Pankreasın Ekzokrin Hastalıklarında Cerrahi Yaklaşımlar
Özet
Ekzokrin pankreas hastalıkları olan Kistik Fibrozis (CF), Akut Pankreatit, Kronik Pankreatit ve Pankreas Kanseri cerrahisindeki güncel yaklaşımlar önemli yönetim farklılıkları göstermektedir. En sık herediter ekzokrin hastalık olan CF, CTFR gen mutasyonu ve duktal obstrüksiyonla seyreder. Akut pankreatit, hafif formlardan yüksek mortaliteli enfekte nekroz süreçlerine kadar değişebilir. Enfekte pankreatik nekroz yönetiminde cerrahi ertelenmeli, perkütan veya endoskopik kateter drenajını içeren "step-up yaklaşımı" öncelikli tercih olmalı ve cerrahi nekrozektomi diğer yöntemlerin yetersiz kaldığı durumlara saklanmalıdır. Geri dönüşümsüz bir süreç olan kronik pankreatitte ana tedavi endikasyonu tıbbi tedaviye yanıtsız ağrı ve lokal komplikasyonlardır. Bu kapsamda duktal genişlemeye göre Partington-Rochelle, Frey, Beger veya Bern gibi drenaj ve rezeksiyonel hibrit ameliyatlar uygulanır. Küratif tedavisi yalnızca cerrahi olan pankreas başı kanserlerinde ise standart veya pilor koruyucu Whipple ameliyatı ve total pankreatektomi gibi yaklaşımlar tercih edilmektedir. Gövde ve kuyruk tümörlerinde distal pankreatektomi teknikleri ile RAMPS prosedürü uygulanmaktadır. Son yıllarda laparoskopik ve robotik olmak üzere minimal invaziv pankreas cerrahisi alternatif birer seçenek haline gelmiştir. Bu kompleks süreçlerin takibi, multidisipliner yaklaşıma sahip üçüncü basamak merkezlerde yönetilmelidir.
Current surgical approaches for exocrine pancreatic diseases, including Cystic Fibrosis (CF), Acute Pancreatitis, Chronic Pancreatitis, and Pancreatic Cancer, exhibit significant management variations. CF, the most common hereditary exocrine disorder, involves CTFR gene mutations and ductal obstruction. Acute pancreatitis ranges from self-limiting mild forms to severe infected necrosis with high mortality. In managing infected pancreatic necrosis, surgery should be delayed; a "step-up approach" involving percutaneous or endoscopic catheter drainage is the preferred first choice, while surgical necrosectomy is reserved for cases where other treatments fail. For chronic pancreatitis, an irreversible condition, primary surgical indications include intractable pain and local complications. Depending on ductal dilation, drainage and hybrid resectional procedures such as Partington-Rochelle, Frey, Beger, or Bern are performed. For pancreatic head cancers, where the only curative treatment is surgery, standard or pylorus-preserving Whipple procedures and total pancreatectomy are utilized. Distal pancreatectomy techniques and the RAMPS procedure are applied for body and tail tumors. In recent years, minimally invasive pancreatic surgery, including laparoscopic and robotic approaches, has emerged as an alternative. Management of these complex diseases is best handled in tertiary centers with multidisciplinary intensive care facilities.
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