后腹腔镜下胰床扩创引流术联合微创腹膜后入路胰腺坏死组织清除术治疗Ⅱ、Ⅲ型重症急性胰腺炎的体会

目的观察后腹腔镜下胰床引流术+MARPN方案治疗SAP疗效及总结经验。方法分析我科2015～2017年治疗4例SAP病人临床资料,其中2例行后腹腔镜下胰床扩创灌洗引流治疗,2例行后腹腔镜下胰床扩创行胰腺坏死组织清除+灌洗引流。结果 1例患者因术中后腹膜裂口导致气腹丧失而终止手术,其余3例患者顺利完成手术;1例术后发生胰瘘,保守治疗后形成胰腺周围假性囊肿,6个月后自行消退。结论早期后腹腔镜下胰床引流术可作为治疗重症急性胰腺炎分期微创手术的一种术式。     

经腹腔镜灌洗引流治疗早期重症急性胰腺炎的体会

目的:探讨重症急性胰腺炎(SAP)早期腹腔镜治疗的效果。方法:2001年1月至2005年1月收治SAP 15例。试用腹腔镜灌洗引流疗法治疗并观察疗效。结果:SAP的急性反应期腹腔粘连轻,腹腔积液未局限,腹腔镜引流术快捷,患者创伤小、术后康复快。结论:SAP腹腔镜手术的效果与合理手术方式、胰腺组织坏死的程度及胰管系统损伤情况密切相关,应遵循个体化原则,在熟练掌握腹腔镜操作技能的前提下开展SAP的腹腔镜手术治疗,是安全有效的。     

经腹腔镜灌洗引流治疗重症急性胰腺炎疗效分析

目的探讨经腹腔镜灌洗引流治疗重症急性胰腺炎(SAP)伴腹腔间隔室综合征(ACS)的疗效。方法应用腹腔镜微创外科技术对23例SAP的ACS病人行胃结肠韧带切开,胰腺被膜切开减压,吸尽胰周渗液及清除坏死组织,并置多管腹腔引流、灌洗。结果除1例SAP病人因术后并发多器官功能衰竭(MOF)、弥漫性血管内凝血(DIC)死亡外,其余22例均痊愈出院,随访半年无复发。结论腹腔镜灌洗引流治疗SAP的ACS方法简单、安全、有效,可以降低死亡率,减少并发症。     

腹腔镜下置管灌洗引流结合腹膜后引流在治疗重症急性胰腺炎中的应用

重症急性胰腺炎（SAP）早期出现的大量腹腔积液、多种胰渌性的有害物质以及胰腺和胰周组织的感染、坏死,对SAP的病程演变起着重要的作用。目前腹腔镜下对重症急性胰腺炎的治疗多采用腹腔镜下行腹腔灌洗、多管引流、网膜囊切开、胰包膜、胰床松解等治疗。但腹腔镜下腹腔内置管灌洗引流有时对腹膜后的脓肿引流不理想。我院自2005年1月至2007年7月共行腹腔镜下置管腹腔灌洗引流结合腹腔镜后腹膜引流治SAP3例,效果良好,现介绍如下。     

后腹腔镜技术在一例重症急性胰腺炎外科治疗中的应用

目的介绍后腹腔镜下坏死组织清除及置管引流术治疗重症急性胰腺炎（SAP）的临床经验。方法 SAP患者1例,男,26岁,术前病程4周余。参考后腹腔镜肾上腺手术方法选取体位、建立腹膜后操作空间、布置Trocar,经腹膜后行胰腺坏死组织清除、置管引流术。结果患者共行2次手术（双侧）,手术时间分别为60min、45min,术中出血量均为20ml,术后留置3根腹腔引流管。患者术后疼痛轻,恢复顺利,2次手术后住院48d。右侧术中损伤后腹膜,左侧术后并发腹膜后感染,均经保守治疗后痊愈。结论对于SAP患者来说,后腹腔镜下坏死组织清除、置管引流术是安全、可行的。该术式具有入路直接、操作简便、坏死组织清除彻底、不入腹腔、手术创伤小等优点。     

