Intra-Abdominal Hypertension in Acute Pancreatitis

The incidence of intra-abdominal hypertension (IAH) in patients with severe acute pancreatitis (SAP) is approximately 60–80%. It is usually an early phenomenon, partly related to the effects of the inflammatory process, causing retroperitoneal edema, fluid collections, ascites, and ileus, and partly iatrogenic, resulting from aggressive fluid resuscitation. It also can manifest at a later stage, often associated with local pancreatic complications. IAH is associated with impaired organ dysfunction, especially of the cardiovascular, respiratory, and renal systems. Using current definitions, the incidence of the clinical manifestation, abdominal compartment syndrome (ACS), has been reported as 27% in the largest study so far. Despite several intervention options, the mortality in patients developing ACS remains high: 50–75%. Prevention with judicious use of crystalloids is important, and nonsurgical interventions, such as nasogastric decompression, short-term use of neuromuscular blockers, removal of fluid by extracorporeal techniques, and percutaneous drainage of ascites should be instituted early. The indications for surgical decompression are still not clearly defined, but undoubtedly some patients benefit from it. It can be achieved with full-thickness laparostomy (midline or transverse subcostal) or through a subcutaneous linea alba fasciotomy. Despite the improvement in physiological variables and significant decrease in IAP, the effects of surgical decompression on organ function and outcome are less clear. Because of the significant morbidity associated with surgical decompression and the management of the ensuing open abdomen, more research is needed to define better the appropriate indications and techniques for surgical intervention.     

Risk Factors and Outcome of Intra-abdominal Hypertension in Patients with Severe Acute Pancreatitis

Background  

Intra-abdominal hypertension (IAH) is common in patients with severe acute pancreatitis (SAP). The aim of the present study was to investigate the risk factors of IAH in SAP patients and assess the prognosis of SAP combined with IAH.     

重症急性胰腺炎合并深部真菌感染易感因素剖析

目的：分析重症急性胰腺炎病人并发深部真菌感染的主要易感因素,并探讨其预防措施。方法：回顾性分析１９９６年１月～１９９９年１２月我院外科收治的１１９例重症急性胰腺炎病例。结果：重症急性胰腺炎病人并发真菌感染以念珠菌为主;病情严重程度、肠外营养和肠功能障碍≥５天对并发真菌感染有重要影响;预防用药可显著降低ＩＣＵ组真菌感染的发生率。结论：在本文比较的易感因素中,病人的病情严重程度、肠外营养、肠功能障碍≥５天等易感因素对重症急性胰腺炎合并真菌感染有显著影响。     

重症急性胰腺炎并发胰腺感染的危险因素分析及防治措施

目的：分析重症急性胰腺炎患者胰腺及胰周坏死的危险因素,探讨防治措施,为临床工作提供帮助。方法：对120例重症急性胰腺炎患者采取治疗后观察患者发生感染的情况,进而对并发胰腺感染的危险因素进行分析。结果：120例重症急性胰腺炎患者中并发胰腺感染者51例,感染率为42.50%,其发生率与患者低氧血症、血淀粉酶、血钙、机械通气、APACHEⅡ评分、糖尿病史等方面有统计学意义（P＜0.05）;患者胰腺坏死组织和腹水经病原菌培养得到85株病原菌,构成比前3位的病原菌分别为阴沟肠杆菌、铜绿假单胞菌和金黄色葡萄球菌。结论：低氧血症、机械通气、APACHEⅡ评分、糖尿病史是重症急性胰腺炎患者并发胰腺感染的危险因素。     

急性重症胰腺炎并发腹腔高压的监测及护理

目的 探讨急性重症胰腺炎并发腹腔高压的监测和护理方法 .方法 对27例急性重症胰腺炎并发腹腔高压患者予观察炎症反应的程度,监测腹内压,行血流动力学、呼吸功能、肾功能、神经系统、凝血功能监护,加强胃管鼻饲生大黄液治疗护理,预防感染,加强基础护理及心理支持等措施.结果 18例痊愈出院,9例发展至腹腔室隔综合征死亡.结论 明确重症胰腺炎早期并发腹腔高压的程度,针对心肺肾胃肠神经和血流动力学等的改变,选择有效的监测和护理手段是成功抢救急性重症胰腺炎并发腹腔高压患者的重要保证.     

