重症急性胆管炎66例的救治

报道15年同由胆石症导致的重症急性胆管炎(ACST)66例的救治，指出胆石症导致的ACST并发多器官功能衰竭(MSOF)是良性胆道疾病最重要、最直接的死亡原因．强调一旦发生MSOF，要给予强有力的“四大一支持”综合疗法。该疗法有助于ACST病人渡过手术难关。在致死性的触发病因击除后，促进器官功能发生逆转，最终使患者获得痊愈。     

63例重症生胆管炎的救治体会

作者报道１５年间由胆石症导致的重症急性胆管炎（ＡＣＳＴ）６３例的救治，指出胆石症导致的重症急性胆管炎（ＡＣＳＴ）并发多器官功能衰竭（ＭＳＯＦ）是良性胆道疾病最重要、最直接的死亡原因，强调一旦发生多器官功能衰竭，要给予强有力“四大一支持”综合疗法，该疗法有助于ＡＣＳＴ病人渡过手术关，在致死性的蟹发病因去除后，促进器官功能发生逆转，最终使患者获得痊愈。     

高龄急性重症胆管炎72例诊治分析

急性重症胆管炎（ACST）发病急骤,病情进展快,是腹部外科常见的严重急腹症。而高龄ACST病人由于并存疾病多和全身重要器官功能减退,其病情更加危重。我院自1990年1月～2005年1月共收治65岁以上的高龄ACST病人72例。现总结分析如下。     

急性重症胆管炎致多器官衰竭35例因素探讨

<正> 急性重症胆管炎(ACST)是胆道外科常见疾病,发病急骤,病情危重,病程进展迅速,若不及时处理或处理不当,常可并发多器官脏器功能衰竭(MSOF),病死率极高。现将我科1990年5月至1999年5月期间,收治急性重症胆管炎并发多器官脏器功能衰竭35例病例,就其与ACST的关系分析如下:     

急性重症胆管炎17例外科治疗体会

急性重症胆管炎（acute cholangitis of severe type，ACST）是外科常见的严重急腹症。我院2000年1月至2007年11月收治急性重症胆管炎17例，现报告如下。     

老年重症急性胆管炎58例治疗体会

本文报告58例老年重症急性胆管炎，认为老年人各重要器官由于生理性退化，且多有其他合并症，其病死率极高，应积极采取术前有效、短时抗休克治疗及合理的抗休克措施。加之对术前合并病的兼治，适时掌握手术时机，采取简单、安全、有效的手术方式及有针对性的应用抗生素，尽早施行胆道减压术，并随时监测防治重要脏器功能衰竭。重症急性胆管炎（ACST）是临床常见的外科感染性危重症，我院于1995～2004年共收治符合ACST诊断者182例，其中60岁以上者58例（31．87％），死亡18例（31．03％），现报告如下。     

重症急性胆管炎手术治疗的体会

目的 为了有效地救治重症急性胆管炎(ACST)病人，达到降低病死率。方法 通过对36例ACST病人治疗预后的回顾性分析，找出该类疾病治疗的一般规律性。结果 5例死亡，31例抢救成功，从中摸索出手术治疗的时机应在病人Charcot三联征的基础上尚未发生较重休克和神经精神症状之前较为安全。结论 重症急性胆管炎是一个多样化临床病理过程，必须早期在未发生严重肝脏及多器官损害之前，不失时机地进行手术，解除胆道梗阻并减压引流。     

老年重症急性胆管炎手术时机的选择

老年重症急性胆管炎 (ACST)是肝胆外科临床的危重疾病 ,病情凶险 ,合并症和并发症多 ,病死率高 ,易发生感染性休克和多器官功能不全综合征 (MODS) ,手术时机的掌握是提高其抢救成功率的关键所在。我们自 1994～ 2 0 0 3年收治了 60岁以上重症急性胆管炎 80例 ,现报告如下。临床     

