胆石性急性胰腺炎的外科治疗问题

胆道与胰腺的解剖与功能互有联系 ,急性胰腺炎的发病胆道因素占有很大比例。在国外以胆囊结石、继发性胆管结石特别是小结石的自然排石过程常是其发生和复发的直接原因 ,因而将此统称之为胆石性胰腺炎。在我国原发性胆管结石、胆道蛔虫症及胆道感染等因素也占重要比重 ,因而较之更为复杂 ,所以称胆源性胰腺炎较为合理。胆道结石的嵌顿、梗阻、排石过程和胆道蛔虫感染这些刺激对壶腹括约肌的损伤引起胰胆出口的痉挛、充血、水肿 ,都导致胆胰管排空不畅和压力升高 ,加上胆胰结合部的不同方式 ,易致胆汁向胰液的返流 ,致使部分病人发生急性胰腺炎或慢性胰腺炎的反复急性发作 ,其中 ,胆胰管出口的排空不畅处于中心的地位 ,并易导致种种并发症的发生。内镜乳头切开引流常是有用的手段。如何认识、诊断和及时进行有效治疗 ,是应该进行充分讨论和达到共识的。现谨约请有关专家就此进行评述。———编者     

Surgical treatment of severe acute pancreatitis

Surgical treatment of severe necrotizing pancreatitis (SNP) is still controversial, inadequate indications and timing of operations being associated with high rates of mortality and morbidity. The aim of the present study is to analyze the indications and results of surgery in patients with SNP. Between 1989 and 2005, necrosectomy followed by open packing drainage (OPD) was performed in 80 patients with SNP. Timing of operations was individualized according to presence of pancreatic necrosis infection. Major postoperative complications were present in 34 patients (42.5%), pancreatic, enteric and biliary fistula, sepsis, iatrogenic bleeding and stress-ulcers being among the most frequently encountered. Secondary contamination of sterile pancreatic necrosis after OPD occurred in 13 patients (35.1%). The overall mortality rate was 32.5%, aggravation of MOF and septic shock being the main causes of death. Late surgical cure for OPD-related incisional hernia was required in 10% of the patients. Infection of pancreatic necrosis is an indication for urgent surgical necrosectomy and repeated re-debridements. Due to technical impossibility to perform adequate necrosectomy and the risk of MOF aggravation, early surgery is not recommended in patients with sterile necrosis. It should be postponed beyond the third week, when the biological condition of the patient is improved and delimitation of necrosis is complete. OPD is an adequate and efficient drainage procedure following necrosectomy. "Prophylactic" OPD for sterile necrosis is not recommended because it is associated with high morbidity rates and secondary infection of necrosis.     

Surgical treatment of acute necrotizing pancreatitis

Between January 1980 and June 1986, 21 patients required surgery for acute necrotizing pancreatitis. Four patients had been transferred from other hospitals; the remaining 17 patients had been treated from the outset at Glasgow Royal Infirmary, representing 3.7 per cent of the 456 patients treated for acute pancreatitis during this time. Necrosectomy was performed on 14 patients and 7 patients were treated by pancreatic resection, with 4 deaths in each group; thus 8 patients (38 per cent) died at a median time of 22 days from onset of their attack. Three of the four patients transferred to our care died, giving a mortality in our own patients of 29 per cent. Of the survivors, all but three had a prolonged and complicated hospital course. Our data confirm that acute necrotizing pancreatitis is still associated with a considerable mortality and morbidity. Early multi-organ failure, advanced age, underlying medical illness and the presence of infected necrosis were associated with a poor outcome. Necrosectomy delayed until the second or subsequent week appeared to be a suitable procedure for the majority of our patients, but shortcomings were apparent with the traditional methods of closed drainage of the pancreatic bed postoperatively. The many demands imposed by this small group of patients suggests that their management is best undertaken in centres in which there is special expertise and this should contribute to a further reduction in the mortality from this condition.     

