手术治疗重症急性胰腺炎

目的:探讨重症急性胰腺炎的手术时机与方式,以降低病死率。方法:1990～2002年收治86例重症急性胰腺炎患者均在ICU行监护及支持治疗,对其一般状况、疾病诊断、手术经过、治疗方法和疗效进行回顾研究。结果:胰腺感染局限或脓肿形成者的手术次数及手术死亡率明显低于有感染性胰腺坏死或液体积聚立即手术者。结论:胰腺感染局限或胰腺脓肿形成时,手术治疗效果好。     

急性重症胰腺炎29例手术治疗体会

急性重症胰腺炎系指形态学上有胰腺坏死 ,临床按危险因素分类属于Ⅱ、Ⅲ级的急性胰腺炎 ,约占急性胰腺炎的 8%～ 15 %。它的特点是起病急、病情重、发展快、并发症多、死亡率高 ,是外科临床中最危重的良性疾病之一。笔者总结我院自 1994年 2月至 2 0 0 1年 10月对 2 9例急性重症胰腺炎行手术治疗 ,效果良好 ,现报告如下。1　临床资料1 1　一般资料 :本组男性 11例 ,女性 18例 ,男女比为 1∶1 6 ,年龄 2 7岁～ 76岁 ,平均 4 4 6岁 ,年龄大于 6 0岁占 16例。1 2　按病因分类 :①胆源性急性重症胰腺炎 16例 :其中胆道梗阻性 14例 ,无胆道梗阻…     

Management of severe acute pancreatitis: it's all about timing

PURPOSE OF REVIEW: This study provides an update on the treatment of severe acute pancreatitis (SAP) with emphasis on nutrition, infection-prophylaxis, biliary pancreatitis, surgical intervention and new randomized controlled trials. RECENT FINDINGS: The most relevant new insights are: (i) early enteral nutrition in SAP is not only capable of reducing infectious complications but may also reduce mortality; (ii) there is increasing evidence that antibiotic-prophylaxis is not capable of preventing infectious complications in SAP; (iii) probiotic-prophylaxis is being considered as an alternative with promising experimental results; (iv) in biliary pancreatitis, early endoscopic retrograde cholangiography with sphincterotomy (within 48 h) is beneficial in case of ampullary obstruction, although it may be withheld in the event of negative endoscopic ultrasound; (v) surgical intervention for infected (peri-)pancreatic necrosis is increasingly being postponed; (vi) minimally invasive strategies are being considered as a full alternative for necrosectomy by laparotomy in infected (peri-)pancreatic necrosis; (vii) the Atlanta classification should no longer be used to describe computed tomography findings in acute pancreatitis; and (viii) only five randomized controlled trials of patients with acute pancreatitis are currently registered in the international trial registries. SUMMARY: Timing of intervention is becoming increasingly important in SAP management.     

重症急性胰腺炎的腹腔镜治疗:手术时机及手术方式探讨

目的探讨腹腔镜治疗重症急性胰腺炎(severeacutepancreatitis,SAP)的手术时机、方法及疗效。方法腹腔镜下分离胃结肠韧带,进入网膜腔暴露胰腺,清除渗出液、浓液,通畅脓腔分隔,但不必进行彻底的胰腺坏死组织清创。网膜囊及盆腔置入灌洗管和多根引流管,术后用大量生理盐水持续灌洗引流至引出的灌洗液澄清,并急性肾功能衰竭病人同时盆腔内置入腹膜透析管行腹膜透析。选择腹腔镜手术时间为发病后18h￣26d不等。结果治愈17例,1例死于多器官功能衰竭,住院时间28￣86d,平均46d。结论采用腹腔镜治疗重症急性胰腺炎对机体的创伤打击小、干扰少,冲洗引流可靠,可有效地改善重症急性胰腺炎的预后,是现行一种安全有效的治疗方法。其手术时机、适应证的选择与传统开腹手术有所不同。     

