非感染性坏死性胰腺炎手术时机的探讨--附62例临床病例报告

目的探讨急性重症胰腺炎非感染性胰腺坏死手术时机.方法对62例非感染性坏死性胰腺炎进行临床和CT评估以决定手术指征,根据手术发现对手术治疗的时机进行评估分析.结果经CT评估病灶大于6 cm、术前诊断为非感染性胰腺坏死41例患者中,32例发病3 ～ 4周后手术治疗.术中发现大网膜及肠系膜根部见大量皂化斑,正常胰腺与坏死胰腺组织分界清楚,10例患者胰腺坏死已合并感染,感染发生率为25%;术后5例患者死亡,病死率为12%;发病2周内手术治疗的9例患者,术中发现正常胰腺组织与坏死胰腺组织之间分界不十分清楚,胰腺及胰周组织水肿明显,术后有1例患者死亡.CT评估病灶小于6 cm,但胰周及腹膜后大片脂肪坏死、液体积聚、消化道有压迫梗阻症状的21例患者全部于发病后3 ～ 4周手术治疗,术中见4例患者胰腺坏死合并感染,3例有粘连性或压迫性消化道梗阻,术后2例死于腹腔内感染和多器官功能衰竭.结论对急性胰腺炎非感染性胰腺坏死,是否需要手术清除坏死组织,应行定期CT评估分析,对于病灶大于6 cm和/或病灶不足6 cm但胰周及腹膜后大片脂肪坏死、液体积聚并有消化道压迫梗阻症状患者,应行手术治疗.手术时机宜在发病后3 ～ 4周.过早手术,坏死组织与正常组织尚未完全分离,术中易出血,增加手术难度和再次手术的机会;过迟手术,坏死组织已合并感染,腹腔内感染严重,需再次手术甚至多次手术.     

感染性心内膜炎手术时机分析

目的回顾性分析感染性心内膜炎病人的临床资料,发现影响手术死亡率和术后呼吸支持时间的重要因素。方法用SPSS11统计学软件分析中山大学附属第一医院近10年住院确诊感染性心内膜炎的手术病人资料。结果影响感染性心内膜炎77例手术死亡率的有意义的因素包括心功能、营养分级和血培养阳性,而术前抗生素的使用时间未发现相关。难以控制感染性心内膜炎的治疗,内科处理7d及超过7d再行手术死亡率分别为1/3和4/6,差异无统计学意义(P>0.05)。结论感染性心内膜炎病人应积极进行术前准备及早手术治疗。     

急性水肿型胆源性胰腺炎46例手术时机探讨

老年胰腺炎是一种非常严重的外科疾病。在我国 ,5 0 %～ 70 %老年胰腺炎为胆源性 ,而其中水肿型占 5 2 5 %。所以正确处理老年急性胆源性水肿型胰腺炎 (ＡＥＢＰＥ )对减少并发症、提高患者生存率 ,尤为重要。本文拟结合我科ＡＥＢＰＥ 46例诊治体会 ,对ＡＥＢＰＥ的手术时机进行探讨。1　 临床资料1.1　一般资料　我科于 1992年 3月至1999年 6月共收治ＡＥＢＰＥ患者 46例 ,占同期胰腺炎总数 6 4% ,其中女 3 2例 ,男 14例 ,年龄 60～ 92岁 ,平均 68 5岁。患者均有腹痛 ,血、尿淀粉酶增高 ,腹部Ｂ超提示胰腺肿胀、胆道结石。其中 3例有糖尿…     

