重症急性胰腺炎的外科治疗

重症急性胰腺炎 (SAP)又称为急性出血坏死性胰腺炎 ,随病因、病期的不同而治疗方法亦不同。胆源性 SAP的治疗原则是 :凡以胆道病为主并伴有梗阻者 ,或 Oddi括约肌狭窄、临床出现梗阻性黄疸时 ,应积极手术治疗 ,以解除胆道梗阻。手术方法可选择经纤维十二指肠镜下 Oddi括约肌切开取石及鼻胆管引流、胆囊切除和胆总管探查 ,T管引流 ,并可加作小网膜胰腺区引流。以胆道病为主但不伴有梗阻者 ,应先非手术治疗 ,待急性胰腺炎缓解后 2～ 3个月再作胆囊切除术。下面重点阐述非胆源性 SAP的外科治疗。1　手术方式1.1　灌洗引流术　适用于胰腺周…     

非梗阻型胆源性胰腺炎的手术时机和手术方式探讨

众所周知,对于梗阻型胆源性胰腺炎,应行急症手术,也可内镜下行乳头括约肌切开(EST),以解除胆道梗阻.但对于非梗阻型胆源性胰腺炎,其手术时机和手术方式,还存在争议.我院自1996年至2006年收治了165例非梗阻型胆源性胰腺炎,现报告如下.     

经内镜鼻胆管引流术治疗胆胰疾病64例的体会

自 1997年 7月至 2 0 0 1年 9月 ,本院共开展经内镜逆行胰胆管造影检查 (ＥＲＣＰ) 5 4 8例 ,其中因治疗急性化脓性胆管炎及非胆源性胰腺炎、预防胆道感染或防止结石嵌顿、治疗胆瘘及减黄治疗而行鼻胆管引流术 (ＥＮＢＤ) 6 4例 ,取得满意疗效。现报告如下。1　临床资料本组患者男 2 7例 ,女 37例 ,平均年龄 5 3 2 (34～78)岁。急性化脓性胆管炎 32例 ,梗阻性黄疸减黄引流 19例 ,ＥＳＴ后引流 9例 ,非胆源性胰腺炎 2例 ,胆道术后胆瘘 2例。引流管留置时间 2～ 36ｄ ,平均 4 7ｄ。2　器材与方法2 .1　器材　ＯｌｙｍｐｕｓＪＦ ＩＴ30型纤…     

思他宁联合早期内镜治疗急性胆石性胰腺炎

目的探讨应用思他宁联合早期内镜治疗急性胆石性胰腺炎(AGP)的疗效.方法应用思他宁联合早期逆行胰胆管造影术(ERCP)、经内镜鼻胆管引流(ENBD)及经内镜乳头括约肌切开(EST)治疗AGP 32例,其中轻症胰腺炎21例,重症胰腺炎11例.结果治愈30例,2例重症胰腺炎内镜治疗后转外科手术治疗,1例术后死亡.结论思他宁联合内镜治疗AGP是安全和有效的,对明确诊断AGP者应及早应用思他宁及内镜介入治疗.     

胆石性胰腺炎的一种简易临床分型法

目的 探讨胆石性胰腺炎合理的临床分型方法,以更好地指导临床选择治疗方案.方法 依据胰腺炎的病情严重程度和胆管有无梗阻,将273例胆石性胰腺炎分成4个临床类型:非梗阻性轻型(Ⅰ型)、梗阻性轻型(Ⅱ型)、梗阻性重型(Ⅲ)、非梗阻性重型(Ⅳ型);再依据胆总管内是否存在结石,将每一类型分成a、b两个亚型.然后对临床分型结果、治疗方法、预后进行分析.结果 Ⅰa型34例,Ⅰb型112例;Ⅱa型59例,Ⅱb型11例;Ⅲa型6例,Ⅲb型4例;Ⅳa型3例,Ⅳb型44例.全组总病死率为3.3%(9/273),Ⅰ型、Ⅱ型、Ⅲ型、Ⅳ型的病死率分别为0、0、10%(1/10)、17.0%(8/47),组间差别具有统计学意义(P<0.05).早期手术、传统非手术以及早期区域动脉灌注治疗Ⅳ型的病死率分别为30.8%(4/13)、25%(3/12)、4.5%(1/22),区域动脉灌注组病死率显著低于其他两组(P<0.05).结论 4型2分法是一种较为合理的胆石性胰腺炎临床分型法.以临床分型为依据细化胆石性胰腺炎治疗原则,可提高临床疗效.但在治疗过程中还需重视临床类型的转变.     

