急性坏死性胰腺炎的外科干预:时机比技术更重要

目前,围绕急性坏死性胰腺炎的手术和非手术治疗、早期手术还是后期手术、微创干预还是开放手术等问题,仍在探索中不断取得进步并逐步形成共识。进一步探索清除胰腺坏死组织最佳手术时机及手术技术、实施微创与开放相结合的外科干预策略、提高针对胰腺坏死组织延期一次性手术清除的成功率,是降低急性坏死性胰腺炎后期病死率的关键。近20年来,对急性坏死性胰腺炎局部并发症病理转归多样性认识的深化,划时代改变了急性坏死性胰腺炎后期的治疗模式。从20世纪末的早期开腹手术引流减压到计划性多次手术清创,再到延期一次性手术,以及近年来探索实施的创伤递进式手术策略,随着治疗理念的变革,逐步实现了疗效的突破。相较于坏死组织的清除技术,手术时机的选择对治疗成功更具重要意义。根据现有针对急性坏死性胰腺炎循证医学研究结果,鉴于急性坏死性胰腺炎病情的复杂性、个体间的差异性、以及有限的多中心研究结果,目前尚不能确定外科技术对改善预后的优势;而手术时机的正确把握,对提高急性坏死性胰腺炎手术治疗效果的地位不容置疑。笔者回顾性分析其团队收治的1000余例外科治疗急性坏死性胰腺炎患者的临床资料,探讨针对急性坏死性胰腺炎后期局部并发症外科干预时机及技术对改善预后的临床意义。     

急性坏死性胰腺炎的外科治疗(文献综述)

近年来,对急性坏死性胰腺炎,已由单纯的胰腺引流手术转到胰腺规则性切除术以及胰腺坏死组织清除术,从而使治疗效果有了提高,并使一些过去认为无法医治的病人得到了挽救。本文的目的就是对近年来外科治疗急性坏死性胰腺炎的进展作一综述。首先,本文所指急性坏死性胰腺炎,包括急性出血性-坏死性胰腺炎和急性化脓性胰腺炎,这三种类型是同一病理变化的不同表现。其次,关于急性水肿性胰腺炎和急性坏死性胰腺炎是否同一疾病的两个阶段的问题,根据 Edelmann G.等作者的临床观察,特别是最近 Boutelier,Ph.的病理研究发现急     

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急性坏死性胰腺炎的治疗一直是个极具挑战性的难题。急性胰腺炎中20%病人为坏死性胰腺炎,坏死性胰腺炎中10%～70%会发生感染,即胰腺坏死感染(IPN)。IPN常发生在病程的第3～8周,属急性胰腺炎中期并发症,也是最严重并发症之一,常加重或导致病人的多器官功能衰竭、出血等并发症,即使接受最好的ICU治疗,不进行外科干预病死率几乎高达100%[1]。     

急性出血坏死性胰腺炎的发病机制和病理变化

急性出血坏死性胰腺炎是外科急症中凶险疾患之一,在病变早期,诊断易被忽略而延误治疗,出血坏死灶不断蔓延,毒性物质大量吸收,可导致机体多器官功能衰竭,死亡率较高。如我院近5年收治急性胰腺炎71例,其中出血坏死型有14例,占20％,死亡6例(40％)。近年来,不少学者对本病发病机制和病理     

急性感染性坏死性胰腺炎的外科治疗进展

【摘要】〓感染性坏死性胰腺炎(infected necrotizing pancreatitis, INP)是以胰腺局部炎症、感染和坏死为特征的一种常见的临床急症,它起病急、病情重、进展快,治疗时间长,花费多,病死率高。通过近十年国内外文献统计研究发现虽然近年来坏死性胰腺炎综合治疗已取得巨大进展,从最初的胰周引流到坏死部分手术切除、由传统的外科开腹胰腺坏死组织清创术进展至微创手术治疗,但是病死率仍居高不下,通过文献研究比对发现,临床上最佳治疗方案还存在争议。急性坏死性胰腺炎的非手术疗法已得到充分肯定。感染坏死性胰腺炎是目前公认的手术治疗急性胰腺炎的适应证,本文就坏死性胰腺炎的外科治疗做一综述。     

