira imodzi yofunika kwambiri yofufuzira ndikubweza pancreatic

Mkuyu. 2. KT. Pancreatic mutu cyst.

Mkuyu. 3. Kubwezeretsa virsungografiya.

cholangiography (RPCH). RPHG imapereka chidziwitso mu anatomy of pancreatic and bile ducts ndipo imathandizira kupanga pancreatic pseudocysts. Ngakhale RPCH imapereka chidziwitso chocheperako cha kukula kwa chotupa, malo ake, minofu yoyandikana, kulumikizana kwa pseudocyst ndi pancreatic duct

Mkuyu. 4. MRPHG. Pancreatic mutu cyst.

kuzindikiridwa mu 40-69% ndipo izi, zimatha kusintha njira zamankhwala, mwachitsanzo, kugwiritsa ntchito ngalande zodutsa. Kafukufuku wasonyeza kuti mu 62-80% ya odwala pali kubwezeretsanso kwa pseudocyst mosiyanitsa, ndiko kuti, kulumikizana kwa cyst patsekeke ndi pancreatic duct kumatsimikiziridwa. Chofunikanso ndichidziwitso cha ma stanctures a pancreatic duct, omwe nthawi zambiri amayambitsa kukula kwa pseudocysts. Nawonso, kuyambiranso kusiyana kwa ma ducts a bile ndi ma pancreatic ducts kungayambitse zovuta zazikulu, monga cholangitis, kapamba, ndi matenda a cyst.

Pakadali pano, maginito a resonance pancreatocholangiography (MRPC) akukondedwa kwambiri. Njira yake siyowonongera, ili ndi zovuta zotsika kwambiri kuposa RPHG, komanso zimatengera zochepa pa kuyeneretsedwa kwapadera kuposa ultrasound, ndipo chidwi cha MRPC ndi 70-92%. Olemba ambiri a MRPC amatchedwa "golide muyezo" wofufuza ndipo akukhulupirira kuti mtsogolomo, popanga tekinoloje ya MRI, njirayi idzalowa m'malo mwaukadaulo.

Kugwiritsa ntchito mosamala kwa odwala omwe ali ndi pseudocysts ndi kotsika kwambiri 2, 14, 15. Madokotala ambiri opanga maopaleshoni amadalira kupatsirana kwa cysts mchikakamizo cha odana ndi kutupa, komabe izi ndizowona pakubwera kwa madzimadzi pachimake chifukwa cha owononga pancreatitis 2, 16.

S. McNees et al. anapeza kuti oposa theka la ma pancreatic clusters amatha kuzimiririka

chisankho. Ma puncture ndi ma drainage osakumba motero amalangizidwa pokhapokha kuwonjezeka kwa kuchuluka kwa madzimadzi (malinga ndi maphunziro a ultrasound kapena KT), ndi mawonekedwe a ululu kapena zizindikiro za kupindika kwa ziwalo zopanda pake mwa kupangika kowonjezereka kwamadzi. Kuthekera kwazosintha mosazungulira kwa cyst kumasiyana kuchokera 8% mpaka 85%, kutengera ukadaulo, malo, ndipo koposa zonse, pa kukula kwa pseudocyst. Popanda mankhwala opangira opaleshoni, ma pseudocysts amatha kutha zokha mkati mwa masabata 46 pambuyo poti chachitika chachikulu cha kapamba. Mu chifuwa chachikulu cha pancreatitis, kusinthasintha kwa ma cyst kumachitika kawirikawiri chifukwa cha khoma lopangidwa mokwanira, kupatula zomwe zimachitika kawirikawiri zomwe zimagwera mu dzenje kapena bile duct 18, 19, 20. Malinga ndi A. Warshaw ndi D. Rattner, pseudocyst ndiye kuti sangathe kuthetsa yekha:

- ngati kuukira kumatha milungu yopitilira 6,

- ndi chifuwa chachikulu,

- pamaso pa zovuta kapena kukhazikika kwa pancreatic duct (kupatula kulumikizana ndi pseudocyst),

- ngati pseudocyst wazunguliridwa ndi khoma lowonda.

Monga tafotokozera pamwambapa, kudzichiritsa komwe kumatheka kumatsimikiziridwa ndi kukula kwa ma pseudocysts: cysts zazikulu kuposa 6 cm sizichotsa konse popanda kuchitapo opaleshoni, ndipo, malinga ndi malipoti ena, ma pseudocysts akulu kuposa 4 cm omwe ali extrapancreatically amathandizira kukhalapo kwa chipatala komanso kukula kwa zovuta.

