重型急性胰腺炎的中西医结合治疗：附145例报告

目的：观察急性重型胰腺炎器官功能不全的发生、发展规律,探索中西医结合方法在保护器官功能、减少并发症、降低病死率的价值。方法：在重症监护条件下,多指标、前瞻性地观测了１４５例急性重型胰腺炎病程规律,使用早期通里攻下法、活血化瘀法的治疗效果。结果：急性重型胰腺炎的病理过程主要包括初期（急性反应期）,进展期（感染期）和恢复期。早期通里攻下对器官功能不全有明确的治疗作用,尤其对呼吸功能不全。有些患者可不经进展期直接进入恢复期,从而提高了治愈率。结论：器官功能不全是重型胰腺炎死亡的最重要原因,早期通里攻下法对器官保护及减少死亡率有肯定疗效。     

王红教授应用大承气汤治疗急性胰腺炎胰腺内分泌功能损伤思路阐释

急性胰腺炎是临床常见的急腹症,中西医结合治疗急性胰腺炎已经达成共识。胰腺炎急性期通常伴胰腺内分泌功能障碍,临床表现为尿糖和血糖水平升高,其主要原因是胰腺炎发生时胰腺β细胞功能损伤。国内外学者已经开始重视急性胰腺炎时胰腺内分泌系统的变化。通里攻下法代表方剂大承气汤治疗急性胰腺炎具有较明显的疗效。“肠-胰岛轴”是肠道感受到营养物质刺激后,迅速调节胃肠道分泌功能和运动功能,将营养摄入的相关信息传至胰岛,从而调节胰岛功能,具有反应灵敏、发生早、作用关键的特点。以肠-胰岛轴为切入点,验证通里攻下法能加速肠蠕动,促进胃肠运动,继而使远端回肠L细胞来自肠道的刺激增加,通过加速肠-胰岛轴中的一种重要肠促胰素——肠促胰素(GLP-1)分泌,减轻急性胰腺炎时胰岛β细胞功能损伤,在急性胰腺炎时胰岛功能保护方面有重要作用,验证通里攻下法治疗急性胰腺炎除了影响胰腺外分泌外,对胰腺内分泌亦有较大影响,可能对急性胰腺炎后糖尿病的研究具有较重大的意义。     

通里攻下法治疗急性胰腺炎时影响因素的探讨

急性重型胰腺炎以其发生急剧、病情凶险、高并发症、高死亡率(30～50%)的特点,引起了国内外学者的广泛关注.在急性胰腺炎急性期的中西医结合治疗中,通里攻下法对该病的治疗占有非常重要的地位.但是由于每位患者就诊时的病理生理状态的不同,使其对通里攻下法治疗的反应也有较大差异.为此我们做了如下研究.     

通里攻下法与活血化瘀法治疗犬急性出血坏死性胰腺炎机理研究─—抗氧化及对RCIA的影响

通里攻下与活血化瘀是中西医结合治疗急腹症的两个重要治法。本文采用牛磺胆酸钠致犬急性出血坏死性胰腺炎（ＡＨＮＰ）模型，研究了ＡＨＮＰ氧化／抗氧化平衡及红细胞免疫功能（ＲＣｌＡ）。通里攻下与活血化瘀的代表方药—大承气汤及丹参的抗氧化作用及其对ＲＣＩＡ的影响。本文提示：①牛磺胆酸钠致ＡＨＮＰ存在氧化／抗氧化平衡失调，活血化瘀及通里攻下均具有抗氧化作用；②通里攻下后动物胰重及腹水量明显减少；③本文首次发现ＡＨＮＰ的红细胞免疫功能损害，通里攻下能明显提高ＲＣＩＡ。     

通里攻下法与活血化瘀法治疗犬急性出血坏死性胰腺炎？…

通里攻下与活血化瘀是中西医结合治疗急腹症的两个重要治法。本文采用牛磺胆酸钠致犬急性出血坏死性胰腺炎（ＡＨＮＰ）模型，研究了ＡＨＮＰ氧化／抗氧化平衡及红细胞免疫功能（ＲＣＩＡ）。通里攻下与活血化瘀的代表方药－大承气汤及丹参的抗氧化作用及其对ＲＣＩＡ的影响。本文提示：①牛磺胆酸钠致ＡＨＮＰ存在氧化／抗氧化平衡失调，活血化瘀及通里攻下均具有抗氧化作用；②通里攻下后动物胰重及腹水量明显减少；③本文首次发现     

