重症急性胰腺炎中西医结合诊治指南（2014年,天津）

目的：制定重症急性胰腺炎（SAP）中西医结合治疗试行指南。方法：以循证医学证据为基础,参阅国内外多项指南内容,征求专家意见和建议,制定出《重症急性胰腺炎中西医结合诊治常规》（2014年）。指南中的推荐意见依据2001年国际感染论坛（ISF）提出的Delphi分级标准,推荐级别分为A-E其中A级最高。结果：SAP是临床上常见的一类急腹症,病程通常分为三期。初始风险评估、早期的重症监护治疗对SAP患者是至关重要的,早期（12～24 h积极的静脉补液最为有利。蛋白酶抑制剂如加贝酯,生长抑素类胰酶抑制剂如善得定,抗炎剂如昔帕泛等,尽管早期研究发现有效,但随后的大样本随机研究证实其效果不理想,不推荐常规使用。SAP患者不推荐常规预防性使用抗生素,无菌性坏死的患者不推荐使用抗生素预防坏死感染的发生,胰外感染应予以抗生素治疗。SAP患者推荐肠内营养以预防感染并发症,应尽量避免单一的肠外营养,经鼻胃内营养和经鼻空肠内营养的疗效和安全性相同。合并有急性胆管炎的AP患者应在入院24 h内行内镜治疗,坏死性胆源性AP患者,为预防感染,应推迟胆囊切除术至活动性炎症缓解、液体积聚消退或稳定后实施。当患者有脓毒症症状时,细针穿刺抽吸物培养是可靠的鉴别无菌性胰腺坏死和感染性胰腺坏死的方法。无症状的假性囊肿与胰腺和/或胰外坏死,不论其大小、位置和/或范围如何,均无需干预。稳定的坏死感染患者,应延迟外科手术、放射学和/或内镜引流的实施一般应在发病后4周以后,以使坏死组织液化及坏死周围纤维囊壁形成。有症状的感染性坏死患者,坏死组织微创清除术优于开放的坏死组织清除术。中医药治疗在降低SAP肺损伤、多脏衰等并发症,缩短病程和降低病死率方面是被实践证实了的有效手段。结论：该指南是以循证医学为?     

选择性去污法治疗重症急性胰腺炎的临床对比研究

尽管外科治疗策略的改善,急性坏死性胰腺炎病人的死亡率仍高达20%～70%.胰腺坏死感染是重症急性胰腺炎(SAP)后期死亡的最重要的原因.预防性抗生素治疗的价值迄今尚未明确证实.无菌的胰腺坏死通过哪种转为感染性的尚不清楚.实验研究和临床观察表明发生细菌向胰腺移位.因主要从胰腺坏死物中分离出的G菌,属肠源性的,故细菌移位的来源可能是肠道.通过对肠内G需氧菌的腔内清除来预防细菌移位可能是一种有效的防止胰腺坏死发生感染的方法.本研究为一随机、对比的多中心临床研究,旨在评价选择性去污法是否降低有客观证据的SAP病人的死亡率.方法 作者收集于1990～1993年间住入16家医     

急性胰腺炎诊治指南(2014版)

