急性胰腺炎诊治指南(2014)解读——急性胰腺炎外科诊治难点分析

<正>急性胰腺炎(AP)的诊治经历了一个多世纪的艰苦探索,直到近代,由于治疗观念的转变,以及技术的进步,AP的病死率才明显下降。但我们对该病的发病机制和发展规律还没有完全了解,其诊治仍面临很多困难,AP发病较重者仍然是临床上常见的凶险疾病,手术死亡率还较高。近年来,AP的研究又取得了巨大进展,其诊治的很多重要方面发生了明显的变化。为此,国内外主要学术团体对AP诊治指南进行了修订、     

急性胰腺炎诊治指南(2014版)

2007年中华医学会外科学分会胰腺外科学组发表的《重症急性胰腺炎诊治指南》对我国急性胰腺炎(AP)的规范化诊断与治疗及临床疗效的改善发挥了重要作用.近年来,AP的研究取得了巨大进展,并对其诊断与治疗产生了影响.为此有必要对之进行修订,修订后的指南更名为《急性胰腺炎诊治指南(2014版)》.AP的诊断依据包括临床特征、血清胰酶浓度及CT检查表现.改良的CT严重指数评分(MCTSI)常用于AP的炎症反应及坏死程度的判断.病理分型有间质水肿型胰腺炎和坏死型胰腺炎.AP依据严重程度分为轻症急性胰腺炎(MAP)、中重症急性胰腺炎(MSAP)和重症急性胰腺炎(SAP).MSAP与SAP的主要区别在于器官衰竭持续时间不同,MSAP为短暂性(≤48 h),SAP为持续性(＞48 h).器官衰竭采用改良的Marshall评分来判断.病程分为3期.早期(急性期)为发病至2周,此期以全身炎症反应综合征(SIRS)和器官衰竭为主要表现,此期构成第1个死亡高峰.中期(演进期)为发病2周至4周,以胰周液体积聚或坏死性液体积聚为主要表现.后期(感染期)为发病4周以后,可发生胰腺及胰周坏死组织合并感染,此期构成MSAP和SAP患者的第2个死亡高峰.局部并发症分为急性胰周液体积聚(APFC)、急性坏死物积聚(ANC)、包裹性坏死(WON)及胰腺假性囊肿.病因治疗主要是胆道疾病的处理.MAP患者病情稳定后即可行胆囊切除术或胆道探查术,MSAP和SAP患者应在后期或行坏死组织清除时一并处理.早期非手术治疗重点是液体复苏及器官功能保护.MSAP和SAP患者肠道功能恢复后即行肠内营养支持治疗.对于部分易感人群选择性使用抗生素治疗.ACS的处理措施包括胃肠道减压及导泻、镇痛镇静、使用肌松剂及床边血滤减轻组织水肿,B超或CT引导下腹腔内与腹膜后引流减轻腹腔压力.外科治疗的指征主要是胰腺局部并发症继发感染或产生压迫症状.无菌性坏死积液无症状者无需手术治疗.手术治疗应遵循延期原则.感染性坏死可先行针对性抗生素治疗及B超或CT引导下经皮穿刺引流(PCD).胰腺感染性坏死的手术方式可分为PCD、内镜、微创手术(主要包括小切口手术、视频辅助手术)及开放手术(包括经腹或经腹膜后途径的胰腺坏死组织清除并置管引流).胰腺感染性坏死病情复杂多样,各种手术方式可遵循个体化原则单独或联合应用.     

《中国急性胰腺炎诊治指南(2021)》解读

近年来,急性胰腺炎(AP)在诊治理念、方式和策略等方面发生了重要变革,对其诊断和治疗的诸多方面产生了深远影响.基于此,2020年底中华医学会外科学分会胰腺外科学组牵头,在《重症急性胰腺炎诊治指南(2007)》和《急性胰腺炎诊治指南(2014)》的基础上,更新并制定了《急性胰腺炎诊治指南(2021)》.新版指南采用以问题...     

