Pankreas Gövde ve Kuyruk Tümörlerinde Cerrahi Tedavi
Özet
Distal pankreatektomi, pankreasın malign veya benign hastalıklarında gövde ve kuyruk bölümünün çıkarılması prosedürüdür. Malign durumlarda komple lenf nodu diseksiyonu için genellikle dalakla birlikte en-bloc rezeksiyon tercih edilirken, benign lezyonlarda dalak koruyucu teknikler, santral pankreatektomi veya enükleasyon uygulanabilmektedir. Bu cerrahi müdahale adenokarsinom, nöroendokrin tümörler, kistik neoplaziler, pseudokistler, travma ve renal hücreli kanser metastazları gibi durumlarda endikedir. Gövde ve kuyruk yerleşimli adenokarsinomlar geç semptom verdiğinden genellikle ileri evrede teşhis edilirler. Preoperatif değerlendirmede kontrastlı BT, MRI, MRCP, DOTATATE PET/BT ve EUS gibi yöntemlerden yararlanılırken, gereksiz laparotomileri önlemek amacıyla evreleme laparoskopisi önerilir. Ameliyatlar açık retrograd yaklaşım, dalak koruyucu yöntemler (damar koruyucu veya Warshaw tekniği), Radikal Antegrad Modüler Distal Pankreatosplenektomi (RAMPS) veya lokal ileri evre tümörlerde Çölyak Aksis Rezeksiyonlu Distal Pankreatektomi (DP-CAR) teknikleriyle gerçekleştirilebilir. Pankreas kapama işleminde stapler veya elle sütür yöntemleri kullanılır. Perioperatif mortalite %0,8-5 seviyelerinde olup, komplikasyonların %40'ı postoperatif pankreatik kaçaklardan kaynaklanır; ayrıca hastaların %10-30'unda endokrin ve ekzokrin yetmezlik gelişebilmektedir.
Distal pancreatectomy is a surgical procedure performed to remove the body and tail of the pancreas due to malignant or benign diseases. In malignant cases, en-bloc resection with the spleen is usually performed to ensure complete lymph node dissection, whereas spleen-preserving techniques, central pancreatectomy, or enucleation can be applied for benign or borderline lesions. This surgery is indicated for adenocarcinomas, neuroendocrine tumors, cystic neoplasms, pseudocysts, trauma, and renal cell carcinoma metastases. Adenocarcinomas of the pancreatic body and tail typically present at an advanced stage due to late symptom onset. Preoperative evaluation utilizes contrast-enhanced CT, MRI, MRCP, DOTATATE PET/CT, and EUS, while staging laparoscopy is recommended to avoid unnecessary laparotomies. Surgical approaches include the open retrograde technique, spleen-preserving methods (splenic vessel preservation or the Warshaw technique), Radical Antegrade Modular Pancreatosplenectomy (RAMPS), and Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for locally advanced tumors. Pancreatic remnant closure is achieved using either stapler or hand-sewn techniques. Perioperative mortality ranges between 0.8% and 5%, with 40% of complications arising from postoperative pancreatic leaks; furthermore, endocrine and exocrine insufficiency develops in 10% to 30% of patients.
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