Early operation in acute hemorrhagic necrotizing pancreatitis]

Between 1973 and 1975, the "early" operation was carried out in 15 patients suffering from acute haemorrhagic-necrotizing pancreatitis to eliminate necrotic parts. Partially necrotizing pancreatitis was identified in 10 patients: 7 survived. All patients with total pancreatic necrosis died. Surgery consisted of digital removal of the necrosis (digitoclasia) and in left resection with adequate drainage. Patients with partially necrotizing acute pancreatitis can be saved by "early" surgery while in patients with total necrosis surgery must be undertaken even earlier, namely before fatal complications set in.     

Resection of the pancreas for acute hemorrhagic and necrotizing pancreatitis

The role of surgery in the treatment of acute hemorrhagic or necrotizing pancreatitis is discussed on the basis of a series of 996 patients with all types of acute pancreatitis who were treated in the years 1967–1976. Pancreatic resection was performed in 29 patients with hemorrhagic or necrotizing pancreatitis during the past 3 years. The extent of resection ranged from 60 to 100% of the pancreas. Eight patients died, for a mortality rate of 28%. Eight of 21 surviving patients developed diabetes requiring substitution therapy. During a follow-up period of 6 to 36 months, 17 patients were able to resume work, 3 are still convalescing, and 1 has retired.

---

Résumé La place de la chirurgie dans le traitement de la pancréatite aiguë hémorragique ou nécrosante est discutée à partir de 996 cas de pancrèatites aiguës de tous types traités entre 1967 et 1976. Au cours des 3 dernières années, une pancréatectomie a été faite chez 29 malades atteints de pancréatite hémorragique ou nécrosante. L'étendue de la résection a été de 60 à 100%. Huit malades sont morts (28%). Parmi les 21 survivants, 8 ont développé un diabète exigeant une thérapeutique de substitution. Le follow-up est de 6 à 36 mois: 17 malades ont pu reprendre le travail; 3 sont encore en convalescence; le dernier a pris sa retraite.

---

---

This work is supported by the Emil Aaltonen Foundation.     

低分子量肝素治疗急性出血坏死性胰腺炎的实验研究

目的 探讨低分子量肝素（ＬＭＷＨ）对急性出血压 坏死性胰腺炎（ＡＨＮＰ）的治疗作用。方法 将６０只大白兔制作成ＡＨＮＰ模型柏随机分为两组：治疗组（ｎ＝３０）用低分子量肝素治疗;对照组（ｎ＝３０）用盐水替代肝素,对比两组动物的生存率和血清肿瘤坏死因子（ＴＮＦ）、淀粉酶（ＡＭＳ）、血栓烷Ｂ２（ＴＸＢ２）、一氧化氮（ＮＯ）、超氧化物歧化酶（ＳＯＤ）和丙二醛（ＭＤＡ）。结果 治疗组生存率高于对照组（Ｐ〈０     

Acute necrotizing hemorrhagic pancreatitis

There is no etiologic treatment for acute necrotizing pancreatitis. Advances in intensive care resulted in a reduction in early death rate by a better control of systemic complications. Delayed death rate from infection is high (20-60%). Diagnostic problems are an important cause, in spite of the aid of computed tomography and echography. The prognosis will further be improved by earlier diagnosis, a better definition of surgical treatment when complications arise, and constant medicosurgical collaboration.     

Total pancreatectomy in acute necrotizing hemorrhagic pancreatitis. Indications and technic]

The place of total pancreatectomy in the treatment of pancreatitis is still ill- defined. The author makes a plea for this operation and notes the indications, the surgical technique and its results and possible complications. The operation is indicated in cases of total or 2/3 rds necrosis of the gland, in cases involving the head of the pancreas and part of the body. The gland should be dissected out and continuity should be restored by choledoco-jejunal and gastro-jejunal anastomoses. The important thing is to carry out this operation early, between the 3rd and 6th day, treating the areas of necrosis before the lesions become the site of uncontrolled infection. 7 patients out of 9 operated on in this way, are alive with easily controlled diabetes, a low fat diet and pancreatic extract.     