Таким образом, случаи регресса и «самоизлечения» сформированных панкреатических кист не могут рассматриваться как повод для пассивной тактики их лечения . Необходимо учитывать, что панкреатические псевдокисты, как указывалось, часто осложняются нагноением, перфорацией в свободную брюшную полость, реже плевральную, а также кровотечениями в

cystic patsekeke kapena mu lumen ya m'mimba. Zomwe zimachitika pochita opaleshoni yothana ndi mayendedwe achilendo ndizovuta kwambiri, ndipo kusinthasintha ndizochepa. Komanso, kupangika kwa kapamba kumatha kukhala chotupa cha chotupa kapena chotupa chokhala ndi zilonda.

Malinga ndi olemba ambiri 6, 18, 22, 23, zomwe zikuthandizira opaleshoni yama pseudocysts ndi:

Mavuto a pseudo-cyst (gawo limodzi ndilokwanira):

- kuphatikizidwa kwa ziwiya zazikulu (m'thupi kapena malinga ndi CT),

- stenosis yam'mimba kapena duodenum,

- stenosis wa wamba bile duct,

- magazi mu pseudocyst,

Zizindikiro za pancreatic pseudocyst:

- nseru ndi kusanza,

- magazi ochokera kumtunda kwam'mimba.

Asymptomatic pancreatic pseudo-cysts:

- pseudocysts woposa masentimita 5, osasintha kukula komanso kupitilira masabata 6,

- mainchesi opitilira 4 cm, omwe amakhala extrapancreatically odwala omwe ali ndi chifuwa chachikulu cha uchidakwa,

- kukayikira kwamchiberekero.

Popeza tidaonetsa njira zochitira opaleshoni, tidayandikira mafunso ofunika otsatirawa: njira zochitira opareshoni

mawayilesi ndi mawu otani omwe angagwiritsidwe ntchito pseudocysts ndi kuchuluka kwa madzi amadzimadzi, njira yanji yosankha - madokotala opaleshoni yamakolo kapena opaleshoni yovuta kwambiri? Kukula kwakukulu, nthawi yolowererapo imatsimikiziridwa ndi gawo la kusiyanitsa kwa pancreatic pseudocyst ndi makoma ake. Pamene cyst ndi khoma lake limapangidwa, mwayi wowonjezerapo kanthu 2, 24, 25. Komabe, nthawi ya kukhalapo kwa cystyo ndi yovuta kudziwa, ndipo ndi ma cysts omwe akutuluka ndikovuta kuneneratu kukula kwa zovuta ndi kulumikizana ndi ductal system. Pankhaniyi, malo akulu amapatsidwa kukhazikitsa njira zosafunikira monga opaleshoni kapena njira yake yomaliza. Njira zingapo zopumira, catheterization yochitidwa motsogozedwa ndi ultrasound ndi complication tomography, komanso njira zochitira laparoscopic, pakali pano ali ndi othandizira ambiri ndipo amawonedwa ngati njira ina yopangira opaleshoni yachikhalidwe 1, 26. Komabe, pakuganiza kwathu, njira zamakhalidwe azikhalidwe zoyambirira ziyenera kuganiziriridwa koyamba opaleshoni.

Ngakhale kupangidwa kwa matekinoloje ochepera komanso kuwonjezereka kwa CT ndi ultrasound, opaleshoni akadali njira yayikulu pakuchiritsira odwala omwe ali ndi pancreatic pseudocysts 27, 28, 29.

Chithandizo cha opaleshoni chimaphatikizapo kukhetsa kwa mkati ndi kunja, njira zosinthira. Njira ya opaleshoni ikuwonetsedwa mu odwala: a) okhala ndi ma pseudocysts ovuta, ndiko kuti, omwe ali ndi kachilomboka komanso ovuta, b) ndi ma pseudocysts omwe amagwirizana ndi kukhazikika kapena kuchepa kwa duct, c) ndi cystic neoplasia, d) yophatikizika ndi pseudocyst ndi bile stenosis njira, e) ndi zovuta, monga kukakamira kwa m'mimba kapena duodenum, mafuta

Walkie-talkie ndi magazi chifukwa cha kukokoloka kwa mitsempha kapena ma pseudo-aneurysms. Nthawi ya opaleshoni zimatengera kusasitsa kwa khoma la cyst. Mu chifuwa chachikulu cha pancreatitis, ma pseudocysts amatha kugwira ntchito popanda kuchedwa, malinga ndi lingaliro kuti kusinthasintha kwa khoma la cyst kwachitika kale ndipo potero akhoza kukana seams, pomwe nthawi yoyenera yovuta kwambiri pseudocysts imakhala yovuta 1, 20.

