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ASPEK PATOLOGI : TUMOR DUKTUS BILIER

- Epitel kolumnar simple


- Most common : aenoca
- !aktor resiko : Terutama "atu paa #a GB$
Paa uktus pro%imal :
- Primar& sclerosin' c(olan'itis
- Pancreato"iliar& uct )unction
- Karakteristik (istolo'i an klasi*ikasi patolo'i sama paa semua "a'ian "ilier$
Ber"ea alam (al : *aktor resiko+ clinical *inin's+ "iolo'ic "e(a,ior
- Similar mor*olo'i en'an aenoca uktal pancreas - pancreato"ilar& . t&pe
- GB aenoca paa GB
#(olan'iocarcinoma paa uktus intra(epatik
Aenoca o* t(e e%tra(epatic "ile uct paa uktus e%tra(epatik$
Serin' sekali paa oran' tua
- !aktor resiko : "atu+ peraan'an / c(olec&stitis
Primar& sclerosin' c(olan'itis
Parasites+ c(oleoc(al c&st$
- Makroskopis : 0 t&pe
Pol&poi
1oular 2 1oular sclerosin' 3
Scirr(ous constrictin'
Di**usel& in*iltrati,e
- Pol&poi - papillar& atau 4ell i*t ca$ 2 "etter pro' 3
- 1oular 5 scirr(ous - cenerun' untuk in*iltrasi )arin'an sekitar an sulit untuk i
reseksi$
- T&pe i**use : men&e"ar secara linear ke sepan)an' uktus
- T&pe i**use 5 constrictin' sulit i"eakan en'an kronik in*lamasi terutama primar&
sclerosin' c(olan'itis$
- T&pe polipoi : *ria"le+ so*t+ an tan
Ulceratin' 5 necrosis )ika tumor "esar
- In*iltratin' - scirr(ous 2 scarlike 3
!irm+ 4(ite+ 'rit(& appearance aki"at esmoplasia 2 e%$ 6arin'an *i"rotic karena
in*lamasi 3 necrosis$
- In,asi ke (epar &an' "erekatan - e%pansik+ 4ell emar ca re$
- In,asi ke (ilus - t(e "ounaries are ill e*ine$
Anatomic istri"ution : untuk tu)uan t(erap& 5 pro'nosis+ i "a'i :
7$ Upper t(ir : i atas c&stic uct )unction+ ke ua uct (epatikus+ common (epatic
uct$
8$ Mile t(ir : upper (al* o* #BD
9$ Lo4er t(ir : istal (al* o* #BD
Ke"an&akan muncul i pro%imal$
#en$ Scirr(ous constrictin' 5 i**use$
#a (ilar - $$$$$$$$$ $- usuall& 'ro4 to linier
- #a mile t(ir . nouler sclerosin' t&pe$ Mene"al sepan)an' lon' se'ment+ narro4
lumen in*lamasi$ Sulit i "eakan en'an c(olan'itis$
Distal t(ir : t(e "est pro' 2 pancreato"ilienektomi 3
Tu$ Marker :
- #A 7: . :+ #EA+ MU#I+ MUSA#+ #K 7: 5 #K ;
- Di**rensial % - tiak aa paa (epato ca$
Ot(er t&pe aenoca 2 selain pancreato"iliar& t&pe 3
- Intestinal t&pe aenoca : mirip en'an aenoca paa GI tract
- Si'net rin' cell ca$ rare
Di**usel& in*iltrati,e pattern o* ini,iuallis or a cor like 'ro4t( pattern$
- Mucinous aenoca
E%tensi,e mucin prouction
Stromal mucin eposition
- Aenos<uamous ca
Mi%ture o* 'lanuler 5 s<uamosus
- #lear cell ca . resem"le renal cell ca
- Uni**
- Sarcomatoi ca
- Uni** ca osteoclastic . like 'iant cell
- Small cell ca
- Lar'e cell neuroenocrine ca
SEROUS #=STADE1OMAS
- Dilapisi epitel ku"oi selapis
- Sel epitel pro cairan serous
- Ductal i**erentiation
- !irm+ 4ell circumscri"e+ multinoular
- > n&a terletak paa caput 5 uncinatus
- Besarn&a 7 . 8? cm
- Pun&a c&st kecil 7 mm . 7 cm
- (one&com" app / spon'e app
- 6aran' 'anas @ 9 A$$$$$$$$$$$$$$$$ @ 7 A
- Paa 4anita
- G / : B ,a'al
B Mil upper a" pain
B iscom*ort
B epi'astric *ullness
B 4ei'(t loss
B palpa"le mass
B 6aunice
B Pancreatitis
B Akut peritoneum
B S&mptomatis - reseksi
B Pancreaticouoenectom&
Kista i caput pancreas
- Distal pancreatectom& tumor paa corpus 5 caua
Spleen i perta(ankan karena )inak
Preser,asi a$ 'ast "re,is
- Sur'ical risk CC - c&st )e)unostom&
S&mptoms tu"u( :
D 0 cm 88 A
E0 cm ;; A
Gro4t( rate ?+F mm / G
Aspirasi cairan : cek #EA HH
Am&lase HH
MU#I1OUS #=STI# 1EOPLASMS
Most *re<uent 0? . 00 A
- Beni'n "ut potensi 'anas - ca si*at a'resi* spectrum
- Iistolo'ik (etero'enositas
Aa "a'ian )inak an 'anas
Ke'anasan tiak apat i sin'kirkan (an&a en'an "iopsi sa)a$
- Macroscopic
Multinoular tumor
Permukaan (alus+ "erkilau
TRAUMA PA1#REAS
Grain' menurut AAST