《急性胰腺炎诊治指南（2014）》解读——急性胰腺炎外科诊治现状与进展

中华医学会外科学分会胰腺外科学组于2007年颁布的《重症急性胰腺炎诊治指南》对我国急性胰腺炎诊治的规范化及疗效的改善发挥了重要作用。近年来,急性胰腺炎的研究取得了巨大进展,对其诊治的很多重要方面产生了明显的影响。为此,学组对之进行了修订,修订后的指南更名为《急性胰腺炎诊治指南（2014）》。参照国际最新进展,急性胰腺炎依据严重程度分为轻症急性胰腺炎（MAP）、中重症急性胰腺炎（MSAP）和重症急性胰腺炎（SAP）。MSAP与SAP的主要区别在于器官功能衰竭持续的时间不同,MSAP为短暂性（≤48 h）,SAP为持续性（>48 h）。按照国内的临床经验,病程分为3期。早期（急性期）：发病1~2周,此期以全身炎症反应综合征（SIRS）和器官功能衰竭为主要表现,此期构成第一个死亡高峰。中期（演进期）：急性期过后,以胰周液体积聚、坏死性液体积聚或包裹性坏死为主要表现。后期（感染期）：发病4周以后,可发生胰腺及胰周坏死组织合并感染,此期构成MSAP/SAP病人的第二个死亡高峰。局部并发症包括急性胰周液体积聚（APFC）、急性坏死物积聚（ANC）、包裹性坏死（WON）及胰腺假性囊肿。外科治疗的指征主要是胰腺局部并发症继发感染或产生压迫症状。无菌性坏死积液无症状者无需手术治疗。手术治疗应遵循延期原则。感染性坏死可先行针对性抗生素治疗及B超或CT导向下经皮穿刺引流（PCD）。胰腺感染性坏死的手术方式可分为PCD、内镜、微创手术（主要包括小切口手术、视频辅助手术）及开放手术（包括经腹或经腹膜后途径的胰腺坏死组织清除并置管引流）。胰腺感染性坏死病情复杂多样,各种手术方式可遵循个体化原则单独或联合应用。     

《急性胰腺炎中西医结合诊疗指南》解读

中西医结合治疗急性胰腺炎（acute pancreatitis,AP）已有50余年的历史,AP已成为中西医结合治疗领域的优势专病病种,在多年的临床应用实践中,逐渐形成了一套相对成熟完备的治疗体系。基于此,2022年由中国中西医结合学会、中华医学会和中华中医药学会提出,在《急性胰腺炎中西医结合诊疗的团体标准》基础上,更新并制订了《急性胰腺炎中西医结合诊疗指南》。该指南凝练了25个重要的临床问题,以此为导向,具体阐述了AP的诊断和治疗,重点阐释了AP的中医分期与辨证、早期液体疗法、疼痛管理、器官支持等早期诊疗时中西医结合的具体方式、手段和作用,强调了中医药的早期优势及尽早干预的时机问题,并就营养支持、病因的管理、后期局部并发症及感染的处理,以及预防复发、远期并发症的随访策略方面提出建议。本文就该指南进行解读。     

2018年版慢性胰腺炎诊治指南解读

正慢性胰腺炎(chronic pancreatitis, CP)是一种复杂难治的胰腺疾病,其主要特点包括机制不清、临床症状顽固、缺乏有效治疗药物、患者需终身治疗。近年来,慢性胰腺炎在全球的发病率不断上升,病因、发病机制和诊疗方式不断更新,美国、日本和欧洲相继颁发了多部临床诊疗指南。2018年3月16日,由中国医师协会胰腺病专业委员会慢性胰腺炎专委会召开第一次学组会议,牵头组织消化内科、胆胰外科、影像科、病理科、内分泌科等多学科专家,对当前     

重症急性胰腺炎诊治指南

中华医学会外科学分会胰腺外科学组于2000年制定的我国《重症急性胰腺炎诊治草案》（以下简称“草案”）在全国实施以来得到了很好的效果。近年来,由于医学科技的迅速发展,新的概念和新的治疗措施不断推出,其中一些已经比较成熟且行之有效。为此,在2004年召开的第十次全国胰腺外科学术研讨会上,     

