介入超声置管引流联合胆道镜清创治疗胰周脓肿

目的 探讨介入超声置管引流后联合胆道镜治疗胰周脓肿的临床效果及应用价值.方法 选取2010年1月1日至2012年12月31日在我院行介入超声置管引流联合胆道镜治疗胰周脓肿患者40例为观察组,与35例行超声引导下置管引流的对照组进行对比分析.结果 与对照组比较,介入超声置管引流联合胆道镜治疗胰周脓肿可明显缩短术后住院时间,减少MODS和脓毒症的发生率（P＜0.05）.结论 介入超声置管引流联合胆道镜治疗胰周脓肿,方法简单、安全,临床效果可靠,是治疗胰周脓肿的有效方法.     

胆道镜在胰腺周围脓肿治疗中的作用

目的拓展微创技术在胰腺周围脓肿(简称胰周脓肿)中的应用,总结胆道镜治疗胰周脓肿的经验和体会。方法回顾性分析我科2000年12月至2008年12月期间收治的36例胰周脓肿患者的临床资料,经超声介入穿刺置管,逐级扩张窦道,胆道镜清创,引流治疗,根据胰周坏死组织特点,充分利用胆道镜的灵活性,全方位多角度反复钳取、网取、负压吸引、彻底清除坏死组织和脓苔。结果全组36例施行B超介入穿刺置管引流,行单管穿刺置管3例,双管穿刺置管7例,三管穿刺置管及以上26例;胆道镜清创次数3～14次,平均5.6次。有6例患者经1～2次胆道镜清创后全身症状改善,血常规和体温恢复正常,饮食恢复,可带管出院。住院时间25～132d,平均76d。经胆道镜清创治愈33例,治愈率为91.7%(33/36);2例因胰周坏死组织范围较大,同时伴有腹腔内多处脓肿加行开腹清创引流,术后恢复较好,治愈出院;1例因并发严重多器官功能衰竭死亡。本组发生出血2例,肠外瘘3例。结论胆道镜对胰周脓肿清创方法简单、操作灵活、疗效可靠,改变了胰周脓肿只能手术引流的观点,减少了患者的创伤,实现了"微创损伤控制"的理念。     

经皮肾镜及胆道镜双镜联合及置管持续灌洗引流治疗胰周脓肿的体会

目的探讨采用经皮肾镜及胆道镜双镜联合及置管持续灌洗引流治疗重症急性胰腺炎(SAP)并发胰周脓肿的临床经验。方法对2例并发胰腺周围脓肿实施经腹腔及腹膜后途径穿刺置管,经皮肾镜联合胆道镜行胰周坏死组织清除及置管持续灌洗引流,对其临床资料进行回顾性分析。结果 2例患者均痊愈,无穿刺及手术并发症。结论经皮肾镜与胆道镜双镜联合及置管持续灌洗引流治疗SAP并发胰周脓肿的效果较好,安全、可靠,可以在临床中选择性推广应用。     

CT引导的经皮穿刺联合胆道镜治疗胰周脓肿

目的:探讨CT引导的经皮穿刺置管引流联合胆道镜治疗胰周脓肿的方法和效果。方法:5例重症胰腺炎合并胰周脓肿患者,在CT引导下行病灶穿刺引流,待窦道形成后,将窦道扩张,用胆道镜经窦道多次清除脓腔内坏死组织。结果:5例患者CT引导下穿刺置管均成功,每例患者经胆道镜脓腔清理2~6次,其中3例治愈;2例胰腺假性囊肿,经开腹行囊肿空肠吻合术治愈。无因穿刺、引流和胆道镜清理脓腔引发的并发症。结论:CT引导经皮穿刺、置管引流、窦道扩张和胆道镜清理,多种微创方法结合是治疗胰周脓的常有方法。     