7$B Minor kontusi tanpa ceera uktus$ Lasrasi super*icial tanpa ceera uktus
8$B Kontusio ma&or tanpa ceera uktus 5 ke(ilan'an )arin'an$ Laserasi ma&or tanpa
ceera uktus 5 ke(ilan'an )arin'an
9$B Transeksi istal atau ceera parenkim en'an ceera uktus
0$ B Transeksi proksimal atau ceera parenkim
J$ B Destruksi masi* paa caput pancreas
Presentasi Klinis
- Karena letakn&a retroperitoneal+ )aran' ter)ai - suit unrelia"le
- Intraoperati,e karena peritonitis atau (emoinamik tiak sta"il
Pemeriksaan la"oratorik
- Tiak aa &an' sensiti,e
- Serum am&lase saat atan' - unrelia"le
Serial - more use*ul
Sensiti*itas 0K . K: A
Spesiti*itas F0 . K7 A
1e'ati,e preicti,e ,alue :9 . :K A
Pemeriksaan raiolo'ic
#T Scan ilakukan "ila (emoinamik sta"il
Tana spesi*ik paa #T scan :
- Transeksi pancreas
- Enlar'ement
- Iematom
- !lui separatin' pancreas 5 splenic ,ein
- Penin'katan attenuation o* *at aroun pancreas
Tana non spesi*ik :
- Pene"alan *ascia renalis anterior
- #airan paa lesser sac
- !ree *lui intra or e%traperitoneal
- Associate in) to local structures
#T )aran' apat menu)ukkan isrupsi uktus
Repeat #T - use *ull
Sensiti*it& F? . K? A
1ormal #T cannot rule out t(e in)ur& $ Unerestimate 'rain' 9? A
ER#P apat "er'una meneteksi isrupsi uktus 5 t(erap& stent
MR#P non in,asi,e
A,anta'e o,er #T
Asses uctal status
#eera parenkim
Intraoperati,e in,esti'ation
Ke"an&akan trauma pancreas )u'a en'an peritonitis atau (emoinamik tiak sta"il
- LLLLL - lakukan e,aluasi men&eluru(+ prioritas utama aala( control
perara(an$
E,aluasi Pancreas :
- Open 'astrocolic li'ament
- e%pose anterior+ in*erior 5 superior sur*ace pancreas 2 "o& 5 tail 3
- Mo"ilise spleen untuk meli(at tail panc$ le"i( aekuat
- Be"askan *le%ousa (epatica 5 koc(er manu,er untuk e%pose
#aput panc 5 prosessus uncinatus$
- Untuk akses ke posterior pancreas : lien *leksura lienalis 5 pancreas i reseksi ari
permukaan ant 'in)al kiri$
- Bila terapat ceera parenkim+ inter'ritas uct panc ma&or (arus i pastikan$
Duktus pancreas normal siMe - sulit i li(at pakai loop 5 pem"erian secretin$ Tiak
irekomenasikan untuk melakukan maneu,er komplek untuk memeriksa
uktusLLL$ Is not reail& apparent$
Pancreato'ra*i melalui uoenum &an' sua( ter"uka$
ER#P introperati,e - time consumin'
In)eksi kontras melalui GB en'an men'klem proksimal uktus (epaticus$
Mor*in untuk kontraksi spin'ter oi$
Tinakan ,isualisasi uktus
Dilakukan "ila a(li "ea( siap melakukan tinakan 2pankreatikouoenektomi "ila i
perlukan 3
MA1AGEME1T
1om : (an&a paa penerita tanpa peritonitis 5 (emoinamik sta"il$
- Lo4er 'rae on #T 2 'r I 5 II 3$ K? A kasusu en'an ke"er(asilan K? A
- Pseuoc&st - 7? . K? A
!lui collection peripancreas$
Operati,e :
- Konisi umum pasien
- Grain' trauma pancreas
- #eera lainn&a
- E%perience a(li "ea(
Lo4 'rae :
B De"riement non ,ia"le tissue
B (emostasis
B Pasan' rain
Be"erapa a(li men&arankan repair kapsul+ namun apat men&e"a"kan
perara(an+ kerusakan le"i( lan)ut 5 pem"entukan pseuoc&st$
Ii'( 'rae
Gr III : istal pancreatektomi
- Bila transeksi+ i pisa(kan paa tempat ts"+ reseksi "a'ian istal$
- Bila transeksi inkomplit+ i,ie pro%$ Lesi 5 preser,e as muc( as possi"le$
- Bila e%tenin' ke pro% 2 sisi kanan 3 ,asa mesenteric sup -ia"etes atau insu*isensi
($ e%erine$
- preser,e 5 anastomosis to rou% 5 &e&unal loop$
- Reseksi panc istal en'an preser,asi spleen "ila (emoinamik sta"il+ tiak (ipotermi
maupun asiosis$
- Setela( reseksi+ semua uktus paa stump pro%imal i li'asi en'an "enan'
nona"sor"a"le$ Parenkim i )a(it secara matras pasan' rain$

Gr IN
- Bila (emoinamik tiak sta"il+ multiple trauma+ in e%perience sur'eon - no attempt
to esta"lis( inte'rit& uct or resection$
- (emostasis 5 e%ternal rainase
Most reco,er 4it(out an& si'ni*icant local complication$ Ot(ers : *istula+ pseuoc&st$
