如何掌握急性胰腺炎的手术时机

急性胰腺炎的手术时机为什么在急性胰腺炎治疗过程中是一个重要问题?而其他外科急腹症的手术时机是不存在讨论的,只要明确诊断及时手术。因为急性胰腺炎有轻型(水肿型)和重型(坏死型)之分,轻型一般毋需手术治疗,只要通过内科治疗可以痊愈。相反,重型胰腺炎在疾病的治疗过程中常常需     

急性胰腺炎并发十二指肠梗阻的外科治疗

目的 探讨急性胰腺炎并发十二指肠梗阻的诊断及治疗。方法 对6例急性胰腺炎并发十指肠梗阻病人的临床资料进行回顾性分析。结果 2例病人施行胃空肠吻合加迷走神经干切断术，无手术并发症，1例施行胃大部切除术，术后发生十二指肠残端瘘；1例行胃空肠吻合术，因同时伴有胆总管下段坏死，术后并发十二指肠瘘及胆汁瘘，经非手术治疗痊愈，2例非手术治疗痊愈。结论 要提高对急性胰腺炎并发十二指肠梗阻的认识。及时诊断，如需手术治疗，以行迷走神经干切断加胃空肠吻合为宜。     

急性重型胰腺炎脂质过氧化物、SOD代谢变化及中西医结合治疗对其代谢影响

应用中西医结合治疗急性重型胰腺炎，测定治疗前、后重型胰腺炎病人血浆脂质过氧化物及红细胞内ＳＯＤ代谢变化。结果表明：急性重型胰腺炎病人血浆ＬＰＯ明显高于轻症病人（Ｐ＜０．０１），轻症病人高于健康人（Ｐ＜０．０５），而红细胞内ＳＯＤ的变化与之相反（Ｐ＜０．０５）。中西医结合治疗可降低重症病人血浆ＬＰＯ，提高红细胞ＳＯＤ的水平。     

急性重型胰腺炎脂质过氧化物,SOD代谢变化及中西医？…

应用中西医结合治疗急性重型胰腺炎，测定治疗前、后重型胰腺炎病人血浆脂质过氧化物及红细胞内ＳＯＤ代谢变化。结果表明：急性重型胰腺炎病人血浆ＬＰＯ明显高于轻症病人（Ｐ〈０．０１），轻症病人高于健康人（Ｐ〈０．０５），而红细胞内ＳＯＤ的变化与之相反（Ｐ〈０．０５）。中西医结合治疗可降低重症病人血浆ＬＰＯ，提高红细胞ＳＯＤ的水平。     

妊娠合并急性胰腺炎

目:探讨妊娠合并急性胰腺炎的临床特点，治疗原则及预防措施，方法：回顾性分析11例妊娠合并急性胰腺炎的发病特点，辅助检查，治疗方法及结局。结果：8例轻型采用保守治疗，无一例因胰腺炎行剖宫产术，母婴均健康出院；3例重型中2例保守治疗后病情加重，行剖宫产术，1例孕30周，发病1d后胎死宫内，自然分娩，行ERCP乳头切开，胰腺及腹腔引流术，孕妇均治愈。结论：动态观察血尿淀粉酶及B超或CT检查对胰腺炎诊断有重要价值。妊娠合并轻型胰腺炎不是剖宫指征，保守治疗效果好；妊娠合并重型胰腺炎一般需尽早剖宫产终止妊娠，除保守治疗外，适当行胆石清除及引流术，轻型胰腺炎不是剖宫产指征。     

急性胰腺炎合并妊娠36例

目的：探讨急性胰腺炎合并妊娠的诊治特点。方法：回顾分析1998年12月—2008年12月收治的36例急性胰腺炎合并妊娠临床资料。结果：6例妊娠大于37周,急诊终止妊娠;8例妊娠35～37周,经积极保守治疗后,剖宫产终止妊娠;7例胎儿已经在子宫内死亡,予引产;4例妊娠刚过27周,发生难免流产;3例手术重型胰腺炎均为死胎,2例行剖宫产术,1例行毁胎术;8例重型胰腺炎中4例并发MOF死亡,3例死亡于呼吸循环衰竭,1例死于消化道出血,均为死胎。28例轻型胰腺炎产妇顺利出院。结论：及时迅速诊断急性胰腺炎合并妊娠并合理地治疗,适时终止妊娠,可确保母婴安全。     

重症急性胰腺炎术后死亡31例分析

目的：分析重症急性胰腺炎病人术后死亡的原因.方法:回顾总结近5年来本院收住手术的119例重症急性胰腺炎病人的资料.结果:术后31例(占24.3%)重症急性胰腺炎术后死亡,死亡原因主要是并发症,包括:成人呼吸窘迫综合征(ARDS)、多器官功能衰竭(MOF)、急性肾功能衰竭、腹腔脓肿、脓毒症、出血及肠瘘等.结论:降低重症胰腺炎术后死亡率的关键在于对并发症的积极预防、及时诊断和有效治疗.     

