腹膜后入路经皮肾镜下感染性胰腺坏死的治疗

目的 探索采用腹膜后入路经皮肾镜治疗感染性胰腺坏死的方法并评价其疗效.方法 2008年6月至2009年8月采用经皮肾镜治疗感染性胰腺坏死6例,均先行腹膜后途径PCD治疗5～36 d,进一步行经PCD窦道的经皮肾镜坏死清除、引流治疗.结果 3例病人接受1次肾镜治疗,2例接受2次治疗,1例接受3次治疗.无手术并发症,无手术病死.1例半年后形成假性囊肿.结论 病例选择合适情况下经腹膜后途径经皮肾镜治疗感染性胰腺坏死的方法简单、创伤小、疗效较好,值得进一步深入探索.     

Percutaneous drainage and necrosectomy in the management of pancreatic necrosis

BACKGROUND: The degree of necrosis and presence of infection are the crucial determinants of the outcome in patients with pancreatic necrosis. In patients with sterile necrosis, the necrotic material can persist and subsequently results in sepsis. Some of these patients will ultimately require an operation to remove the necrotic material. Percutaneous necrosectomy has been introduced to remove this residual debris in a minimally invasive way. METHODS: We retrospectively reviewed all patients with pancreatic necrosis who had percutaneous drainage (PCD) performed. Percutaneous pancreatic necrosectomy (PCPN) was done for those patients whose necrotic cavity failed to resolve. RESULTS: Percutaneous drainage was performed in eight patients, four with evidence of infection by the positive culture in the aspirate. In three of them, the necrotic cavity completely resolved after drainage. Percutaneous necrosectomy was performed in another three patients through the tract placed by the radiologist and another one through a sinus tract after an operation. The necrotic cavity in three of them completely resolved after percutaneous necrosectomy. CONCLUSION: Those patients who had 'organized necrosis' after the acute episode of pancreatitis could receive benefit from percutaneous necrosectomy. The persistent symptoms could be alleviated after the removal of the residual necrotic material. It could also be useful after an open surgery to remove any residual devitalized tissue.     

Percutaneous direct endoscopic pancreatic necrosectomy

Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive “step-up” approach is the cornerstone of the management of infected pancreatic necrosis (IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections (PFC) (< 2-4 wk) where the wall has not formed; in PFC in paracolic gutters/pelvis; or in walled off pancreatic necrosis (WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy (PDEN). There have been technical advances in PDEN over the last two decades. An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.     

Pancreatic necrosis:Complications and changing trend of treatment

Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the "gold standard" procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical(MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.     

重症急性胰腺炎并发胰腺脓肿和胰腺坏死的外科治疗

目的：探讨重症急性胰腺炎并发感染性胰腺炎坏死（IPN）和胰腺脓肿（PA）的外科治疗。方法：12例IPN和3例PA病人均采取手术方法治疗,清除胰腺脓肿,坏死组织和胰腺周围坏死组织,并行腹腔灌洗和引流。结果：11例IPN病人和3例PA病人痊愈出院,1例IPN历经4次手术并发腰椎感染和骨质破坏,另1例IPN痊愈后1年又复发,已经2次手术,现正在恢复中,结果：IPN和PA是重症急性胰腺炎的最严重并发症,影像学检查显示胰腺或周围存在难消退的积液时,应积极行手术治疗,彻底清除感染坏死组织并加局部灌洗和引流。     

Treatment of Acute Pancreatic Pseudocysts After Severe Acute Pancreatitis

Treatment of acute pancreatic pseudocysts (APP) after an episode of severe acute pancreatitis (SAP) remains controversial. Both population heterogeneity and limited numbers of patients in most series prevent a proper analysis of therapeutic results. The study design is a case series of a large, tertiary referral hospital in the surgical treatment of patients with APP after SAP. An institutional treatment algorithm was used to triage patients with complicated APP and organ failure based on Sequential Organ Failure Assessment scores to temporizing percutaneous or endoscopic drainage to control sepsis and improve their clinical condition before definitive surgical management. Over a 10-year period of study (December 1995 to 2005), 73 patients with APP after an episode of SAP were treated, 43 patients (59%) developed complications (infection 74.4%, perforation 21%, and bleeding 4.6%) and qualified for our treatment algorithm. Percutaneous/endoscopic drainage was successful in controlling sepsis in 11 of 13 patients (85%) with severe organ failure and allowed all patients to undergo definitive surgical management. The morbidity (7 vs 44.1%, P = 0.005) and mortality rates (0 vs 19%, P = 0.04) were significantly higher in complicated vs uncomplicated APP. Acute pancreatic pseudocysts after SAP are unpredictable and have a high incidence of complications. Once complications develop, there is a significantly higher morbidity and mortality rate. In complicated APP with severe organ failure, percutaneous/endoscopic drainage is useful in controlling sepsis and allowing definitive surgical management.     