急性出血性坏死性胰腺炎并发急性肺损伤的实验研究

目的 探讨急性出血性坏死性胰腺炎（AHNP）并发急性肺损伤（ALI）病理改变。方法 制作AHNP并ALI的动物模型。观察胰腺及肺脏的功能及组织结构变化。结果 模型制作后1h胰腺出现肿胀、充血，12h后出现典型的AHNP病理改变，同时发现肺组织结构及功能改变，表现为PaO2明显下降，PaCo2升高，肺组织含水量增加，镜下可见肺间质及肺泡炎性细胞浸润，水肿，出血，肺泡细胞出现空泡化、脱落及衰变等典型的ALI病理改变。结论 该模型符合AHNP并发ALI的病理生理改变，与临床AHNP并发ALI病理过程相似，可用于AHNP并发ALI的机理和药效评估的研究。     

乌司他丁区域动脉灌注治疗急性出血坏死性胰腺炎的研究

目的　观察乌司他丁 (UTI)对急性出血坏死性胰腺炎 (AHNP)大鼠的治疗作用。方法　 96只AHNPSD大鼠分成 4组 ,A组 :对照 ;B组 :区域动脉生理盐水 ;C组 :静脉UTI组 ;D组 :区域动脉UTI。 6、2 4h测血清淀粉酶、脂肪酶、磷脂酶 (PL)A2、超氧化物歧化酶 (SOD)、内毒素、丙二醛 (MDA)、血栓烷 (TX)B2、6 Keto PGF1、可溶性白细胞介素 (sIL) 2受体 (R)、肿瘤坏死因子(TNF) α、IL 6、IL 8。结果　D组的血清淀粉酶、脂肪酶、PLA2、sIL 2R、TNF α、IL 6、IL 8、内毒素、MDA和TXB2 /6 Keto PGF1α低于其他组 ;SOD高于其他组 (P <0 .0 5 )。结论　区域性动脉灌注UTI对AHNP大鼠具有良好的治疗作用 ,能清除释放入门静脉血内的细胞因子和氧自由基 ,稳定TXB2 /6 Keto PGF1α的比值 ,减轻胰腺腺泡细胞超微结构的破坏。     

Laparoscopic necrosectomy for acute necrotizing pancreatitis

Severe acute pancreatitis (SAP), a disease state that is often complicated by an intricate pathologic process, has remained difficult to manage and is associated with high morbidity and mortality rates. Approximately 80% of patients have a mild form of the disease, while the other 20% develop a severe life-threatening form of the disease. These patients are at great risk for infection, multisystem organ failure, and, possibly, death. Necrotizing or infected pancreatitis requires a multimodal approach and often offers an indication for surgical intervention. The retroperitoneum of the patient with necrotizing pancreatitis should be treated as an abscess cavity, and drainage and debridement of all necrotic tissue should be performed. Over the past several decades, great achievements have been made in the treatment of the patient that presents with acute pancreatitis. However, the morbidity and mortality have remained high, according to recent literature. The laparoscopic era brings new alternatives in the surgical management of pancreatic diseases. Advances in laparoscopic technology and instrumentation allow the utilization of minimally invasive techniques, and lessen the stress of surgery in the already compromised pancreatitic patient. Received: July 4, 2000 / Accepted: December 28, 2000     

Surgical treatment of acute necrotizing hemorrhagic pancreatitis. Analysis and prospective deductions on 58 cases

Three degrees of severity could be recognized in 58 patients operated upon for severe acute hemorrhagic pancreatitis, based on results of intensive care, particularly anti-shock therapy, wide peritoneal lavage, and possible need for endoscopic relief of sphincter of Oddi obstruction due to a stone. The principal parameters evaluated were clinical and biological features and the course of the affection. As a result of these data, 44 pancreatic resections of variable extension and 14 excisions of necrotic tissues were performed. Results of these two types of operations, as well as the dominant causes of postoperative and secondary deaths, are analyzed in detail. The indications for surgery are discussed, together with the tactical methods to be applied as a function of the general condition and the detailed study of the pancreas and the state of the adjacent organs. Particular importance should be attached to the presence of respiratory insufficiency. The possible need for routine biliary external drainage is discussed, and the major role played by parenteral nutrition, which should be initiated as early as possible, is emphasized. These findings suggest that two fundamental principles should guide surgery of acute hemorrhagic pancreatitis: the need for surgery in selected cases, though over-aggressive operations should be avoided, and, more particularly, the concept, to be shared of the need for repeated operations, enabling avoidance of excessive procedures during initial surgery.     

Post-ERCP acute necrotizing pancreatitis

An analysis of acute necrotizing pancreatitis (ANP) after endoscopic retrograde cholangiopancreatography (ERCP) was carried out. The incidence of ANP was 0.5% (5/914) for ERCP and 0.5% (2/370) for endoscopic sphincterotomies (EST). All the five patients were obese, middle-aged or older women. Four had a suspicion of common bile duct stones and the fifth a pancreatic tumour as an indication for ERCP. Two had most probably a functional sphincteric disorder and the third was without clear pathological findings. In the remaining two cases the bile duct cannulation failed and repeated pancreatic duct cannulation occurred; while in one case the pancreatic duct was not cannulated. The four pancreatographies were normal and without parenchymal opacification. Symptoms of acute pancreatitis started within 6 hours after ERCP. The pancreatitis was severe by Ranson criteria and necrotizing by evaluation at laparotomy. All the patients showed bacterial growth either in bile, blood or ascitic fluid early in the course of pancreatitis (E. coli, Str. faecalis or Klebsiella pneumoniae). The possible pathogenetic factors of post-ERCP ANP are discussed.     

