Zusammenfassung
Die chronische Pankreatitis ist durch einen fortschreitenden irreversiblen fibrösen Umbau des Bauchspeicheldrüsenparenchyms gekennzeichnet. Häufigste Ursache der Erkrankung ist regelmässiger Alkoholgenuss neben anatomischen Normvarianten wie Pancreas divisum, Gallensteinen oder genetischer Prädisposition. Der fibrotische Umbau der Drüse mit konsekutivem Parenchymverlust führt zunächst zu exokriner Insuffizienz und Maldigestion und im fortgeschrittenen Zustand auch zu Diabetes mellitus. Neben dem Funktionsverlust der Drüse kommt es zu mechanischen Komplikationen wie der Bildung von pankreatischen Pseudozysten, duodenaler Obstruktion und Cholestase.
Etwa 50% der Patienten mit chronischer Pankreatitis müssen im Laufe ihres Lebens wegen therapierefraktärer chronischer Schmerzen oder Komplikationen operiert werden. Neuere molekularbiologische Untersuchungen zeigen, dass dem Bauchspeicheldrüsenkopf häufig die Schrittmacherrolle der Erkrankung zukommt, so dass die Entfernung dieser entzündlichen Gewebsmasse Hauptziel des operativen Vorgehens sein muss. Radikal resezierende Verfahren wie die Kausch-Whipple-Operation führen zu einer ausgezeichneten Schmerzreduktion, sind aber auch in ihrer pyloruserhaltenden Variante aufgrund des großen Organopfers und des Verlustes der Duodenalpassage mit einer nicht zu vernachlässigenden Morbidität vergesellschaftet. Vor etwa 30 Jahren wurde von H.G. Beger erstmals die Technik der duodenumerhaltenden Pankreaskopfresektion beschrieben, die als organerhaltendes Operationsverfahren die Schmerzproblematik und Komplikationen der chronischen Pankreatitis beseitigt, ohne die Duodenalpassage zu opfern. In der Zwischenzeit wurden weitere Modifikationen der Beger-Technik beschrieben (Frey, Izbicky, Berner Modifikation), deren gute Ergebnisse unterstreichen, dass organerhaltendes Operieren bei der Behandlung der chronischen Pankreatitis im Vordergrund stehen sollte.
Abstract
Chronic pancreatitis is an inflammatory disease characterized by the progressive conversion of pancreatic parenchyma to fibrous tissue. The most frequent causes are alcohol overconsumption and anatomic variants such as pancreas divisum, cholelithiasis, and individual genetic predisposition. The process of fibrosis with consecutive loss of pancreatic parenchyma leads to exocrine insufficiency and maldigestion and, in advanced stages of the disease, to diabetes mellitus. Beside exocrine and endocrine malfunction, mechanical complications occur such as the formation of pancreatic pseudocysts and duodenal and common bile duct obstruction. About 50% of patients with chronic pancreatitis need surgical intervention due to untreatable chronic pain. As recent investigations suggest that the head of the pancreas triggers the chronic inflammatory process, resection of this inflammatory mass must be regarded as pivotal in any surgical intervention. Radical techniques such as the Whipple procedure are undoubtedly successful regarding pain reduction but, even in its pylorus-preserving variant, associated with high postoperative morbidity due to a large loss of pancreatic parenchyma and the absence of duodenal passage. Thirty years ago, H.G. Beger described for the first time the technique of duodenum-preserving pancreatectomy, which better combines resection of the pancreatic head with low morbidity. Over the years, different variations of the original Beger technique (Frey, Izbicky, Berne modification) have been developed, and the excellent results obtained with these methods underline that organ-sparing techniques should be preferred in the surgical treatment of chronic pancreatitis.
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Köninger, J., Friess, H., Müller, M. et al. Die duodenumerhaltende Pankreaskopfresektion. Chirurg 75, 781–788 (2004). https://doi.org/10.1007/s00104-004-0826-8
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DOI: https://doi.org/10.1007/s00104-004-0826-8