重症急性胰腺炎术后胃肠道瘘的治疗

目的　探讨重症急性胰腺炎术后胃肠道瘘的治疗方法。方法　对 1996～ 1999年间收治的 2 8例急性胰腺炎术后胃肠道瘘患者的临床资料进行回顾性分析。结果　给予生长抑素、生长激素治疗 ,经瘘流出液量显著减少 (P <0 .0 1)。全部患者均治愈 ,瘘愈合的平均时间为 (5 2± 16)d(2 4～2 2 7d)。 85 .7%的胃肠道瘘经非手术治疗痊愈。结论　绝大部分胰腺炎术后胃肠道瘘经非手术治疗可获痊愈 ,生长抑素、生长激素序贯治疗可显著加速瘘的愈合。     

Sequential organ failure assessment score in predicting outcome in patients with acute pancreatitis

Aims/Objectives

To evaluate the sequential organ failure assessment (SOFA) score pertaining to the severity and outcome in acute pancreatitis, and compare its outcome with the APACHE II score in terms of accuracy and ease of operation with a view to establishing whether the SOFA scoring system can replace APACHE II in predicting severity and outcome of acute pancreatitis.

Methods

Fifty cases of acute pancreatitis were evaluated in this prospective study. These patients were treated as per standard protocols and followed up daily. Both SOFA and APACHE II scores were calculated at admission and thereafter at 48-hour intervals till discharge or death. Subsequently, the data were analysed, and receiver operating characteristic curves were made for SOFA, APACHE II and other biochemical parameters; a p-value < 0.05 was taken as significant.

Results

The SOFA score showed a significant association in predicting the severity of the disease, especially during the first week. Moreover, it decreased the predicted severity of APACHE II by 18% and mortality by 4.5%.

Conclusion

On the day of admission, SOFA scores were comparable with APACHE II in predicting the outcome with a higher area under the ROC curve, and displayed better predicting capability as compared to APACHE II.     

重症急性胰腺炎的营养支持

目的探讨营养支持在重症急性胰腺炎治疗过程的作用。方法对４６例重症急性胰腺炎病人进行治疗的同时给予营养支持。在行全肠外营养２～３周后始加用肠内营养,同时减少肠外营养量;肠外营养加肠内营养１周后逐步改为全肠内营养,直到病人达到了或基本达到了正氮平衡。结果在营养支持期间,绝大多数病人达到了或基本达到了正氮平衡。结论只要使用和管理妥当,营养支持在重症胰腺炎治疗中将会达到良好的预期目的。     

重症急性胰腺炎合并急性肾功能衰竭的临床特点及治疗体会

目的 分析重症急性胰腺炎(SAP)合并急性肾功能衰竭(ARF)的临床特点,并总结治疗体会.方法 ①回顾分析南京军区南京总医院近9年63例SAP合并ARF临床资料,用多元直线回归方法分析影响ARF发生率的相关因素;②63例病人均行肠内营养支持(62.4±20.6d)和连续性肾脏替代治疗(CRRT)(15.6±8.7 d),51例行机械通气(21.7±12.4 d),54例早期腹腔穿刺,34例置鼻胆管或经皮经肝胆囊穿刺引流,18例行腹膜后脓肿穿刺引流,50例手术治疗.结果 SAP合并ARF的死亡率为31.7%,发生率为10.6%,SIRS持续时间、病情严重程度、ARDS、MODS、腹腔间室综合征等是SAP合并ARF的重要影响因素.结论 SIRS持续时间、病情严重程度、ARDS、MODS、腹腔间室综合征等是SAP合并ARF的重要影响因素;早期液体复苏、CRRT、有效维护脏器功能和局部引流是治疗成功的重要环节.     

重症急性胰腺炎手术时机的再探讨

目的 在改变早期手术为积极、有效、综合的非手术治疗的基础上．进一步探讨重症急性胰腺炎(SAP)的手术时机，以降低死亡率。方法 对1990至1997年收治的143例SAP进行分析．所有病人均在ICU行监护及支持治疗。前期(1990～1994年)，对胰腺感染(包括感染性胰腺坏死或液体积聚及胰腺脓肿)均急诊行引流及清创手术；近期(1995～1997年)采取延期手术的方法，将胰腺感染局限或胰腺脓肿作为手术指征。结果 胰腺感染局限或脓肿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(P<0．05)。结论 胰腺感染局限时手术治疗的效果优于胰腺感染未局限时手术，常一次手术成功。     

重症急性胰腺炎肠粘膜屏障功能的损害及预防

重症急性胰腺炎(severe acute pancreatitis,SAP)是临床上常见的危急重症,其中胰腺和胰周感染是SAP的主要死因,即使在发病早期救治成功,也常在疾病的第二、三周发生胰腺及其它器官继发感染,导致死亡[1].胰周脓肿的发生率虽不超过SAP的5%,但死亡却占SAP死亡患者的80%以上.     

