急性胰腺炎诊治的现状与进展

<正>21世纪以来,随着基础研究与临床实践的进步,急性胰腺炎(acute pancreatitis,AP)的诊断和治疗水平大大提高,国内外AP诊治指南得到更新~([1-4])。结合国际最新进展和我国国情,中华医学会外科学分会胰腺外科学组对我国2007年《重症急性胰腺炎诊治指南》进行增补和修订,颁布了《急性胰腺炎诊治指南(2014)》~([5]),以便于规范我国,AP诊治过程。本文结合我国最新的临床指南及国内外相关研究,对AP的诊治现状与进展阐述如下。     

妊娠合并急性胰腺炎诊治体会

目的总结妊娠合并急性胰腺炎(AP)诊治经验。方法回顾性分析1998～2004年收治的10例妊娠合并AP患者的诊治过程。结果妊娠合并AP多于妊娠中晚期发病,且多为重症急性胰腺炎(SAP)。本组10例中,孕妇无一例死亡,胎儿死亡2例(1例宫内死亡),其余痊愈出院。结论妊娠合并AP在临床上有其特殊性,及时诊断和“个体化”综合治疗是关键。     

基层医院用腹腔镜技术诊治急性腹痛的价值(附536例报告)

目的 :探讨在基层医院用腹腔镜诊治和治疗急性腹痛的价值。方法 :为 5 36例急性腹痛患者行腹腔镜诊断与治疗 ,并和剖腹诊治比较。结果 :腹腔镜组与剖腹组的确诊率差异无显著性 (P >0 0 5 ) ,在住院时间、手术时间、并发症发生上差异有显著性 (P <0 0 1)。结论 :腹腔镜诊治急性腹痛具有快速、安全、创伤小、并发症少及康复快等特点     

急性化脓性胆管炎46例诊治体会

目的:分析探讨急性化脓性胆管炎的病因、诊断以及处理方法,提高基层医院外科救治效果。方法:对46例急性化脓性胆管炎患者的救治处理措施分析总结。结果:治愈37例,占80.4%;好转7例,占15.2%,有效率95.7%。死亡2例占4.3%。结论:手术治疗是快速、有效的救治急性化脓性胆管炎的处理方法。     

《中国急性胰腺炎诊治指南（2021）》解读

近年来,急性胰腺炎（AP）在诊治理念、方式和策略等方面发生了重要变革,对其诊断和治疗的诸多方面产生了深远影响。基于此,2020年底中华医学会外科学分会胰腺外科学组牵头,在《重症急性胰腺炎诊治指南（2007）》和《急性胰腺炎诊治指南（2014）》的基础上,更新并制定了《急性胰腺炎诊治指南（2021）》。新版指南采用以问题为导向的表述方式,重点阐释了AP的诊断与分类标准,AP早期的液体治疗、镇痛与营养支持治疗及后期感染性并发症的处理,同时提出了AP的随访策略。     

腹腔镜技术在普通外科急腹症及腹部外伤诊治中的应用体会

目的:探讨腹腔镜技术在普通外科急腹症及腹部外伤诊治中的临床效果及应用价值。方法:回顾分析2008年10月至2013年10月应用腹腔镜技术诊治248例普通外科急腹症及腹部外伤患者的临床资料。结果:248例均在腹腔镜探查下明确诊断,211例成功完成腹腔镜手术,37例(14.92%)中转开腹;发现术前误诊11例、腹腔无明显病变及脏器损伤5例,共16例(占6.45%)。死亡2例。结论:腹腔镜技术诊治急腹症及腹部外伤具有独特优点,在快速明确诊断减少误诊的同时可一并于镜下进行治疗;镜下不能处理的患者也可为开腹手术提供合理方案及路径,是积极、微创、安全的诊治方法,患者创伤小、痛苦轻、康复快,值得推广应用尤其基层医院。     