胆道镜经引流窦道清创技术治疗胰周脓肿

目的评价胆道镜经引流窦道清创治疗胰周脓肿的疗效。方法2008年1月～2011年12月,对81例开腹清创引流或超声引导穿刺引流未愈的胰周脓肿,胆道镜经引流窦道进入病灶内部,以活检钳和取石网钳取脓苔及坏死脱落组织,生理盐水灌洗脓腔,反复清创和持续引流,达到治愈。结果治愈76例,治愈率93．8％。4例因CT显示坏死区域靠近肠系膜血管或脾门部位改行开腹手术,1例因并发严重多器官功能衰竭死亡。76例治愈者接受胆道镜清创2—9次,平均5．1次,第一次镜下清创至治愈拔管时间25～132d,平均37d。胆道镜清创并发出血2例,肠漏1例,保守治愈。76例治愈患者随访3～38个月,其中〉12个月39例,无病灶残余。结论胆道镜完成对胰周脓肿病灶的清创,方法简单,临床效果可靠。     

介入超声穿刺引流联合胆道镜清创:胰周坏死感染的微创化解决方案

目的 以微创技术手段建立胰周坏死感染引流和清创的一体化治疗模式,并探讨其临床应用价值.方法 2006年3月至2008年1月,共对17例患者施行介入超声穿刺引流联合胆道镜清创.其中男性13例,女性4例.采用超声引导对胰周坏死感染经皮穿刺引流;以Cook筋膜扩张器(8～30 F)对穿刺窦道由细到粗逐级扩张,并将穿刺引流管(6～8 F)更换为较大口径引流管(22～24F),改善引流效果;胆道镜经扩张成型窦道进入病灶内部,直视下完成坏死组织的清创;通过持续有效引流和反复清创促进愈合.结果 本组17例患者,15例采用此方法治愈,治愈率88.2%,2例因技术原因中转开腹手术;15例患者平均治愈时间73 d,平均住院时间57 d;并发窦道和腹腔出血各1例,消化道瘘2例,均经非手术治愈;所有患者随访至今健在,无胰周感染坏死残留或复发.结论 介入超声穿刺引流联合胆道镜清创在达到胰周坏死感染目标化治疗的同时,实现了"损伤控制"的现代外科理念.     

介入超声穿刺引流治疗胰周脓肿

目的 探讨采用介入超声技术行胰周脓肿引流的可行性.方法 回顾性分析2006年7月至2009年11月成都军区总医院收治的36例胰周脓肿患者的临床资料.结合胰周脓肿的部位、范围、形状等因素,确定穿刺点位置.根据穿刺点与靶区的空间对应关系,计算导管针进入的角度和方向,在超声引导下置入引流管引流.结果 36例患者均成功接受穿刺引流,33例治愈,治愈率为92%,平均治愈时间37 d.3例因穿刺引流效果欠佳改行开腹手术引流.3例患者并发肠外瘘,经非手术治疗痊愈.所有患者随访3～48个月,无脓肿残留或复发.2例并发1型糖尿病,1例消化不良,2例合并胆囊结石,经对症治疗痊愈.27例患者体质量较术前增加.结论 介入超声穿刺引流治疗胰周脓肿切实可行.     

介入超声穿刺引流治疗胰周脓肿

目的 探讨采用介入超声技术行胰周脓肿引流的可行性.方法 回顾性分析2006年7月至2009年11月成都军区总医院收治的36例胰周脓肿患者的临床资料.结合胰周脓肿的部位、范围、形状等因素,确定穿刺点位置.根据穿刺点与靶区的空间对应关系,计算导管针进入的角度和方向,在超声引导下置入引流管引流.结果 36例患者均成功接受穿刺引流,33例治愈,治愈率为92%,平均治愈时间37 d.3例因穿刺引流效果欠佳改行开腹手术引流.3例患者并发肠外瘘,经非手术治疗痊愈.所有患者随访3～48个月,无脓肿残留或复发.2例并发1型糖尿病,1例消化不良,2例合并胆囊结石,经对症治疗痊愈.27例患者体质量较术前增加.结论 介入超声穿刺引流治疗胰周脓肿切实可行.     

介入超声微通道引流技术在胰周脓肿治疗中应用

目的 运用超声介入技术,建立胰周脓肿的微创化治疗.方法 对36例确诊胰周脓肿患者实施B超引导经皮穿刺置管引流,分析疗效.结果 36例均成功接受穿刺引流,33例治愈,治愈率91.7%,平均治愈时间67d,其中3例并发肠外瘘,非手术治愈.另3例因穿刺引流效果欠佳改行开腹手术引流治愈.结论 介入超声穿刺引流在达成胰周脓肿治疗目的 的同时,更以一种微创手段诠释了"损伤控制"的现代外科理念.     