高淀粉酶血性腹水在急性重型胰腺炎早期诊断的价值

高淀粉酶血性腹水在急性重型胰腺炎早期诊断的价值陈伟宏，张振海，罗鸣云，尚培中急性重型胰腺炎早期诊断与手术，是降低病死率最有效的方法之一。我院自１９８５年以来，将全部确诊的急性胰腺炎采取腹水肉眼血性观察及淀粉酶定量研究，认为高淀酶血性腹水对急性重型胰腺...     

迟发性腹腔室隔综合征的诊断和治疗

目的探讨重症急性胰腺炎病人并发迟发性腹腔室隔综合征的诊断和治疗方法。方法回顾性分析301例重症急性胰腺炎患者，5例在感染期发生迟发性腹腔室隔综合征。2例早期患者采用非手术治疗，3例后期患者一经诊断后，即行手术减压治疗。结果非手术治疗患者．均于迟发性腹腔室隔综合征发生后1～2d死亡；手术患者，均得以存活，总体死亡率达40％。结论重症急性胰腺炎病人并发迟发性腹腔室隔综合征具有极高的死亡率；早期诊断并及时治疗迟发性腹腔室隔综合征对抢救生命具有重要意义。     

内镜下括约肌切开术治疗急性胰腺炎的护理

为了提高急性胰腺炎病人的治疗效果，对10例急性胰腺炎病人行内镜下括约肌切开术治疗。同时做好术前准备及术后常规、饮食、引流管护理和并发症护理。结果10例病人术后住院8－21d痊愈出院，随访3－6个月，无复发，提示内镜下括约肌切开术治疗急性胰腺炎疗效好，高质量的术前，术后护理是手术成功的重要保证。     

JPN Guidelines for the management of acute pancreatitis: surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.     

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。     

Management strategy for acute pancreatitis in the JPN Guidelines

The diagnosis of acute pancreatitis is based on the following findings: (1) acute attacks of abdominal pain and tenderness in the epigastric region, (2) elevated blood levels of pancreatic enzymes, and (3) abnormal diagnostic imaging findings in the pancreas associated with acute pancreatitis. In Japan, in accordance with criteria established by the Japanese Ministry of Health, Labour, and Welfare, the severity of acute pancreatitis is assessed based on the clinical signs, hematological findings, and imaging findings, including abdominal contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). Severity must be re-evaluated, especially in the period 24 to 48 h after the onset of acute pancreatitis, because even cases diagnosed as mild or moderate in the early stage may rapidly progress to severe. Management is selected according to the severity of acute pancreatitis, but it is imperative that an adequate infusion volume, vital-sign monitoring, and pain relief be instituted immediately after diagnosis in every patient. Patients with severe cases are treated with broad-spectrum antimicrobial agents, a continuous high-dose protease inhibitor, and continuous intraarterial infusion of protease inhibitors and antimicrobial agents; continuous hemodiafiltration may also be used to manage patients with severe cases. Whenever possible, transjejunal enteral nutrition should be administered, even in patients with severe cases, because it seems to decrease morbidity. Necrosectomy is performed when necrotizing pancreatitis is complicated by infection. In this case, continuous closed lavage or open drainage (planned necrosectomy) should be the selected procedure. Pancreatic abscesses are treated by surgical or percutaneous drainage. Emergency endoscopic procedures are given priority over other methods of management in patients with acute gallstone-associated pancreatitis, patients suspected of having bile duct obstruction, and patients with acute gallstone pancreatitis complicated by cholangitis. These strategies for the management of acute pancreatitis are shown in the algorithm in this article.     

妊娠期急性胰腺炎的诊断和治疗：附48例报告

目的 探讨妊娠期急性胰腺炎的临床特点和诊断与处理原则.方法 回顾性分析8年收治的妊娠期急性胰腺炎48例的临床资料.38例行非手术治疗(治愈36例);10例手术治疗,手术以清除坏死组织和终止妊娠为主.结果 全组以单纯性胰腺炎居多,占64.58%(31/48).孕妇死亡5例(10.42%).胎儿死亡3例(6.25%),均为重症胰腺炎患者.孕妇合并重症胰腺炎的病死率为29.41%.结论 妊娠期急性胰腺炎属于发病率不高,但病死率较高的严重疾患,是妊娠合并外科急腹症死亡的首位因素.该病治疗以非手术治疗为主,病情严重者应及时手术治疗,并不因妊娠而改变手术指征.治疗中同时需顾及孕妇和胎儿的安全.     

Acute pancreatitis associated with primary hyperparathyroidism

Coexistence of primary hyperparathyroidism and acute pancreatitis has widely been reported in literature, but a causal relationship remains controversial. A case of acute pancreatitis as a first symptom of primary hyperparathyroidism with severe hypercalcemia is reported. In this patient a reduction of serum calcium level was obtained with medical therapy and resulted in the resolution of acute pancreatitis symptoms within 10 days. At the same time a parathyroid adenoma was clinically identified and elective parathyroidectomy was performed with complete normalization of intact parathyroid hormone and serum calcium level. At three-year follow-up, no recurrence or complications of pancreatitis were documented. The presented case suggests a cause and effect relationship between acute pancreatitis and severe hypercalcemia which should be kept in mind in the differential diagnosis of non-biliary, non-alcoholic acute pancreatitis. Reduction of hypercalcemia with medical treatment can represent a good chance for elective surgical neck exploration.     