Kutulutsa kwakunja kumasonyezedwa kwa ma cysts oyambitsidwa ndi zomwe ali ndi kachilombo komanso kuphulika kwa cysts. Izi sizigwira ntchito konse kwa odwala omwe ali ndi pancreatitis yayitali, pancreatic cyst itachitika atalumikizana ndi chiwopsezo cha pancreatitis. Amakhulupirira kuti zisonyezero zakunja zotulutsa za ma pancreatic cysts zimachitika mu 25-30% ya odwala omwe ali ndi nthawi yayitali komanso pamaso pa kubwezeretsedweratu kwam'mimba. Chimodzi mwazinthu zazikulu zoyipa za ntchito zotere ndi kuthekera kwakukulu kwa chitukuko cha pancreatic yomwe idakhalapo kale pancreatic ndi purististas. Pafupipafupi mavutowa amatha 10-30% 2, 19.

Kukhetsa kwamkati ndi njira yosankhira ma pseudocysts osakhwima. Kutengera ndi topographic anatomy, pseudocystogastrotomy ndiyotheka kwa cysts mwachindunji pafupi ndi khoma lakumbuyo yam'mimba. Cysts yaying'ono (15 cm), yoyenera pseudocyst-unostomy. Pali kutsutsana kuti zotsatira za pseudocystogastrostomy ndi pseudocystoduodenostomy ndizofanana. Pseudo-cystogastrostomy imadziwika kuti ndi yosavuta, yachangu, komanso yofatsa.

opaleshoni, koma amayamba kutaya magazi pafupipafupi m'matumbo. Pseudo-cystejunostomy imawoneka yotchuka kwambiri, ndipo zotsatira zake zimakhala bwino pang'ono kuposa ndi pseudocystogastrostomy. K. Newell et al. Sindinapeze kusiyana kwakukulu pa kuchuluka kwa ma cyst omwe amayambiranso kapena kufa pakati pa cystogastro ndi cysto-unostomy, koma nthawi yothandizira ndi kuchepa kwa magazi inali yochepa pambuyo pa cystogastrostomy.

Kuphwanya wachibale kuti achite mkati mwa drainage ndikuwonetsa zomwe zili mu cyst, njira yowonongeka mu kapamba, magazi kulowa mkati mwa cyst kapena duodenum, ndi kapisozi wosasinthika wa chotupa. Kugwiritsa ntchito kwa cystodigestive anastomoses kumatha chifukwa cha zovuta zomwe zingayambitse zovuta za postoperative: kusakwanira kwa anastomotic sutures, kuchuluka kwa kapamba, kuchepa magazi. Koyambirira kwa ntchito, makamaka ndi ma pseudocysts okhala ndi zizindikiro za kutupa, anastomotic edema imayamba, yomwe imapangitsa kuti pakhale kusakwanira kukhetsa madzi ndi chitukuko cha kusadziletsa kapena kuyambiranso kwa cyst mtsogolo, chifukwa chake pali malingaliro othandizira kuphatikizira kwa anastomosis ndi njira zosiyanasiyana zakumwa kunja.

Kuyang'ananso ndi njira ina yodutsira madzi mkati mwa pseudocysts ndi mawonekedwe a mankhwalawa monga: kapamba wambiri, chifuwa, kutaya kwa m'mimba kuchokera pseudoaneurysms, kutsekeka kwa duct kapena duodenum, komanso kulephera kukhetsa kwa pseudocyst. Kuyambiranso kumachitika m'njira zosiyanasiyana, kuphatikiza mbali yamanzere kapena mbali yakumanzere pancreatectomy (opareshoni

Whipple, pancreaticoduodenectomy ndi kuteteza pylorous, ntchito Beger kapena Frey). Kuyambiranso kwa thupi ndi mchira wa kapamba limodzi ndi cyst ndikulimbikitsidwa kwa cysts yomwe ili mu distal theka la kapamba, chifukwa cha zipinda zambiri, chifukwa cholumikizidwa ndi cyst, komanso kwa odwala omwe abwerera m'mbuyo pambuyo poti atsekereza (mkuyu. 5, onani kuyika kwa utoto). Distal pancreatic resection imabweretsa kutayika kwa gawo lalikulu la chiwalo, zomwe zimatha kupangitsa kukula kwa matenda osokoneza bongo a shuga kapena kuperewera kwa kapamba.