2014年欧洲加速康复外科协会《胃切除术加速康复外科指南》热点问题解读

加速康复外科(ERAS)是近年来新兴的围术期一系列优化处理措施.该学科以减少手术患者的创伤应激,减少术后并发症,加快患者康复为目标.它是一系列有效措施的组合而产生的协同结果.2014年7月,欧洲加速康复外科协会根据最新循证医学证据组织专家制订了《胃切除术加速康复外科指南》.现就该指南中热点问题做一简要解读,以期为我国该领域的临床工作提供循证医学证据.     

急性胰腺炎的诊治共识解读

1992年亚特兰大研讨会提出了一个全球性共识和普遍适用的急性胰腺炎分类系统,虽然其分类一直是有用的,但临床应用混乱。本文结合最新进展,对国际上最新修订亚特兰大成人急性胰腺炎(>18岁)的共识作一解读,主要论述急性胰腺炎的诊断标准、严重程度分类及急性胰腺炎出现并发症时胰腺及胰周影像学上的形态变化,并对中国中西医结合学会普通外科专业委员会最新制定的重症急性胰腺炎中西医结合诊治指南中的中医治疗做一研读。     

《日本急性胰腺炎治疗指南（2015）》评介

《日本急性胰腺炎治疗指南》发表于2006年,2010年进行了修订。结合2013年对亚特拉大分类重新评价的国际共识,2015年日本再次对其指南进行了更新修订。《日本急性胰腺炎治疗指南（2015）》针对17项与诊治相关的临床领域,以循证医学为指导原则,设计了39个临床具体问题及43条推荐意见。针对抗生素的预防性应用、胰管支架留置在预防内镜逆行胰胆管造影（ERCP）后胰腺炎中的作用、非甾体抗炎药物在预防ERCP后胰腺炎中的作用、腹腔灌洗对改善病人预后的作用等4个课题重新进行了荟萃分析。《日本急性胰腺炎治疗指南（2015）》较为全面地总结概括了急性胰腺炎临床诊治的指导原则,反映了急性胰腺炎治疗现状与进展,值得参考、学习和借鉴。     

急性胆源性胰腺炎41例外科治疗临床体会

目的探讨急性胆源性胰腺炎(acute biliary pancreatitis ABP)外科治疗的时机与方法。方法 41例ABP患者均采用外科手术治疗。结果本组41例患者均获治愈。结论对ABP的治疗应根据其病情与类型而定,对伴有胆总管下端梗阻或胆道感染的重症ABP应急诊或早期(72 h)手术,对不伴胆道完全梗阻、胆管炎的重症ABP患者,早期采取保守治疗,手术尽量延至病情稳定后。对急性水肿性ABP可经保守治疗,病情稳定后2～4周行胆道手术,但保守治疗期间若出现胆管炎、胆囊坏疽或穿孔应急诊手术。     

JPN Guidelines for the management of acute pancreatitis: diagnostic criteria for acute pancreatitis