经皮肝穿刺胆道引流术在重症急性胆管炎治疗中的应用

重症急性胆管炎（acute cholangitis of seversetype,ACST）常继发于胆管结石及胆管良恶性狭窄,进展迅速,病情危重,有文献报道死亡率高达15％以上。及时、有效地解除胆道梗阻并通畅引流,是治疗ACST的最重要、最基本的方法。但ACST早期易出现高热、黄疸、休克和多器官功能损害等症状,使得麻醉和手术面临巨大的危险,手术并发症和死亡率较高。     

重症急性胆管炎诊治的研究进展

重症急性胆管炎（ACST）是在胆道梗阻的基础上合并严重感染而引起感染性休克及全身多器官衰竭的危重疾病，其病死率较高。因此采取有效的措施对其及时诊断和救治显得尤为重要。笔者就ACST近年来诊治的研究进展进行简要综述，包括ACST的病因、诊断标准、诊断的技术方法以及非手术和手术治疗等。

     

Treatment of 10 cases of multiple organ failure

From 1985 to 1987, 10 cases of multiple organ failure (MOF) caused by severe infection, major surgery, and trauma were treated in our hospital. The sequence of the organs that came to a failure varied with different diseases. The diagnosis was made on the objective index and numbers of the failed organs. All patients were monitored and treated with modern medical equipment including hemodialysis, plasma-exchanging technique, and artificial heart-lung machine. It was found that the increase of curative rate lay on the intensive care and comprehensive treatment. Five patients in this group survived, and the diagnosis of MOF was finally confirmed by autopsy (heart, lung, liver, kidney, brain, and GI tract) in three cases. Based on the pathological findings, the authors suggested that patients with MOF could only be cured when the disease was on its first, second, or early third stage.     

The microbiology of multiple organ failure. The proximal gastrointestinal tract as an occult reservoir of pathogens

The microbiology of infection acquired in the intensive care unit (ICU) was studied prospectively in 205 consecutive patients admitted to a surgical intensive care unit. A multiple organ failure (MOF) score was calculated for each admission. Susceptibility to ICU-acquired infection increased with increasing MOF scores. While Escherichia coli, Bacteroides fragilis, and enterococci were the most common isolates from infections present at the time of ICU admission, Staphylococcus epidermidis, Candida, and Pseudomonas dominated infections occurring in patients with high MOF scores. Mortality correlated highly with infection due to S epidermidis or Candida and only poorly with infection due to Pseudomonas or E coli; significant foci of invasive infection were frequently absent at autopsy. Quantitative cultures of proximal gastrointestinal fluid in 16 of these patients showed Candida, S epidermidis, and Pseudomonas to be the most common isolates, and all but one patient colonized with these organisms had invasive infection with the same organism. The proximal gastrointestinal tract appears to be an important occult reservoir of the predominant pathogens in MOF.     

Incidence and reversibility of organ failure in the course of sterile or infected necrotizing pancreatitis.

BACKGROUND: Multiple organ failure (MOF) and infected necrosis are both considered severe adverse events during the course of necrotizing pancreatitis. HYPOTHESIS: The incidence of MOF and its reversibility in patients with necrotizing pancreatitis are influenced by the presence or absence of infected necrosis. DESIGN: Case series. SETTING: Intensive care, university teaching hospital. PATIENTS: Forty-three patients with necrotizing pancreatitis and failure of at least 1 organ were prospectively included. MAIN OUTCOME MEASURES: Organ failure defined according to the Goris classification; MOF defined by the simultaneous occurrence of 3 organ failures and graded with an MOF score. Microbial status of necrosis was assessed by percutaneous or intraoperative sampling. Surgical drainage was performed in patients with infected necrosis, whereas sterile necrosis was managed conservatively. RESULTS: Infected necrosis occurred in 27 patients (63%). The mean (+/-SEM) number of organ failures was greater in cases of infection (3.6 +/- 1.1 vs 2.6 +/- 1.5; P =.02). Multiple organ failure occurred more frequently in cases of infected necrosis (23/27 vs 7/16; P<.01) and was responsible for an increased mortality in this subgroup (33% vs 6%; P =.1). The severity of MOF graded by the MOF score was related to the bacteriologic status of necrosis. CONCLUSIONS: The higher mortality commonly attributed to MOF in patients with infected necrosis appears to be due to a higher frequency and an increased severity of MOF. Conservative management in patients with severe necrotizing pancreatitis and sterile necrosis complicated by MOF is supported by the high reversibility rate of MOF and the low mortality rate observed in this series.     