2007年中华医学会外科学分会胰腺外科学组发表的《重症急性胰腺炎诊治指南》对我国急性胰腺炎(AP)的规范化诊断与治疗及临床疗效的改善发挥了重要作用.近年来,AP的研究取得了巨大进展,并对其诊断与治疗产生了影响.为此有必要对之进行修订,修订后的指南更名为《急性胰腺炎诊治指南(2014版)》.AP的诊断依据包括临床特征、血清胰酶浓度及CT检查表现.改良的CT严重指数评分(MCTSI)常用于AP的炎症反应及坏死程度的判断.病理分型有间质水肿型胰腺炎和坏死型胰腺炎.AP依据严重程度分为轻症急性胰腺炎(MAP)、中重症急性胰腺炎(MSAP)和重症急性胰腺炎(SAP).MSAP与SAP的主要区别在于器官衰竭持续时间不同,MSAP为短暂性(≤48 h),SAP为持续性(＞48 h).器官衰竭采用改良的Marshall评分来判断.病程分为3期.早期(急性期)为发病至2周,此期以全身炎症反应综合征(SIRS)和器官衰竭为主要表现,此期构成第1个死亡高峰.中期(演进期)为发病2周至4周,以胰周液体积聚或坏死性液体积聚为主要表现.后期(感染期)为发病4周以后,可发生胰腺及胰周坏死组织合并感染,此期构成MSAP和SAP患者的第2个死亡高峰.局部并发症分为急性胰周液体积聚(APFC)、急性坏死物积聚(ANC)、包裹性坏死(WON)及胰腺假性囊肿.病因治疗主要是胆道疾病的处理.MAP患者病情稳定后即可行胆囊切除术或胆道探查术,MSAP和SAP患者应在后期或行坏死组织清除时一并处理.早期非手术治疗重点是液体复苏及器官功能保护.MSAP和SAP患者肠道功能恢复后即行肠内营养支持治疗.对于部分易感人群选择性使用抗生素治疗.ACS的处理措施包括胃肠道减压及导泻、镇痛镇静、使用肌松剂及床边血滤减轻组织水肿,B超或CT引导下腹腔内与腹膜后引流减轻腹腔压力.外科治疗的指征主要是胰腺局部并发症继发感染或产生压迫症状.无菌性坏死积液无症状者无需手术治疗.手术治疗应遵循延期原则.感染性坏死可先行针对性抗生素治疗及B超或CT引导下经皮穿刺引流(PCD).胰腺感染性坏死的手术方式可分为PCD、内镜、微创手术(主要包括小切口手术、视频辅助手术)及开放手术(包括经腹或经腹膜后途径的胰腺坏死组织清除并置管引流).胰腺感染性坏死病情复杂多样,各种手术方式可遵循个体化原则单独或联合应用.     

《急性胰腺炎诊治指南（2014）》解读——急性胰腺炎外科诊治现状与进展

中华医学会外科学分会胰腺外科学组于2007年颁布的《重症急性胰腺炎诊治指南》对我国急性胰腺炎诊治的规范化及疗效的改善发挥了重要作用。近年来,急性胰腺炎的研究取得了巨大进展,对其诊治的很多重要方面产生了明显的影响。为此,学组对之进行了修订,修订后的指南更名为《急性胰腺炎诊治指南（2014）》。参照国际最新进展,急性胰腺炎依据严重程度分为轻症急性胰腺炎（MAP）、中重症急性胰腺炎（MSAP）和重症急性胰腺炎（SAP）。MSAP与SAP的主要区别在于器官功能衰竭持续的时间不同,MSAP为短暂性（≤48 h）,SAP为持续性（>48 h）。按照国内的临床经验,病程分为3期。早期（急性期）：发病1~2周,此期以全身炎症反应综合征（SIRS）和器官功能衰竭为主要表现,此期构成第一个死亡高峰。中期（演进期）：急性期过后,以胰周液体积聚、坏死性液体积聚或包裹性坏死为主要表现。后期（感染期）：发病4周以后,可发生胰腺及胰周坏死组织合并感染,此期构成MSAP/SAP病人的第二个死亡高峰。局部并发症包括急性胰周液体积聚（APFC）、急性坏死物积聚（ANC）、包裹性坏死（WON）及胰腺假性囊肿。外科治疗的指征主要是胰腺局部并发症继发感染或产生压迫症状。无菌性坏死积液无症状者无需手术治疗。手术治疗应遵循延期原则。感染性坏死可先行针对性抗生素治疗及B超或CT导向下经皮穿刺引流（PCD）。胰腺感染性坏死的手术方式可分为PCD、内镜、微创手术（主要包括小切口手术、视频辅助手术）及开放手术（包括经腹或经腹膜后途径的胰腺坏死组织清除并置管引流）。胰腺感染性坏死病情复杂多样,各种手术方式可遵循个体化原则单独或联合应用。     

对2013年急性胰腺炎诊治指南的理解

从1889年Fitz的系统介绍重症急性胰腺炎（SAP）到2002年国际胰腺协会（IAP）系统地提出规范化急性胰腺炎处理指南,历时113年,临床医师们先后4次认识上的升华.近十多年来,急性胰腺炎的治疗再次取得了实质性的进展.2013年,由IAP/APA（美国胰腺协会）在循证医学证据基础上,合作制定了最新版急性胰腺炎处理指南.现对新指南的理解和分析进行如下阐述.     