Kugwira ntchito kwa cystectomy kwayokha kumatha kuchitika pakawonedwe kamodzi kokhala ndi ma pseudocysts ang'onoang'ono omwe amakhala. Kuvuta kwa ntchito zotere ndikofunikira kulekanitsa khoma la pseudocyst pazinthu zoyandikana komanso kuchokera pansi pa kapamba.

Ganizirani za njira zomwe zingawononge pang'ono. Ndipo tsopano atha kubwezeretsa opaleshoni yachikhalidwe? Ndi zolowerera zochepa ziti zomwe zimaphatikizidwa molimba mtima pazachipatala cha opaleshoni pakuchiza pancreatitis yovuta ndi zovuta zake?

Chimodzi mwazomwe amachititsa kuti endicopic pancreatic decompression is endoscopic papillotomy or wirsungotomy drainage 32, 33. Cholinga ndikupanga kulumikizana pakati pa patseudocyst patsekeke ndi m'mimba. Zosintha zingapo pakupanga anastomosis zimatheka mwina transpapillary kapena transmapally. Ngati ma cyst amalumikizana ndi pancreatic duct, ndiye kuti drapapillary drainage imakhala njira yosankhira. Pre-anachita sphincterotomy ndi cannulation kudzera kutulutsa kwa cyst patsekeke, kenako mtsogoleri

a stent pulasitiki 19, 34 adayikidwa.Ndi zizindikiro za kupitiliza kwa cyst, kupezeka kwa ma necrotic masamba, catheter imaphatikizidwanso mu cyst patsekero kudzera pamphuno kuti muthere ndi kusamba. Pafupifupi, malinga ndi olemba, stent imatha miyezi 4.4 (ndi regst), ndipo kubwezeretsa kwa stent kumachitika pambuyo pa masabata 6-8, 35, 36, 37. Njirayi imalonjeza kwambiri zochizira odwala omwe ali ndi pancreatitis yoyamba, chifukwa amachepetsa pancreatic duct matenda oopsa. Komabe, madzi am'mimbamo amakumana ndi zovuta, monga kusunthira kolimba m'mbali zonse za distal ndi proximal, kuchuluka kwa kapamba, kufalikira kwa tsinde ndipo, chifukwa chake, kuyambiranso kwa chotupa. Kafukufuku akuwonetsa kuti kufalikira kwa stent kumachitika mu 50% ya odwala masabata 6 atayika. Pali malipoti a kusinthika kwa kusintha kwa pathological mu kapamba ndi ma ducts omwe amakhala ndi stent yayitali. Pambuyo pake, kuchokera kwa 8-26% ya odwala omwe anali ndi vuto lodzikongoletsa anagwiritsidwa ntchito njira yachikhalidwe 25, 34.

Drainage drainage imagwiritsidwa ntchito ndi pseudocyst omwe khoma lake limayandikira kwambiri khoma lamimba kapena duodenum, kapena kapisozi ndi khoma lawo. Kukhazikika komwe kwatchulidwa kumadziwika ndi compact tomography, ultrasound kapena endoscopic, momwe malo a cystic bulging mu lumen ya ziwalo amatsimikiza bwino. Kudzera mwa malembedwe aposachedwa, kubowola kwa cyst ndi kufunitsitsa kwa zomwe zalembedwazo kumachitika, ndiye kuti dzenje kukhoma kwamimba ndi cyst limapangidwa ndi singano papillotome. Mitsempha ya cyst imayatsidwa ndi catheter, yomwe imachotsedwa pambuyo poti ngongole yathunthu idathiridwa. Mutha kuchita ma transpapillary kapena transmural drainage mu 92% ndi 100% milandu.

Tezi 37, 39.