The gastrointestinal tract. The "undrained abscess" of multiple organ failure.

OBJECTIVE: This study determined the association between proximal gastrointestinal (GI) colonization and the development of intensive care unit (ICU)-acquired infection and multiple organ failure (MOF) in a population of critically ill surgical patients. SUMMARY BACKGROUND DATA: ICU-acquired infection in association with progressive organ system dysfunction is an important cause of morbidity and mortality in critical surgical illness. Oropharyngeal and gastric colonization with the characteristic infecting species is common, but its association with ICU morbidity is poorly defined. METHODS: A prospective cohort study of 41 surgical ICU patients was undertaken. Specimens of gastric and upper small bowel fluid were obtained for quantitative culture; the severity of organ dysfunction was quantitated by a numeric score. RESULTS: One or more episodes of ICU-acquired infection developed in 33 patients and involved at least one organism concomitantly cultured from the upper GI tract in all but 3. The most common organisms causing ICU-acquired infection--Candida, Streptococcus faecalis, Pseudomonas, and coagulase-negative Staphylococci--were also the most common species colonizing the proximal GI tract. Gut colonization correlated with the development of invasive infection within 1 week of culture for Pseudomonas (90% vs. 13% in noncolonized patients, p < 0.0001) or Staphylococcus epidermidis (80% vs. 6%, p < 0.0001); a weaker association was seen for colonization with Candida. Infections associated with GI colonization included pneumonia (16 patients), wound infection (12 patients), urinary tract infection (11 patients), recurrent (tertiary) peritonitis (11 patients), and bacteremia (10 patients). ICU mortality was greater for patients colonized with Pseudomonas (70% vs. 26%, p = 0.03); organ dysfunction was most marked in patients colonized with one or more of the following: Candida, Pseudomonas, or S. epidermidis. CONCLUSIONS: The upper GI tract is an important reservoir of the organisms causing ICU-acquired infection. Pathologic GI colonization is associated with the development of MOF in the critically ill surgical patient.     

Revision of the multiple organ failure score

BACKGROUND AND AIM: The multiple organ failure (MOF) score published by Goris et al. in 1985 was one of the first attempts to quantify severity of organ dysfunction and failure based on expert opinion in surgical intensive care unit patients. Fifteen years later a reassessment of this score is mandatory. PATIENTS AND METHODS: Daily MOF scores were documented in patients admitted to the surgical ICUs in Nijmegen (NL) and Cologne (D). Patients with an ICU stay < or = 3 days were excluded. Organ dysfunction (1 point) and organ failure (2 points) were recorded for the following organ systems: lung, heart, kidney, liver, blood, gastrointestinal tract (GI), and central nervous system (CNS). Maximum scores were computed, and logistic regression analysis was used to optimize point weights for each organ system. Predictive power was analyzed using receiver operating characteristic (ROC) curves. RESULTS: In all, 147 patients, mean age 56 years, were included with a total of 2,354 observation days. Hospital mortality was 30.6%. GI failure was present on only 3.3% of days, without impact on mortality. Valid evaluation of CNS was impossible in most cases due to sedation and ventilation. Reweighting of the score items revealed only marginal improvements in prediction. Mortality consistently increased with increase in number of failed organs. This phenomenon was even more pronounced in older patients, e.g., 55% mortality (age > or = 60) versus 0% (age < 60) with two failing organs. CONCLUSION: Due to problems in definition and assessment (reliability) CNS and GI should not be considered in future assessments of the MOF score. The original point weights in the remaining five organ systems provide a valid and reliable risk stratification, at least in surgical ICU patients.     