简讯

以天津市南开医院副院长、天津市中西医结合急腹症研究所副所长崔乃强教授为首的天津市南开医院外科学术交流团一行三人 ,于 2 0 0 1年 10月 1日至 2 1日赴美进行学术交流及考察。代表团应美国北卡路来那州东卡路来那大学ＢＲＯＤＹ医学院外科的邀请 ,在该校作了学术讲演 :崔乃强 :通里攻下法治疗急性重型胰腺炎 ;陈鲳 :通里攻下法防治多器官功能不良综合征 ;何培坤 :中国食管癌的治疗。演讲后回答了听众提出的问题 ,并受到好评。ＢＲＯＤＹ医学院向三位教授授予访问教授的荣誉称号。代表团参观了该医学院普通外科、消化外科、心胸外科 ,分…     

重型急性胰腺炎重用甘遂138例报告

重型急性胰腺炎是外科常见急腹症,近年来国内外一致报告有增加的趋势。我院1980~1994年收治重型急性胰腺炎138例,大部分行中西医结合非手术疗法,其中重点解决严重腹胀、腹痛、麻痹性肠梗阻,重用甘遂通里攻下,临床收到良好效果。     

通里攻下法治疗肠源性内毒素血症的临床观察——附34例？…

我们选择临床中急性弥漫性腹膜炎患者，给予通里攻下法配合常规治疗，进行临床观察。结果表明：腹膜炎病人血中内毒素含量增高（Ｐ〈０．０１），并引起ＴＮＦ、ＰＧＦ１α和ＴＸＢ２的增高（Ｐ〈０．０１）。术后用通里攻下法的代表方剂大承气汤、承气合剂治疗，能使血中ＬＰＳ、ＴＮＦ、ＴＸＢ２含量下降（Ｐ〈０．０１ Ｐ〈０．０１ Ｐ〈０．０５），机体恢复加快，抗生素的使用减少（Ｐ〈０．０５）。通里攻下法是一种治疗肠源     

学术动态

重症急性胰腺炎是外科难治性疾病,其起病急,病情变化快,常伴有全身炎性反应综合征和多器官功能障碍综合征,病死率仍高达20%左右。现代西医尚无满意治疗方法。90年代以来,中西医结合工作者根据胰腺炎的临床表现和中医见证,采用以通里攻下法为主的治疗方式,中西医结合获得较满意的临床效果。这些经验逐步为医务界接受,一些中药,如大黄煎剂口服、芒硝外用等已经写入中华外科学会胰腺学组、中华消化学会胰腺学组的胰腺炎治疗指南之中。为此,国家科技部和国家中医药管理局设立了《疑难病中医干预疗效评价的研究》这一研究项目。重症急性胰腺炎中…     

清胰汤治疗重型急性胰腺炎的临床研究

本研究观察了通里攻下法治疗重型急性胰腺炎（ＳＡＰ）的临床疗效。观察结果表明，与单纯西医治疗组相比，在西医治疗的基础上加用清胰汤能明显降低血清多形核粒细胞弹性蛋白酶（ＰＭＮ－Ｅ）、磷脂酶Ａ２活性（ＰＬＡ２）、可溶性白细胞介素－２受体（ＳＩＬ－２Ｒ）、内毒素（ＬＰＳ）的水平。从而证明了清胰汤能有效地控制ＳＡＰ时超强的全身炎症反应，减轻对机体的损害，有助于保护各脏器功能，从而达到降低病死率的目的。     

Imaging of acute pancreatitis and its complications. Part 2: Complications of acute pancreatitis

The Atlanta classification of acute pancreatitis was introduced in 1992 and divides patients into mild and severe groups based on clinical and biochemical criteria. Recently, the terminology and classification scheme proposed at the initial Atlanta Symposium have been reviewed and a new consensus statement has been proposed by the Acute Pancreatitis Classification Working Group. Major changes include subdividing acute fluid collections into “acute peripancreatic fluid collection” and “acute post-necrotic pancreatic/peripancreatic fluid collection (acute necrotic collection)” based on the presence of necrotic debris. Delayed fluid collections have been similarly subdivided into “pseudocyst” and “walled of pancreatic necrosis”. Appropriate use of the new terms describing the fluid collections is important for management decision-making in patients with acute pancreatitis. The purpose of this review article is to present an overview of complications of the acute pancreatitis with emphasis on their prognostic significance and impact on clinical management and to clarify confusing terminology for pancreatic fluid collections.     