The currently used diagnostic criteria for acute pancreatitis in Japan are presentation with at least two of the following three manifestations: (1) acute abdominal pain and tenderness in the upper abdomen; (2) elevated levels of pancreatic enzyme in the blood, urine, or ascitic fluid; and (3) abnormal imaging findings in the pancreas associated with acute pancreatitis. When a diagnosis is made on this basis, other pancreatic diseases and acute abdomen can be ruled out. The purpose of this article is to review the conventional criteria and, in particular, the various methods of diagnosis based on pancreatic enzyme values, with the aim of improving the quality of diagnosis of acute pancreatitis and formulating common internationally agreed criteria. The review considers the following recommendations: — Better even than the total blood amylase level, the blood lipase level is the best pancreatic enzyme for the diagnosis of acute pancreatitis and its differentiation from other diseases. — A pivotal factor in the diagnosis of acute pancreatitis is identifying an increase in pancreatic enzymes in the blood. — Ultrasonography (US) is also one of the procedures that should be performed in all patients with suspected acute pancreatitis. — Magnetic resonance imaging (MRI) is one of the most important imaging procedures for diagnosing acute pancreatitis and its intraperitoneal complications. — Computed tomography (CT) is also one of the most important imaging procedures for diagnosing acute pancreatitis and its intraabdominal complications. CT should be performed when a diagnosis of acute pancreatitis cannot be established on the basis of the clinical findings, results of blood and urine tests, or US, or when the etiology of the pancreatitis is unknown. — When acute pancreatitis is suspected, chest and abdominal X-ray examinations should be performed to determine whether any abnormal findings caused by acute pancreatitis are present. — Because the etiology of acute pancreatitis can have a crucial influence on both the treatment policy and severity assessment, it should be evaluated promptly and accurately. It is particularly important to differentiate between gallstone-induced acute pancreatitis, which requires treatment of the biliary system, and alcohol-induced acute pancreatitis, which requires a different form of treatment.     

腹腔镜胆囊切除术后早期急性胰腺炎的诊断与处理

目的探讨腹腔镜胆囊切除（laparoscopic cholecystectomy,LC）术后早期胰腺炎的临床特点及治疗措施。方法1998年4月～2006年6月,行LC18470例,术后早期（〈14d）急性胰腺炎16例（0.09%）。对于无胆道梗阻的病例,采取综合保守治疗（胃肠减压、抗感染、应用生长抑素等）;如明确有胆道梗阻,则行开腹胆总管探查术。结果14例保守治疗治愈,住院时间8～22d,平均12d;开腹手术2例。无围手术期死亡。16例随访5个月～3年,平均14个月,无胰腺炎、胆总管结石复发。结论LC术后在不恰当饮食等各种诱因作用下早期易并发以腹痛为主要表现的急性胰腺炎,多数经保守治疗可取得很好的效果。     

2013年国际胰腺病学会与美国胰腺病学会《急性胰腺炎治疗的循证性指南》解读

急性胰腺炎（AP）是世界范围内常见的需急诊入院救治的急腹症之一,其重症患者病死率高达30％,合理的诊断和治疗需要最新循证医学的证据。白2002年国际胰腺病学会（IAP）公布《IAP急性胰腺炎外科治疗指南》以来,AP的诊断和治疗有了实质性进展。2013年IAP与美国胰腺病协会（APA）根据最新循证医学证据联合制订了《急性胰腺炎治疗的循证性指南》。现就该指南的更新并对比相关指南的变化做一解读。     

JPN Guidelines for the management of acute pancreatitis: cutting-edge information

The JPN Guidelines for the Management of Acute Pancreatitis are organized under the subject headings: epidemiology, diagnosis, management strategy, severity assessment and transfer criteria, management of gallstone pancreatitis, nonsurgical management, and surgical management. The Guidelines contain cutting-edge information on each of these subjects, as well as a section on the Japanese medical insurance system which provides information that should prove useful to physicians in other countries. The quality of the evidence was evaluated by the evidence-based classification method used at the Cochrane Library. The levels of recommendation of the individual management methods contained in the Guidelines were determined on the basis of the evaluation of evidence by the consensus of the members of the Working Group (see below). The Japanese Society for Abdominal Emergency Medicine, the Japan Pancreas Society, and the Research Group for Intractable Diseases and Refractory Pancreatic Diseases (which is sponsored by the Japanese Ministry of Health, Labour, and Welfare) were commissioned to produce the JPN Guidelines for the Management of Acute Pancreatitis. A Working Group of 20 physicians specializing in pancreatic diseases and emergency medicine investigated and analyzed 14821 cases retrieved by means of a Medline (1960–2004) search and discussed the available literature on acute pancreatitis (limited to human pancreatitis). The Working Group held many general discussions in order to reach a consensus on the content of the Guidelines. After producing a draft, the Publishing Committee of the JPN Guidelines for the Management of Acute Pancreatitis posted it on a website and asked for comments and criticisms. Subsequently, a final version of the Guidelines was published in Japanese in 2003. The Publishing Committee is now making the Guidelines available to a much wider readership by bringing out an English version.     