胃肠道创伤303例临床分析

目的探讨胃肠道创伤的发生特点及其临床表现、诊治方法。方法回顾分析303例胃肠道创伤患者临床资料,其中227例(74.9%)合并腹部其他脏器或血管损伤。行破裂口缝合修补术213例(70.3%)、空腔脏器部分切除吻合术35例(11.6%),余保守治疗,对合并伤均作相应处理。结果本组男女伤员比例为9.6∶1;平均年龄28.2岁;以工人为主。主要致伤原因为锐器切割、交通事故及钝性击打,合计占67%。治愈294例(97%),余9例死于失血性休克或多器官功能障碍综合征。结论准确全面的早期诊断、正确处理胃肠道破裂、重要脏器合并伤以及MODS是腹部创伤诊治过程中的重要内容。男性青壮年工人是胃肠道创伤的高危人群,对其进行健康教育、提高基层医院诊治水平有望降低此病的社会危害。     

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胰腺外科在腹部外科中是一个新兴的学科 ,近 2 0年来胰腺外科疾病的诊治水平 ,有了长足的发展 ,在大的医疗中心有专门的胰腺外科 ,甚至有急性胰腺炎及胰腺癌诊治中心。但在市级以下基层医院 ,仍属于普通 (腹部 )外科 ,胰腺外科疾病的诊断与治疗水平亟待提高。在临床上常遇到由于对诊断、手术时机、术式选择不当或术后出现并发症 ,在短期内再次手术。由于胰腺外科疾病种类繁多 ,术式多样 ,难以作全面概述 ,本文仅从临床上常遇到的情况 ,结合自己的体会 ,作一简要介绍。1　胰腺囊性肿块诊治中值得注意的问题　　胰腺囊性病变包括先天性胰腺囊…     

急性胰腺炎217例病因与临床诊治分析

目的 探讨急性胰腺炎(acute pancreatitis,AP)的病因、临床特点和诊治经验.方法 回顾性分析2005年1月至2010年12月217例AP患者的临床资料.结果 217例AP占同期收治外科急腹症的10.6％,其中男性占60.4％,女性占39.6％.平均年龄52.5岁.发病原因以胆源性、高脂血症、创伤性这三者多见.164例(75.6％)为轻症AP,53例(24.4％)为重症AP.151例69.6％)行手术或内镜治疗,66例(30.4％)行非手术治疗.治愈或好转203例(93.5％),53例重症AP共死亡14例(26.4％).结论 明确AP发作的病因并针对其病因、分型采取有效的治疗是减少并发症、提高治愈率的关键.     

基层医院成人创伤性脾破裂341例诊治体会

目的 提高基层医院对脾破裂的诊治水平.方法 对2000年1月至2013年12月本院收治的341例创伤性脾破裂患者诊治情况进行回顾性分析.结果 根据外伤史、查体、诊断性腹腔穿刺和B超、CT等检查,诊断正确率为96.77％.非手术治疗成功42例;手术治疗299例,10例死亡,其余痊愈出院.结论 基层医院处理创伤性脾破裂,应详细询问外伤史,仔细进行体格检查,对诊断不明仍疑有脾破裂者,要密切注意病情变化,减少漏诊;可适当选择非手术治疗,但应严格掌握其适应证,对手术病例根据医院自身技术条件坚持“抢救生命第一”的基本原则,不盲目施行保脾手术.     

Diagnosis,severity stratification and management of adult acute pancreatitis–current evidence and controversies

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.     

32例老年急性胰腺炎临床特点分析

目的 总结诊治老年人急性胰腺炎的临床经验,以提高对老年人急性胰腺炎的认识和重视.方法 回顾性分析近10年来收治的急性胰腺炎中60岁以上的患者32例临床资料.结果 32例中发病原因胆道疾病有22例,高脂血症5例,酒精性3例,不明原因2例.轻症20例,重症12例,重症占37.5％.全组死亡率6.25％,重症急性胰腺炎死亡率...     