Postoperative hyperamylasemia (POH) and acute pancreatitis after pancreatoduodenectomy (POAP): State of the art and systematic review

BackgroundPostoperative hyperamylasemia is a frequent finding after pancreatoduodenectomy, but its incidence and clinical implications have not yet been analyzed systematically. The aim of this review is to reappraise the concept of postoperative hyperamylasemia with postoperative acute pancreatitis, including its definition, interpretation, and correlation.MethodsOnline databases were used to search all available relevant literature published through June 2019. The following search terms were used: “pancreaticoduodenectomy,” “amylase,” and “pancreatitis.” Surgical series reporting data on postoperative hyperamylasemia or postoperative acute pancreatitis were selected and screened.ResultsAmong 379 screened studies, 39 papers were included and comprised data from a total of 9,220 patients. Postoperative hyperamylasemia was rarely defined in most of these series, and serum amylase values were measured at different cutoff levels and reported on different postoperative days. The actual levels of serum amylase activity and the representative cutoff levels required to reach a diagnosis of postoperative acute pancreatitis were markedly greater on the first postoperative days and tended to decrease over time. Most studies analyzing postoperative hyperamylasemia focused on its correlation with postoperative pancreatic fistula and other postoperative morbidities. The incidence of postoperative acute pancreatitis varied markedly between studies, with its definition completely lacking in 40% of the analyzed papers. A soft pancreatic parenchyma, a small pancreatic duct, and pathology differing from cancer or chronic pancreatitis were all predisposing factors to the development of postoperative hyperamylasemia.ConclusionPostoperative hyperamylasemia has been proposed as the biochemical expression of pancreatic parenchymal injury related to localized ischemia and inflammation of the pancreatic stump. Such phenomena, analogous to those associated with acute pancreatitis, could perhaps be renamed as postoperative acute pancreatitis from a clinical standpoint. Patients with postoperative acute pancreatitis experienced an increased rate of all postoperative complications, particularly postoperative pancreatic fistula. Taken together, the discrepancies among previous studies of postoperative hyperamylasemia and postoperative acute pancreatitis outlined in the present review may provide a basis for stronger evidence necessary for the development of universally accepted definitions for postoperative hyperamylasemia and postoperative acute pancreatitis.     

Severe acute pancreatitis--diagnostic and therapeutic strategy

To establish the optimal diagnosis and therapeutical strategy in severe acute pancreatitis. 94 (56.9%) severe acute pancreatitis (79 males and 15 females, aged between 26 and 81), selected from 165 acute pancreatitis admitted in the last 5 years (2000-2004) were analyzed. The disease was assigned as severe when one or more of the following criteria were present: Ranson score >3 on admission or at 48 hours, APACHE II score >8, visceral failures, Balthazar CT score C, D or E and local complications (infected necrosis, pseudocyst or pancreatic abscess). Medical treatment (aggressive supportive intensive care therapy, minimizing pancreatic secretion and antibiotic therapy) was the first therapeutical step in all cases. 49 (52.1%) patients were operated on: 20 as early surgery imposed by biliary sepsis (16 cases) or by an acute abdomen with uncertain etiology and unfavourable evolution, and 22 as late surgery (at least 12 days after onset), imposed by the presence of the infected pancreatic necrosis, visceral failures or other local complications, the necrosectomy being the main surgical procedure for infected necrosis. 77 (81.9%) cases had a fair evolution. The conservative treatment led to a complete recovery in 37 (37.2%) cases. We registered an overall mortality rate of 12.7% and postoperative mortality rate of 14%; we also registered 5 (10.2%) postoperative complications: 4 pancreatic and 1 colonic fistulae. (1) The treatment of the severe acute pancreatitis must be performed only in the specialized multidisciplinary well equipped centers with very well trained staff. (2) Medical conservative treatment (aggressive supportive intensive care therapy and antibiotic therapy) is the main therapeutical method within the acute phase (first two weeks). (3) Very restrictive surgical indications within the acute phase. (4) Necrosectomy is the main surgical procedure for the infected necrosis.     