Gr N$ pancreaticouoenektomi
Bila sta"il
Bila perlu packin' - ama'e control$
80 . 0K )am - e*initi* pancreaticouoenektomi$
Outcome
- 8J A p% mor"iit&
Ii'(er 'rae (i'(er complication
- Persistent rain output or *istula almost all close spontan in *e4 4eeks
Analo'ue somatostatin - ecrease output
Oral *eein' tolerance$
- Peripancreatic *lui collection or pseuoc&st
6ika tiak aa ceera uktus - resol,e spontan
6ika aa+ cairan menetap 5 mem"entuk pseuoc&st$
T( / percutaneus raina'e atau internal raina'e
Mortalit& ?+J A B 7 A tiak "er(u"un'an lan'sun' en'an KT$
Kao : 'r I . II KT ; A
Ii'(er KT 8: A
Represent mortalit& *rom more se,ere associate in)ur& in p% 4it( (i'(er
'rae pancreatic in)ur&$
Iernia paa anak sese'era mun'kin+ tapi )ika aa isertai unesensus testis+
tun''u sampai umur 7 ta(un karena )aran' inkarserata ole( karena anulusn&a "esar
6a(it iap(ra'm : terputus+ E mua( i )epit en'an klem ellis$
S(ort "o4el s&nrome ter)ai paa min''u ke ti'a
Gan''uan a"sor"si paa "a'ian LL MatLL su"stitusi Mat terse"ut$
Gan''uan BO! ,ol,ulus tiak aa &an' spesi*ik as&metri 'as usus satu sisi$
1&eri ,ol,ulus : n&eri stran'ulasi n&eri luar "iasa
Makin lama i tuna makin i "in'un'kan
Per*orasi 'aster coup O poi'nar$ 1&eri sekalipaa epi'astrium+ "erkuran' setela(
F )am karena peritoneum ilusi
!ase I P F )am : n&eri menaak aki"at ran'san' kimia n&eri makin "erkuran'
II P F . K )am : ilusi ole( cairan peritoneum
III tim"ul peritonitis
Sala( satu DD app akut ruptur 'aster
Rupture 'all "laer 2 karena cairann&a turun ke *osa iliaka 3
Kalau per*orasi i antara p&lorus
6a(it primer kemuian "& pass 'astro&e&unostom&
#oup O poi'nar
Kista c(oleocus "iasan&a paa anak8 )aran' paa e4asa+ inin'&a tipis
Kalau paa e4asa )aran' (ati (ati mun'kin suatu o"struksi i istaln&a+ inin'
mene"al mun'kin aa tumor i istaln&a+ se(arusn&a i PA
ETIOLOG= PATIOGE1ESIS 5 DIAG1OSTI# ASSESME1T O! A#UTE
PA1#REATITIS
Penemuan "atu i #BD tiak le"i( ari 9 mm paa :? A p% en'an 'allstone
pancreatitis 5 @ 0? A paa p% en'an 'allstone tanpaLL$$ aala( pentin'$
Gam"ar anatomic
- Inteructal an'le "et4een lo4er #BD 5 panc uct E "esar pen en'an panc$
- Pan)an common c(annel at least J mm
;J A paa pen panc i "anin'kan
8? A paapen 'allstone tanpa panc
Tiak apat i )elaskan mekanismen&a
- #&stic uct le"ar small stones
7$ Aan&a "atu atau LLL$$$paa #BD re*lu%
8$ Batu &an' impacte paa tempat keluarn&a panc uct re*lu% pancreatic )uice
9$ Batu kecil+ ire'uler &an' n&an'kut i ampulla men&e"a"kan n&eri 5 munta( en'an
potensi re*lu% uoenal )uiceLLL "atu 5 ke pancreas$
7$ Re*lu% "ile "ile lecit(in 5"ile salt merusak mukosa uct pancreas 5 potensiasi
in*eksi "acteri 5 ru's seperti aspirin
8$ Re*lu% panc )uice menim"ulkan n&eri
9$ Re*lu% uoenal )uice enterokinase en'an tekanan tin''i paa uct panc
men'akti*kan tr&psino'en$
Bilar& s(o'e : men'anun' Kristal kolesterol+ ca "illiru"iact 'ranulos
men&e"a"kan pancreatitis akut$
Pre'nanc& 5 pancreatitis akut
:? A 'allstone relate
Eraikasi "atu mence'a( panc selama ke(amilan 5 ke(amilan "erikutn&a
Biliar& iskinesia
Motilit& isorer paa s*in'ter oi$
Trouli :F preciseLLLLLL$$ "ila spasme s*in'ter ter"ukti men&e"a"kan
pancreatitis akut "erulan'
Umpullar& LLLL$ + c(oleoc(al c&st
Sclerosin' c(olan'itis+ in*estasi cacin' pen&e"a" lain pancreatitis akut$
In,esti'asi *or stones
!oto polos 7? . 7F A raio opa<ue USG
#T tiak / )aran' "ias mei(at "atu sens 8? A
MRI : 0? A
MRI / MR#P KJ A sens
Se"elum t(erapeutic en'an ER#P
EUS apat meli(at "atu 7 mm . 8 mm akurasi :? A
Ps li,er apat mem"eakan karena "atu atau alco(ol
C enM trans*erase+ C ALP+ C "iliru"in "atu
EF? IU / L
EK? IU / L alam 80 )am
Ako(ol
Palin' seikit 7?? 'r alco(ol / (ari
LL$$$$a'e 0? ta(un
Emua i "anin' "ilier J9 ta(un+ mekanisme "elum )elas+ merokok "iasan&a 8?