《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。     

微创技术在重症急性胰腺炎及其并发症中的应用

本文对微创技术在重症急性胰腺炎（severe acute pancreatitis，SAP）中的应用范围及其价值进行概述。强调微创技术在SAP中应用的自觉性必须更新知识、转变观念、注意科技动态的发展，更好地把最新科技成果应用于SAP的治疗中，最大限度地提高SAP的治疗效果。目前，微创技术包括腹腔镜技术、十二指肠镜技术和导管介入技术，主要用于SAP的早期，包括采用Seldinger技术，它可将导管送入接近胰腺出血坏死区域的血管内（可采用CT判断）。常用置管的血管有腹腔干及其分支、肠系膜上动脉等，通常采用持续灌注的方法。使用的药物有抑制胰酶合成和胰液分泌的药物、高效能并能通过血胰屏障的抗生素、改善微循环药物、稳定胰腺细胞膜功能和抑制各种炎症介质反应的药物。用药一般持续7～14d。治疗性十二指肠镜技术亦用于SAP早期（入院后72h），方法有内镜十二指肠括约肌切开术（endoscopic sphincterotorny，EST）、内镜鼻胆管引流术（endoscopic nasobiliary drainage，ENBD）、内支架等。腹腔镜技术则用于明确诊断，腹内高压的减压引流，必要时也可行坏死胰腺组织的清除。微创技术同样适用于治疗SAP的并发症如胰腺脓肿、胰腺假性囊肿、腹腔内大出血等。     

腹腔镜置管灌洗引流在重症急性胰腺炎早期治疗中的应用体会

目的 探讨腹腔镜下置管灌洗引流（LPLD）在重症急性胰腺炎（SAP）早期的治疗体会。方法 采用LPLD法治疗早期SAP患者28例，行胃结肠韧带切开，胰腺被膜切开减压，吸尽胰周渗液及清除坏死组织，并置多管腹腔引流、灌洗。结果 全组无死亡病例，均获治愈，随访1～28个月，无并发症发生，恢复良好。结论LPLD治疗早期SAP，方法简单、安全、有效，可以降低SAP死亡率，减少并发症，在临床上应该推广运用。     

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。     

腹腔镜干预重症急性胰腺炎感染性坏死13例

[摘 要] 目的 探讨腹腔镜下治疗重症急性胰腺炎感染性坏死的手术时机、方法及疗效。方法 回顾性分析中南大学湘雅医学院附属株洲医院肝胆外科2016年1月至2017年12月期间实施腹腔镜下坏死组织清除及引流术的13例重症急性胰腺炎合并感染的临床资料。术前通过CT明确拟引流的感染病灶及拟采用路径,敞开感染病灶,通过直视下低压间断的生理盐水冲洗感染灶,清除部分坏死组织,病灶区放置多根腹腔引流管,术后6～10 d冲洗引流,如坏死组织较多,术后1个月开始用胆道镜和（或）经皮肾镜冲洗取出其内坏死物。结果 重症急性胰腺炎感染性坏死自发病距手术干预时间平均24.5 d（14～40 d）,均在腹腔镜下完成手术,无中转开腹。术中平均出血量60 mL（40～150 mL）,平均手术时间120 min（90～180 min);术中放置引流管的数量平均为4.3根（3～6根）。术后3例患者出现B级胰瘘,无腹腔内出血及假性囊肿形成,无死亡病例,术后平均住院时间77.5 d（15～230 d）。结论对经皮穿刺置管引流效果不佳或者不宜穿刺的重症胰腺炎感染性坏死的患者,采用腹腔镜下的胰周感染清创引流术是安全、有效的。     

重症急性胰腺炎合并胰腺周围大量积液的不同处理

目的:探讨重症急性胰腺炎(SAP)合并胰腺周围大量积液不同处理方式的疗效。方法:回顾性分析2008年10月—2016年5月收治的162例SAP合并胰腺周围大量积液患者的临床资料,其中68例行保守治疗(保守治疗组),67例行超声或CT引导下经皮穿刺置管引流治疗(穿刺引流组),13例行腹腔镜手术治疗(腹腔镜组),14例行开腹手术治疗(开腹组),比较各组的相关临床指标。结果:各组一般资料具有可比性;穿刺引流组与腹腔镜组症状体征消失时间、血淀粉酶恢复正常时间均明显短于保守治疗组,保守治疗组腹腔内积液大体吸收时间、膀胱压下降时间明显晚于其余各组(均P0.05);穿刺引流组与腹腔镜组住院时间明显短于保守治疗组与开腹组,并发症发生率也明显低于保守治疗组与开腹组(均P0.05);保守治疗组的治疗有效率明显低于其余各组,再手术率明显高于其余各组(均P0.05);保守治疗组与开腹组病死率明显高于穿刺引流组与腹腔镜组(均P0.05)。结论:B超或CT引导下穿刺及腹腔镜后入路置管引流对治疗SAP合并胰腺周围大量积液疗效较好,且并发症发生率与病死率较低。     