JPN Guidelines for the management of acute pancreatitis: severity assessment of acute pancreatitis

This article addresses the criteria for severity assessment and the severity scoring system of the Ministry of Health and Welfare of Japan; now the Japanese Ministry of Health, Labour, and Welfare (the JPN score). It also presents data comparing the JPN score with the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Ranson score, which are the major measuring scales used in the United States and Europe. The goal of investigating these scoring systems is the achievement of earlier diagnosis and more appropriate and successful treatment of severe or moderate acute pancreatitis, which has a high mortality rate. This article makes the following recommendations in terms of assessing the severity of acute pancreatitis: (1) Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis (Recommendation A). (2) Assessment by a severity scoring system (JPN score, APACHE II score) is important for determining treatment policy and identifying the need for transfer to a specialist unit (Recommendation A). (3) C-reactive protein (CRP) is a useful indicator for assessing severity (Recommendation A). (4) Contrast-enhanced computed tomography (CT) scanning and contrast-enhanced magnetic resonance imaging (MRI) play an important role in severity assessment (Recommendation A). (5) A JPN score of 2 or more (severe acute pancreatitis) has been established as the criterion for hospital transfer (Recommendation A). (6) It is preferable to transfer patients with severe acute pancreatitis to a specialist medical institution where they can receive continuous monitoring and systemic management.     

JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis

The basic principles of the initial management of acute pancreatitis are adequate monitoring of vital signs, fluid replacement, correction of any electrolyte imbalance, nutritional support, and the prevention of local and systemic complications. Patients with severe acute pancreatitis should be transferred to a medical facility where adequate monitoring and intensive medical care are available. Strict cardiovascular and respiratory monitoring is mandatory for maintaining the cardiopulmonary system in patients with severe acute pancreatitis. Maximum fluid replacement is needed to stabilize the cardiovascular system. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with necrotizing pancreatitis. Although the efficacy of the intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional measures, blood purification therapy and continuous regional arterial infusion of a protease inhibitor and antibiotics, depending on the patient's condition.     

胆源性胰腺炎手术时机的探讨

目的探讨胆源性胰腺炎（ＧＰ）的手术时机。方法采用统计学方法分析了５３例ＧＰ的临床资料。结果早期手术组（入院４８小时内）及延期手术组（入院４８小时后）并发症发生率分别为２９．２０％和３．５０％（Ｐ＜０．０５）;死亡率分别为８．３０％和０（Ｐ＜０．０５）。ＡＰＡＣＨＥ－Ⅱ记分≤８的轻型ＧＰ死亡率与手术时机无关,但早期手术组的并发症发生率（１１．１０％）及胆总管探查率（９１．７０％）明显高于延期手术组（Ｐ＜０．０５）。ＡＰＡＣＨＥ－Ⅱ记分＞８的重型ＧＰ并发症发生率及死亡率与手术时机有关,即早期手术组明显高于延期手术组。结论轻型ＧＰ应待急性发作缓解后延期手术;重型ＧＰ应采用延期与个体化相结合的处理原则。     

JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis

Gallstones, along with alcohol, are one of the primary etiological factors of acute pancreatitis, and knowledge of the etiology as well as the diagnosis and management of gallstones, is crucial for managing acute pancreatitis. Because of this, evidence regarding the management of gallstone-induced pancreatitis in Japan was collected, and recommendation levels were established by comparing current clinical practices with optimal clinical practices. The JPN Guidelines for managing gallstone-induced acute pancreatitis recommend two procedures: (1) an urgent endoscopic procedure should be performed in patients in whom biliary duct obstruction is suspected and in patients complicated by cholangitis (Recommendation A); and (2) after the attack of gallstone pancreatitis has subsided, a laparoscopic cholecystectomy should be performed during the same hospital stay (Recommendation B).