急性出血坏死性胰腺炎现代治疗的评价

急性出血坏死性胰腺炎(八HNP)外科治疗的地位现已肯定。手术时机和手术方式仍有较大的争议。分歧的焦点在于早期施行较大而规则性胰腺切除抑或延迟施行较小而限制性胰腺坏死组织清除术,以及居中的腹部拉链术和腹腔开放填塞。指出手术时机取决于对八HNP病理特征的认识和病人全身情况及腹部体征。强调根据AHNP的病理变化和病理生理改变的特点,兼顾病人的耐受性,准确地掌握手术时机,合理地选择手术方式,可望明显的改善AHNP的治疗现状。     

急性坏死性胰腺炎保守治疗成功1例临床分析及文献复习

目的 总结急性坏死性胰腺炎继发包裹性胰腺坏死的特点、诊断及治疗方法.方法 回顾性分析我院1例急性坏死性胰腺炎继发包裹性胰腺坏死的治疗经过,总结包裹性胰腺坏死的发病机制、临床特点及外科治疗并复习近期国内外相关文献.结果 该例包裹性胰腺坏死经保守治疗后自行消退.结论 部分无菌性包裹性胰腺坏死经保守治疗后可自行消退,继发感染时应微创或手术治疗.     

重症急性胰腺炎外科综合治疗的现状与思考

重症急性胰腺炎(SAP)作为一种特殊类型的外科急腹症,自从确立外科在其治疗中的主导地位的近半个世纪以来,大致经历了从早期手术引流、针对胰腺坏死感染手术到针对特殊病例早期手术等三个主要的历史阶段.在我国,自从2000年中华医学会外科学分会胰腺外科学组制定<重症急性胰腺炎诊疗草案>以来[1],已逐渐形成我国SAP综合治疗的个体化方案.现对SAP外科综合治疗的现状以及对若干相关问题的思考阐述如下.     

急性胰腺炎外科干预策略的演变与进展

急性胰腺炎是外科常见急腹症。从19世纪中期第一次被人们认识, 到目前形成以step-up升阶梯为主流的多元化微创治疗模式, 急性胰腺炎治疗的外科干预大致可分为5个阶段:探索阶段、保守治疗阶段、胰腺切除阶段、胰腺坏死组织清创引流阶段、多学科协作模式下以微创为首选的治疗阶段。急性胰腺炎外科干预策略的演变与进展, 离不开科学技术的进步、治疗理念的更新和对急性胰腺炎发病机制的深入理解。本文对每阶段急性胰腺炎治疗的外科特点进行概述, 以阐释急性胰腺炎外科治疗的发展历程, 期望对探索未来急性胰腺炎外科治疗的发展有所帮助。     

骨髓间充质干细胞对急性出血坏死性胰腺炎大鼠血清细胞因子浓度的影响

白细胞过度激活及细胞因子级联反应是引起重症急性胰腺炎(severe acute pancreatitis,SAP)全身炎症反应综合征、多器官功能衰竭以至死亡的重要原因.本文通过观察骨髓间充质干细胞(bone mesenchymal stem cells,BMSCs)对急性出血坏死性胰腺炎大鼠血清TNF-α、IL-6、IL-10浓度变化以及胰腺组织形态学改变、肺功能的影响,初步探讨BMSCs在急性出血坏死性胰腺炎炎症早期的治疗作用及机制.     

Surgery for Acute Pancreatitis

Surgery for acute pancreatitis has undergone significant changes over the last 3 decades. A better understanding of the pathophysiology has contributed to this, but the greatest driver for change has been the rise of less invasive interventions in the fields of laparoscopy, endoscopy and radiology. Surgery has a very limited role in the diagnosis of acute pancreatitis. The most common indication for intervention in acute pancreatitis is for the treatment of complications and most notably the treatment of infected walled off necrosis. Here, the step-up approach has become established, with prior drainage (either endoscopic or percutaneous) followed by delay for maturing of the wall and then debridement by endoscopic or minimally invasive surgical methods. Open surgery is only indicated when this approach fails. Other indications for surgery in acute pancreatitis are for the treatment of acute compartment syndrome, non-occlusive intestinal ischaemia and necrosis, enterocutaneous fistulae, vascular complications and pseudocyst. Surgery also has a role in the prevention of recurrent acute pancreatitis by cholecystectomy. Despite the more restricted role, surgeons have an important contribution to make in the multidisciplinary care of patients with complicated acute pancreatitis.     