"atan' paa pemeriksaan spasme s*in'ter Oi$
Acute alco(ol in'estion
Menin'katkan LLLL pancreatic "icar"onat 5 protein secretion
#(ronic in'estion menurunkan "icar"onate
Menin'katkan ,iskositas en'an protein CC
ER#P inuce panceatitis
7A B 9 A setela( ER#P+ "ila en'an ES : 0 . J A
De*inisi menurut consensus :
7$ 1&eri a"omen &an' "aru tim"ul atau mem"erat
8$ Am&lase menin'kat 9 . 0 % alam 80 )am
9$ Perlu pera4atan 8 (ari 2 minimal 3
!actor resiko LLL$$
7$ Perna( pancreatitis inuce
8$ #BD tiak mele"ar
9$ Usia mua
0$ !emale
J$ Biliru"in 1
F$ Dis*un'si s*in'ter oi
Diclo*enac minimiMin' pancreatitis in (i'(risk p%
Tumor ampulla ,ater
Inisial presentasi mun'kin "erupa pancreatitis akut
Iiperparatiroiism
Aa (u"un'an (iperkalsemia en'an pancreatitis akut
I&perlipiemia
Tri'liseria menin'kat atin' en'an pancreatitis akut$ 6u'a alko(olisme
Dru' inuce pancreatitis
Dia'nosis o* e%clusion
- #orticosteroi 2 point 7 sampe 0 aa "ukti kuat 3
- Aspara'inase
- LL$$
- Nalproic aci
- Diuretic a'ents
Acute Niral illness
#o%sakine B
Iep A necrosis *ocal paa panc tapi minor pro"lem paa (ep "erat
Panc LL$$
J . 70 A paa serial otopsi
F A paa stui ER#P
Tiak "ersatun&a ,entral "u 5 orsal
Main uct o* LLL
Accessor& uct o* santorini
#ontro,ersial
Gan''uan aliran paa uktus santorini
Tiak spesi*ik "er(u"un'an en'an pancreatitis akut
Iereiter
6aran'
@ 8? ta(un panc akut 5 pro'ress men)ai panc kronik selama 8? ta(un
Ii'( risk *or ca paa usia ;? t(n
Ri4a&at LLL$$ 5LLL$
- Alco(ol
- I&perlipiemia
- ER#P inuce+ enoscop& papillar& treatment+ sur'er& 5 o"at8an
Bloo test
ALT+ AST+ ALP
ALT E 7J? IU / L LLL
Spec 90 . :F A paa "atu
Bil+ ALPLLLLLL
Sens KJ A spec F: A paa "atu
Bloo neutral )ar E 7??? m' / l
I&perlipiemia pen&e"a" pancreatitis
I&perkalemia
I&perparat(&roi
USG
Biliar& stone+ pele"aran #BD
Rate LL$$ 8? . :? A karena 'as usus
S(oul not "e rule LL "ila tiak meli(at "atu
#T
- Panc #a
- LLLLLL$
- Tiak apat meli(at "atu+ akurasi 0? . J9 A
MRI / MR#P
ER#P Q ES 0K )am NS E 0K )am
Earl& late complication lo4er
9 A NS ; A
ER#P Q ES alone NS kolesistektom&
Recurrent LLLL$ 7+J A paa ER#P Q ES alone
1amunLLLL$ Bilier 99 A paa &an' kolesistektom&
Paa p% tua ;? t(n kolesistektom& E LL$$
Komplikasi "ilier setela( 7; t(n 87 NS F A
Timin' kolesistektom&
Earl& NS elektrolit
1o i** komplikasi 5 mortalit&
Trauma tumpul a"omen
Bo& o* pancreas a'ainst ,ert collum
Presentasi klinis
1&eri a"omen atas menaak isertai munta(+ n&eri men)alar ke pun''un'+ *lui
e*icit karena mual munta(+ kunin' i sertai kolan'itis
Paralitik ileus
Disease se,erit& menurut 6apanese 'uiline
Pro'nostic
7$ TDS @ K? mmIG atau BE @ B 9LL$$
8$ PaO8 @ F? mmI' atau en'an resp
9$ BU1 E 0? SK E 8+??