玫瑰痤疮诊断与治疗的研究进展

玫瑰痤疮好发于面中部的慢性炎症性皮肤病，临床上较为常见，但治疗方法有限，且治疗效果 不理想。目前西医对该疾病的认识仍不完善，病因病机也尚未明确，中医对该病诊治各有见解，中医治疗 有一定临床疗效，但治疗思路各异，未形成规范治疗系统，且长期疗效及安全性无法确定。本综述主要总 结了玫瑰痤疮的临床表现、发病机制、西医治疗现状、古代中医对玫瑰痤疮病因病机的认识及近现代中医 治疗现状，以期为临床玫瑰痤疮诊治提供系统、全面的诊疗资料。     

Potential harmful effect of iodinated intravenous contrast medium on the clinical course of mild acute pancreatitis

HYPOTHESIS: A worse clinical outcome might be expected in patients with acute pancreatitis (AP) who receive intravenous contrast medium for a nondynamic contrast-enhanced computed tomographic (CECT) study early during hospital admission. DESIGN: Cohort analytic study. SETTING: Tertiary care center. PATIENTS: Of 126 patients with mild AP, 52 patients underwent CECT to establish AP diagnosis (group 1), and the remaining 74 did not (group 2). MAIN OUTCOME MEASURES: Survival and development of local or systemic complications during the hospital stay. Potential confounders were demographic, clinical, and biochemical data, as well as therapeutic measures. The Atlanta classification was used to define local and systemic complications. RESULTS: Mean age, etiology of AP, prognostic score on admission, and pharmacologic treatment were similar between groups. Local and systemic complications were more frequently observed in patients who underwent CECT (odds ratio, 11.4; 95% confidence interval, 2.0-64.8; P =.008). Six patients, all in group 1, developed a pancreatic abscess (odds ratio, 20.8; P =.004). In 5 of them, a second CECT showed more severe AP changes. The association between CECT and abscess development was more apparent in patients with a body mass index of 25 or more and/or nasogastric suction. Six patients in group 1 and 1 in group 2 had systemic complications (odds ratio, 9. 5; P =.01). There were no deaths. CONCLUSIONS: The observed increased incidence of local and systemic complications in patients with mild AP who undergo CECT, particularly in those with a body mass index of 25 or more, suggests a potentially harmful effect of intravenous contrast medium. Until this issue is clarified, it seems reasonable to restrict the use of dynamic CECT to patients with severe AP, protracted clinical course, or suspected local septic complication.     

Acute pancreatitis after aortic surgery

Acute pancreatitis (AP) after aortic surgery has rarely been reported. A retrospective review of all abdominal and thoracoabdominal aortic operations complicated with AP from January 1982 to March 1992 was performed to study the presentation and outcome of this infrequently recognized complication. Thirteen cases of AP were found among 1965 abdominal aortic operations (0.7% incidence). The distribution of the original aortic operations was as follows: eight elective abdominal aortic aneurysm repairs, two aortoiliac grafts for aortoiliac occlusive disease, and three aortorenal bypasses. Two cases of pancreatitis complicated 170 thoracoabdominal aortic operations (1.2% incidence). Ten patients had mild pancreatitis, nine were discharged without any pancreatic complications after receiving supportive treatment. Five patients with severe AP died of multisystem organ failure despite aggressive surgical treatment; 4 had infected necrosis. The overall mortality was 40 per cent; severe AP resulted in a 100 per cent mortality. The diagnosis of severe AP was usually made in the second postoperative week, significantly later (P < 0.01) than for patients with mild disease. Typically, patients with mild AP presented with hyperamylasemia at a median of 5 postoperative days, and severe AP was found at reoperation or autopsy after a period of unexplained sepsis. Five patients with mild AP were found to have biliary tract stones, with one requiring endoscopic stone extraction. In conclusion, pancreatitis is an uncommon, although perhaps underreported complication. Underreporting may be due to a lack of hyperamylasemia when severe pancreatitis is diagnosed. The severe form is diagnosed late in patients with postoperative sepsis, associated with infected necrosis, and lethal. The complication may be reduced by incidental cholecystectomy for cholelithiasis.     