重症急性胰腺炎外科手术干预时机的探讨

目的 探讨重症急性胰腺炎(SAP)外科手术干预的时机.方法 回顾我院1998年3月～2007年12月收治的157例SAP病例,按胰腺坏死面积及是否感染分级,分别分析外科干预及保守治疗对治愈率的影响.结果 本资料显示:总手术治愈率为80.4%,总非手术治愈率为87.1%,差异无统计学意义.30%的坏死面积者,非手术疗法效佳;50%的坏死面积者,手术疗法效佳;而在30%～50%之间者,手术及非手术疗法疗效无明显差异.胰腺坏死未合并感染组,非手术疗法效佳;町疑感染组及胰腺坏死合并感染组,手术疗法效佳.结论 外科干预在治疗SAP中占有重要地位,应结合胰腺坏死面积及是否感染等具体情况选择外科手术干预的时机.     

美国胃肠病协会关于急性胰腺炎胰腺坏死处理临床实践专家共识更新解读

美国胃肠病协会（AGA）于2019年8月在Gastroenterology（《胃肠病学》）杂志上发表了针对胰腺坏死处理的临床实践专家共识的更新，归纳并总结了当前的临床证据与专家意见，旨在为胰腺坏死这一复杂临床情况的最佳干预提供指导建议。近年来，随着临床实践的不断深入，急性胰腺炎胰腺坏死的处理经历了较大的变革。从一开始的以手术为主的清创策略过渡到现阶段较为成熟的升阶梯治疗模式。针对胰腺坏死的治疗主要包含两个方面：非手术治疗和有创干预。其中，非手术治疗主要包括抗菌治疗和营养支持等。一旦坏死组织发生感染或无菌性坏死使病人产生显著临床症状，提示有强烈干预指征时，此时更多地依赖于有创干预。升阶梯治疗模式的主要内容为：以经皮引流或透壁内镜引流为首要手段，对于引流无法处理的大量固体坏死，可进行经皮微创或经内镜下坏死清除，若微创手段干预无效可进行开放手术清创。关于选择经皮微创阶梯治疗还是经内镜阶梯治疗，目前尚无研究显示两者之间对病死率等主要临床结局产生影响，不同治疗中心可根据各中心的专业特长和医疗资源，合理选择治疗方案。     

Surgical management and complex treatment of infected pancreatic necrosis: 18-year experience at a single center

Infected pancreatic necrosis (IPN), the most severe form of acute pancreatitis, is responsible for most cases of pancreatitis-related morbidity and mortality. Since 1986, 220 patients with IPN have been treated. The surgical treatment was performed on average 18.5 days (range, 8–25 days) after the onset of acute pancreatitis and consisted of wide-ranging necrosectomy, combined with widespread drainage and continuous lavage. In 108 of the 220 cases, some other surgical intervention (distal pancreatic resection, splenectomy, total pancreatectomy, cholecystectomy, colon resection, etc.) was also performed. Following surgery, the supportive therapy consisted of immunonutrition (glutamine and arginine supplementation) and modification of cytokine production with pentoxifylline and dexamethasone. Continuous lavage was applied for an average of 44.5 days (range, 21–95 days), with an average of 9.5 L (range, 5–20 L) of saline per day. The bacteriologic findings revealed mainly enteral bacteria, but Candida infection was also frequently detected (21%). Forty-eight patients (22%) had to undergo reoperation. The overall hospital mortality was 7.7% (17 patients died). In our experience, IPN responds well to adequate surgical treatment, continuous, longstanding widespread drainage and lavage, together with supportive therapy consisting of immunonutrition and modification of cytokine production, combined with adequate antibiotic and antifungal medication. Presented at the Nineteenth World Congress of International Society for Digestive Surgery, December 8–11, 2004, Yokohama, Japan.     