Severity scoring for prognostication in patients with severe acute pancreatitis: comparative analysis of the Ranson score and the APACHE III score

BACKGROUND: Despite a paucity of validation, the Ranson score is still the most popular method for gauging the severity of pancreatitis. HYPOTHESES: The Ranson score more accurately predicts outcomes in patients with severe acute pancreatitis (SAP) when compared with APACHE (Acute Physiology and Chronic Health Evaluation) III scores, and the individual components of the Ranson score differ in their capacities to predict outcome in patients with SAP. METHODS: Patients admitted with SAP to a university surgical intensive care unit (ICU) were studied prospectively. Each component and the total Ranson score were recorded. Also recorded were the APACHE II and III scores. These Ranson variables were compared using univariate analysis of variance for mortality, need for operative debridement, and need for an ICU stay for longer than 7 days. Significant variables were then analyzed by a multivariate analysis of variance to assess independent predictors of mortality, the need for debridement, and prolonged length of stay. Data are given as the mean +/- SEM. RESULTS: Seventy-six patients (21.1% mortality), aged 61.8 +/- 1.9 years, were studied. The mean APACHE III score was 48.2 +/- 3.3, and the mean ICU stay was 10.4 +/- 2.1 days. The number of positive Ranson variables was significantly higher in nonsurvivors compared with survivors (5.6 +/- 0.5 vs 3.4 +/- 0.2; P<.001), as were the APACHE III score (76.9 +/- 9.9 vs 40.5 +/- 2.5; P<.001) and ICU stay (24.9 +/- 7.5 vs 76.5 +/- 1.9 days; P =.002). Ranson variables that predicted mortality included values for blood urea nitrogen, calcium, base deficit, and fluid sequestration. CONCLUSIONS: The Ranson score remains a valid predictor of outcomes in patients with SAP, and individual Ranson variables determined 48 hours after hospital admission predicted adverse outcomes more accurately than early Ranson variables in patients with SAP.     

重症急性胰腺炎早期合并胰腺感染的危险因素分析

目的探讨与重症急性胰腺炎（SAP）早期胰腺感染有关的危险因素。方法回顾性分析2002年1月-2007年3月间收治的86例重症急性胰腺炎患者的年龄、性别、病因、人院时APACHEⅡ评分、血淀粉酶、血钙、血糖、血细胞比容、平均动脉压、ALT、AST、总胆红素、血清白蛋白、血肌酐、尿素氮、胰腺坏死、低氧血症、机械通气、肠功能障碍及导管应用等因素和胰腺感染的相关性。结果禁食时间、胰腺坏死程度、胆源性致病因素、低氧血症、肠功能障碍、血肌酐、尿素氮和人院血细胞比容与SAP患者继发感染的发生率呈正相关（P〈0．05），血清白蛋白水平与SAP患者继发感染的发生率呈负相关（P〈0．01）；其余各影响因素与胰腺感染均无明显相关性（P〉0．05）。结论在SAP发病过程中，禁食时间较长、胰腺坏死程度增高、胆源性致病因素、低氧血症、肠功能障碍以及血肌酐、尿素氮和人院血细胞比容的升高可能是导致胰腺发生感染的重要因素。     

重症急性胰腺炎68例治疗结果分析

目的探讨重症急性胰腺炎(severeacutepancreatitis,SAP)手术时机与预后的关系。方法对我院1988年1月~2004年12月收治的68例SAP病人的手术时机选择与并发症发生率、病死率和再手术率进行回顾性分析。结果早期手术组、延期手术组和非手术组的并发症发生率分别为73.3%、33.3%、26.0%,早期手术组较后两组差异有显著意义(P<0.05);病死率分别为33.3%、13.3%、13.0%,早期手术组明显高于后两组(P<0.05);早期手术组再手术率为46.6%,而延期手术组为16.6%(P<0.01)。结论SAP应避免在急性期手术,而尽量采用非手术或延期手术治疗。     

重症急性胰腺炎患者并发Wernicke脑病的护理

目的探讨重症急性胰腺炎(SAP)治疗中并发Wernicke脑病患者的护理对策。方法对12例SAP并发Wernicke脑病患者早期加强病情观察、针对患者的症状加强安全护理、早期大剂量使用维生素B1并做好用药护理、健康教育及心理护理。结果2例因SAP病情加重死亡;10例患者痊愈出院,随访1年,均无复发病例。结论及时有效的护理是治疗Wernicke脑病,提高SAP患者综合治疗效果的关键环节。     

Late mortality in patients with severe acute pancreatitis.