Oli'uria
0$ LDI E 8 %LLLLL
J$ Platelet @ 7?$???L$$
F$ Serum #a @ ;+J m' / l
;$ #RP E 7J m' / l
K$ SIRS criteria E 9
:$ A'e E ;? ta(un
Dera)at #T
7$ E%trapancreatic in*lamasi
Anterior pararenal space ?
Root o* mesocolon 7
Be&on lo4er pool o* kine& 8
8$ LLLL$$ lesion o* panc
1 Se'men ?
2 Se'men 7
Entire 8 se'men or more 8
Total score ? or 7 'r I
8 'r I
9 'r III
Pro'LL$ E 9 2 se,ere 3
Atau )ika #T 'r 8 2se,ere 3
Kriteria ia'nostic )apan 'uielines
7$ 1&eri a"omen akut 5 tenerness paa a"omen atas
8$ Penin'katan ent$ Pancreas alam ara( an urine
9$ Penemuan a"omen paa pancreatitis akut &an' i apat ari USG+ #T atau MRI
Pen en'an ua positi,e 5 rule out
Pen& pancreas 5 a" lainn&a LLL$$
Lipase sensiti,itas KJ . 7?? A en'an am&lase
Spesi*itas K0+ ;A B :: A
Le"i( superior aripaa am&lase
Am&lase menin'kat paa pen& kel$ Liur
LLLLL$$
Tr&psin "utu( 4aktu lama
Pemeriksaan en'an imunolo'i
P(olipase A8 s$$a
Menin'katkanLLL$ 5 kaarn&a koreksi en'an sensiti,itas pen&$
Dia'nostik Ima)in'
#%R 5 a" plain *oto tiak spesi*ik untuk men&in'kirkan ia'nose lain
#%R pleural e**use+ ARDS+ pneumonia
Paa a" plain
LL$$ :
- Ileus
- #olon cut o** si'ns
- Dilate uoenal loop
- Gas paa retro$
USG
Test LLL &an' ilakukan
Pem"esaran pancreas
In*lamasi sekitar panc
Ascites
Batu "ilier
LLLLLL$$
#T
- Pem"esaran pancreas
- Penin'katan konsentrasi )arin'an lemak sekitar panc 5 retroperitoneal
- !lui collection
- Pseuoc&st
- LLL$$ panc &an' tiak "iasan&a
- Panc necrosis
- Gas sekitar panc
- 6u'a mem"aik alam menetukan era)at "esarn&a pen&akit
MRI
- #T sulit alam menetukan LLL$ Panc "ila tiak i sertai pem"esaran$
ER#P : tiak untuk ia'nosisLLL
E*ek sampin'n&a
Dia'nosis etiolo'i
- Se'era setela( ia'nosis pancreas te'ak
- Treatment polic& k(usun&a paa 'allstone inuce panreatitis
Ter'antun' pen&e"a" :
- Gallstone
- I&perlipiemia+ trauma+LL$ Inkomplit uct panc+LLL$ Glan paratiroi+ tumor
La"oratoric
6aunice+ ALP C+ 6 GT C+ transmirase C
USG aan&a "atu GB atau #BP 2 'allstone inuce 3
1amun karena "atun&a kecil masuk ke uo$
T(erapeutic Inter,ention 5 Sur'er& o* acute pancreatitis
Berasarkan morp(olo'&
- Panc eematosus
Panc necrotiMin' 7? . 8? A
Mortalitas 70 B8J A
Kalau en'an in* mortalitas 9? . 0? A
Panc necrosis terin*eksi curi'a "ila+
- #linical 4orserin'
- Data (ematolo'i+ kultur "akteri ara(
- Enoto%in alam ara(
- #T scan : 'as "u""les p 5 sekitar panc
Memastikan
!1A en'an #T / USG 'uie
Akurasi K: . 7?? A
!alse ne' 8? . 8J A
Inikasi+ timin' 5 *rekuensi
Paa necrosis &an' LLL konser,ati*
Treatment untuk pancreatitis necrosisterin*eksi
- Bea(
- Inter,entional raiolo'& INR
- Enoscopic
- Bila konisi sta"il mana)emen konser,ati* masi( i pertim"an'kan
- Anti"iotic K min''u E
KapanLG
S(oul "e ela&e as lon' as possi"le
Stui retrospekti* mem"uktikan
Earl& NS ela&e
9: A 78 A mortalit&
R#T "& Mret kk R:;
Earl& ;8 )am a*ter onset NS ela&e 78 a*ter onset
Mortalit& JF A NS 8; A
Stui ole( "esselink 8??;
Mem"anin'kan
Earl& 2 70 (ari 3 NSLLLL
2 7J . 8: (ari 3 NS ela&e 2 9? (ari 3
Mortalit& 8J A NS 0J A NS K A
Rasionaln&a "atas antara LL$ 5 necrotic men)ai E )elas
1ecrosectom&
Less LLLLLL "etter LLLLL$$con,entional open sur'er&
Lon' term *ollo4 LLL$ Post necrosectom&
- Dis*un'si pancreas 2 ecrease e%o 5 enocrine 3
- Structure LLL 5 stenosis panc uct
Pancreatic pseuoc&st inikasi "ea(
7$ Disertai 'e)ala n&eri a"omen
8$ Komplikasi in*eksi atau perara(an
9$ Mem"esar selama *ollo4 up
0$ E F cm
J$ Tiak aa kecenerun'an men'ecil selama F min''u
F cm . F 4eeks criteria "ukan inicator a"solute
Mana'ement acute pancreatitis
Main'ots
Principles o* mana'ement :
- Resusitasi an monitorin'
- 1utritional support