急性重症胰腺炎患者死亡预后因素临床分析

目的探讨影响急性重症胰腺炎预后的可能有关因素。方法回顾性分析1998年1月～2010年3月76例急性重症胰腺炎(Ranson评分≥3分,且APACHEⅡ评分≥8分)患者的临床资料。按照患者是否于入院60日内死亡分为死亡组(n=11)和存活组(n=65)。分析患者APACHEⅡ评分、Ranson评分、年龄、氧合指数、血肌酐等12项指标。结果入院60日内死亡患者共11例。与存活组相比,死亡组APACHEⅡ评分高(16.57±3.10vs12.04±2.95,t=2.859,P=0.006),Ranson评分高(4.71±0.76vs3.87±0.73,t=2.859,P=0.006),氧合指数低[(221±41)mmHgvs(285±48)mmHg,t=-3.353,P=0.002],血钙低[(1.77±0.39)mmol/Lvs(1.98±0.39)mmol/L,t=-2.187,P=0.033],血肌酐高[(103.1±24.4)μmol/Lvs(78.4±14.5)μmol/L,t=2.607,P=0.037],血糖水平高[(13.7±2.8)mmol/Lvs(11.0±1.5)mmol/L,t=2.448,P=0.047],碱剩余值低[(-1.33±2.93)mmol/Lvs(0.70±2.23)mmol/L,t=-2.149,P=0.036],血红细胞压积值低(0.35±0.04vs0.40±0.04,t=-2.957,P=0.013)。结论 APACHEⅡ评分、Ranson评分、氧合指数、血钙、血肌酐、血糖水平、碱剩余、血红细胞压积值可能是早期判断急性重症胰腺炎患者预后的指标。     

重症急性胰腺炎治疗中抗生素的合理应用

重症急性胰腺炎（SAP）是一种病情凶险、并发症多及死亡率高的常见急腹症。随着对急性胰腺炎基础理论的深入研究和临床诊治经验的积累，尤其是治疗药物的不断发展和重症监护水平的提高，SAP的早期死亡率已明显下降，但后期的胰腺和胰周感染及其并发症引起的死亡率仍高达50％以上，如何降低感染的发生已成为SAP治疗中的关键问题。     

Identification of Risk Factors for Perioperative Mortality in Acute Mesenteric Ischemia

Introduction Acute intestinal ischemia is in most cases a lethal condition with a low survival rate. Risk factors of perioperative mortality are poorly defined. The aim of this study was to define risk factors that predict an adverse outcome of acute mesenteric ischemia (AMI). Methods A total of 132 consecutive patients (73 men, 59 women), mean ± SD age 71.96 ± 13.64 years, who underwent surgery because of AMI in a university tertiary care center were evaluated over a period of 10 years. Clinical features, laboratory findings, etiologic factors, and surgical procedures were recorded and assessed as possible risk factors for perioperative mortality. Results Of 132 patients, 86 (65.2%) died during the perioperative period as a direct result of AMI. Significant univariate predictors of perioperative mortality were age (P = 0.01), cardiopathy (P = 0.002), digoxin intake (P = 0.015), shock (P = 0.01), urea plasma level (P < 0.001), creatinine (P < 0.001), potassium (P = 0.042), low pH (P = 0.015) and bicarbonate (P = 0.035); hemoglobin ≥ 2.48 mmol/L (P = 0.035); time delay to surgery (P = 0.023); colonic involvement (P < 0.001); small and large bowel involvement (P < 0.001); arterial versus venous ischemia (P = 0.007); and intestinal resection (P < 0.001). In the multivariate analysis, the variables previous cardiac illness (P = 0.045), urea plasma levels (P < 0.001), and small and large bowel involvement were identified as independent risk factors of perioperative mortality. Intestinal resection (P < 0.001) was a favorable predictor. Conclusions Age, time delay to surgery, shock, and acidosis significantly increase the risk of mortality due to AMI, whereas intestinal resection has a protective effect. However, only previous cardiac illness, acute renal failure, and large bowel ischemia have a negative effect as independent risk factors of mortality of AMI.     