梗阻型胆源性胰腺炎发病后48h内行内镜治疗的效果评价

目的探讨梗阻型胆源性胰腺炎于发病后48 h内行内镜治疗的临床效果。方法对158例梗阻型胆源性胰腺炎患者的临床资料进行回顾性分析,将在发病后48 h内进行内镜治疗的患者89例作为观察组,将69例在早期采取保守治疗基础上于发病48 h后行内镜治疗的患者作为对照组,观察其治疗效果。结果观察组治疗成功率为94.38%,对照组治疗成功率为75.36%,两组成功率比较差异显著(P0.05);观察组病死率为1.12%,对照组为4.34%,两组无明显差异(P0.05)。观察组临床症状缓解时间、生化指标恢复正常时间、住院时间均低于对照组,差异显著(P0.05)。观察组重症患者并发症发生率为9.4%,低于对照组重症患者的40.9%(P0.05)。两组病死率、轻症患者并发症发生率比较无显著差异(P0.05)。结论梗阻型胆源性胰腺炎患者于发病后48 h内行内镜治疗能有效改善其临床症状,减少并发症的发生率,尤其是重症患者更应于发病后48 h内行内镜治疗;轻症患者保守治疗无效时也应尽早行内镜治疗。     

思他宁联合早期内镜治疗急性胆石性胰腺炎

目的 探讨应用思他宁联合早期内镜治疗急性胆石性胰腺炎(AGP)的疗效。方法 应用思他宁联合早期逆行胰胆管造影术(ERCP)、经内镜鼻胆管引流(ENBD)及经内镜乳头括约肌切开(EST)治疗AGP32例，其中轻症胰腺炎21例，重症胰腺炎11例。结果 治愈30例，2例重症胰腺炎内镜治疗后转外科手术治疗，1例术后死亡。结论 思他宁联合内镜治疗AGP是安全和有效的，对明确诊断AGP应及早应用思他宁及内镜介入治疗。     

重症急性胆源性胰腺炎的诊断与治疗

目的探讨重症急性胆源性胰腺炎(SABP)的诊断方法及疗效。方法回顾性分析8年36例SABP的临床资料。结果36例SABP中，26例非梗阻性SABP行保守治疗，治愈24例，2例因胰腺坏死继发感染而转外科手术；10年梗阻性SABP中8例先行急诊ENBD，病情平稳后再行EST/ENBD，2例发生壶腹部结石嵌顿病情恶化而行急诊切开取石并引流，均成功治愈。全组治愈率94．44％(34／36)。结论梗阻型SABP应尽早予以EST/ENBD解除胆道梗阻；非梗阻型SABP宜先积极保守治疗，当治疗72h后病情无缓解或并发感染时应积极中转外科手术。     

急性胆源性胰腺炎的诊治体会

目的总结急性胆源性胰腺炎的诊治体会,以改进诊治方法.方法对110例胆源性胰腺炎的临床资料进行回顾性分析.结果 110例中83例确是胆源性胰腺炎,其中入院时胆道仍有梗阻者(梗阻型)34例,梗阻已解除者(非梗阻型)49例.其余27例不是胆源性胰腺炎,20例只是胆源性一过性胰高压,7例乃一般胰腺炎,发病与胆道无关.结论诊断胆源性胰腺炎要有根据,临床上不可凡遇胆道有结石,血或(和)尿淀粉酶升高就诊断为胆源性胰腺炎.要根据治疗前胆道有无梗阻对胆源性胰腺炎分型论治:梗阻型应尽早引流解除胆道梗阻,非梗阻型宜积极保守治疗,病情缓解后在同一住院期内手术.胆源性一过性胰高压和胰腺炎要按胆道或胰腺病情处理,不可一概按胆源性胰腺炎治疗.     