- ER#P
- Anti"iotik pro*ilaksis
- Sur'ical mana'ement
Resusitasi an monitorin' :
- A'resi* pen''antian cairan &an' (ilan' ke e%tra,askular atau 9r space
- Kaan' kaan' i perlukan cairan E 8?? ml / )am IN
- mence'a( komplikasi sistemik seperti acute renal insu**icienc&
- Resusitasi &an' tiak aekuat )u'a menam"a( kerusakan paa pankreas
- Pen'a4asan ketat paa *un'si perna*asan+ kario,askular+ *un'si 'in)al
- !lui "alance+ electroc&te+
- I#U )ika se,ere
- 1arkotik *or pain control
- 1GT+ tiak perlu suction rutinterutama )ika iapati ileus paralitik untuk mence'a(
munta( an aspirasi$
1utritional support :
- Dulu pem"atasan makan melalui oral+ teorin&a mence'a( stimulus ter(aap kelen)ar
eksokrin &an' akan menam"a( ceera pancreas karena i lepaskann&a ent$ Proteolitik
- Sekaran' : unnecessar&
- Paa kasus mil : puasa sin'kat+ "ila n&eri "erkuran' - penerita apat makan
- Se,ere : (iperkar"olics(unte+ ileus - TP1
Keuntun'an nutrisienteral 2 naso&e&unal *eein' 3 :
- Le"i( merata
- Tiak aa komplikasi cat(eter . relate
- Men)a'a inte'ritas mukosa intestinal
- Mence'a( peru"a(an *un'si "arrier an permea"ilitas intestinal
T(e role o* ER#P
- #(oleoc(olit(iasis - ma)or cause o* acute pancreatitis
- ER#P $$$$$$$$$$$$ untuk ia'nosis sekali'us t(erapi paa acute pancreatitis
- Pen''unaan ER#P paa konisi / kasus pancreatitis "ilier en'an o"struksi "ilier
atau kolan'itis - )elas
- $$$$$$$$$$$$$$ paa kasus tanpa o"struksi most - not recommene
- MR#P use as a ia'nostic rool t(at ma& allo4 ER#P to "e use selecti,el&$
Anti"iotik pro*ilaksis
- In*eksi apat ter)ai paa nekrosis &an' "esar
80 A ter)ai paa min''u pertama+ ;7 A ter)ai paa min''u keti'a
- !lora GI "aik aero"ik maupun non
$ E coli 9J A
$ Klei"sella pneumonial 80 A
$ Streptococcus 80 A
$ Stap(&lococcus 70 A
$ Pseuomonas 77 A
- Pro*ilaksis i 'unakan karena tin''in&a mortalitas &an' apat ter)ai paa
pancreatitis en'an in*eksi+ namun en'an ter)ain&a penam"a(an *lora aki"at
pen''unaa AB an ter)ain&a resistensi an in*eksi )amur - pen''unaan AB
pro*ilaksis men)ai kontro,ersi$
- Konsensus :
Broo spectrum AB s(oul "e use earl& in t(e course o* necrotiMin' pancreatitis$
Particular& *or patients 4it( or'an *ailure or sepsis$
Laman&a : 7 . 0 min''u$ Be"erapa peneliti - 70 (ari$
- Anti *un'al *luconaMole paa kasus pancreatitis necrotiMin' en'an AB pro*ilaksis
- Gut econtamination - en'an AB non a"sor"a"le 2 karena kumann&a "erasal ari
GIT 3
- masi( menun''u stu& le"i( lan)ut
Pen'an'anan Bea($ Inikasi an Timin'
7$ Dia'nostic uncertainl&
8$ Intra a"ominal 5 $$$$$$$$$$$ unrelate to necrotiMin' pancreatitis suc( as per*orate
,iscus
9$ In*ecte necrosis ocumente "& !1A or e%traluminal 'as on #T
0$ Se,ere sterile necrosis
J$ S&mptomatic or'aniMe pancreatic necrosis
In*ecte pancreatic necrosis :
- Mortalit& 7?? A 4it(out inter,ention
- Raio'rap(ic : emp(&sematous pancreatitis or 'as intraperitoneal
- #T 'uiin' !1A - neee to ia'nose in*ection
- #linical istinetion is imposi"le $$$$$$$$ se,ere sterile necrosis 5 in*ecte pancreatic
necrosis - leukositosis 5 *e,er
- Pasien pasien en'an se,ere pancreatitis &an' tiak mem"aik alam 4aktu 8 min''u
- (arus i cari kemun'kinan aan&a in*eksi$
Se,ere sterile pancreatic necrosis
- Se"elum 7::7 e"riement
- 7::7 "rale& 5 allen pu"lis(e LL p% 4it( 1OM
- 6u'a en'an aan&a !1A 'uie - 1OM
Or'aniMe Pancreatic 1ecrosis
Paa "e"erapa penerita &an' ilakukan 1OM : men'alami persistent pain+ malaise+
ina"ilit& to eat 2 Persistent un4ellness 3 Sars(a4
Patolo'i &an' "er(u"un'an en'an konisi terse"ut : Or'aniMe pancreatic necrosis 2
"aron 3 : proses maturasi in*lamasi en'an "atas &an' )elas en'an )arin'an pancreas