Mavuto ambiri komanso azovuta kwambiri pakumwa ma transmural amatuluka magazi kuchokera kukhoma la m'mimba kapena duodenum. Amafunikira opaleshoni yodzidzimutsa. Milandu yodukiza m'mimba komanso kukhetsa kwa madzi osapindulitsa 9, 26, 37 akufotokozedwanso. Katsimikizidwe kazabwino pambuyo poti kukhetsa kwa pseudocyst akuyerekezedwa kuchokera pa 66% mpaka 81%. Kusanthula mauthenga osiyanasiyana pakugwiritsa ntchito ngalande za endoscopic, zinthu zotsatirazi zitha kupangidwa kuti zikwaniritse 6, 10, 19, 39:

1. Mtunda kuchokera pa pseudocyst kupita kukhoma la chimbudzi chomgaya ndi wochepera 1 cm,

2. Kuthana ndi gawo la ma pseudocysts apamwamba mpaka khoma loyandikana,

3. Kukula kwakukulu kuposa masentimita 5, kupindika kwamatumbo, chotupa chimodzi, gawo logwirizana ndi pancreatic duct,

4. Ma cyst okhwima, ngati kuli kotheka isanafike transpapillary, pancreatography,

5. Kuyang'ana kuwola mu pseudocyst,

6. Kusagwira bwino ntchito kwa chithandizo chamankhwala, nthawi yayitali yodwala kuposa masabata anayi,

7. Neoplasm ndi pseudo-aneurysm siyenera kuyikidwa pambali.

Malinga ndi E. Rosso, yemwe adasanthula ma endoscopic ngalande zonse za transmural ndi transpapillary pseudocysts mwa 466 odwala, kuchuluka kwa zovuta kunali 13.3%, kuyambiranso kwa cyst kutsatiridwa ndi chithandizo cha opaleshoni kunadziwika mu 15,4%.

Kuwongolera kwa ma pseudocysts, kuchuluka kwa madzimadzi, cysts pachimake motsogozedwa ndi ultrasound kapena CT ndi gawo lina lamankhwala lomwe limawonedwa ngati njira ina yothandizira opaleshoni yachikhalidwe. Ndipo ngati endoscopic

Popeza sichimagwiritsidwa ntchito kawiri kawiri m'makliniki a dziko lathu, njira zothandizira matenda ndikuwongolera zomwe zimayang'aniridwa ndi ultrasound zimaphatikizidwa molimba mtima pazida zamankhwala kuchipatala ambiri. Kukhetsa kwa ma piercutane kumatanthauza komwe kunja kwa catheter, ngalande zimachitika kudzera mu singano-conductor 7 - 12 B "nkhumba mchira" kapena ikani timayipi 14 - 16 B. Drainage kudzera trocar yapadera imagwiritsidwanso ntchito. Kuphatikiza apo, pali njira zina zotulutsira madzi m'mimba, kudzera mu duodenum, transhepatic, transperitoneal ndi retroperitoneal. Mitundu ina pakugwiritsira ntchito kwa dziwe lamagetsi imadziwika. Chifukwa chake, malinga ndi olemba angapo, kugwiritsa ntchito nthawi yayitali catheter (kupitilira masabata 6-7) kumapangitsa kuti njira ziwoneke bwino mu 16% milandu, kubwereranso m'milandu 7%, ndipo kuchuluka kwa zovuta kumafika 18%. Chofunikira china ndicho kusakwanira kwa njira yodutsa ma drainage omwe ali ndi odwala omwe ali ndi pancreatitis yayikulu, makamaka pamene ma pseudocysts amalumikizidwa ndi duct system 3, 7. Malinga ndi deta ya K Helee e! a1. , zabwino zimapezeka osati mochulukirapo kuposa mu 42% yowonera, koma mwa b. Oi11o, odwala odwala ndi kapamba, ma pseudocysts sakhala omangidwira ndi kukoka kwa madzi. Olemba ambiri m'malo mwa ngalandeyi amatenga ma punctures obwereza bwino ndi kufunitsitsa kwa zomwe zili mu cyst, zomwe zimapewa zovuta zomwe zimakhudzana mwachindunji ndi catheter, zomwe ndi matenda, kuchepa kwa catheter, kusintha kwamkati mwa khungu. Mavuto azachulukirapo akuphatikiza kutuluka kwa njira ya ntchito kapena kusunthira kwa catheter ndi zomwe zili mkati mwa pseudocyst wolowa m'mimba. Ngakhale

Izi zovuta, njira yokhotakhota kubowola ndi kukoka kwa pseudocyst chifukwa cha pachimake kapamba imatha kuganiziridwa kuti njira yakusankhira.