内镜治疗重症急性胆源性胰腺炎的临床研究

目的探讨内镜治疗重症急性胆源性胰腺炎(severe acute biliary pancreatitis,SABP)的价值。方法36例入院确诊为SABP后急诊手术。16例合并急性胆囊炎、胆囊结石,行内镜下鼻胆管引流术(endoscopic naso-biliary drainage,ENBD);11例合并缩窄性乳头炎或胆总管结石,行内镜下乳头切开术(endoscopic sphincterotomy,EST)及ENBD;4例弓形刀及造影导管插入胆总管困难,选用针形刀行EST,并行ENBD;2例造影导管插入胆总管时,导丝反复进入胰管3次以上,用弓形刀切开十二指肠乳头括约肌后,寻找胆管开口,施行ENBD;3例行ENBD失败后改开腹手术。全组术后配合系统的内科治疗。结果ENBD成功施行33例,其中治愈29例,治愈率81%(29/36),死亡4例,病死率11%(4/36)。失败3例。术后胰周感染3例,无十二指肠乳头出血、十二指肠穿孔及胆管炎。全组住院时间15~75d,平均22d。26例成功者随访12~36个月,平均18个月,无胰腺炎症状复发。结论内镜治疗重症急性胆源性胰腺炎,配合系统的内科治疗,可明显减少患者的痛苦,...     

非胆源性重症急性胰腺炎的治疗方式选择

目的探讨非胆源性重症急性胰腺炎的治疗方式选择。方法回顾性分析2004~2010年期间我科收治的175例非胆源性重症急性胰腺炎患者的临床资料,其中157例非手术治疗,18例在非手术治疗的基础上,外科微创手术干预治疗。结果 157例非手术治疗,治愈150例(95.2%),死亡7例(4.8%),死亡原因为多器官功能衰竭;手术干预18例,治愈13例(72.2%),死亡5例(27.8%),其中3例全身感染合并胰腺坏死,2例十二指肠瘘、胰瘘、腹腔内反复出血。结论非胆源性重症急性胰腺炎以非手术综合治疗措施为基础治疗,非手术治疗无效具备手术指征时,应综合患者情况适时进行外科微创手术干预。     

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.     

Acute Renal Failure Complicating Severe Acute Pancreatitis

The records of 563 patients admitted to the hospital with diagnosis of acute pancreatitis have been studied retrospectively. The aim of the study was to investigate the prevalence of acute renal failure (ARF) in these patients, and to evaluate the most important risk factors for ARF development and mortality. The prevalence of ARF in studied population was 14%, but only 3.8% of ARF patients with acute pancreatitis had isolated renal failure. Other patients had additional failure of other organ systems, 68.4% of whom had multiorgan failure (MOF) before the onset of ARF. In only 8.9% of ARF patients was the renal system the first organ system to fail. Patients with ARF were significantly older, had more preexisting chronic diseases (including chronic renal failure), usually had MOF, and local pancreatic complications relative to these in the group with normal renal function. The development of ARF was directly influenced by severity of acute pancreatitis. The mortality rate in ARF patients was 74.7%, compared to an 7.4% mortality of patients with acute pancreatitis and normal renal function. Preexisting chronic disease, the presence of MOF and their number, local pancreatic complications, and older age of the patients increased mortality in ARF patients. The prognosis of patients with oliguric ARF requiring renal replacement therapy was extremely poor, indicating the importance of prevention of ARF in the patients with acute pancreatitis.     

Uncomplicated Acute Diverticulitis: Identifying Risk Factors for Severe Outcomes

Background

The management of uncomplicated (Modified Hinchey Classification Ia) acute diverticulitis (AD) has become increasingly conservative, with a focus on symptomatic relief and supportive management. Clear criteria for patient selection are required to implement this safely. This retrospective study aimed to identify risk factors for severe clinical course in patients with uncomplicated AD.