Surgical intervention in acute pancreatitis

There is no one operative treatment for acute pancreatitis. Surgery is indicated to resolve diagnostic uncertainty and perhaps to modify the early course of gallstone pancreatitis. Peritoneal lavage is useful in reversing early-phase systemic circulatory effects mediated by toxins in the ascitic fluid, but does not modify the underlying pancreatitis. When pancreatitis progresses to pancreatic and peripancreatic necrosis, the ultimate outcome is determined by a) the amount of necrosis, b) the extent of extrapancreatic necrosis, and c) bacterial contamination of necrosis. The amount of pancreatic regional necrosis that can be safely observed for healing is unknown; large collections tend to become infected secondarily and thus should be evacuated. Computed tomographic scanning is the best current means of detecting pancreatic necrosis and abscesses. Only percutaneous aspiration can reliably differentiate sterile from infected collections. As sepsis is the most common cause of death in acute pancreatitis, adequate surgical drainage is essential, while antibiotic therapy is only adjunctive. Aggressive treatment directed at the two principal causes of death, early-phase shock and late-phase sepsis, should reduce mortality to about 1% overall and to about 5% in cases complicated by regional necrosis and sepsis.     

Acute necrotizing pancreatitis: Surgical indications and technical procedures

Necrosis of pancreatic parenchyma or extrapancreatic tissues is present in 10%-20% of patients with acute pancreatitis, defining the necrotizing presentation frequently associated with high morbidity and mortality rates. During the initial phase of acute necrotizing pancreatitis the most important pillars of medical treatment are fluid resuscitation, early enteral nutrition, endoscopic retrograde colangiopancreatography if associated cholangitis and intensive care unit support. When infection of pancreatic or extrapancreatic necrosis occurs, surgical approach constitutes the most accepted therapeutic option. In this context, we have recently assited to changes in time for surgery (delaying the indication if possible to around 4 wk to deal with “walled-off” necrosis) and type of access for necrosectomy: from a classical open approach (with closure over large-bore drains for continued postoperative lavage or semiopen techniques with scheduled relaparotomies), trends have changed to a “step-up” philosophy with initial percutaneous drainage and posterior minimally invasive or endoscopic access to the retroperitoneal cavity for necrosectomy if no improvement has been previously achieved. These approaches are progressively gaining popularity and morbidity and mortality rates have decreased significantly. Therefore, a staged, multidisciplinary, step-up approach with minimally invasive or endoscopic access for necrosectomy is widely accepted nowadays for management of pancreatic necrosis.     

重症急性胰腺炎肠内营养时机对患者预后的影响

目的探究不同时机给予重症急性胰腺炎(SAP)患者肠内营养对其预后的影响。方法选取2016年6月至2020年6月于我院消化科治疗的62例SAP患者,采取随机数字表法将其分为研究组和对照组,各31例。两组患者入院后均进行对症支持治疗,同时研究组患者入院后48 h内给予肠内营养,对照组患者入院后5 d内给予肠内营养。比较两组患者的血清炎症指标、营养指标、住院情况及并发症发生情况。结果治疗后,两组的PCT、CRP水平均降低,且研究组明显低于对照组(P<0.05)。治疗后,两组的PA、Alb水平均升高,AMS水平均降低,且研究组明显优于对照组(P<0.05)。研究组的住院时间、住ICU时间及住院费用均明显少于对照组(P<0.05)。研究组的肺功能不全、腹腔感染及多器官功能障碍的发生率明显低于对照组(P<0.05)。结论对SAP患者进行早期肠内营养支持可以更有效地促进患者机体炎症反应和营养失衡状态的改善,同时还能减少各种并发生的发生,从而促进患者早日康复。     

Aprotinin in severe acute pancreatitis

Aprotinin, a Kunitz protease inhibitor, has a wide inhibitory action with particular activity against trypsin, chymotrypsin and kallikrein, making it theoretically attractive in ameliorating the effects of acute pancreatitis. Its use in acute pancreatitis has been studied for the last 50 years with disappointing results. In this paper, we review the previous studies and argue that all the studies have not been adequately powered, have inappropriate end‐points, but most importantly have not attained adequate plasma and peritoneal levels of aprotinin to produce sufficient inhibitory activity. We hypothesise that a well‐powered study with adequate aprotinin dosing may clarify its clinical benefit in severe acute pancreatitis.     

