重症胰腺炎残余感染期治疗体会

重症胰腺炎按病程分为三期，病程超过2个月者为残余感染期。我院从1999年2月～2003年4月共治疗重症胰腺炎残余感染期患者16例，现将治疗体会报告如下。     

胆源性重症急性胰腺炎手术治疗时机分析

目前急性胰腺炎早期以非手术治疗为主,但是,片面强调延期手术治疗可能增加病死率,尤其对重症胰腺炎中的暴发性胆源性胰腺炎[1].对于胆源性重症急性胰腺炎只要掌握好了手术时机和指征,就可能避免因手术增加病死率的风险.对江西省永新县人民医院近10年收治的胆源性重症急性胰腺炎患者的临床资料结合文献进行同顾性总结和分析,以探讨胆源性重症胰腺炎的较好治疗方案.     

重症急性胰腺炎手术方式的演变

经过近 30年的探索 ,重症急性胰腺炎的外科治疗已经有了长足的进步 ,治疗方案的选择经历了从内外科到外科手术治疗 ,再从单一的手术治疗模式向“个体化方案”发展阶段。手术方式的演变不再是一个孤立的问题 ,它随着对重症急性胰腺炎认识的深入而逐步全面。重症急性胰腺炎的诊断、分类分级、治疗方案的完善、全病程的演变和对暴发性胰腺炎的认识 ,都无不与手术方式的演变密切相连。2 0世纪 70年代在我国 ,重症急性胰腺炎的手术治疗 ,最初主要方式是小网膜囊灌洗引流、胰包膜切开减压和三造瘘。到了 2 0世纪 80年代 ,手术方式进入了全面发展阶…     

重症急性胰腺炎的围手术期处理

近１０年来,对重症急性胰腺炎的治疗方案已达成共识,即以胰腺坏死并发感染为界限,采用手术或非手术治疗。一些非胆源性重症急性胰腺炎,如无感染,非手术治疗均能治愈。重症急性胰腺炎的围手术期处理是提高治愈率、保证手术安全及预防并发症发生的重要措施。一、重症急...     

肠外肠内营养支持疗法在重症胰腺炎治疗中的应用

肠外肠内营养支持疗法在重症胰腺炎治疗中的应用温州医学院附属第二医院外科（３２５０２７）陈荣，陈公高，李玉燕，邱金妹急性重症胰腺炎病情危重、发展迅速，少数患者发病早期即死亡，多数则因其病程长、消耗大而产生诸多并发症。根据１９８９年全国６８９例手术治疗分...     

创伤性重症急性胰腺炎早期手术与非手术治疗时机选择的临床研究

目的 探讨创伤性重症急性胰腺炎患者的手术治疗与非手术治疗疗效.方法 回顾分析36例创伤性重症急性胰腺炎患者的临床资料.结果 36例创伤性重症急性胰腺炎患者手术组21例,死亡2例,病死率为9.52%,非手术组15例,死亡5例,病死率为33.33%,非手术组病死率高于手术组,有统计学差异(P＜0.05).结论 对必须手术治疗的创伤性重症急性胰腺炎,及时手术就能够明显提高创伤性重症急性胰腺炎的治愈率.     

创伤性重症急性胰腺炎患者手术时机选择的临床研究

目的 研究创伤性重症急性胰腺炎患者手术的最佳时机。方法 选择我院2006年5月至2011年11月收治的84例创伤性重症急性胰腺炎患者,分为早期手术治疗组（36例）和个体化治疗组（48例）,对两种不同手术时机的治疗效果进行分析。结果 早期手术治疗组患者病死率为36.11%,个体化治疗组患者病死率为8.33%,差异具有统计学意义（P＜0.05）,个体化治疗组的疗效优于早期手术治疗组（P＜0.05）。 创伤性重症急性胰腺炎患者的手术时机应当按照个体化治疗方案进行,当出现腹膜刺激征、腹部移动性浊音、感染恶化加重等应及时实施手术。     