重症急性胰腺炎局部并发症外科干预策略

重症急性胰腺炎(SAP)病程后期以感染性胰腺坏死为主的第2次"死亡高峰"是临床治疗的重要挑战。外科医师对感染性胰腺坏死干预指征、时机、策略及方式的掌控尤为重要,对其早期预测与识别、术后管理与协作也需不断加强。目前,感染性胰腺坏死的外科干预呈现微创化、阶段化、多学科化、专业化和多元化特点,临床医师不仅应建立以疾病为中心的综合治疗体系,还应重视SAP的非感染性局部并发症,防患于未然。笔者结合临床实践,就目前SAP局部并发症外科干预的临床实践进行探讨,旨在进一步提高SAP患者后期整体治愈率。     

2013年国际胰腺病学会与美国胰腺病学会《急性胰腺炎治疗的循证性指南》解读

急性胰腺炎（AP）是世界范围内常见的需急诊入院救治的急腹症之一,其重症患者病死率高达30％,合理的诊断和治疗需要最新循证医学的证据。白2002年国际胰腺病学会（IAP）公布《IAP急性胰腺炎外科治疗指南》以来,AP的诊断和治疗有了实质性进展。2013年IAP与美国胰腺病协会（APA）根据最新循证医学证据联合制订了《急性胰腺炎治疗的循证性指南》。现就该指南的更新并对比相关指南的变化做一解读。     

重症急性胰腺炎并发感染治疗观念的更新

1889年Fitz首次对急性胰腺炎(acute pancreatitis,AP)作出较全面的阐述.一个多世纪以来,人类对重症急性胰腺炎(severe acute pancreatitis,SAP)的认识及治疗取得了巨大的进步. 2002年国际胰腺病学联合会制定的外科治疗急性胰腺炎的循证医学指导建议指出,SAP的病程大致分为两个阶段[1]:第一阶段即病程早期(发病最初14 d内),由于炎性介质的大量释放,以全身炎症反应综合征(systemic inflammatory response syndrome,SIRS)为特点[2];第二阶段即疾病发生2周以后,则以SAP并发感染相关的脓毒症为特点[3].     

早期手术治疗重症急性胰腺炎20例分析

摘要： 为探讨重症急性胰腺炎（SAP）早期手术的效果，对6年间收治的20例SAP患者，在非手术治疗24~48h仍无好转的情况下因符合手术指征而行早期手术治疗进行回顾性分析。术中吸净腹腔积液；如胰腺坏死较轻不剪开胰腺被膜，如胰腺坏死较重则剪开胰腺被膜充分松动胰床，但不作过多的胰腺及腹膜后坏死组织清除。胆源性胰腺炎加行胆囊切除加T管引流。术后保持引流通畅。结果示，本组早期手术治愈率85.0%(17/20)，死亡3例，病死率15.0%，均死于术后多脏器衰竭。手术至死亡时间分别为21，31，36d。提示积极早期手术治疗可提高SAP的治疗效果。     

微创技术联合胰周贯穿式灌洗引流治疗感染性胰腺坏死体会

目的 探讨采用微创技术联合胰周贯穿式灌洗引流方式治疗重症急性胰腺炎（SAP）并发感染性胰腺坏死的疗效。方法 回顾性分析2016 年2 月至2019 年8 月株洲中心医院6 例SAP并发感染性胰腺坏死患者的临床资料,这些患者均先实施经腹腔及腹膜后途径穿刺置管,联合经皮肾镜或胆道镜行胰周感染坏死组织清除,术后再经过胰周置管行贯穿式灌洗引流,对其临床资料进行回顾性分析。结果 6例患者术后感染均得到有效控制,无穿刺及手术并发症,平均接受经皮肾镜下胰腺坏死组织清除术1 次,胆道镜下胰腺坏死组织清除术2.3次,第一次清创术后至拔管时间平均为55 d（36～74 d）。均痊愈出院,随访半年以上无胰腺坏死感染复发,无死亡病例。结论 CT引导下经皮穿刺置管引流,肾镜、胆道镜等微创技术联合胰周贯穿式灌洗引流的方法治疗SAP并发感染性胰腺坏死疗效好且安全,可以在临床中推广应用。     

JPN Guidelines for the management of acute pancreatitis: surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.     