胰周脓肿经超声介入穿刺联合胆道镜清创治疗36例经验总结

目的 探讨胰周脓肿治疗的新方法,创建微创治疗胰周脓肿理念,提高急性胰腺炎治愈率.方法 超声介入穿刺置管于脓肿内,采用Cook筋膜扩张器逐级扩张窦道至24F,通过胆道镜在直视下清除坏死组织、脓苔、反复冲洗至脓肿治愈.结果 36例胰周脓肿经超声介入穿刺联合胆道镜清创,33例治愈,治愈率91.7%,并发出血2例,肠外瘘3例,病死1例.结论 超声介入穿刺置管联合胆道镜清创治疗胰周脓肿,减少患者创伤,降低并发症和病死率.此方法操作简单,安全可靠,并发症少,治愈率高.

Abstract：

Objective To explore a new method of parapancreatic abscess treatment and establish an idea of minimally invasive technologies for parapancreatic abscess to improve the recovery rate of acute pancreatitis. Methods The patients had experienced percutaneous puncture and placed drainage tube under the ultrasound guidance first, then the sinus tract was expanded gradually to 24F perimeter by Cook's fascia expender. Finally, the necrotic tissue and pyogenic membrane was removed and repeatedly washed under guidance of choledochoscopy. Results The recovery rate was 91.1 %(33/36). The complication incidence was 10.7% (hemorrage:2 cases, external intestinal fistula:3 cases, and fatal MOF: 1 case). Conclusions The viewpoint which parapancreatic abscess only can be cured by drainage operation can be changed by associating debridement by choledochoscope with percutaneous puncture drainage under the ultrasound guidance. It is a simple, safe and effective method. It can be used to reduce the patients' damage, complication and mortality and accomplish the idea of damage control by minimally invasive technologies.     

ERCP术后并发胰周及腹膜后脓肿的非手术处理

目的 总结ERCP术后并发胰周及腹膜后脓肿的非手术处理方法并评价其临床应用价值.方法 该组共收集2000年以来笔者遇到的5例ERCP后并发胰周及后腹膜脓肿的病人,所有病例均采用B超或CT引导下穿刺、于脓肿最低位处置人菊花头引流管引流.非手术处理还包括抗炎、抑酶药物的使用等.结果 所有病人均经引流等治疗后痊愈,引流时间在20～90 d不等,平均引流时间为52.4 d.总住院时间在35～165 d不等,平均91.8 d,无一例中转手术治疗.结论 穿刺引流术治疗ERCP术后造成的胰周脓肿或后腹膜脓肿安全有效,具有创伤小、痛苦轻、恢复快、并发症少等优点.穿刺点应尽可能选定在脓肿的最低位,可达到最佳的引流效果.     

ERCP术后并发胰周及腹膜后脓肿的非手术处理

目的 总结ERCP术后并发胰周及腹膜后脓肿的非手术处理方法并评价其临床应用价值.方法 该组共收集2000年以来笔者遇到的5例ERCP后并发胰周及后腹膜脓肿的病人,所有病例均采用B超或CT引导下穿刺、于脓肿最低位处置人菊花头引流管引流.非手术处理还包括抗炎、抑酶药物的使用等.结果 所有病人均经引流等治疗后痊愈,引流时间在20～90 d不等,平均引流时间为52.4 d.总住院时间在35～165 d不等,平均91.8 d,无一例中转手术治疗.结论 穿刺引流术治疗ERCP术后造成的胰周脓肿或后腹膜脓肿安全有效,具有创伤小、痛苦轻、恢复快、并发症少等优点.穿刺点应尽可能选定在脓肿的最低位,可达到最佳的引流效果.     