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目的　探讨胆源性重症胰腺炎手术时间。方法　对 1997年 7月至 1999年 9月收治胆源性重症胰腺炎 2 3例进行前瞻性分析 ,随机分为早期手术治疗组 10例和保守治疗组 13例。结果　入院后 1周内行急诊手术10例 (即早期手术治疗组 ) ,死亡 2例 ,治愈 8例 ,平均病程 ( 90± 12 4)d ;保守治疗组 13例 ,晚期手术 10例 (多保守治疗 2～ 3周后 ) ,死亡 1例 ,3例未行手术自动出院 ,出院后均有程度不同再次发作 ,平均病程 ( 40± 6 6 )d。结论　胆源性重症胰腺炎早期 ( 2周内 )亦可保守治疗 ,如能度过急性炎症反应期 ,保守治疗 2～ 3周后为手术最佳时期 ,可以缩短住院时间 ,减少并发症 ,降低手术死亡率。     

重症胰腺炎合并感染的诊治

重症胰腺炎合并感染是重症胰腺炎治疗过程中最为棘手的问题之一,也是导致重症胰腺炎病程迁延、并发症频发和死亡率增加的主要原因.其主要的感染类型有腹腔感染、肺部感染、血管内导管感染、肠源性感染和泌尿系感染.这些感染在重症胰腺炎的病程中可相继出现,亦可组合出现,常令临床医生顾此失彼,从而导致治疗失败,功亏一篑.因此在治疗重症胰腺炎的过程中,应据此类感染的发生、发展规律,适时采取措施,及时诊治.     

重症急性胰腺炎23例治疗体会

重症急性胰腺炎（ＳＡＰ）又称急性坏死性胰腺炎，是普外科常见的急腹症，其发病突然，病程进展迅速，死亡率高，治疗棘手，是临床上的一大难症。多年来围绕手术或非手术，手术时机和手术方式的选择讨论较激烈。为探索ＳＡＰ的治疗，我们对本院２３例ＳＡＰ患者手术和非手...     

Operative treatment of severe acute pancreatitis

Summary BACKGROUND: Operative treatment of severe acute pancreatitis is still related to high mortality rates. By avoiding early surgical intervention patient survival may be significantly improved. METHODS: Review both of the literature as well as of own results has led to a conservative approach in severe acute pancreatitis at the surgical department of the Medical University Vienna. RESULTS: Delaying surgery up to the third week after onset of disease improves patient survival significantly. Moreover, surgical control of pancreatic necrosis can be achieved by a single operation. CONCLUSIONS: The conservative approach in severe acute pancreatitis is a promising therapeutic conception. Organ failure during the early phase of disease can be successfully managed by means of intensive care treatment.      

急性胆源性胰腺炎41例外科治疗临床体会

目的探讨急性胆源性胰腺炎(acute biliary pancreatitis ABP)外科治疗的时机与方法。方法 41例ABP患者均采用外科手术治疗。结果本组41例患者均获治愈。结论对ABP的治疗应根据其病情与类型而定,对伴有胆总管下端梗阻或胆道感染的重症ABP应急诊或早期(72 h)手术,对不伴胆道完全梗阻、胆管炎的重症ABP患者,早期采取保守治疗,手术尽量延至病情稳定后。对急性水肿性ABP可经保守治疗,病情稳定后2～4周行胆道手术,但保守治疗期间若出现胆管炎、胆囊坏疽或穿孔应急诊手术。     