Materials and methods

Patients admitted to General Surgery at two New Zealand tertiary centres over a period of 18 months were included. Univariate and multivariate analyses were carried out in order to identify factors associated with a more severe clinical course. This was defined by three endpoints: need for procedural intervention, admission >7 days and 30-day readmission; these were analysed separately and as a combined outcome.

Results

Uncomplicated AD was identified in 319 patients. Fifteen patients (5%) required procedural intervention; this was associated with SIRS (OR 3.92). Twenty-two (6.9%) patients were admitted for >7 days; this was associated with patient-reported pain score >8/10 (OR 5.67). Thirty-one patients (9.8%) required readmission within 30 days; this was associated with pain score >8/10 (OR 6.08) and first episode of AD (OR 2.47). Overall, 49 patients had a severe clinical course, and associated factors were regular steroid/immunomodulator use (OR 4.34), pain score >8/10 (OR 5.9) and higher temperature (OR 1.51) and CRP ≥200 (OR 4.1).

Conclusion

SIRS, high pain score and CRP, first episode and regular steroid/immunomodulator use were identified as predictors of worse outcome in uncomplicated AD. These findings have the potential to inform prospective treatment decisions in this patient group.

     

急性重症胰腺炎四联疗法的意义

近三年收治的１６例急性重症胰腺炎采用我科制定的四联疗法无一例死亡和遗留并发症，本文总结四联疗法各自的要点，经济及作用意义，其结果表明：（１）生长抑素八伏是较强的胰腺分泌抑制剂，对迅速扭转病情，减少并发症和改善预后起重要作用；（２）ＴＰＮ除保证禁食期的营养外，还抑制胰腺外分泌；（３）手术彻底清除坏死灶及持续胰周冲洗是阻止闰情发展和防止并发症的基本措施，均应尽早手术。     

大鼠急性重症胰腺炎Bcl-2基因mRNA转录水平的实验研究

目的：研究急性重症胰腺炎（SAP）中细胞凋亡现象及Bcl-2基因对急性重症胰腺炎中细胞凋亡的影响。方法：采用大鼠胆胰管逆行注入牛磺胆酸钠的方法，制作大鼠SAP模型。对各组模型进行血淀粉酶、腹水量测定，利用原位末端标记法和琼脂糖凝胶电泳检测凋亡小体及凋亡梯形。采用定量逆转录聚合酶链式反应检测细胞凋亡调控基因Bcl-2基因mRNA转录水平。各组胰腺标本进行病理学检查。结果：各时间组血淀粉酶含量、腹水量随着时间的延长而升高。凋亡小体造模后2h组即可检出，术后4h组检出明显且数量较多，造模后16h时极少见到。造模后2h组凋亡梯形出现，造模后4h组凋亡梯形明显规整，造模后16h无梯形检出。胰腺组织Bcl-2基因mRNA表达水平于模型制作后增高，2h组达到高峰，后于8、16h组下降到正常水平。结论：大鼠急性重症胰腺炎的发病过程中，同时存在细胞坏死和凋亡两种不同的细胞死亡方式。胰腺组织中存在明显的细胞凋亡现象同时伴有凋亡梯形的出现。抑制凋亡基因Bcl-2基因mRNA表达水平发生明显的变化。细胞凋亡现象可能具有保护与加重损害的双重作用。     

Metabolic Management of Severe Acute Pancreatitis

The metabolic management of severe acute pancreatitis involves early identification of patients with severe pancreatitis, aggressive fluid resuscitation, organ support, and careful monitoring in an intensive care environment. Recent evidence has helped to define the roles of enteral feeding, prophylactic antibiotics, endoscopic retrograde cholangiopancreatography, computed tomography, and fine-needle aspiration for bacteriology. The most difficult decision in the management of these patients is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. Key metabolic events in the acinar cell, pancreas, and intestines are now being unraveled, as is the basis for the systemic manifestations and organ dysfunction associated with pancreatitis. This gives hope for the development of more specific metabolic interventions, which will likely target the maintenance of intestinal integrity and function, preservation of pancreatic microcirculation, and balanced modulation of the inflammatory response.     