Surgical treatment of acute necrotizing pancreatitis

The purpose of this work is to summarize the experience in treatment of patients with acute destructive pancreatitis and to carry out comparative analysis of the results of "open" and "closed" types of the treatment for this disease. 233 patients of the study group underwent surgery which demanded parietal deperitonization and mobilization of the pancreas from the retroperitoneal space, drainage of all parts of retropancreatic bat and drainage of biliary tracts, total continuous retroperitoneal neuro-vegetative blockade, local hypothermia and omentobursostomy with further regular elective pancreosequesf8p4omies and sanation of the cavity of the omental bursae with local sorbtion--dehydration therapy. The number of the days of inhospital stay in the study group made up 43.5 +/- 3.3, and in the control group--64.2 +/- 4.1 (p < 0.05). The level of postoperative complications in the study group made up 36.6%, in control group--85.1%, lethality being 18.2 and 50.0%, respectively. In the study group long-term unfavourable follow-up results were obtained only in 2.9% of patients, whereas in control group--in 31.6%.     

Surgical treatment of acute necrotic-hemorrhagic pancreatitis

The clinical course of an episode of acute pancreatitis varies from a mild transitory form to a severe necrotizing form characterized by multisystem organ failure and mortality in 20% to 40% of cases. Mild pancreatitis does not need specialized treatment, and surgery is necessary only to treat underlying mechanical factors such as gallstones or tumours of papilla of Vater. On the other hand, patients with severe necrotizing pancreatitis need to be identified as early as possible after the onset of symptoms to start intensive care treatment. Patients with infected necrosis, approximately 10 to 20%, must undergo surgical intervention, which consists of an organ-preserving necrosectomy followed by postoperative drainage-lavage or the method of "open abdomen". The Authors report a series of 20 patients operated on for acute necrotizing pancreatitis from 1998 to 2000. They describe the indications and methods of treatment, in particular the additional procedure following necrosectomy.     

Surgical treatment of patients with acute pancreatitis

Results of treatment of patients with acute pancreatitis are analyzed. Efficacy of staged treatment of patients with acute destructive pancreatitis is demonstrated. The ineffective conservative therapy during 1-3 days is regarded as indication for half-open surgical method (median laparotomy, necrsecvestrectomy, omentopancreatobursostoma and lumbostoma formation). General purulent peritonitis is indication for open method (laparostoma formation). Unitized surgical tactics permitted to reduce lethality from 4.2 to 2.5%.     

Surgical treatment of patients with acute pancreatitis]

Since 1963 to 1973 in the clinic 1449 patients were treated for acute pancreatitis and cholecystopancreatitis. A considerable increase in the number of these patients was observed during recent 8 years, mainly on account of destructive forms. 92 patients were operated upon (6.3%), including 9 subjects with pancreatic edema, 39--with hemorrhagic pancreatitis, 36--with pancreonecrosis, 8--with purulent pancreatitis. Indications to surgical therapy are considered to be as follows: the presence of initial signs of diffuse peritonitis or prounced signs of limited peritonitis, if the conservative therapy during 8-10 hours was a failure.     

Surgical treatment of an acute non-biliary aseptic necrotizing pancreatitis

The results of treatment of 345 patients, operated on for an acute nonbiliary aseptic necrotic pancreatitis, are adduced. There was established, that rejection to perform an early open access operations with simultaneous application of modern miniinvasive procedures for peritonitis of the enzyme origin (laparoscopy, laparocentesis), an acute aseptic accumulations of liquid in bursa omentalis and cellular tissue of retroperitoneal space, pancreatic pseudocysts (puncture-drainage interventions under ultrasonographic guidance) and as well as direct operative interventions on pancreatic gland and cellular tissue of retroperitoneal space, using extraperitoneal miniaccesses in presence of sequesters, have permitted to lower postoperative lethality from 15.2 to 4.1%, and to secure a purulent-septic complications prophylaxis in 93.2% of patients. Application of the puncture-drainage interventions under ultrasonographic control, as well as lumbotomy and sequestrectomy, in the environment of aseptic inflammation, have permitted to escape purulent complications occurrence while an acute aseptic accumulations of liquid are present in bursa omentalis in 96.1% of patients and in cellular tissue of retroperitoneal space--in 69.6%.