胆源性胰腺炎手术时机的探讨

目的探讨胆源性胰腺炎（ＧＰ）的手术时机。方法采用统计学方法分析了５３例ＧＰ的临床资料。结果早期手术组（入院４８小时内）及延期手术组（入院４８小时后）并发症发生率分别为２９．２０％和３．５０％（Ｐ＜０．０５）;死亡率分别为８．３０％和０（Ｐ＜０．０５）。ＡＰＡＣＨＥ－Ⅱ记分≤８的轻型ＧＰ死亡率与手术时机无关,但早期手术组的并发症发生率（１１．１０％）及胆总管探查率（９１．７０％）明显高于延期手术组（Ｐ＜０．０５）。ＡＰＡＣＨＥ－Ⅱ记分＞８的重型ＧＰ并发症发生率及死亡率与手术时机有关,即早期手术组明显高于延期手术组。结论轻型ＧＰ应待急性发作缓解后延期手术;重型ＧＰ应采用延期与个体化相结合的处理原则。     

Acute pancreatitis after surgical treatment of abdominal aortic aneurysm

INTRODUCTION: Acute pancreatitis after surgical treatment of non ruptured aneurysm of abdominal aorta is a rare complication, considered to be due to pancreatic ischemia or peroperative trauma of pancreas. The aim of this study is to describe 4 new cases of this complication and to discuss its etiology. PATIENTS AND METHODS: From January 1995 to November 2000, 365 patients underwent elective surgery for a non ruptured abdominal aorta aneurysm. Four (1.1%) men, aged 66 to 79 years and operated for an aneurysm which diameter ranged from 60 to 77 mm, developed postoperative acute pancreatitis. The abdominal approach was a midline incision in 3 cases and a retroperitoneal lombotomy in one case. Superior pole of the aneurysm always adjoined or involved the right renal artery. The aortic clamping was supra-renal in 3 cases and celiac in one case. Diagnosis of acute pancreatitis was established at days 2, 4, 12, and 23 after surgery on abdominal computed tomography in 3 cases and at reoperation in one case. RESULTS: Three patients died, including 2 from early multiple organ failure and one peroperatively during surgical attempt to treat a prostheto-digestive fistula. One patient was alive and asymptomatic with a 2-years follow-up. CONCLUSION: Acute pancreatitis is a rare and serious complication after surgical treatment of abdominal aorta aneurysm. Its diagnosis is often delayed. The main etiological factor of this complication could be trauma of pancreas during supra-renal clamping through a midline incision.     

慢性胰腺炎39例外科治疗体会

目的　探讨慢性胰腺炎病人的外科治疗方法。方法　对本院 1980年 1月～ 2 0 0 0年 12月间 39例接受手术治疗的慢性胰腺炎病人的病史进行回顾性分析。结果　本组病例的病因最多为胆源性 ,其次为胰石性和酒精性。其诊断多依赖于临床表现和影像学改变。手术适应证主要是肿块性胰腺炎、胰管结石、胰腺假性囊肿、顽固性腹痛和无法排除恶性疾病者。手术方式则根据不同的分类来选择 ,不外乎胰管引流或 (和 )胰腺切除术。结论　部分严重的病人通过手术治疗可以缓解腹痛 ,提高生活质量 ,并控制胰腺内、外分泌功能的恶化     

Reduction in mortality with delayed surgical therapy of severe pancreatitis

The indications for surgery in acute pancreatitis have changed significantly in the past two decades. Medical charts of patients with acute pancreatitis treated at our institution were analyzed to assess the effects of changes in surgical treatment on patient outcomes. A total of 136 patients with radiologically defined severe pancreatitis were primarily treated or referred to our institution between 1980 and 1997. Severity of the disease (Ranson score), indications for surgical intervention, timing of surgery, and mortality rates were compared during three study periods: 1980 to 1985 (period I), 1986 to 1990 (period II), and 1991 to 1997 (period III). In period I patients underwent exploratory laparotomy if their clinical status did not improve markedly within 72 hours of admission to the hospital, whereas during period II surgery was reserved for patients who had secondary organ failure together with pancreatic necrosis seen on CT scan. During period III the aim was to operate as late as possible in the presence of pancreatic necrosis or when infected necrosis was suspected. The policy of limiting the indications for surgery resulted in a decrease in surgically treated patients from 68% to 33% (P < 0.001). Likewise, surgical intervention was performed later. In period I, 73% of operations were performed within 72 hours of admission, compared to 32% in period III (P = 0.008). The mortality rate for patients who underwent early surgery (within 72 hours) was higher than for those who underwent late surgical exploration of the abdomen (P = 0.02). Overall, the mortality rate for patients with severe pancreatitis was reduced from 39% to 12% (P = 0.003). Mortality among patients treated nonoperatively did not change significantly. The present study supports the policy of delayed surgery in severe acute pancreatitis. Early surgical intervention often results in unnecessary procedures with an increase in the number of deaths. Whenever possible, prolonged observation allows selection of patients who are likely to benefit from delayed surgery or nonoperative treatment. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (poster presentation).     