EUS联合ERCP在梗阻型轻症急性胆源性胰腺炎中应用及对细胞因子和淀粉酶的影响

目的观察超声内镜(EUS)联合十二指肠镜逆行性胆胰管造影(ERCP)对梗阻型轻症急性胆源性胰腺炎患者的治疗效果及对细胞因子、淀粉酶的影响。方法梗阻型轻症急性胆源性胰腺炎患者90例,随机分为对照组(n=45)和观察组(n=45)。对照组采用开腹手术治疗,观察组采用EUS联合ERCP治疗。观察两组治疗前、后肿瘤坏死因子(TNF)-α、白细胞介素(IL)-2、白细胞IL-6、IL-8、IL-10及淀粉酶水平变化。结果观察组治疗后腹痛缓解时间、尿淀粉酶恢复正常时间、血淀粉酶恢复正常时间及住院时间、显著短于对照组(P<0.05);观察组治疗后TNF-α、IL-2、IL-6及IL-8水平低于对照组(P<0.05);观察组术后并发症发生率(8.89%),显著低于对照组(20.00%,P<0.05)。结论梗阻型轻症急性胆源性胰腺炎患者采用EUS联合ERCP治疗效果理想。     

重症急性胰腺炎术后并发胃十二指肠瘘的诊治

目的 探讨SAP术后并发胃十二指肠瘘的原因、形成机制、诊断和治疗经验.方法 收集1996年1月至2007年12月期间收治的18例SAP术后并发胃十二指肠瘘患者的临床资料进行回顾性分析.结果 18例SAP患者,4例行胆囊切除、胆总管切开取石术,4例行胰腺坏死组织清除术及开放式蝶式引流,10例行胰腺坏死组织清除,胰床松动及腹腔闭式引流.其中发生十二指肠瘘12例(66.7%),胃瘘6例(33.3%),发生于术后3周之内14例(77.8%).术后3周之后4例(22.2%).16例(88.9%)经引流、冲洗脓腔、抗感染等非手术治疗均获治愈,平均住院时间65 d.2例(11.1%)分别死于腹腔内出血、腹腔感染并发腹腔间室隔综合征(ACS)和MODS.结论 SAP术后并发胃十二指肠瘘经过恰当的非手术治疗是可以获得痊愈的.     

老年急性胰腺炎53例临床分析

目的探讨老年急性胰腺炎的临床特征及诊治方法。方法回顾性分析53例老年急性胰腺炎患者的临床资料。结果老年急性胰腺炎多合并有基础疾病,诱发因素主要为胆系疾病39例,占73.6%,临床主要表现为腹痛、腹胀、发热等。行急诊手术9例,术后6例发生并发症,经对症处理后均好转,死亡3例;行择期手术21例,术后发生并发症10例,经对症处理后均好转;其余23例经非手术保守治疗痊愈。结论老年急性胰腺炎主要病因为胆系疾病,临床表现多种多样,症状不典型,且合并症多,病情重,内科积极治疗有助于改善预后。     