急性坏死性胰腺炎治疗的临床分析

目的:对急性坏死性胰腺炎(ANP)的内、外科治疗进行临床分析。方法:对58例ANP进行了分析,其中非手术组15例,手术组43例。在治疗的以下几个方面进行了对比:在非手术组中是否使用胰液/胰酶抑制剂;在手术组中72小时内和72小时后手术;在抗生素治疗上,二联用药(头孢唑啉 甲硝唑)与多联用药。结果:非手术组中用过胰液分泌抑制剂或胰酶抑制剂者死亡率为12、5％,显著低于未用过胰液分泌抑制剂或胰酶抑制剂者(71.4％,P<0.05);手术组中72小时以内手术者死亡率为36.7％,显著低于72小时以上者(84.6％,P<0.01);抗生素治疗方面,二联用药(头孢唑啉 甲硝唑)与广谱、多联用药的死亡率无显著差异(P>0.05)。结论:由于胰液/胰酶抑制剂能降低轻症ANP的死亡率,轻症病人应积极采用胰液/胰酶抑制剂为主的综合治疗,重症病人应早期手术;而在抗生素治疗上,除非有严重感染,一般仅需二联用药,无需多种广谱抗生素联用。     

老年人急性坏死性胰腺炎155例临床特点及治疗体会

回顾性分析本院 2 0年来收治的 155例资料完整的老年急性坏死性胰腺炎 (ＡＮＰ)患者的临床资料 ,报道如下。　　一、资料与方法　　 1981～ 2 0 0 0年 ,共收治ＡＮＰ患者 2 76例 ,年龄 19～ 83岁 ,老年组 ( 60～ 83岁 ) 155例 ( 56 2 % ) ,其中 60～ 69岁 97例(占老年组的 62 6% ) ;非老年组 ( 19～ 59岁 ) 12 1例( 4 3 8% )。所有ＡＮＰ患者均符合全国胰腺会议 (成都市 ,19 96年 )诊断标准〔1〕。依据手术记录、ＣＴ检查统计胰腺坏死面积 :<3 0 %、3 1%～ 50 %、51%～ 10 0 %予以评价。病因、并发症、治疗情况依据病历记录统计。老年组行…     

重症急性胰腺炎治疗方法的临床探讨

目的探讨重症急性胰腺炎(severe acute pancreatitis，SAP)患者手术时机与指征。方法回顾性分析我院1999年1月～2004年1月79例SAP患者的治疗方法，手术时机选择与并发症发生率、病死率。结果 本组收集患者79例，其中非手术治疗28例，早期手术治疗33例，延期手术治疗18例。非手术组、早期手术组、延期手术组的并发症发生率分别为7．14％(2例)、33．33％(1l例)和11．11％(2例)，各组病死率分别为3．57％(1例)、15．15％(5例)和5．56％(1例)，早期手术组明显高于其他两组。结论 SAP的治疗选择是直接影响预后的重要因素，应根据SAP的病情实施个体化治疗方案。     

急性胆源性胰腺炎手术时机的选择

急性胰腺炎是临床常见的急腹症，发病原因以酒精和胆道疾患较常见。从2003年9月至2004年9月，我科共收治AP患者142例，其中胆源性胰腺炎（acute biliary pancreatitis，ABP）104例，占73．2％，手术73例。为探讨ABP最佳手术时机，我们进行了回顾性分析，现报告如下。     

急性坏死性胰腺炎的诊断和内科治疗

急性胰腺炎（ＡｃｕｔｅＰａｎｃｒｅａｔｉｔｉｓ,ＡＰ）是胰腺的急性炎症过程,常伴上腹部剧痛。在多数情况下,血中胰酶水平包括淀粉酶和脂肪酶增高,至少达到正常值上限的３倍。在临床上,根据其严重程度,可分为轻型和重型两大类。前者在诊断和治疗上均无困难,一般疗程为１～２周,患者多在１月内恢复,胃肠胰腺功能恢复正常。重型胰腺炎又称急性重症胰腺炎（ＡｃｕｔｅＳｅｖｅｒｅＰａｎｃｒｅａｔｉｔｉｓ,ＡＳＰ）或急性出血坏死性胰腺炎（ＡｃｕｔｅＨａｅｍｏｒｒｈａｇｉｃａｎｄＮｅｃｒｏｔｉｚ－ｉｎｇＰａｎｃｒｅａｔｉ…     