《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。     

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重症急性胰腺炎(SAP)是涉及多学科、多系统的复杂疾病,关于其治疗方案多年来一直存有争论。随着重症医学及SAP发病机制研究的进展,治疗的天平不断偏向非手术治疗,越来越多的SAP病人通过非手术治疗获得痊愈。虽然如此,但在胆源性胰腺炎、暴发性胰腺炎等特定类型的胰腺炎及坏死感染、胰腺脓肿、胰腺假性囊肿、出血等并发症的治疗中,外科手术仍然有着无可替代的重要作用。把握手术的适应证及手术时机,选择合适的手术方式,对提高SAP的疗效有着重要的临床意义。     

Surgical management of severe pancreatitis including sterile necrosis

Background/Purpose: Severe pancreatitis develops in 15% to 20% of patients with acute pancreatitis, morphologically characterized by extra- and intrapancreatic necrosis and associated with single or multiple organ failure. It is well accepted that surgery is indicated in patients with infected pancreatic necrosis. However, management of sterile necrosis is still controversial. In a prospective study, we evaluated the effect of maximal intensive care unit (ICU) treatment combined with prophylactic antibiotics in patients with necrotizing pancreatitis. Methods: A total of 306 consecutive patients with acute pancreatitis were hospitalized between November 1993 and August 2001. All patients with necrotizing pancreatitis diagnosed by computed tomography received ICU treatment, including antibiotics (imipenem/cilastin). Fine-needle aspiration of pancreatic necrosis was performed in patients with clinical signs of sepsis, and necrosectomy combined with continuous postoperative lavage was indicated when bacterial testing demonstrated infection. In the presence of sterile necrosis, surgery was only performed when there was no clinical improvement despite maximal ICU treatment. Results: Necrotizing pancreatitis was found in 121 patients. Infected necrosis was verified in 41 patients (34%) at a mean of 26 days. Four percent of patients with sterile necrosis and 95% of patients with infected necrosis were operated on. The surgical procedure was successful in 83% of patients as a single intervention; relaparotomy had to be performed in only 7 patients (17%). Pancreatic abscesses were found in 7 patients; four of these were drained interventionally. The overall mortality of the patients with necrotizing pancreatitis was 9.9%. The mortality of patients with sterile and infected necrosis was 2.5% and 24%, respectively (sterile vs infected; P < 0.01). Conclusions: Due to improved intensive care treatment, including prophylactic antibiotics, surgical intervention is usually not indicated in the early course of severe acute pancreatitis. Surgery is clearly indicated in patients with proven infected necrosis. Patients with sterile necrosis should undergo surgery when there is no clinical improvement within 4 weeks of intensive care treatment. In the majority of patients a single intervention is sufficient. Reinterventions are rare and even in patients with abscess formation are not needed, because these can easily be drained interventionally. Received: March 26, 2002 / Accepted: April 15, 2002 Offprint requests to: M.W. Büchler     

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).     

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.      

感染性胰腺坏死的诊治进展

感染性胰腺坏死（IPN）是急性胰腺炎最严重的并发症之一，常引起严重的脓毒症和器官功能衰竭，甚至导致患者死亡。近年来，随着急性胰腺炎治疗理念和技术的不断进步，IPN的病死率有所下降。但IPN的诊断，尤其是早期诊断仍十分困难，IPN的干预时机、干预方式和干预策略仍有较多争议。并且，由于IPN的诊治往往涉及多学科合作，因此，统一认识、充分发挥多学科诊疗模式的优势显得十分重要。笔者通过文献复习并充分结合本单位的实践经验，就IPN的诊断、病原学变化及治疗进展等进行系统阐述。     

Early operation in acute hemorrhagic necrotizing pancreatitis]

Between 1973 and 1975, the "early" operation was carried out in 15 patients suffering from acute haemorrhagic-necrotizing pancreatitis to eliminate necrotic parts. Partially necrotizing pancreatitis was identified in 10 patients: 7 survived. All patients with total pancreatic necrosis died. Surgery consisted of digital removal of the necrosis (digitoclasia) and in left resection with adequate drainage. Patients with partially necrotizing acute pancreatitis can be saved by "early" surgery while in patients with total necrosis surgery must be undertaken even earlier, namely before fatal complications set in.     

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.