重症急性胆源性胰腺炎内镜治疗回顾性研究

目的：评价治疗性逆行胰胆管造影术（ERCP）对重症急性胆源性胰腺炎（SABP）的疗效及安全性。方法：回顾分析65例SABP患者内镜治疗情况,比较早期及择期内镜治疗成功率、症状缓解及对预后的影响。结果：65例患者ERCP成功60例（成功率92．3％）。其中急诊ERCP成功率87．7％,择期ERCP成功率100％。33．83％ERCP未见胆管结石。对于无胆道梗阻的SABP患者,比较急诊与择期ERCP组患者的腹痛缓解、体温、白细胞计数、肝功能、淀粉酶等恢复正常时间无显著性差别（P〉0．05）。结论：SABP行治疗性ERCP的诊治创伤小、有效。对于急性期SABP无明确胆道梗阻及感染,早期ERCP增加治疗风险及不成功率;病情稳定后择期ERCP可增加成功率并减少风险,不会加重病情。     

Early endoscopic sphincterotomy in the management of acute gallstone pancreatitis in elderly patients

Eighteen elderly patients with acute attacks of gallstone pancreatitis underwent early endoscopic sphincterotomy of the papilla of Vater. Eleven patients were considered to be at high risk for surgery due to chronic cardiorespiratory or renal problems. The outcome of these patients was compared with that of 20 consecutive elderly patients with gallstone pancreatitis treated at the same time by means other than endoscopic sphincterotomy. Endoscopic sphincterotomy resulted in an immediate clinical improvement in all patients, except in one patient who developed transient cholangitis; there was no mortality. In contrast, there was one death (5%) and 20% morbidity in the controls. Mean hospitalization period was shorter in patients undergoing sphincterotomy (6 compared with 9.5 days), although the patients managed by sphincterotomy were initially more seriously ill than controls. Only two of the 11 high-risk patients underwent elective cholecystectomy; all others were well during a mean follow-up of 22 months. It is concluded that early endoscopic sphincterotomy is highly effective and safe in acute attacks of gallstone pancreatitis in elderly high-risk patients.     

非手术治疗急性重症胆源性胰腺炎

目的 探讨急性重症胆源性胰腺炎非手术治疗的效果和中转手术的指征。方法 回顾分析本院收治157例急性重症胆源性胰腺炎非手术治疗的死亡率、并发症和中转手术的情况。结果 157例中治愈145例，死亡12例，治愈率92．4％。治疗过程中有65例出现各类并发症，其中多器官功能不全或衰竭18例(11．5％)，坏死组织继发感染6例(3．8％)，胰腺假性囊肿29例(18．5％)，急性肺损伤25例。患预后与人院时APACHE—Ⅱ评分有关。有9例中转手术(5．7％)，包括6例胰腺坏死组织继发感染和2例不能控制的胆道感染。梗阻性和非梗阻性重症胆源性胰腺炎在死亡率和胰腺坏死组织继发感染发生率上相似。结论 急性重症胆源性胰腺炎经积极非手术治疗可获得满意疗效。梗阻性急性重症胆源性胰腺炎当存在不能控制的胆道感染时需早期行胆道手术。中转手术的指征为胰腺坏死组织继发感染、不能控制的胆道感染及治疗期间出现其他外科并发症。     

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES: Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy. METHODS: Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations. RESULTS: Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (相似文献   