急性坏死性胰腺炎的免疫调节治疗

有关急性坏死性胰腺炎(ANP)炎症免疫学的研究为其免疫调节治疗提供了理论依据。免疫调节治疗正成为ANP综合治疗中一个重要组成部分,现介绍该领域近期研究进展。     

不同手术时机治疗老年胆源性急性胰腺炎的疗效比较

胆源性急性胰腺炎作为比较常见的临床疾病,但预后相对较差,临床上多采用手术治疗。老年胆源性急性胰腺炎患者多伴有不同程度的内科基础性疾病,给手术治疗带来不小的难度。本研究探讨不同手术时机对老年胆源性胰腺炎患者的疗效。1资料与方法1.1一般资料2009年9月至2012年9月我院老年胆源性胰腺炎患者60例,随机分为对照组(延期手术)和观察组(早期     

经皮置管负压冲洗联合内镜引流治疗重症急性胰腺炎合并胰腺坏死组织感染

目的 观察经皮置管负压冲洗联合内镜引流(PCD+ NPI+ ED)治疗重症急性胰腺炎(SAP)合并胰腺坏死组织感染(IPN)的临床效果.方法 回顾2011年7月至2012年7月经PCD+ NPI+ED联合技术治疗的17例合并IPN的SAP患者的临床资料,分析临床治疗过程及预后.结果 17例患者IPN确诊距发病时间为(26.9 ±7.9)d.13例革兰阴性菌感染,3例革兰阳性菌感染,1例侵袭性真菌感染.首次PCD+ NPI治疗距发病时间为(34.8±11.6)d.B超引导下置管1例,CT引导下置管8例,B超和CT联合引导下置管8例,每例患者平均所置负压冲洗引流管为(3.5±1.2)根.首次ED治疗距首次PCD+ NPI时间为(26.7 ±9.6)d,每例患者平均ED治疗(2.1 ±0.9)次.2例中转剖腹手术引流,距确诊IPN时间分别为24d和56 d.17例患者均无PCD+ NPI置管相关并发症发生,第1例患者在ED治疗过程中发生出血,ED治疗后2例并发十二指肠瘘,1例并发高位空肠瘘,1例并发降结肠瘘,2例腹腔出血.无新发脏器功能障碍和脓毒血症.1例在PCD+ NPI+ ED联合治疗前即并发多器官功能不全和脓毒血症,虽中转剖腹手术引流仍无法有效控制脓毒血症而病死.结论 PCD+ NPI+ ED联合技术可使IPN患者避免剖腹手术引流,减少并发症发生,改善患者预后.     

重症急性胰腺炎患者血清抵抗素水平与胰腺坏死的关系

目的 探讨重症急性胰腺炎(SAP)患者血清抵抗素水平与胰腺坏死之间的关系.方法 对四川大学华西医院2008年3月至2008年11月收治的28例SAP患者进行前瞻性研究,根据CT结果分为坏死组和非坏死组,用酶联免疫吸附试验(ELISA)检测患者入院时的血清抵抗素浓度.对血清抵抗素预测胰腺坏死做ROC曲线分析.结果 非坏死组21例,坏死组7例,两组性别、年龄、基础疾病之间差别无统计学意义(P＞0.05).26例SAP患者血清抵抗素浓度为(0.1730～7.4920)ng/ml,平均为(3.7102±1.6987)ng/ml.ROC曲线下面积为0.884±0.108,95%可信区间为0.672～1.097,渐近线信号0.003.据此得出P=0.003,＞0.50.结论 血清抵抗素可能对预测胰腺坏死有一定的临床应用价值.     

Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis: A randomized clinical trial

Background/objectivesThere is substantial evidence of superiority of enteral nutrition (EN) to parenteral nutrition in acute pancreatitis (AP) treatment, but few studies evaluated its effectiveness compared to no intervention. The objective of our trial was to compare the effects of EN to a nil-by-mouth (NBM) regimen in patients with AP.MethodsPatients with AP were randomized to receive either EN via a nasojejunal tube initiated within 24 h of admission or no nutritional support. Systemic inflammatory response syndrome (SIRS) was assessed as the primary outcome. Secondary outcomes included mortality, organ failure, local complications, infected pancreatic necrosis, surgical interventions, length of hospital stay, adverse events and inflammatory response intensity. Outcomes were compared using Student's t-test and Mann–Whitney U test as appropriate.Results214 patients were randomized in total, 107 to each group. SIRS occurrence was similar between groups, with 48 (45%) versus 51 (48%), respectively (RR 0.94; 95% CI 0.71–1.26). No significant reduction of persistent organ failure (RR 0.81; 95% CI 0.52–1.27) and mortality (RR 0.59; 95% CI 0.28–1.23) was present in the EN group. There were no significant differences in other outcomes between the groups. When analyzing the occurrence of SIRS and mortality in subgroup of patients with severe disease no significant differences were noted.ConclusionOur results showed no significant reduction of persistent organ failure and mortality in patients with AP receiving early EN compared to patients treated with no nutritional support (NCT01965873).     

胸腔积液联合血液浓缩对急性胰腺炎严重度评估的临床价值

目的：探讨胸腔积液、血液浓缩和二者的联合应用对急性胰腺炎疾病严重程度的评估价值，并观察胸腔积液与急性胰腺炎病因，并发症及死亡率的关系。方法：对136例急性胰腺炎住院患者作回顾性分析，急性胰腺腺炎及其严重度评估的标准依据患者的临床表现，实验室检查及增强CT检查。记录患者的胸片和红细胞压积检测结果，并分析胸腔积液与急性胰腺炎患者的病因，并发症及预后的相关性。结果：轻型急性胰腺炎（MAP）96例，重症急性胰腺炎（SAP）40例。SAP患者合并胸腔积液者18例（45％），有血液浓缩现象者6例（15％），胸腔积液和血液浓缩同时存在者5例（12．5％）；MAP患者合并胸腔积液者10例（10．4％），血液浓缩者2例（2．1％），无胸腔积液和血液浓缩同时存在者，两者相比有显著性差异（P＜0．01）；此外，胆源性急性胰腺炎合并胸腔积液者11例（14．4％），酒精性急性胰腺炎合并胸腔积液者5例（48．1％），P＜0．05，结论：胸腔积液，血液浓缩均可作为SAP的独立预测指标，但以胸腔积液联合血液浓缩最为准确。胸腔积液与酒精性急性胰腺炎的病因具有明显的相关性，但未发现胰腺局部并发症如胰腺假性囊肿以及患者死亡率与胸腔积液的关系。     

Factors and outcomes associated with pancreatic duct disruption in patients with acute necrotizing pancreatitis

Background and aimsAcute necrotizing pancreatitis (ANP) can affect main pancreatic duct (MPD) as well as parenchyma. However, the incidence and outcomes of MPD disruption has not been well studied in the setting of ANP.MethodsThis retrospective study investigated 84 of 465 patients with ANP who underwent magnetic resonance cholangiopancreatography and/or endoscopic retrograde cholangiopancreatography. The MPD disruption group was subclassified into complete and partial disruption.ResultsMPD disruption was documented in 38% (32/84) of the ANP patients. Extensive necrosis, enlarging/refractory pancreatic fluid collections (PFCs), persistence of amylase-rich output from percutaneous drainage, and amylase-rich ascites/pleural effusion were more frequently associated with MPD disruption. Hospital stay was prolonged (mean 55 vs. 29 days) and recurrence of PFCs (41% vs. 14%) was more frequent in the MPD disruption group, although mortality did not differ between ANP patients with and without MPD disruption. Subgroup analysis between complete disruption (n = 14) and partial disruption (n = 18) revealed a more frequent association of extensive necrosis and full-thickness glandular necrosis with complete disruption. The success rate of endoscopic transpapillary pancreatic stenting across the stricture site was lower in complete disruption (20% vs. 92%). Patients with complete MPD disruption also showed a high rate of PFC recurrence (71% vs. 17%) and required surgery more often (43% vs. 6%).ConclusionsMPD disruption is not uncommon in patients with ANP with clinical suspicion on ductal disruption. Associated MPD disruption may influence morbidity, but not mortality of patients with ANP. Complete MPD disruption is often treated by surgery, whereas partial MPD disruption can be managed successfully with endoscopic transpapillary stenting and/or transmural drainage. Further prospective studies are needed to study these items.     