5 peripancreas &an' se(at$
#astillo kk : no "ene*it ela&in' operation lon'er t(an 0 4eeks *rom t(e onset o* t(e
illness$
Dia'nosis acute pancreatitis 2 Iistor&+ amilase+ lipase 3

H
Assesment o* se,erit&
Mil acute pancreas Se,ere acut panc
B !lui resc B I#U
B 1PO inisial B A''resi,e *lui rosc
B 1GT *or ileus B Initial 1PO
B Enteral *eein' 4(en tolerate B 1GT *or ileus
B ER#P i* "iliar& o"st B Enteral *eein' i*
B #T i* *ailure to impro,e 2 a*ter ;8 ( 3 B ER#P i*
B TP1 i*
B #T scan a*ter ;8 (
1o pancreatic necrosis Pancreatic necrosis
B Mana'e as se,ere AP B Pro*ilaksis AB
B Repeat #T : * B #T 'uie !1A i*
#linical eterioration clinical eterioration
1e'ati,e !1A Positi,e !1A
BSteik necrosis B In*ecte necrosis
B O"ser,ation+ supporti,e B Pancreatic e"riement
B Repeat !1A i* clinical eterioration
B Persistent s&mptoms E 7 "ln - operasi
PROSEDUR BEDAI
Ditu)ukan paa pen&e"a"n&a 'allsstone panc
Komplikasin&a : c(olestectom& setela( peraan'an panc rea
ER#P en'an papilotomi "ila ter"ukti aa o"struksi "ilier atau c(olan'itis
Dilema paa pem"ea(an untuk pancreatitis necrosis
Reseksi
7:F? . 7:;? parsial atau total pankreaktomi mortalit& F? A+ o,ertreatment+
)arin'an se(at ter"uan'$
PA1#REATI# PSEUDO#=ST
S(ackel*orOs
- Sekumpulan cairan sekresi pankreas &an' ikelilin'i inin' *i"rous atau
'ranulasi &an' tim"ul aki"at pankreatitis akut atau kronik+ trauma pankreas+
o"struksi uktus karena ke'anasan$
- ;J A ari lesi kistik pankreas
7$ Tiak aa epitel : mem"eakan en'an c&stic neoplasms+ parasitik+
con'enital+ an kista ekstrapancreas
8$ Konsentrasi enMim pancreas tin''i
9$ Ter)ai 0 min''u setela( trauma atau pank$ Akut
Acute *lui collection
- Earl& in t(e course o* acute panc$
- Lack a iscrete 4all o* *i"rous or 'ranulation tissue
- Re'resi spontan+ tiak "er(u"un'an en'an uktus
- Dise"ut )u'a pseuoc&st
Pancreatic a"scess
Purulent in*ecte *lui
Little or no necrotic material
Ter)ai E 0 min''u setela( onset pank akut
Etilo'i
- Ter)ai J . 7? A paa penerita pank akut
-
- 0J . J? A i kaput
- 7J A multipel
- FJ A karena pankreatitis aki"at alko(ol+ 7J A "atu empeu+ 7J . 7? A karena
trauma$
Gam"aran klinis :
- :? A n&eri a"omen
- J? . ;? A earl& $$$$$$$$$$$$ nausea 5 ,omitin' mass e**ect
- 8? . J? A 4ei'(t loss
- 7? A )aunice
- 7? A lo4 'rae *e,er
Paa pemeriksaan : a"ominal tenerness "a'ian atas tera"a massa 8J . 0J A
Komplikasi : sepsis karena in*+ s(ock karena perara(an+ ikterus karena$$$$$$$$$
Se,ere pain karena rupture
Dia'nosis :
- 1o e*initi* la" $$$$$$$
- J? A am&lase 5 lipase menin'kat
Am&lase &an' tetap menin'kat setela( pank akut $$$$ curi'a aan&a
pseuokist$ $$$$$$$$$ (a,e mil leucoc&tosis+ ele,ate li,er *unction test
- #T scan : pre*erre
- USG a" less in,asi,e
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
- MRI . MR#P
Pseuokis serous c&st neop$ Mucinous #1
Am&lase (i'( ,aria"le ,aria"le
#&tolo'& 2 B 3 2 B 3 usuall& 2 Q 3
Niscosit& lo4 lo4 usuall& (i'(
#EA / #A 78J lo4 / lo4 lo4 / ,aria"le (i'( / ,aria"le
#A 7:: ,aria"le ,aria"le (i'(
#EA E 7:8 m' / ml ;: A aala( mucinous
@ J m' / ml speciti*it& J A untuk pseuokis atau kista aenoma serous
ER#P
De*ine uktus pankreatikus
Iampir semua pseuokis mempun&ai kelainan / a"normalitas paa uktusn&a
8J . J? A a"normal c(olan'ioor'an
Al'oritme a(earne PM kk
S&mptomatic pancreatic pseuoc&st
Electi,e non electi,e in*eksi (emmora'e
Per*orm ER#P
!aile uct communication raiolo'ical / sur'ical inter,ention
Sur'er& &es no
Sur'er& Drainase perkutan
Den'an ER#P menurunkan a,erse outcome
Per)alanan pen&akit
6aran' re'resi spontan
Tiak ian)urkan konser,ati*
J? A men'alami komplikasi
=eo at al 7::?