微创腹膜后入路胰腺坏死组织清除术治疗感染性胰腺坏死18例疗效分析

目的 观察微创腹膜后入路胰腺坏死组织清除术（MARPN）治疗感染性胰腺坏死（IPN）的临床疗效并总结经验。方法 回顾性分析2013年9月至2016年7月中南大学湘雅医院收治的18例采用MARPN治疗的IPN病人的临床资料,其中15例行经皮穿刺引流术+MARPN,3例为开放手术+MARPN。结果 18例病人胰周引流液培养结果均为多重病原菌感染。15例（83.3%）行MARPN后脓毒症完全逆转痊愈出院,1例因并发出血和肠瘘中转开放手术。术后发生胰瘘7例（38.9%）、肠瘘5例（27.8%）、出血2例（11.1%）。3例（16.7%）病人因继发出血或肠瘘,最终导致多器官功能衰竭而死亡。结论 采用以MARPN为重要方式的升阶梯或降阶梯治疗方案是治疗IPN的有效策略。     

Necrotizing pancreatitis: Indications for surgery and surgical techniques

The term, “acute pancreatitis”, covers in terms of clinical, pathological, biochemical and bacteriological data, different entities in regard to the natural course of the disease. Interstitial edematous pancreatitis and necrotizing pancreatitis are the most frequent clinical manifestations; pancreatic abscess and postacute pseudocyst are late complications, mostly of necrotizing pancreatitis, developing after 3–5 weeks. The first choice of treatment is non-surgical management, even in patients with a severe complicated course of the disease. Patients who develop surgical acute abdomen, clinical sepsis syndrome, shock syndrome, or a severe type of mechanical or adynamic ileus must be treated surgically. Patients who do not respond to maximum intensive care measures for pulmonary, renal, cardiocirculatory, and metabolic dysfunction are candidates for surgical treatment, despite the possibility of sterile necrosis causing systemic complications. Surgical treatment is indicated in patients with infected necrosis, debridement and continuous closed lavage or open packing with re-operation being the most accepted treatment protoclos. When necrosectomy/debridement plus closed postoperative lavage was employed as a standard surgical treatment, hospital mortality was less than 20% in patients with infected necrosis as well as those with sterile necrosis. In pancreatic abscess and postacute pseudocyst, the treatment of first choice is intervention via ultrasound- or CT-guided percutaneous puncture and drainage of the abscess cavity. However, the majority of patients with a pancreatic abscess, treated interventionally, are candidates for a surgical drainage procedure because the interventional drainage fails to control the sepsis rapidly.     

B 超引导下经皮穿刺置管引流治疗重症急性胰腺炎局部并发症

目的:探讨B超引导下经皮穿刺置管引流(PCD)治疗重症急性胰腺炎(SAP)局部并发症的临床价值。方法:回顾分析2006年1月—2009年10月行B超引导下PCD治疗SAP局部并发症的42例患者的临床资料,其中急性液体积聚14例,无菌性胰腺坏死12例,感染性胰腺坏死9例,包裹性坏死感染1例,胰腺脓肿4例,胰腺假性囊肿2例。并检查穿刺液是否伴感染,观察引流后临床症状、引流效果和影像学的改变。结果:42例中,14例急性液体积聚均治愈(100%),但有2例发生胰周感染,1例出现肠外瘘,无死亡;无菌性胰腺坏死12例中治愈9例(75.0%),3例发生胰腺感染并手术,死亡1例;感染性胰腺坏死9例中治愈2例(22.2%),4例引流效果差而手术,死亡2例,3例放弃治疗;包裹性坏死感染1例PCD后囊内出血急诊手术后死亡;4例胰腺脓肿治愈1例(25.0%),3例中转手术,无死亡。2例胰腺假性囊肿分别于第1,2个月后治愈拔管。结论:B超引导下PCD便捷安全,在治疗SAP不同局部并发症中有着不同的意义。对部分SAP局部并发症,B超引导下PCD可避免传统外科干预。     

