经皮肾镜与腹腔镜手术治疗重症急性胰腺炎并感染性胰腺坏死的临床疗效比较

背景与目的:目前,外科治疗重症急性胰腺炎(SAP)合并感染性胰腺坏死(IPN)的理念已从以往的早期开腹手术向延期、微创、创伤递进式、通畅引流式的手术方式过渡。本研究按照这一新理念,比较两种微创手术方式治疗SAP合并IPN的疗效差异。方法:回顾性分析2014年1月—2019年5月收治的SAP合并IPN患者共53例患者资料,其中26例行经腹膜后入路肾镜胰周脓肿清创治疗(经皮肾镜组),27例行腹腔镜清创(腹腔镜组),比较两组患者术前一般资料、主要疗效指标以及手术前后相关感染指标的变化。结果:两组患者术前一般资料无统计学差异(均P0.05)。所有患者手术均顺利完成,经皮肾镜组中5例患者术后2周床旁局麻下二次经窦道探查清理,腹腔镜组2例中转开腹。经皮肾镜组与腹腔镜组比较,前者平均手术时间(51.8 min vs.57.4 min)、平均术中出血量(50.2 mL vs.65.8 mL)、平均术后排气时间(21.6 h vs.22.7 h)、平均术后住院时间(48.5 d vs.51.2 d)、平均住院费用(8.2万元vs.10.6万元)均明显减少(均P0.05)。两组患者术后1、7 d引流量较术前均增加,而体温、白细胞计数、降钙素原、C反应蛋白、白介素6、胰腺炎CT严重指数(CTSI)评分等感染指标均在术后不同时间点较术前下降(部分P0.05),而两组间以上指标在相同时间点无均无明显差异(均P0.05)。经皮肾镜组与腹腔镜组术后肠瘘、胰瘘、出血、肺炎、假性囊肿等并发症总发生率差异无统计学意义(34.6% vs.37%,P0.05)。结论:SAP合并IPN患者经两种手术方法治疗后,感染中毒症状均可得到改善,效果明确。与腹腔镜手术比较,经皮肾镜治疗在手术时间、出血量、术后恢复及费用方面更具优势,且不增加并发症发生率,可在临床中进一步推广应用。

Comparison of clinical efficacy between percutaneous nephroscopic and laparoscopic surgery for severe acute pancreatitis with infectious pancreatic necrosis

Background and Aims: At present, the concept of surgical treatment of severe acute pancreatitis (SAP) combined with infectious pancreatic necrosis (IPN) has gone through a transition from the previous early open surgery to the delayed surgery with minimally invasive, step-up approach and adequate drainage. According to this new concept, this study was conducted to compare the clinical efficacy of two minimally invasive surgical methods in treatment of SAP with IPN. Methods: The clinical data of 53 patients with SAP who developed IPN treated from January 2014 to May 2019 were retrospectively analyzed. Of the patients, 26 cases underwent percutaneous nephroscopic necrosectomy via retroperitoneal approach (percutaneous nephroscopic group) and 27 cases underwent laparoscopic necrosectomy (laparoscopic group). The preoperative general data, main efficacy variables and the changes in infection indexes before and after surgery were compared between the two groups of patients. Results: There were no significant differences in the general data between the two groups of patients (all P>0.05). Operations were uneventfully completed in all patients, 2 cases in percutaneous nephroscopic group underwent second sinus tract exploration and debridement 2 weeks later under bedside local anesthesia, and 2 cases in laparoscopic group were converted to open surgery. Comparison between percutaneous nephroscopic group and laparoscopic group showed that the average operative time (51.8 min vs. 57.4 min), average intraoperative blood loss (50.2 mL vs. 65.8 mL), average time to postoperative gas passage (21.6 h vs. 22.7 h), average length of postoperative hospital stay (48.5 d vs. 51.2 d), and average hospital cost (82 000 yuan vs. 106 000 yuan) were significantly decreased in the former (all P<0.05). The postoperative drainage volume of patients in both groups were increased compared with those before surgery, and the infection indexes that included the body temperature, white blood cell count, procalcitonin, C-reactive protein, interleukin-6, and score of CT severity index (CTSI) for pancreatitis were all decreased after surgery compared with those before surgery (partial P<0.05), but there were no differences in all above variables between the two groups at the same time point (all P>0.05). The incidence of total postoperative complications such as intestinal fistula, pancreatic fistula, bleeding, pneumonia and pancreatic pseudocyst showed no significant difference between percutaneous nephroscopic group and laparoscopic group (34.6% vs. 37%, P>0.05).Conclusion: The symptoms of infection and intoxication in patients with SAP and concomitant IPN can be significantly improved by the two treatment methods, and they both have demonstrable efficacy. Compared with laparoscopic surgery, percutaneous nephroscopic procedure has advantages in terms of operative time, blood loss, postoperative recovery and hospitalization cost, without increasing the incidence of complications. So, it is recommended to be used in clinical practice.