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。     

Severe acute pancreatitis: role for laparoscopic surgery

Minimally invasive surgery is a new and promising treatment modality in the management of patients with severe acute pancreatitis (SAP). Aim of our study was the evaluation of our first experiences with laparoscopic surgery in the management of patients with SAP. METHODS: A total of 65 patients complied with Atlanta recommendations for SAP and were included into this retrospective study. Indications for laparoscopic surgery were SAP presented with intraabdominal or retroperitoneal exudates and detected by ultrasound (US) and/or contrast enhanced computer tomography (CT) scan, and the presence of acute calculous cholecystitis when 3 to 5 days of conservative treatment did not show clinical improvement and surgical treatment was considered. Patients with improvement after initial therapy received conservative therapy only. Bacteriological cultures were done for abdominal exudates and necrotic tissue obtained during surgery. RESULTS: Totally, 39 patients were operated and 26 were treated conservatively only. Laparoscopic surgery was started in 31 patients and completed in 26 patients. The overall conversion rate was 16.1 %. Laparoscopic drainage of the intraabdominal exudate was done in 26 patients including drainage of the lesser sac in five of them. Laparoscopic cholecystectomy in 25 cases and laparoscopically assisted jejunostomy in 6 cases were performed as a part of the procedure. Conventional surgery was the primary procedure in 8 patients. Peripancreatic abscess formation was observed in one case one month after laparoscopic procedure and was cured with conventional surgical drainage. Bile leakage from the cystic stump was successfully treated with endoscopic papillotomy in one case. All patients survived after laparoscopic procedures. Overall complication rate was 7.7 % and mortality reached 3.1 %. CONCLUSIONS: Laparoscopic drainage of the abdominal cavity, drainage of the lesser sac and revision of the retroperitoneal compartment can be safely carried out as an alternative to the conventional surgical approach. Laparoscopic cholecystectomy and/or jejunostomy may be additionally performed if indicated.     

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??Step by step treatment around pancreatic region with minimally invasive surgery for severe acute pancreatitis FAN Ying-fang??FANG Chi-hua??XIANG Nan??et al. Department of Hepatobiliary Surgery??Zhujiang Hospital of Southern Medical University??Guangzhou 510282??China
Corresponding author:FANG Chi-hua??E-mail??fangch_dr@126.com
Abstract Objective To investigate the clinical effect of step by step minimally invasive surgery around pancreat region for patients with severe acute pancreatitis??SAP??. Methods Thirty-six patients with SAP admitted between September 2003 and October 2009 at the Department of Hepatobiliary Surgery??Zhujiang Hospital of Southern Medical University were performed medical treatment. At the same time, patiens were also given minimally invasive treatments step by step. step1??With local anesthesia??patients were put the home-made double drainage tube in peritoneal cavity around the region of pancreas, and patiens with acute suppurative cholangitis (ASC) also performed by emergency surgery such as endoscopic sphincterotomy (EST) or endoscopic nasobiliary drainage (ENBD). Through double drainage tube, all patient’s cavity was persistently douched using 0.5% 5-FU saline solution. step2??After the symptoms of SAP was controlled, patients with biliary stone were performed by laparoscopically operations including laparoscopic cholecystectomy(LC), laparoscopic common bile duct lithotomy, EST, etc. Results All 36 SAP patients were performed with full of minimally invasive therapy successfully. Patient’s drainage fluid amylase concentration, blood amylase concentration and leukocytes were decreased significantly after one week??t=2.68, P=0.013??t=2.41, P=0.028??t=2.32, P=0.035??. The cure rate, improvement rate and mortality rate of 36 cases was 94.44%, 100% and zero respectively. Conclusion Step by step minimally invasive surgical treatment around pancreatic region for SAP have many advantages including minimally invasive, few complications and significant effect. The therapeutic schedule should have potential value for clinical application.     