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胰腺炎病人原则上应住院接受治疗,需密切监测病人的意识状态、心肺功能及尿量的变化,给予充分的液体复苏和镇痛等,同时要进行病因学评估和疾病严重性评估。对于重症急性胰腺炎病人应进入重症医学科治疗,接受器官功能监护、血液净化以及营养支持等。胰腺炎诊断48 h内应反复评估病情的严重程度,参考血流动力学指标的变化,给予病人充分的液体复苏,恢复血流动力学稳定。重症急性胰腺炎病人在行液体复苏时,通常需要大量的液体才能稳定病人的血流动力学指标。为防治重症急性胰腺炎病人的感染性并发症,建议预防性应用抗生素。为防治器官功能障碍和其他并发症,可应用大剂量的合成蛋白酶抑制剂。重症急性胰腺炎病人的营养支持应首选肠内营养。对于重症急性胰腺炎病人,可选择应用持续动脉灌注治疗和持续血液净化治疗。     

Severe acute pancreatitis. Clinical, diagnostic, and therapeutic features

BACKGROUND: The aim of this study is to define the actual role of surgical therapy in severe acute necrotizing pancreatitis. METHODS: A retrospective analysis has been carried out on the surgical treatment of severe acute pancreatitis at the Institute of General Surgery and Surgical Specialties, University of Siena (Italy). From January 1980 to December 1997, 230 patients affected by acute pancreatitis were admitted to institution: 24 patients affected by severe disease (necrotizing pancreatitis: clinical and radiological diagnosis, by CT-scan) was choosen for this study. Of 24 patients, 15 were males and 9 females, with mean age of 55 years (range 30-80). In all cases, surgical procedure consisted in pancreatic necrosectomy, multiple abdominal and retroperitoneal drainage and closed management; operated patients with biliary pancreatitis underwent colecystectomy and, if necessary, common biliary duct drainage. RESULTS: The patients underwent surgical procedure, but the remaining 14 were treated by intensive medical care: mortality in these two groups was respectively 40% (4 cases) and 21% (3 cases). CONCLUSION: The conclusion is drawn that intensive medical care is the first therapeutic approach in severe acute pancreatitis, reserving surgery only to selected cases, as those affected by pancreatic infectes necrosis or those who get worse despite of conservative therapy. As to surgical technique, closed procedures vs open or semiopen, and conservative surgery (necrosectomy, multiple drainage and abdominal washing) vs anatomical resection are preferred.     

妊娠并发高血脂性重症胰腺炎的诊治

【摘要】 目的 探讨妊娠并发高血脂性重症胰腺炎(hyperlipidemic severe acute pancreatitis,HLSAP）临床诊断与治疗特点。方法 回顾性分析2002年1月一2013年1月广州医学院第三附属医院收治妊娠并发高血脂性重症胰腺炎患者27例临床资料。结果 27例患者,死亡4例,治愈23例,治愈率85．1％。手术治疗17例,应用血液透析滤过治疗21例,存活病例平均住院43天。结论 妊娠并发高血脂性重症胰腺炎的治疗以主要致力于降低TG含量、治疗胰腺炎、保护孕妇和胎儿为主;及时制定适合妊娠期高脂血症性重症胰腺炎的综合性治疗方案,慎重地选择外科手术时机及手术方式,同时多学科协作抢救有利于提高疗效。     

创伤性重症急性胰腺炎早期手术与非手术治疗时机选择的临床研究

目的 探讨创伤性重症急性胰腺炎患者的手术治疗与非手术治疗疗效.方法 回顾分析36例创伤性重症急性胰腺炎患者的临床资料.结果 36例创伤性重症急性胰腺炎患者手术组21例,死亡2例,病死率为9.52%,非手术组15例,死亡5例,病死率为33.33%,非手术组病死率高于手术组,有统计学差异(P＜0.05).结论 对必须手术治疗的创伤性重症急性胰腺炎,及时手术就能够明显提高创伤性重症急性胰腺炎的治愈率.     

EST严重并发症的外科治疗

目的探讨EST术后严重并发症的外科治疗。方法收治14例EST术后并发严重出血、穿孔、胰腺炎病人。其中单纯出血5例，单纯穿孔5例，穿孔伴出血3例，穿孔伴重症胰腺炎1例。结果单纯出血4例、单纯穿孔5例、穿孔伴出血2例病人存活。单纯出血1例、穿孔伴出血2例及穿孔伴重症胰腺炎1例病人死亡。结论早期诊断，积极手术是降低死亡率的关键。对穿孔伴出血或胰腺炎的病人，为减少胆汁、胰液对EST切口的刺激，应建立通畅的腹腔引流。