Clinical analysis of multiple organ failure in burned patients

Severely burned patients often show various degrees of organ failures, and when several vital organs are involved mortality becomes extremely high. A study was undertaken to elucidate the aetiology and clinical significance of multiple organ failure (MOF) in burned patients. One hundred and fifty-eight burned patients were analysed for organ failures in five vital organs or systems, the heart, lung, liver, kidney and blood clotting system. There were 91 organ failures observed in 34 patients, of which 26 had MOF. The most frequently affected organ was the lung, followed by the heart, kidney, liver and the blood clotting system. The mortality rate was 76.9 per cent in MOF and 1.5 per cent in non-MOF patients. Septicaemia was closely associated with the development of MOF. Also, inhalation injury and 'shock' were contributing factors to the morbidity. Five extensively burned patients had an early development of MOF without infectious foci and this type of early MOF was attributed to endotoxaemia possibly originating from the patient's own intestinal flora.     

A review of post-operative multiple organ failure in peripheral arterial diseases

Two-hundred- and-fifty-one patients of peripheral arterial diseases underwent 281 operations for past 11 years in our institute, and multiple organ failure (MOF) occurred in 10 patients (4.0%). These patients were reviewed and were compared with in other diseases. Survival rate was 50% and all the patients with 4 or more organ disorders died. Incidence and survival rate were not significantly different from operative time, blood loss and blood transfusion. Significant difference was observed between elective operation (3.0%) and emergent operation (20.0%). Compared with other diseases, MOF occurred more rarely in peripheral arterial diseases than in aortic aneurysms, but occurred 1.4 times of digestive diseases. While the gastro-intestinal bleeding as the initial failure organ occurred more frequently in peripheral arterial diseases than in other diseases, heart and respiratory failures were rare. MOF occurred after peripheral arterial intervention as well as other abdominal and thoracic surgery. To avoid MOF it is important to avoid MOF that the emergent surgery should be kept out and that general status, especially the grade of diabetes mellitus should be evaluated sufficiently.     

Misdiagnosis using endoscopic retrograde cholangiopancreatography in a patient with postcholecystectomy pain

Summary Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential tool to investigate patients with the postcholecystectomy syndrome. A normal cholangiogram usually rules out the presence of biliary tract disease, and further investigations are directed towards other organ systems. We present a case in which a normal ERCP caused a significant delay in reassessing the biliary tree in a patient who eventually presented with choledocholithiasis. A repeat ERCP should be considered in patients with persistent biliary tract pain, even if the initial ERCP shows no abnormality.     

The role of the gastrointestinal tract in postinjury multiple organ failure

Despite intensive investigation, the pathogenesis of postinjury multiple organ failure (MOF) remains elusive. Laboratory and clinical research strongly implicate that the gastrointestinal tract plays a pivotal role. Shock with resulting gut hypoperfusion appears to be one important inciting event. While early studies persuasively focused attention on bacterial translocation as a unifying mechanism to explain early and late sepsis syndromes that characterize postinjury MOF, subsequent studies suggest that other gut-specific mechanisms are operational. Based on our Trauma Research Center observations and those of others, we conclude that: 1) bacterial translocation may contribute to early refractory shock; 2) for patients who survive shock, the reperfused gut appears to be a source of proinflammatory mediators that may amplify the early systemic inflammatory response syndrome; and 3) early gut hypoperfusion sets the stage for progressive gut dysfunction such that the gut becomes a reservoir for pathogens and toxins that contribute to late MOF.     

Evaluation of severity in shock

Shock is defined as organ failure due to the disturbance of perfusion in vital organs and various humoral mediators. Multiple organ failure (MOF) is a typical pathophysiologic condition subsequent to shock. Therefore the severity of shock should be evaluated based on the severity of organ failure. Recent advances in our understanding of the pathophysiology of shock have demonstrated that organ failure is the summation of cellular dysfunction in vital organs caused by tissue hypoxia and various humoral mediators. We have developed and clinically applied the cellular injury score (CIS) as a severity scoring system in patients with shock and resultant MOF. The CIS is derived from the scoring of three parameters of intracellular metabolism: the arterial ketone body ratio (AKBR); osmolality gap (OG); and blood lactate level. The CIS correlates well with the degree of organ failure and mortality rate in patients with MOF and accurately indicates the severity of shock in individual patients. Our results suggest that the CIS is a useful scoring system based on the pathophysiology of shock, not only to predict the outcome and evaluate the severity in patients with shock and MOF but also to predict the development of MOF subsequent to shock.