强脉冲光及微晶磨削治疗面部寻常性痤疮的疗效分析

目的:比较强脉冲光和微晶磨削治疗不同时期面部寻常性痤疮的临床疗效。方法:将90例痤疮患者随机分为两组:A组:48例,采用强脉冲光治疗;B组:42例,采用微晶磨削治疗。治疗时间各组分别为1个疗程,治疗后观察两组的临床疗效。结果:强脉冲光治疗针对轻中度痤疮效果明显,微晶磨削治疗针对重度尤其是脓疱性痤疮及其痤疮后留下的凹陷性瘢痕效果显著,差异有显著统计学意义。结论:不同时期的痤疮采用不同方法治疗可以取得较好的临床疗效。     

一次性切开挂线对口引流术治疗蹄铁型肛周脓肿38例

采用低位一次性切开、高位挂线加脓腔对口引流治疗蹄铁型肛周脓肿38例,一次性治愈37例,治愈率为97．3％。无肛门失禁、狭窄及畸形。该手术方法克服了分期手术疗程长、痛苦大的缺点。     

重视肠瘘的早期诊断与快速治疗

腹部外科手术后发生肠瘘，尤如大江决堤，令人见之“色变”。紧随肠瘘之后就是感染、出血和水电解质失衡。感染和出血失控又会进一步加重脏器功能损害，导致多脏器功能障碍。整个病程中患者能量与蛋白质的摄入、消化与吸收均会不同程度地受到影响，营养不良随之发生。诸多并发症相继出现并相互影响，形成恶性循环，病程迁延，最终引起一个或多个脏器功能的衰竭，导致治疗失败。     

Current status of the treatment of acute colonic diverticulitis: a systematic review

Aim This paper addresses the current status of the treatment of acute colonic diverticulitis by an evidence‐based review. Method A systematic search in PUBMED, MEDLINE, EMBASE and Google scholar on colonic diverticulitis was performed. Diagnostic tools, randomized controlled trials, non‐randomized comparative studies, observational epidemiological studies, national and international guidelines, reviews of observational studies on elective and emergency surgical treatment of diverticulitis, and studies of prognostic significance were reviewed. Criteria for eligibility of the studies were diagnosis and classification, medical treatment, inpatients and outpatients, diverticulitis in young patients, immunosuppression, recurrence, elective resection, emergency surgery, and predictive factors. Results Some 92 publications were selected for comprehensive review. The review highlighted that computed tomography is the most effective test in the diagnosis and staging of acute diverticulitis; outpatient treatment can be performed for uncomplicated diverticulitis in patients without associated comorbidities; conservative treatment is aimed at those patients with uncomplicated acute diverticulitis; elective surgery must be done on an individual basis; laparoscopic approach for elective treatment of diverticulitis is appropriate but may be technically complex; in perforated diverticulitis, resection with primary anastomosis is a safe procedure that requires experience and should take into account strict exclusion criteria. Conclusion The heterogeneity of patients with colonic diverticular disease means that both elective and urgent treatment should be tailored on an individual basis.     

穴位贴敷治疗原发性骨质疏松症的研究进展

原发性骨质疏松症是一种常见的慢性病,病发往往悄无声息,多数患者并发骨折后才能发觉。随着中医药近几十年的发展,有关防治原发性骨质疏松症的中医临床研究日趋丰富,为中医药抗骨质疏松症的疗效提供了有力证据,在内治法和外治法两个方面均取得了显著的疗效。中医外治法[1]具有见效快,副反应小等特点,且历史悠久,使用方便。本文所讨论的穴位敷贴法属于中医外治法的一种类型,随着穴位贴敷运用的发展,目前在临床上出现了各种制剂,如透皮吸收贴剂、透皮控释制剂等,其药物有效成分吸收率更高,疗效更佳,广泛运用于内科疾病如哮喘、便秘和失眠等,在防治骨质疏松方面同样具有较好的疗效,但在临床上得不到较高的重视,临床研究报道相对较少,本文参考近5年文献从中医理论出发对穴位敷贴防治骨质疏松症的机制、选穴和临床运用等方面进行归纳和总结。旨在方便为各位学者提供穴位敷贴防治方法的最新研究状况,提升对穴位敷贴法的认识,使之在临床上得到更好的运用。