- Operasi ilakukan "ila iapatkan n&eri a"omen menetap+ kista mem"esar+
komplikasi pseuokis
- 0K A "er(asil en'an non operati,e
- F? A complete re'resi setela( 7 ta(un
- 0? A tetap atau men'ecil
- E F cm perlu $$$$$$$$
- D F cm 0? A $$$$$$$
- E 7? cm 8; A "er(asil en'an non op
1o strict cut o** TT
Mana)emen
- O"ser,asi
- Perkutan rainase
- Draina'e enoskopik
- Transpapillar& enoscopic raina'e or $$$$$$$$
- Operati,e : Drainase internal+ e%ternal
resection
Perkutan rainase :
!aktor preiksi ke"er(asilan :
- Letak paa tail
- Nol @ 7?? cc
- Le,el am&lase intrac&stic rena(
Kontra inikasi :
- Aa soli e"ris atau pancreatic necrosis
- Tiak aa akses &an' aman
- Perara(an intrakistik
- O"struksi uktus total 2kontro,ersi3
Enoscopic approac( transmural :
- Kista+ letak paa corpus atau kaput an menon)ol ke alam lumen intestinal
- !aktor &an' "er(u"un'an en'an ke"er(asilan :
a$ Lokasi kaput korpus
"$ Te"al inin' kista @ 7 cm
c$ Sekuner ari trauma atau pank kistik
Operati,e inter,ention "iopsi inin' kista
3 stanar :
B #&sto&e&unostomi rou% n =
B #&stouoenostom&
B #&sto'astrostom&
a$ #&sto&e&unostom& "ila letak paa asar mesocolon trans,ersum
"$ #&sto'astrostom& : kista menempel paa inin' posterior 'aster
c$ #&stouoensotom& : lokasi paa kaput+ prosessus $$$$$$$$$$$$ &an' "er)arak @
7 cm ari lumen uoenum
)aran' i'unakan karena $$$$$$$$$$$$$ uoenal $$$$$$$$ 5 *istula
Etiolo'&+ Pat(o'enesis+ 5 Dia'nosis o* #(ronic Pancreatitis
Pen&e"a" umumn&a aala( alko(ol a"use ;? A+ unerl&in' 'enetic+ cellular
an molekular aspect$
Pat(o'enesis
I&potesis : necrosis . *i"rosis+ to%ic . meta"olic+ o%iati,e stress+ plu' 5
stone *ormation+ o"struksi uktus+ o"struksi uktus primer+ sentinel acute panc
e,ent 2SAPE3
Ima'in' ER#P+ EUS relia"le
- met(o o* $$$$$$ paa *ase a4al+ "ila tiak aa EUS ER#P 5 #T cukup
relia"le
MRT / MR#P en'an $$$$$$$$$
Klasi*ikasi "erasarkan etiolo'&
Ti'ar . ?
To%ic . meta"olic+ iiopatik+ 'enetik+ autoimmune+ recurrent se,ere+ o"struc
ti,e
7$ To%ic . meta"olic
Alko(ol+ most common cause namun (an&a J . 7? A &an' itemukan
men)ai pancreatitis kronis secara klinis$ F? . :? A pasien en'an
pancreatitis kronis mempun&ai ri4a&at alko(ol selama 7? B7J t(n mulai
usia pu"ertas$ Batas kritis $$$$$$$$$$$$$$$$$$$$$$$$$
Aa *aktor preiposisi : 'enetic+ perokok+ (i'( *at iet+ $$$$$$$$$$$$$$$
'allstone+ 'ener+ (ormonal *actor+ pola $$$$$$$$$+ namun iperkirakan paa
pasien 'enetic E "erperan suscepti"le$
Rokok inepenent *actor+ mekanisme (ampir sama en'an alko(ol
- Meru"a( sekresi 5 komposisi panc )uice
- menurunkan panc )uice 5 sekresi "icar"onat 5 men'inuksi oksiati*
stress$
Gen $$$$$$$$ mutasi paa 'en $$$$$$$
Panc kronis paa to"acco a"use+ karena 'en ini "erperan alam etoksi*ikasi 5
perta(anan sel+ tiak untuk alko(ol a"use
#alcium$
Men'akti*kan tripsino'en nekrosis an *i"rosis+ paa (iperkalsemia aki"at
(iperparatiroi
- Direct ama'e to sel $$$$$$$
- Intrauctal stone *ormation
- Protein plu' *ormation
8$ Iiopat(ic
9? A tiak aa *aktor resiko+ mutasi serum protease in(i"itor+ $$$$$t&pe 7
2 SPI1K 7 3$ 8J A panc kronis $$$$$$$
8 onset
Earl& : 8 ecae
1&eri a"omen 'am"aran klinis utama
Tanpa insu*isiensi e%ocrine 5 enocrine
Late : 0?O s
1&eri tiak selalu+ si'ni*ican insu*isien e%o 5 enocrine