Opaleshoni ya laparosopic ya ma pseudocysts angathenso kuthandizidwa ndi opaleshoni yowoneka bwino ya 41, 42. Zochitika ndi laparoscopic cystogastrostomy ndi pseudocystejunostomy ndizochepa. Mitundu itatu yayikulu ya laparoscopic yosiyanasiyana yamakina amkati ikufotokozedwa: intramural cystogastrostomy, anterior cystogastrostomy and postterior cystogastrostomy 13, 18. Njira ziwiri zoyambirira zimagwiritsidwa ntchito. Poyambirira, matayala amaphatikizidwa ndikuwonetsa m'mimba ndipo khoma lakunja limadulidwa ndi coagulator, ndikutsatira kupangika kwa anastomosis. Ndi anterior cystogastrostomy, gastrotomy imachitidwa ndipo anastomosis imapangidwanso kudzera pachipupa chakumbuyo cham'mimba. Munjira zonsezi, olemba mbendera amagwiritsidwa ntchito, koma cystejunostomy sichigwiritsidwa ntchito kawirikawiri ndipo palibe chidziwitso chochepa pakuchita bwino kwake m'mabuku. Ubwino wa kulowererapo kwa laparoscopic ndikukonzanso mwachangu ndikukhazikika kwakanthawi kachipatala. Ofufuzawo awonanso zovuta za njirayi: kuchuluka kwa kapamba, magazi ochokera ku anastomosis zone. Mu chipatalacho, njira zopangira opaleshoni zotere, mwachidziwikire, zimafunikira kupezeka kwa malo apadera, zida zapamwamba komanso zida. Pfotokozera mwachidule kugwiritsa ntchito njira zowononga zachilengedwe machitidwe padziko lapansi, ziyenera kudziwidwa kuti ngakhale zambiri zachitikadi, palibenso zambiri pazotsatira za nthawi yayitali (makamaka ntchito za laparoscopic), zotsatira zochepa poyerekeza njira zingapo zamankhwala ochiritsira

ntchito zamankhwala. Komabe, zoyesayesa zikuchitika kuti njira zofananirana, kupanga maumboni, ndi zotsutsana. Chifukwa chake mu ma protocol a bungwe la America la gastroin-testinal endoscopy zosowa zotsatirazi zikuwonetsedwa:

1. Pakadali pano, palibe njira zokwanira zochizira odwala a cystic neoplasms, kukhuthala kwa endoscopic pancreatic cysts kuyenera kugwiritsidwa ntchito pokhapokha kutengera kwa chotupa chikhalidwe cha cysts,

2. Kuunika kwa endoscopic ultrasound kumafunika.

Ndiye kuti, njira zazikuluzikulu ndi "kukhala tcheru" komanso kupezeka kwa zida zapamwamba.Olemba angapo amapereka zotsatirazi pakuchita mwanjira yachikhalidwe 6, 8, 15, 19:

1) kukhalapo kwa zotsutsana ndi kugwiritsa ntchito njira za endoscopic kapena radiological kapena chizindikiritso cha kusakwanira kwawo,

2) kuphatikiza kwa pseudocyst ndi ma pancreatic ducttures ambiri,

3) matenda ovuta, mwachitsanzo, kuphatikiza kwa pseudocyst ndi "yotupa yotupa" mumutu wa kapamba,

4) kuphatikiza kwa pseudocyst ndi zovuta za wamba bile duct,

5) Zofanana ndi mitengo ikuluikulu ya venous,

6) pseudo-cysts,

7) kutengera kwa pseudocyst mchira wa kapamba,

8) magazi osasamala,

9) amaganiza chotupa chikhalidwe cha chotupa.

Pankhaniyi, njira zowononga zachilengedwe za kapamba zimachepa chifukwa cha mawonekedwe a kapamba ndi kapamba.

ma ducts, kuchuluka kwa kusintha kwawo. Pamaulula mawonekedwe a duct system, kulumikizana pakati pa pseudocyst ndi ma ducts, mwina mungachite bwino kugwiritsa ntchito njira zachikhalidwe zopangira opaleshoni kuyambira kumayambiriro 8, 15, 19.

Mpaka pano, tili ndi zomwe takumana nazo pogwiritsa ntchito njira zambiri zochitira opaleshoni pseudocysts pamwambapa. Odwala 300 omwe ali ndi pancreatitis yosagwirizana ndi kukhalapo kwa pseudocysts adayendetsedwa ku Vitebsk Regional Science Science and Practical Center "Opaleshoni ya Matenda a Chiwindi ndi Pancreas". Zambiri pazomwe zimachitidwazo komanso zina mwazotsatira zawo zafotokozedwera.