Management of Severe Acute Pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.     

Antibiotic prophylaxis in severe acute pancreatitis- what are the facts?

After acute pancreatitis, sepsis secondary to infected pancreatic necrosis is the main cause of late stage death. Routine prophylactic antibiotic use following a severe attack of pancreatitis has been proposed but remains contentious. Three recent randomised controlled studies compared routine antibiotic prophylaxis to no treatment. All three showed reduced sepsis rates and two showed reduced rates of pancreatic infection, but in none was there any effect on operation rate. Only one study, from Finland, has shown any effect on mortality. A feature of the use of prophylactic antibiotics in acute pancreatitis is the increased frequency of drug-resistant or unusual organisms, including fungi, cultured from pancreatic tissue removed at necrosectomy. Mortality may be increased in this group of patients. The aim of antibiotic prophylaxis is a reduced death or operation rate rather than reduced sepsis rates per se and it is possible that the use of prophylactic antibiotics in acute pancreatitis merely masks the underlying disease process without affecting the natural history. There are, thus, too many uncertainties to enable a clear recommendation on routine antibiotic prophylaxis in severe acute pancreatitis. Further well-designed, adequately powered studies are required to establish the role of antibiotic prophylaxis in severe acute pancreatitis.     

Minimally Invasive Management of Pancreatic Abscess, Pseudocyst, and Necrosis: A Systematic Review of Current Guidelines

BACKGROUND: Minimally invasive techniques have been used to manage infected pancreatic necrosis and its local complications, although there are no randomised trials to evaluate these techniques. The aims of this study were to review the scope and quality of recommendations in current clinical practice guidelines on the role of percutaneous catheter drainage and endoscopic techniques for pancreatic abscess, pseudocyst, and infected pancreatic necrosis and identify the degree of consensus between guidelines. METHODS: A MEDLINE search was performed to identify current guidelines from any professional body published in the English language. Guidelines were analysed to determine their specific recommendations for using percutaneous catheter drainage and endoscopic techniques to manage pancreatic abscess, infected pseudocyst, and infected pancreatic necrosis. RESULTS: Sixteen guidelines were reviewed. Percutaneous catheter drainage for pancreatic abscess was recommended by eight guidelines; for infected pseudocysts, one guideline did not recommend its use and six recommended its use; for infected necrosis, two guidelines did not recommend its use and four recommended its use. Endoscopic management of both pancreatic abscess and infected pseudocyst was recommended by seven guidelines; for infected necrosis, endoscopic management was recommended by ten guidelines. Ten guidelines did not include levels of evidence to support their recommendations. CONCLUSIONS: Guidelines lacked consensus in their recommendations for minimally invasive management of pancreatic abscess, infected pseudocyst, and infected necrosis, and few recommendations were graded according to the strength of the evidence. More prospective trials are needed to provide evidence where it is lacking, which should be incorporated into clinical practice guidelines.     

Multiple organ failure following severe acute pancreatitis: its clinically patterns and pathogenetic factors]

To detect the clinical course and possible pathogenetic factors of multiple organ failure (MOF) after severe acute pancreatitis (SAP), we investigated retrospectively 70 consecutive patients with SAP for a 16-year period. Two different patterns of MOF were identified: rapid-single phase MOF developed early after SAP attack, and delayed tow-phase MOF developed progressively and sequentially with a lag phase. The clinical course of MOF was characterized by a severely systemic inflammatory response. Clinical variables associated with the evolution of MOF included early circulatory shock, pancreatic sepsis and severe pancreatic necrosis, which might be the leading one. It is suggested that the generalized inflammatory response triggered by the toxic focus seems to be the final common pathway linking SAP with MOF syndrome.     

Acute necrotizing pancreatitis: can tigecycline be included in a therapeutic strategy?

Introduction

Acute necrotizing pancreatitis is a severe and life-threatening disease. Infection, which occurs in about 30% of cases, is the most feared complication. Antibiotic therapy is still discussed and there are no clear recommendation in literature. These clinical series underline the importance of having a clear antibiotic protocol, including tigecycline, in the management of acute necrotizing pancreatitis.