Walled-off pancreatic necrosis: Wishing our pancreatitis nomenclature was correct

The ultimate reason why pancreatologists have strived to establish definitions for inflammatory pathologies of the pancreas is to improve patient care.Although the Atlanta Classification has been used for around for 17 years,considerable misunderstanding of the key elements of the nomenclature still persists.While a recent article by Stamatakos et al aimed to deal with an entity not clearly def ined in the 1993 document,it is replete with factual and conceptual errors as well as contradictory statements.     

Interventional strategies in infected necrotizing pancreatitis: Indications,timing, and outcomes

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.     

重症急性胰腺炎早期死亡因素分析

目的探讨与重症急性胰腺炎（SAP）死亡相关的早期危险因素。方法回顾性分析自2001年1月～2005年12月收治的86例SAP患者。根据预后不同将SAP患者分为生存组和死亡组，分别对两组患者入院24h内临床和实验室检查资料进行对比及Logistic回归分析。结果死亡组19例的APACHE Ⅱ评分、24h内尿量、血肌酐、动脉血氧分压、血浆凝血功能及腹水发生率与生存组67例相比较．差异有统计学意义（P〈0．01）．血糖、血三酰甘油、血清白蛋白、血钙、血pH值、入院时呼吸频率、心率及麻痹性肠梗阻发生率差异也有统计学意义（P〈0．05）．而年龄、性别、平均动脉压、血尿淀粉酶、白细胞、红细胞压积、血小板及肝功能无显著差异。经多因素Logistic回归分析显示．腹水、动脉血氧分压、血清白蛋白和SAP死亡相关。结论腹水、动脉血氧分压和血清白蛋白是SAP死亡独立的早期危险因素。     

经皮置管与负压冲洗引流治疗重症急性胰腺炎合并胰腺坏死组织感染

目的 观察经皮置管加负压冲洗引流治疗重症急性胰腺炎(SAP)合并胰腺坏死组织感染(IPN)的临床效果.方法 回顾性分析2010年1月至2011年12月治疗的71例SAP合并IPN患者的临床资料,根据采取的置管引流疗式分为经皮置管引流(PCD)组(52例)和PCD+负压冲洗(NPI)组(19例).PCD组置入猪尾巴引流管间断冲洗引流IPN;PCD+ NPI组置入负压冲洗引流管持续负压冲洗引流IPN.中转开腹手术指征为置管引流3d后全身情况无改善;出现脓毒性休克、腹腔大出血、消化道瘘等并发症;引流3周后IPN缩小的范围≤1/2.结果 PCD+ NPI组中转开腹手术率为15.8％(3/19),明显低于 PCD组48.1％ (25/52,P＜0.05);内镜引流7例(36.8％),明显多于PCD组0例(P＜0.01);首次置管距中转开腹手术时间为(22±11)d,明显晚于 PCD组的(10±6)d(P ＜0.05).两组每例平均置管次数及置管根数、开腹手术次数、开腹手术并发症发生率的差异均无统计学意义.PCD+NPI组病死率为15.8％ (3/19),PCD组为13.5％( 7/52),两组差异无统计学意义.PCD+ NPI组患者的ICU治疗天数、住院天数、住院费用均低于 PCD组,但差异无统计学意义 结论 PCD+ NPI可有效降低IPN患者中转开腹手术率.