腺苷对急性出血坏死性胰腺炎肠道屏障功能保护机制的实验研究

目的研究腺苷对猪急性出血坏死性胰腺炎(AHNP)肠道屏障功能保护作用的机制.方法12只成年小型猪经ANHP成模后随机均分成对照组和腺苷治疗组(简称腺苷组),比较两组动物在AHNP诱发前后不同时相点肠道血流量、肠道通透性、门静脉血细菌和内毒素的变化.结果(1)腺苷组在AHNP成模后8,24h和第7d时肠道血流量显著高于对照组(P<0.01或P<0.05);(2)腺苷组成模后8,24h和第3d肠道通透性显著低于对照组(P<0.05或P<0.01);(3)对照组门静脉血细菌和内毒素明显增加,腺苷组门静脉血细菌数在AHNP诱导后第24h和第3d较对照组显著下降(P<0.05或P<0.01);门静脉血内毒素含量显著低于对照组各时相点(P<0.01或P<0.001).结论腺苷能显著增加肠道血流量;腺苷可以明显减轻肠粘膜损害,保护肠道屏障功能,腺苷的这种作用可能是通过增加肠道血流量而实现的;腺苷可以明显减少肠道细菌和内毒素移位.     

氯化钆对大鼠急性出血坏死性胰腺炎肺损伤的影响

目的　观察氯化钆对大鼠急性出血坏死性胰腺炎 (AHNP )肺损伤的影响 ,探讨肝脏Kupffer细胞在该病理过程中的作用。方法　 42只Wistar大鼠随机分为假手术组、模型组、氯化钆预防组( 10mg/kg)、氯化钆对照组 ( 10mg/kg)。假手术组仅翻动腹腔脏器数次即关腹 ;模型组经胆胰管逆行注射 5 %牛磺胆酸钠 ( 1ml/kg ,0 .1ml/min)诱发AHNP ;氯化钆预防组在AHNP造模前 1d经尾静脉注射氯化钆溶液。 3组动物于术后 3h ,6h分批取材 :( 1)经腹主动脉取血 ,测定血清淀粉酶、TNFα和IL 1(假手术组加测血AST和ALT) ;( 2 )取右肺一部分匀浆 ,测定MPO ;另一部分经 10 %甲醛固定 ,行组织病理学观察 ;( 3 )取左肺进行肺泡灌洗 ,分离收集并纯化肺泡巨噬细胞 ;提取核蛋白后采用化学发光ELISA法检测NF κB (p65 )的表达情况 ;( 4 )留取胰腺组织行组织病理学观察。氯化钆对照组经尾静脉注射氯化钆溶液 2 4h后处死 ,取血测定血AST和ALT。结果　氯化钆预防组在造模后 3h及 6h ,肺组织MPO水平、血清TNFα及IL 1水平、肺泡巨噬细胞NF κB(p65 )的表达水平均显著低于模型组 (均为P <0 .0 1) ;肺组织病理学改变显著减轻。血清淀粉酶及胰腺病理改变两组无显著差别。结论　预防性应用氯化钆可明显减轻AHNP大鼠所并发的肺损伤 ;肝脏Kupffer细     

腹腔镜技术治疗出血坏死性胰腺炎

目的:探讨腹腔镜诊断治疗急性出血坏死性胰腺炎(acute hemorrhagic necrotizing pancreatitis,AHNP)的价值。方法:回顾分析我院2003年3月至2008年7月应用腹腔镜诊治出血坏死性胰腺炎5例患者的临床资料。结果:5例患者均经腹腔镜探查明确诊断,并同时在腹腔镜下完成治疗,术后无并发症发生。结论:腹腔镜用于诊治AHNP具有独特的优势,既能明确诊断又能同时治疗,降低了阴性剖腹探查率,可提高患者术后的生存质量,值得临床推广。     

APACHE O评分系统对急性胰腺炎预后的评估价值

急性胰腺炎是一种常见的外科急腹症,病情复杂．预后差．APACHE Ⅱ评分系统是目前一较全面的多冈素预后评分系统,但仍存在一定局限性。APACHEO评分系统（APACHEⅡ评分加肥胖指标评分）是近年提出的一种急性胰腺炎预后评分系统日,本文旨在通过比较APACHE O评分与APACHEⅡ评分对急性重症胰腺炎的判断能力,对急性胰腺炎局部、全身并发症及死亡率的预测价值,旨在明确APACHE O评分系统对急性胰腺炎预后的评估价值.