Surgical approaches to chronic pancreatitis: indications and imaging findings

Chronic pancreatitis (CP) is an irreversible, inflammatory process characterized by progressive fibrosis of the pancreas that can result in abdominal pain, exocrine insufficiency, and diabetes. Inadequate pain relief using medical and/or endoscopic therapies is an indication for surgery. The surgical management of CP is centered around three main operations including pancreaticoduodenectomy (PD), duodenum-preserving pancreatic head resection (DPPHR) and drainage procedures, and total pancreatectomy with islet autotransplantation (TPIAT). PD is the method of choice when there is a high suspicion for malignancy. Combined drainage and resection procedures are associated with pain relief, higher quality of life, and superior short-term and long-term survival in comparison with the PD. TPIAT is a reemerging treatment that may be promising in subjects with intractable pain and impaired quality of life. Imaging examinations have an extensive role in pre-operative and post-operative evaluation of CP patients. Pre-operative advanced imaging examinations including CT and MRI can detect hallmarks of CP such as calcifications, pancreatic duct dilatation, chronic pseudocysts, focal pancreatic enlargement, and biliary ductal dilatation. Post-operative findings may include periportal hepatic edema, pneumobilia, perivascular cuffing and mild pancreatic duct dilation. Imaging can also be useful in the detection of post-operative complications including obstructions, anastomotic leaks, and vascular lesions. Imaging helps identify unique post-operative findings associated with TPIAT and may aid in predicting viability and function of the transplanted islet cells. In this review, we explore surgical indications as well as pre-operative and post-operative imaging findings associated with surgical options that are typically performed for CP patients.     

Surgical management of acute pancreatitis

Acute pancreatitis is a formidable problem that infrequently necessitates surgical intervention. Indications for operation may be divided into four main categories: (1) uncertain diagnosis, (2) deteriorating condition, (3) biliary pancreatitis, and (4) pancreatic abscess. One of the most important contributions concerning acute pancreatitis has been the development of predictive criteria that allow quantitation of the severity of disease and precise comparison of various reported series. During a 2-year period, 222 patients with acute pancreatitis were seen at our institution, and 62 of these patients (28%) underwent operation. Biliary pancreatitis accounted for 63% of our cases. The overall mortality of 24% was directly related to the severity of the pancreatitis. Cholecystectomy, during the same hospital admission, is advised for treatment of biliary pancreatitis.     

进展期急性胆囊炎的手术时机

目的探讨进展期急性胆囊炎(AAC)患者经皮经肝胆囊穿刺引流术(PTGBD)后行腹腔镜胆囊切除术(LC)的手术时机。方法回顾分析某院近3年收治的AAC患者的临床资料(共242例),其中85例患者于PTGBD后接受LC治疗,85例患者中54例患者于PTGBD后5~12 d内接受LC(平均时间7 d),为早期手术组;31例患者于66~100 d内行LC(平均时间79 d),为延期手术组。比较两组患者手术操作时间、术中出血量、中转开腹率、手术并发症发生率、人均住院日、人均住院费用、PTGBD引流管相关并发症的差异。结果早期手术组患者的手术操作时间(46.9±9.3)min较延期手术组(75.6±9.0)min短(P<0.01);早期手术组患者的术中出血量(21.1±9.3)mL较延期手术组(12.5±6.4)mL多(P<0.01);两组患者均无中转开腹情况;早期手术组患者无手术并发症,延期手术组术后胆漏1例、术后腹腔出血1例(P=0.13);早期手术组患者的人均住院日(13.6±2.7)d短于延期手术组的(16.7±2.7)d(P<0.01);早期手术组人均住院费用为(2.6±0.49)万元,明显少于延期手术组的(3.2±0.65)万元(P<0.01);早期手术组无PTGBD引流管相关并发症,延期手术组脱管3例,堵塞1例(P=0.016)。结论AAC患者PTGBD后早期行LC安全可行,符合快速康复外科理念。     

重症急性胰腺炎手术时机和手术方式的再探讨

目的 再次探讨重症急性胰腺炎（SAP）手术时机和手术方式。回顾性分析了39例SAP患者的手术时机、手术方式及病死率。结果 （1）随手术距发病时间延长，病死率逐渐降低，但无显著性差异（P〉0．05）。（2）随胰腺坏死感染程度增加、休克及MODS的再现手术病死率显著增加（P〈0．05）。（3）术式以胰腺坏死组织清除，胆囊、胃、空肠三造瘘，胰周多管引流为主。结论 SAP手术的时机是影响手术病死率的重要因素，采用综合治疗与延期手术为处理原则，取得满意疗效。术式选择应以简单有效，去除病因，清除病灶，充分引流为基本原则。