Open Abdomen after Severe Acute Pancreatitis

Abstract The need for surgical decompression for abdominal compartment syndrome is becoming more frequent in patients with severe acute pancreatitis, especially in association with massive fluid resuscitation at the early stages of the disease. Decompression can be achieved with either a full-thickness laparostomy that can be performed through a vertical midline or transverse subcostal incision, or by performing a subcutaneous linea alba fasciotomy. Following a fullthickness laparostomy the open abdomen can be best managed with some form of negative abdominal pressure dressing. During dressing changes every 2–3 days, every attempt should be made to gradually close the fascial incision starting from edges, but avoiding recurrent abdominal compartment syndrome. Gradual closure is more likely to succeed in association with a negative fluid balance. Peripancreatic exploration or necrosectomy is seldom required at the initial laparostomy, unless performed for late onset abdominal compartment syndrome associated with infected peripancreatic necrosis. Primary fascial closure should always be attempted. If impossible and there is no need for subsequent abdominal re-exploration, the open wound should be covered with split-thickness skin grafting directly over the bowel loops. After a maturation period of 9–12 months definitive repair of the abdominal wall defect is performed utilizing the components separation technique, mesh repair, or a pedicular or microvascular tensor facia lata flap. Knowledge of the available decompression and reconstruction options is essential for individualized management of patients with severe acute pancreatitis and abdominal compartment syndrome. More research and comparative studies are needed to determine the most successful methods to be used.     

内给氧在重症急性胰腺炎非手术治疗中的应用

目的 观察内给氧治疗重症急性胰腺炎的临床效果.方法 对2005年2月至2009年3月期间收治的55例重症急性胰腺炎患者采用非手术治疗,在给予奥曲肽或施他宁、抗生素及基础性支持治疗的基础上,按入院时间先后分为2组,试验组(n=28)给予注射用内给氧治疗1周,对照组(n=27)未用内给氧.结果 试验组动脉血氧分压在应用内给氧治疗前为(53.8±8.1) mm Hg,治疗后为(87.9±9.5) mm Hg;血氧饱和度治疗前为(81.1±7.4)%,治疗后为(93.2±6.7)%;治愈病例中血淀粉酶降至正常的时间,试验组平均为(29.4±7.2) h,对照组平均为(162.1±46.8) h;死于急性呼吸窘迫综合征者试验组为0(0/28),对照组为14.8%(4/27);上述指标差异均有统计学意义(P＜0.05).结论 内给氧配合基础性治疗对重症急性胰腺炎有较好疗效,实用性较强.     

Causes of Death and Risk Factors for Mortality in Patients With Severe Chronic Obstructive Pulmonary Disease

ObjectiveThe objective of this study was to assess the causes of death and risk factors for mortality in a cohort of patients with severe chronic obstructive pulmonary disease (COPD).Patients and methodsWe studied 203 patients with severe COPD (forced expiratory volume in 1 second [FEV₁] <50%), who were attended in our respiratory department day hospital (2001-2006). Clinical variables were recorded on inclusion, and clinical course and causes of death were retrospectively reviewed.ResultsThe mean (SD) age of patients was 69 (8) years and the mean FEV₁ was 30.8% (8.2%). One-hundred and nine patients died (53.7%); death was attributed to respiratory causes in 72 (80.9%), with COPD exacerbation being the most frequent specific cause within this category (48.3%). During follow-up, 18.7% required admission to the intensive care unit (ICU). Survival at 1, 3, and 5 years was 80%, 53%, and 26%, respectively. The multivariate analysis showed that mortality was associated with age, stage IV classification according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), cor pulmonale, and hospital admission during the year prior to inclusion. Need for admission to the ICU during follow-up was a factor independently associated with higher mortality.ConclusionsMortality in patients with severe COPD was high and exacerbation of the disease was one of the most frequent causes of death. Age, GOLD stage, cor pulmonale, prior admission to hospital, and need for admission to the ICU during follow-up were independent predictors of mortality.