ANAEROBIC BACTERIA,THE COLON AND COLITIS

Anaerobic bacteria constitute more than 90% of the bacteria in the colon. An anaerobic environment is needed to maintain their growth and the production of short-chain fatty acids by these bacteria from carbohydrates. Short-chain fatty acids are rapidly absorbed and essential for metabolic as well as functional welfare of the colonic mucosa. The importance of these acids in water absorption and in the pathogenesis of colitis is discussed in relation to the concept of “energy deficiency diseases” of the colonic mucosa.     

重症急性胰腺炎相关性肾损伤的发病机制及防治

重症急性胰腺炎相关性肾损伤的发病机制尚未完全明确,目前主要有肾脏血流动力学异常、炎性递质与细胞因子释放、肾小管细胞凋亡、肠道细菌和内毒素移位等学说,文中就近年来其发病机制及防治研究进展作一综述.     

内毒素对急性出血坏死性胰腺炎早期细菌易位的影响及甘遂治疗作用的实验研究

本文报告以大白鼠急性出血坏死性胰腺炎(AHNP)模型为实验对象,研究内毒素预处理对AHNP早期细菌、内毒素易位的影响,并进一步探索在内毒素血症状态下甘遂对AHNP引起的细菌、内毒素易位的治疗作用。实验分三组:①AHNP对照组;②AHNP内毒素预处理组;③AHNP内毒素预处理加甘遂治疗组。结果显示①内毒素能明显增加AHNP时细菌、内毒素易位;②甘遂不仅能够显著减少肠腔游离细菌总数、降低肠腔内毒素池,而且可以吸收腹腔(或血液)中的内毒素自肠道排出,从而发挥其阻碍AHNP时细菌、内毒素易位的作用。内毒素对机体免疫功能有害,甘遂则无不良影响。     

生长抑素治疗急性胰腺炎的临床研究

目的 探讨生长抑素治疗急性胰腺炎的临床效果。方法 应用人工合成的生长抑素类似物－－奥曲肽治疗３８例和非奥曲肽治疗５９例急性胰腺炎。观察了两组以及奥曲肽治疗用药前后血甭淀粉酶及胰液粉酶的含量,比较了两组并发症的发生率。结果 奥曲肽能有效降氏血清淀粉酶和胰液淀粉酸酶的活性,改善临床症状和体征,降低并发症的发生。结论 奥曲肽有助于性胰腺炎的治疗。     

内镜、腹腔镜序贯治疗急性胆源性胰腺炎

目的总结内镜、腹腔镜序贯治疗急性胆源性胰腺炎的临床效果. 方法我院2000年3月～2003年6月收治急性胆源性胰腺炎54例.入院后24 h内54例行经内镜逆行性胰胆管造影(ERCP)及取石术,7例因Oddi括约肌狭窄加行EST.所有患者均放置鼻胆管引流,待胰腺炎恢复后,53例施行腹腔镜胆囊切除术(LC),其中2例中转开腹;1例因胰周脓肿行开腹胆囊切除,胰周坏死组织清除. 结果未发生与内镜操作有关的严重并发症及手术并发症.随访6个月～3年,无胰腺炎复发. 结论早期内镜治疗急性胆源性胰腺炎安全有效,待胰腺炎缓解后,序贯应用LC,可体现微创手术的优点,不失为目前较理想的治疗方法.     

外科治疗急性胆源性胰腺炎

目的探讨急性胆源性胰腺炎（ABP）手术时机和术式的选择.方法回顾性分析247例急性胆源性胰腺炎的临床资料.结果非手术治疗10例,死亡4例;12例急诊手术后发生并发症5例,死亡2例;169例延期手术术后发生并发症1例,治愈;56例择期手术无并发症发生.结论以胆道梗阻为主的ABP应急诊手术解除胆道梗阻;胆道无梗阻先采用非手术治疗,胰腺炎控制后,再处理胆道病变.     

组织蛋白酶B在急性胰腺炎发病中的作用探讨

为探讨组织蛋白酶Ｂ在急性胰腺炎（ＡＰ）发病中的作用，对１１只急性水肿性胰腺炎犬和１２只急性出血坏死性胰腺炎犬（ＡＨＮＰ）的胰腺腺泡细胞内组织蛋白酶Ｂ的分布情况进行了检测，并与７只正常犬进行比较。结果：实验犬ＡＰ早期即有胰腺腺泡细胞内组织蛋白酶Ｂ的再分布现象，ＡＨＮＰ犬尤为明显（Ｐ＜０．０１）。由此表明，组织蛋白酶Ｂ在ＡＰ的发病中具有一定的作用