BACKGROUND: Mortality due to severe or necrotizing acute pancreatitis most often results from multiorgan dysfunction syndrome (MODS) occurring either early (within the first 14 days) or 2 weeks or more after the onset of symptoms due to septic complications. The aim of this study was to analyse the course of the disease in patients who died from severe acute pancreatitis. METHODS: Between January 1994 and August 2000 details of 263 consecutive patients with acute pancreatitis were entered prospectively into a database. All patients were treated in an intermediate or intensive care unit. RESULTS: The overall mortality rate was 4 per cent (ten of 263 patients). The mortality rate was 9 per cent (ten of 106) in patients with necrotizing disease. No patient died within the first 2 weeks of disease onset. The median day of death was 91 (range 15-209). Six patients died from septic MODS. Ranson score, Acute Physiology and Chronic Health Evaluation (APACHE) II score during the first week of disease, pre-existing co-morbidity, body mass index, infection and extent of necrosis were significantly associated with death (P < 0.01 for all parameters). However, only infection of the necrotic pancreas was an independent risk factor in the multivariate analysis. CONCLUSION: Early deaths in patients with severe acute pancreatitis are rare, mainly as a result of modern intensive care treatment. Nine of the ten deaths occurred more than 3 weeks after disease onset. Infection of pancreatic necrosis was the main risk factor for death.     

防治重症急性胰腺炎感染的临床研究

目的 探讨防止重症急性胰腺炎(SAP)后期感染的治疗方法，提高SAP后期治疗水平。方法 总结分析1995—1999年和2000--2001年4月两个阶段共收治的134例SAP病人的治疗效果。第1阶段用常规保守治疗；第2阶段采取尽早进食，肠内营养及口服肠道益生菌等措施治疗。结果 第1阶段收治SAP后期102例，感染发生45例(44．1％)，复发5例(4．90％)，住院时间平均56d，死亡11例(9．8％)。第2阶段收治32例，感染7例(21．8％)，住院时间平均38d，复发2例(6．25％)，死亡2例(6．25％)。结论 适度提前进食、肠内营养及口服肠道益生菌等治疗措施有助于降低SAP后期感染率，改善预后。     

重症急性胰腺炎患者肠内营养的研究进展

重症急性胰腺炎是一种较常见的外科疾病.重症急性胰腺炎患者处于高分解代谢状态,需要加强营养支持.早期肠内营养支持能改善重症急性胰腺炎患者的营养状况,保护肠屏障功能,减少肠道细菌移位调节炎性介质反应,降低住院费用.有关重症急性胰腺炎的肠内营养时机,目前尚有争论.我们现结合近年来国内外相关文献,对重症急性胰腺炎肠内营养治疗的可行性及具体实施予以综述.     

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目的探讨动态APACHEⅡ评分和POSSUM评分在重症急性胰腺炎治疗中联合应用的价值。方法1995～2002年对43例重症急性胰腺炎病人每日进行APACHEⅡ评分，均先予非手术治疗，如评分下降，继续支持治疗，如评分进行性上升，考虑有感染性坏死、腹腔内出血、胃肠道穿孔原因时急诊手术、每次手术后均进行POSSCM评分，并计算术后并发症发生概率和死亡发生概率。结果根据动态评分结果，16例采用非手术治疗，16例单次手术，11例多次手术结论动态，APACHEⅡ评分能较好判断手术时机，POSSUM评分能较好地预测术后并发症、死亡的发生，并能对需再次手术病例起较好的预警作用。     

Treatment of acute pancreatitis patients with functional liver failure

Methods of extracorporal detoxication hemo- and lymphosorption, intraportal injection of drugs and oxygenated solutions as well as ultraviolet irradiation of auto-blood are included in the routine scheme of treatment of patients with acute pancreatitis. The treatment concerned was used in 77 patients with acute pancreatitis and advanced hepatic insufficiency and resulted in arresting the latter in 43 of the patients. To prevent the development of acute hepatic insufficiency proved to be possible in 20 patients with a destructive form of acute pancreatitis. The intraportal injection of oxygenated solutions against the background of acute experimental pancreatitis contributed to prevention of hypoxia of the liver.     

早期内镜治疗在重症急性胆源性胰腺炎治疗中的作用

目的：探讨早期内镜干预治疗重症急性胆源性胰腺炎的临床效果。
方法：90例重症急性胆源性胰腺炎患者,其中保守治疗组30例,内镜治疗组30例,手术治疗组30例,观察其疗效及并发症,评价早期内镜干预治疗的疗效。
结果：内镜治疗组30例患者均治愈,保守治疗组治愈25例(83.3%),手术治疗组治愈28例（93.3%）,内镜治疗组疗效明显优于非内镜治疗的两组（P＜0.05）
结论：早期内镜干预解除了胆胰管开口的梗阻,通畅了胆胰液的引流,微创、安全、有效,是治疗重症急性胆源性胰腺炎的理想方法。