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??Prevention and treatment of surgery-related complications of gastrectomy in era of minimally invasive surgery LIANG Han. Department of Gastric Cancer Surgery??Tianjin Medical University Cancer Institute & Hospital??National Clinical Research Center for Cancer??Tianjin 300060??China
Abstract In recent 20 years minimally invasive surgery has become the main direction of gastric surgery. Laparoscopic gastrectomy not only results in better cosmetic outcomes??but also reduces intraoperative blood loss??adhesion in peritoneal cavity and postoperative pain??leading to faster recovery of peristalsis and shorter hospital stay. Intraoperative bleeding is the most common complication. Postoperative delayed massive heamorrhage is the fatal complication which may cause the death of the patients. Duodenal stump leakage is one of the complication which should not be ignored and should be treated aggressively. Although the incidence of pancreatic fistula is significantly lower than that of open surgery, it should be taken seriously. The three-dimension (3D) laparoscopic system can restore the amplifying real operative field. The learning curve of the beginners by 3D laparoscopy will be shortened and the probability of bleeding during the operation will be decreased when compared with 2D laparoscopy. Robotic surgical system is a revolutionary achievement of surgery. The naked eye amplifying 3D operative field and flexible mechanical arms help the operator to reduce the surgery-related complications and achieve the aim of minimally invasive and accurate operation.     

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随着近年来微创外科的发展,重症急性胰腺炎(SAP)的治疗方式发生了很大的变化。传统开腹坏死组织清创手术由于其并发症发生率和病死率较高,促进了内镜、影像学、腹腔镜等微创技术在SAP治疗中的应用不断增加。由于缺少前瞻性随机对照研究,难以规范SAP微创治疗模式。各种微创治疗手段也还存在一定的局限性,尚不能完全替代传统开放手术。因此,目前应加强多学科协作,动态、个体化地合理选择治疗方式。     

多元化微创技术在治疗重症急性胰腺炎中的临床实践

目的重症急性胰腺炎(SAP)的治疗始终是国内外学者关注的热点话题,纵观SAP的诊治发展史,其治疗观念呈现着曲折式前进的态势。随着微创理念的发展,SAP的外科治疗方式发生了很大的变化,尤其在治疗晚期感染性胰腺坏死(IPN)时,传统的开腹清创引流术逐渐被经皮穿刺引流、内镜、腹腔镜等微创技术以及创伤递进式(step up approach)治疗策略取代,呈现多元化微创的治疗方式。故倡导微创理念是21世纪SAP外科干预的基本原则和必然趋势。     

Minimally invasive surgical approaches and management of prostate cancer

For clinically localized prostate cancer, radical prostatectomy remains the "gold standard" treatment. New forms of minimally invasive therapies are sought out by patients, however, because of the potential morbidity associated with open surgery. With quality-of-life aspects influencing patient decision making, minimally invasive therapeutic modalities have generated great interest among patients. Laparoscopic radical prostatectomy, robotic-assisted laparoscopic prostatectomy, brachytherapy, cryotherapy, and high-intensity focused ultrasound are all considered to be minimally invasive treatment options for the management of clinically localized prostate cancer.     

Videolaparoscopic Resection of Insulinomas: Experience in Two Institutions

Laparoscopic resection of islet cell tumors has been performed in some selected cases. The aim of the study was to analyze the experience of two institutions in the laparoscopic management of insulinomas. In a 4-year period, videolaparoscopic resection of sporadic insulinomas was performed in 9 patients. All patients had hypoglycemia/hyperinsulinism and a solitary tumor demonstrated by image studies. Demographics, surgical findings, results, and complications were analyzed. Mean age of the patients was 43 years. One patient was male and eight were females. One tumor was located in the head of the pancreas, 4 in the body, and 4 in the tail. Laparoscopic resection was completed in all patients. Procedures included 4 enucleations and 5 distal pancreatectomies. Pancreatic resection with splenic preservation was achieved in 4 cases. Intraoperative ultrasound was used in 7 patients. Mean size of the tumors was 1.6 cm. All patients became normoglycemic after surgery. Complications included one pancreatic fistula, one pleural effusion, and one peripancreatic fluid collection. All resolved spontaneously. In a follow-up period between 3 and 48 months no evidence of recurrence has been observed. This series supports laparoscopic resection of preoperatively localized benign solitary insulinomas. The operation provides the advantages of minimally invasive surgery and can be safely performed in most cases.