NOTES and endoscopic pancreatic necrosectomy for the GI endoscopist

Endoscopists seek to conduct more aggressive surgical procedures that surpass the limitations of existing endoscopic procedures. Endoscopic pancreatic necrosectomy and natural orifice transluminal endoscopic surgery (NOTES) are typical examples of this new trend; both are performed through the gastrointestinal wall without a skin incision. Endoscopic necrosectomy is effective for managing organized pancreatic necrosis and abscesses. The necrotic tissues are removed endoscopically by directly entering the cavity of the organized pancreatic necrosis. NOTES is a possible advance over surgical intervention, as it is a less invasive, more cosmetic, and effective procedure. There are various approaches, including the esophagus, stomach, colon, and vagina; Various procedures are possible using NOTES, such as cholecystectomy, appendectomy, full-thickness stomach resection, splenectomy, gastrointestinal (GI) anastomosis, and peritoneoscopy. The requirements for NOTES include high proficiency in endoscopic techniques, including knowledge of various devices, anatomy, and surgical procedures. Since most GI endoscopists have no surgical background, to increase the usage of NOTES, GI endoscopists should form and lead teams that include various specialists. We believe that endoscopic necrosectomy and NOTES represent a major shift in the treatment paradigm because physicians can treat beyond the gastrointestinal wall and endoscopic procedures will replace surgical treatment.     

Ultrasound-guided percutaneous drainage of infected pancreatic necrosis

Background

The role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis.

Methods

The patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient.

Results

Percutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage.

Conclusions

Ultrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.     

Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess

Background/Purpose Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated. Methods After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct. Results ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far. Conclusions ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.     

The role of surgery in the management of acute pancreatitis.

Surgical intervention in acute pancreatitis may have varied goals. Early laparotomy may be required for diagnostic purposes. There is, however, no convincing evidence that attempts to reduce the morbidity of severe pancreatitis by early operative pancreatic drainage, early formal pancreatic resection, or early biliary procedures have been effective. In fact, they may be harmful. Peritoneal lavage by catheter induced under local anesthesia may ameliorate early cardiovascular and respiratory complications in some patients. Preliminary experience suggests that early operative debridement of devitalized pancreatic tissue with postoperative lavage may be helpful in selected patients. Patients with infections of devitalized pancreatic or peripancreatic tissue require operative debridement and drainage or packing. Other complications such as colonic necrosis or pseudocysts also require operative treatment. Rarely do patients require operation to relieve protracted pancreatitis. Patients with gallstone-associated pancreatitis should usually undergo surgical correction of their cholelithiasis as soon as their pancreatitis has subsided.     

Conservative treatment as an option in the management of pancreatic pseudocyst

BACKGROUND: Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Traditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience. PATIENTS AND METHODS: A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10). RESULTS: All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass. CONCLUSIONS: These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.     

Necrosectomy in acute pancreatitis

Indications for surgical intervention in necrotizing pancreatitis, and the specific technique to be employed, have been controversial. Accumulating data suggest that pancreatic debridement is not beneficial in patients with sterile pancreatic necrosis. Infected pancreatic necrosis, on the other hand, is widely accepted as an absolute indication for surgical intervention. The choice of a specific technique (conventional closed drainage, lesser sac lavage, or open packing) depends upon the extent and the location of the infected process. Open packing is superior for patients with extensive infected necrosis.     

Pancreatic abscess: 10 years experience

Background: Secondary infections of pancreatic and peripancreatic necrosis account for most of the deaths following acute pancreatitis. These infections occur in the form of ‘infected pancreatic necrosis’ and ‘pancreatic abscess’. The latter is a rare complication of acute pancreatitis in comparison with the former. Methods: Twenty‐one patients with pancreatic abscess were managed over a 10‐year period at a tertiary care centre in Northern India. The present report details the clinical profile, investigations performed and management strategy (surgery and intervention radiology) of these patients. The role of surgery and percutaneous catheter drainage (PCD) in the management of pancreatic abscess is discussed, with emphasis on the successful outcome seen in a properly selected group of patients managed by PCD. Results: Of the 21 patients, 12 were managed by percutaneous intervention, nine were managed surgically (of these, two had a prior PCD) and two patients were managed conservatively. The overall mortality was 9.5% (2/21). Thus, percutaneous management was suitable for 57% patients, was successful in 83.3%, with a mortality of 8.3%. Surgical therapy alone was offered to 33% of patients, was successful in 85.7%, with a mortality of 14.2%. Complications were seen in four of the nine patients managed by percutaneous drainage alone and eight of the nine patients managed surgically. Conclusions: Pancreatic abscess is a potentially lethal complication in patients recovering from acute pancreatitis. Early diagnosis and prompt intervention with careful selection of patients based on computed tomography imaging for surgical or percutaneous radio­logical management, is met with a successful outcome in a majority of patients. The roles of surgery and PCD are complementary.     

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.