Kusanthula mwatsatanetsatane kwazinthu zathu sikupezeka pamutuwu, chifukwa chake tidziwonetsa zambiri.

Monga tikuwonera patebulopo, timagwiritsa ntchito njira zosiyanasiyana. Mwambiri, ntchito zam'madzi zimakhazikitsidwa kale (49.7%). Njira zotsogola zimagwiritsidwa ntchito mu 24.7% ya milandu, komanso kulowererapo pang'ono mu 24.3%. Ponena za zovuta m'magulu osiyanasiyana, ochepa kwambiri mwaiwo adadziwika pogwiritsa ntchito maukadaulo ochepera. Komabe, ziyenera kunenedwa kuti kulowererapo monga pseudocyst punication pansi pa Ulamuliro wa ultrasound kunali kozindikira kwambiri mwachilengedwe ndipo mwanjira zina sangafanane ndi pancreatic resections ndi mitundu yosiyanasiyana ya maopareshoni omwe amapangidwa motsutsana ndi zovuta za cysts (magazi, kuwonjezereka). Nthawi yomweyo, opaleshoni ya draarosopic drainage (cystogastro- ndi cystejunostomy) analibe zovuta, zomwe mosakayikira zimatsimikizira chiyembekezo cha njirayi. Mavuto obwera pambuyo pake m'magulu awo ndiosiyana kwambiri. Chiwerengero chachikulu kwambiri chinali postoperative

Zomwe zimachitidwa opaleshoni yopanga ma pseudocysts ndi awo

Mavuto Imfa Abs. n, abs.

Kudzala 149 (49.7%) 27 18.12 6 4.03

1. cystogastrostomy + ngalande zakunja 1

2. Duodeiocystovirsung ostomy 12 2 16.67

3. Du de n o qi mtengo 41 6 14.63 1 2.44

4, Cystogastrostomy 33 7 21.21 2 6.06

5. Cystejunostomy 26 3 11.54 I 3.85

6. Pakreatocis! Ndimakhala wopanda phokoso komanso ine 8 12,5

7. Pancreatogastrostoma 2

8. Zida zakunja 24 8 33.33 2 8.33

9. Cystomentopexy ndi ngalande zakunja 2

Kubwereza 74 (24.7%) 12 14.86 1 1.35

1. Mbali yamanzere yamanja pancreatic yokhala ndi cyst 38 3 5.26 1 2.63

2. Proximal resection of the pancreatic head (Begei ') 26 8 30,77

3. Proximal resection ya mutu kapamba (Bernese version) 5 I 20

4. Opaleshoni Frey. 5

Opaleshoni yovomerezeka yochepa 73 (24.3%) 3 4.11

1. Laparoscopic cystoejunostomy 8

2. Laparoscopic cystogastrostomy 2

3. Kugwetsa ndi kukoka pansi pa ultrasound control 62 3 4.84

4. Laparoscopic cystectomy 1

I. cystectomy 4

ZONSE 300 42 14 7 2.33

creatitis ndi zovuta zake - odwala 15, magazi - odwala 7, kapamba wa fancula - odwala 9, kulephera kwa suture - odwala 4, fistula ya biliary - odwala 3, komanso pylephlebitis, thromboembolism, matumbo, kusungunuka kwa ozizira.

Kubwereza zowerengera ndi zomwe takumana nazo, timalolera kuti titchulepo ndi kupereka malingaliro pazithandizo za pseudocysts.

M'malingaliro athu, ndikofunikira kuchitira mankhwalawa ndi cysts omwe akutuluka pang'onopang'ono

teknoloji yowononga. Punuction ndi drainage ndikofunikira kupaka ntchito ndi kuwonjezeka kwa kukula kwa cyst, mawonekedwe a ululu kapena kukakamiza kwa ziwalo zapafupi. M'mawonekedwe athu, ndikupanga ma cysts, kulowererapo motsogozedwa ndi ultrasound kunathandizira kuchiritsa odwala pafupifupi 70%, omwe akufanana ndi deta ya olemba akunja.

Kupindulitsa kwa njira zowotcha ma pseudocysts mu chifuwa chachikulu cha khansa ndizokayikitsa. Muzochitika zoterezi ziyenera kuonedwa ngati gawo lazindikiritso kupatula kapena kutsimikizira chotupa, kafukufuku

zomwe zili mu cyst, kuzindikira mgwirizano wa cyst ndi duct system.