Timing of surgery for acute gallstone pancreatitis

One hundred four consecutive patients with acute gallstone pancreatitis underwent biliary surgery. The relationships between the timing of surgery, the severity of pancreatitis, and the surgical outcome were examined. Patients were divided into three groups according to the timing of surgery and into four groups according to the gross pancreatic pathologic characteristics observed at operation. Patients who underwent surgery early tended to have a higher incidence of common bile duct stones and more severe forms of pancreatitis; however, neither the timing of surgery nor the severity of pancreatitis had a significant impact on surgical outcome. Other factors, such as the level of serum amylase on admission and presence or absence of choledocholithiasis, did not significantly influence the natural history of the disease or the outcome of surgical therapy, whereas advanced age was associated with higher morbidity. Hemodynamic status and the overall condition of the patients were more important than either the timing of surgery or the gross pathologic characteristics of the pancreas in determining surgical outcome. We conclude that the timing of surgery is not a critical factor in the outcome of surgery for acute gallstone pancreatitis. Provided that the patient is stable and has no medical contraindications, surgery on the biliary tract can be performed safely at any time after initial resuscitation of the patient and confirmation of diagnosis.     

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目的探讨经皮穿刺置管引流治疗重症急性胰腺炎的价值和时机。方法回顾性分析北京协和医院2007年1月至2012年3月收治的29例重症急性胰腺炎病人(男性18例,女性11例;年龄23~79岁,平均38岁)的临床资料。所有病人接受了CT引导下经皮穿刺置管(管径大小10~18F)引流治疗。结果 29例病人中,25例(86.2%)穿刺引流治疗有效,其中有19例免于外科手术,有6例于穿刺引流后14~49d(中位时间23d)接受了外科手术治疗;4例(13.8%)引流治疗无效的病人,均死于感染和器官功能衰竭。有1例发生穿刺引流后出血。结论当保守治疗重症急性胰腺炎无效时,经皮穿刺治疗引流可以有效地控制胰腺坏死、感染引起的全身脓毒症状,为择期外科手术治疗创造条件,甚至可以免于外科手术治疗。     

微创技术在重症急性胰腺炎外科治疗中的应用——争议与共识

随着微创理念的发展,重症急性胰腺炎局部并发症的外科治疗方式发生了很大变化。传统开腹清创引流手术由于其并发症发生率和病死率较高,逐渐被经皮穿刺引流、内镜、肾镜、腹腔镜等微创技术取代。对有手术指征的重症急性胰腺炎患者,推荐采用创伤递进式治疗策略,先行经皮穿刺引流或内镜技术缓解急性感染症状,对效果不佳者可再行坏死组织清除术,提倡视频辅助、经皮肾镜、腹腔镜等微创术式,可减少危重患者外科干预后的创伤和相关并发症,对某些患者,微创治疗可能完全替代传统外科手术。     

重症胰腺炎并发胰十二指肠下动脉瘤破裂大出血

目的　提高对重症胰腺炎合并假性动脉瘤的诊治水平。方法　报告 1例重症胰腺炎并发胰十二指肠动脉瘤出血的诊治过程并文献复习。结果　该患者经受 3次腹部手术未能止血 ,用经导管动脉栓塞出血停止。结论　经导管动脉栓塞是重症胰腺炎并发假性动脉瘤出血的首选方法