ERCP术后并发胰周及腹膜后脓肿的非手术处理

目的 总结ERCP术后并发胰周及腹膜后脓肿的非手术处理方法并评价其临床应用价值.方法 该组共收集2000年以来笔者遇到的5例ERCP后并发胰周及后腹膜脓肿的病人,所有病例均采用B超或CT引导下穿刺、于脓肿最低位处置人菊花头引流管引流.非手术处理还包括抗炎、抑酶药物的使用等.结果 所有病人均经引流等治疗后痊愈,引流时间在20～90 d不等,平均引流时间为52.4 d.总住院时间在35～165 d不等,平均91.8 d,无一例中转手术治疗.结论 穿刺引流术治疗ERCP术后造成的胰周脓肿或后腹膜脓肿安全有效,具有创伤小、痛苦轻、恢复快、并发症少等优点.穿刺点应尽可能选定在脓肿的最低位,可达到最佳的引流效果.     

Percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections

Operative drainage is the cornerstone of therapy for pancreatic abscess. Recently it has been suggested that successful percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections may serve as definitive therapy. We undertook therapeutic, computed tomography-directed percutaneous drainage in a selected group of 29 patients with infected pancreatic and peripancreatic fluid collections. Twenty-three patients (79%) were successfully treated with percutaneous drainage. Of six patients (21%) representing failures of percutaneous drainage, four died and two recovered after operative drainage. The four patients who died had a mean APACHE (acute physiology and chronic health evaluation) II score of 23 and five of Ranson's prognostic signs. Ranson's signs and APACHE II scores were predictive of success and mortality. We conclude that in selected patients, infected pancreatic and peripancreatic fluid collections can be treated definitively with therapeutic percutaneous catheter drainage. Based on this experience, recommendations regarding patient selection are included.     

腹腔镜手术治疗肝脓肿的应用体会

目的:探讨腹腔镜肝脓肿置管引流术及腹腔镜肝脓肿切开引流术的适应证、手术方法和临床应用.方法:回顾分析2000年1月至2010年6月为63例肝脓肿患者施行腹腔镜手术的临床资料,其中34例行腹腔镜肝脓肿置管引流术,29例行腹腔镜肝脓肿切开引流术.结果:63例均在腹腔镜下完成,无一例中转开腹.腹腔镜肝脓肿置管引流术手术时间平...     

Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains

We reviewed our recent experience with management of 23 consecutive patients with acute necrotizing pancreatitis. All patients had documented necrotizing pancreatitis with parenchymal or peripancreatic necrosis. Our method of treatment has evolved from our previous approach of controlled open lesser sac drainage (marsupialization) to staged necrosectomy/debridement with delayed primary closure over drains. With this latter approach, hospital mortality was 4 of 23 patients (17 per cent), but significant morbidity still occurred in 12 of 23 patients (52 per cent). However, recurrent intra-abdominal abscess before discharge occurred in only one patient. We believe that this operative approach toward the severely ill patient with acute necrotizing pancreatitis who requires operative intervention will minimize the occurrence of intra-abdominal sepsis.     

Interventional and surgical treatment of pancreatic abscess

Pancreatic abscess is one of the infectious complications of acute pancreatitis. It is a collection principally containing pus, but it may also contain variable amounts of semisolid necrotic debris. Most of these abscesses evolve from the progressive liquefaction of necrotic pancreatic and peripancreatic tissues, but some arise from infection of peripancreatic fluid or collections elsewhere in the peritoneal cavity. Included also are abscesses found after surgical débridement and drainage of pancreatic necrosis. Although open surgical treatment of infected necrosis is the established treatment of choice, percutaneous drainage of abscesses is successful in some circumstances. We used percutaneous catheter drainage in 39 patients during 1987–1995. Only 9 of 29 (31%) attempts at primary therapy were successful; 2 patients died, and 18 required subsequent surgical drainage. On the other hand, 14 of 14 patients with recurrent or residual abscesses after surgical drainage were successfully drained percutaneously. Percutaneous catheter drainage of pancreatic abscesses may be useful for initial stabilization of septic patients, drainage of further abscesses after surgical intervention (especially when access for reoperation will be difficult), associated abscesses remote from the pancreas, and selected unilocular collections at a sufficient interval after necrotizing pancreatitis to have allowed essentially complete liquefaction.