Njira za Endoscopic (dravural drainage and transpapillary) zitha kugwiritsidwa ntchito mwa odwala omwe ma cyst amakhala pafupi ndi khoma la m'mimba kapena duodenum kapena pali mgwirizano pakati pa cyst ndi duct system. Tsoka ilo, kusowa kwa kafukufuku wathu sikulola kuyesa kwathunthu kwa njirazi.

Kutulutsa kwakunja kwa pseudocyst kumawerengedwa kuti ndi gawo lofunikira kuti likhala ngati khoma la cyst ndikutulutsa kwa peritonitis kapena kachilombo ka cyst kotsutsana ndi momwe wodwalayo aliri.

Drainage wamkati ndi njira yosankhira chithandizo cha pseudocysts chosavuta. Kutengera kutengera kwachilengedwe ndi topographic anatomy, cystogastrostomy, cystoduodenostomy, kapena cystoejunostomy iyenera kugwiritsidwa ntchito. Opaleshoni yamtunduwu ndi yosavomerezeka mwa odwala omwe ali ndi kapamba kapamba ndipo m'malo omwe anastomosis singathetse matenda oopsa. Pazosankha zamkati zamkati, njira yoyenera kwambiri, mwa lingaliro lathu, ndi cystejunostomy, popeza m'chiuno chamatumbo atayimitsidwa pamodzi ndi Ru, anastomosis imatha kupangidwa pafupifupi kulikonse komwe kuli cyst, komanso kuwunika kwa khoma kwake. Cystejunostomy, yothandizidwa ndi kukhetsa kwa cyst patsekeke, imatha kugwira ntchito kwa omwe ali ndi kachilombo.

Njira zotsogola, ngakhale ndizovuta kukwaniritsa kwake, ndizothandiza pakulimbikitsa kwa odwala omwe ali ndi pseudocysts, komabe, pochita opaleshoni yamtunduwu, ndikofunikira kuyesetsa kuteteza kwakukulu kwa endo- ndi exocrine pancreatic ntchito, chifukwa amatsogolera pakupanga shuga

beta kapena kuperewera kwa kapamba.

Distal resection imapangidwira cysts mu distal theka la kapamba, chifukwa cha chipinda chambiri komanso zolakwika, komanso kubwereranso m'madzi atatha kukokoloka. Ndi ma pseudocysts okhala ndi kuthekera pamutu wa kapamba, ndikofunikira choyamba kuwunika kusintha kwa mutu wa kapamba, wotchedwa "kutupa kwakukulu". Odwala omwe ali ndi chifuwa chachikulu cha pancreatitis ndi pseudocysts ndi kupindika kwa bile duct kapena duodenum, kuyimitsidwa kwina kungasonyezedwe (opareshoni ya Kausch-Whipple, pRoric-kusunga PDR kapena duodenum-kusunga pancreatic resection). Mu chifuwa chachikulu cha pancreatitis, opareshoni iyenera kukhala ndi cholinga chothana ndi "woyendetsa zowawa", yemwe ndi mutu wosintha wa kapamba. Proximal resection (Operation Beger) kapena "mtundu wake wa Bernese" amathetsa kupweteka kwam'mimba komanso zovuta izi. Njira yolowera opaleshoni imasonyezedwanso kwa odwala omwe akutuluka magazi kulowa mu cyst patity ndikupanga pseudo-aneurysm.

Tikuwona ntchito ya laparoscopic monga njira yodalirika yoperekera chithandizo kwa odwala omwe ali ndi pancreatitis yayikulu ndi pseudocysts. Nthawi yomweyo, ndikufuna kudziwa kuti kusankhidwa kwa odwala pazinthu izi kuyenera kukhala kosamalitsa, poganizira zotsutsana pamwambapa.

Pomaliza kuwunika kwamutu womwe takambirana, tikuwona kuti ndizofunikira kubwereza Ch. Russell: “Ndikofunika kunena motsindika kuti kuchiritsa ma cysts okha sikungathetse vuto la chifuwa chachikulu. Chifukwa chake, opaleshoni ya cyst iyenera kuphatikizapo kuyesa kwathunthu kwa

kapamba wonse ndi njira yankho lafunso loti kapena pali cholepheretsa chamba cha pancreatic. "

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Adilesi yolemba makalata

210023, Republic of Belarus, Vitebsk, pr. 4runze, 27, Vitebsk State Medical University, dipatimenti ya Opaleshoni, FPK ndi PC, tel. kapolo.: 8 (0212) 22-71-94 Schastny A.T.