Clinical series

Six patients with clinical and radiological diagnosis of necrotizing acute pancreatitis are treated in Emergency Surgery Department, following a conservative management, which includes fluid resuscitation, intensive care unit and radiological monitoring, ultrasound-guided percutaneous drainage and an antibiotic treatment protocol, that includes tigecycline. No one of the six patient undergo surgery (mean hospital stay: 44 days). In a six months follow-up all patients are alive and in good clinical conditions.

Discussion

Infection is the most important factor which determinate prognosis and outcome of acute necrotizing pancreatitis. Antibiotic prophylaxis is still discussed and there are no clear antibiotic treatment guidelines in literature. Despite its side effects on pancreatic gland, tigecycline is successful in resolution of sepsis, caused by infected pancreatic necrosis.

Conclusions

Collaboration with infectivologist and a clear antibiotic protocol is fundamental to solve infected necrosis. Antibiotic treatment, set up as soon as possible, is successful in our six patients, as they recover without undergoing surgical procedures. Tigecycline offers broad coverage and efficacy against resistant pathogens for the treatment of documented pancreatic necrosis infection. However, further studies are necessary to fully understand the safety profile and efficacy of tigecycline.     

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital

Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis. Sixteen patients underwent surgery: six patients for septic abdomen, four patients for pancreatic necrosis and two patients due to abdominal compartment syndrome. Four patients had a combination of surgical procedures for pancreatic necrosis and for abdominal compartment syndrome. Overall mortality was 9.1%. Severe acute pancreatitis represents a complex pathology that requires a multidisciplinary approach. Establishing best practice treatments and evidence-based guidelines for severe acute pancreatitis may improve outcomes in low-volume hospitals.     

腹膜后入踣手术治疗胰腺坏死并感染的安全性及疗效分析

目的 探讨腹膜后入路手术治疗胰腺坏死并感染的方法、安全性及疗效.方法 分析2008年1月至2013年3月9例重症急性胰腺炎（serious acute pancreatitis,SAP）发生胰腺坏死并感染在局麻或者全麻下实施了腹膜后入路胰腺坏死组织清除引流术患者的临床资料.5例经过1次手术,4例经过2次手术;8例首次手术为双侧清除引流,1例为单侧.结果 术后患者全身中毒症状迅速缓解,无任何并发症发生,首次手术时间60～80 min,平均（73±5.7） min,随访期间8例患者症状均完全消失,无复发,1例患者于术后6周死于心肌梗塞.结论 对于重症急性胰腺炎发生胰腺坏死并感染的患者,腹膜后入路行胰腺坏死组织清除引流术是直接、安全、有效、可行的治疗方法.     

Antibiotics in trauma and orthopedic surgery -- a primer of evidence-based recommendations

Systematic reviews and meta-analyses published in recent years have allowed drafting of evidence-based guidelines for antibiotic prophylaxis in orthopedic and trauma surgery. It is important to recognize the limitations of the recommendations derived from the available body of evidence. Since some of the most relevant randomized controlled clinical trials were performed more than 20 years ago, it is sometimes difficult to apply the data to today's clinical practice. In establishing consensus guidelines, it could prove difficult to identify areas for improvement through further research and better compliance. Although recommendations for optimized treatment of orthopedic implant infections are not currently based on first-class evidence, there are very promising new concepts emerging in this field, and we are awaiting more data and decisive conclusions from larger clinical trials.     

Infectious complications in necrotizing pancreatitis

Patients with CT evidence of more than 50 % necrosis, or an increased CRP or procalcitonin are at risk of developing severe pancreatitis and septic complications and should be monitored in an intensive care unit. ERCP and sphincterotomy are indicated in patients with biliary pancreatitis and impacted gall stones, biliary sepsis, or obstructive jaundice. In septic patients with necrotizing pancreatitis, a FNA should be performed for differentiation of sterile and infected pancreatic necrosis. Adequate volume resuscitation and analgesic treatment are the most important treatment of acute pancreatitis. Antibiotic prophylaxis reduces septic complications in severe necrotizing pancreatitis and should be started early. Surgical therapy is indicated in patients with infected pancreatic necrosis. The surgical technique of choice is open necrosectomy with postoperative closed lavage of the lesser sac.