43例腹腔结核并发肠穿孔患者的外科治疗效果分析

目的 分析外科治疗腹腔结核致肠穿孔患者的临床情况。方法 收集河北省胸科医院2008—2016年收治的43例经手术病理确诊的腹腔结核伴肠穿孔患者,所有患者经胸部X线摄影或CT扫描检查均为可疑肺结核。描述性总结分析其术前临床表现、实验室检测及各项检查、术中探查及手术方式、术后治疗及并发症、治疗结果、随访结果等临床资料。结果 43例患者术后病理证实均存在腹腔结核,其中32例非急诊患者临床诊断明确者18例,11例急诊患者术前均未明确诊断;术中探查均存在肠穿孔,其中术前考虑单纯肠梗阻3例、肠梗阻伴肠穿孔30例(8例急诊和22例非急诊患者术前经诊断性穿刺诊断肠穿孔)、单纯肠穿孔10例。40例(93.0%)因病变范围广泛、感染严重行Ⅰ期肠切除+造瘘术,其中12例切口感染患者经切口换药、引流后治愈;8例发生肠瘘患者除2例(保守治疗、二次手术各1例,年龄均>65岁)因多脏器功能衰竭死亡外,余6例经治疗后预后良好;2例发生肠梗阻患者1例行二次手术、1例保守治疗后治愈;余18例患者造瘘术后恢复良好。2例(回盲部肿物伴穿孔1例,腹腔感染较轻1例)行回盲部切除+回结肠吻合术;1例因近回盲部出现回肠局部单一穿孔,且同时并发腹腔淋巴结结核、局部淋巴结节和穿孔部位回肠粘连,但腹腔感染较轻的患者行回肠部分切除+肠吻合术,术后无严重并发症。抗结核治疗12个月后均治愈停药。37例患者停药后随访18~24个月,4例患者失访,随访期内16例患者有间断轻微腹痛症状,其他患者一般情况均良好。结论 腹腔结核伴肠穿孔是严重的消化道结核并发症,规范的抗结核药物治疗是基础,而外科手术是有效治疗的首选方式,治疗效果良好。     

CT-guided percutaneous peripancreatic drainage: a possible therapy in acute necrotizing pancreatitis

BACKGROUND/AIMS: To examine the effectiveness of therapeutic percutaneous drainage of peripancreatic fluid in the treatment of acute necrotizing pancreatitis. METHODOLOGY: Twenty-eight patients treated for serious acute necrotizing pancreatitis (19 male, 9 female; average age 47.3 years) took part in the study. The cause of acute necrotizing pancreatitis was alcohol abuse in 20 of the cases, gallstone disease in 7 cases, endoscopic retrograde cholangiopancreatography in 2 cases, trauma in one case, and 4 of the cases had unknown cause. In all cases preventative antibiotics were given as part of intensive therapy, early nasojejunal nutrition was used, and we endeavored to avoid surgery or to delay it depending on the case. The acute peripancreatic fluid was drained percutaneously. In total, percutaneous drainage was used in 12 patients. RESULTS: Of the 28 patients, only 3 patients recovered solely with conservative therapy, without drainage. Three patients recovered using only percutaneous drainage without surgery. In 9 patients surgery was necessary after percutaneous drainage was performed. In the remaining 13 patients, only surgical treatment was used, without percutaneous drainage. In total 20 reoperations were done in 10 patients. Of the 12 patients treated with percutaneous drainage, one patient died. The total mortality was 14.3%. CONCLUSIONS: In certain cases the percutaneous drainage of the acute peripancreatic fluid that collects in acute necrotizing pancreatitis is sufficient for the total recovery of acute necrotizing pancreatitis, in other cases can be used to postpone surgery.     

Gallstone Pancreatitis

Opinion statement The majority of patients with acute gallstone pancreatitis have a mild attack and recover without additional treatment. In about 20% of patients, the attack is severe and is associated with a mortality rate of about 20%. Patients with severe pancreatitis require management in a high-dependency or intensive care setting. These patients are best managed in a specialized unit. Antibiotic prophylaxis is advised in patients with necrosis, and imipenem and cefuroxime are recommended. In severe pancreatitis, early enteral nutrition is recommended through a nasojejunal tube. In patients with severe pancreatitis or with cholangitis, urgent endoscopic retrograde cholangiopancreatography within 72 hours is indicated, and when appropriate, a sphincterotomy and clearance of the bile duct is performed. In sterile necrosis, conservative treatment is indicated unless the patient fails to improve or deteriorates, whereupon surgery is considered. If there is infection of pancreatic necrosis or abscess (pancreatic or peripancreatic), surgery is indicated. A symptomatic and persistent pancreatic pseudocyst requires intervention with either endoscopic drainage (transpapillary pancreatic stent, cystgastrostomy, or cystduodenostomy), percutaneous drainage, or surgery. Before discharge, patients should undergo cholecystectomy, or if they are unfit for surgery, endoscopic sphincterotomy and bile duct clearance.