Therapeutic and diagnostic protocol for mild acute biliary pancreatitis: our experience and review of the literature

Through a critical review of the literature, the authors analyze and re-assess the current diagnostic and therapeutic algorithms used in the treatment of mild acute biliary pancreatitis, reporting their experience with 27 cases observed in the Policlinico Umberto I Emergency Department (Rome) over the period from March 2003 to May 2005. All patients were treated with the same diagnostic and therapeutic protocol: once the diagnosis of acute biliary pancreatitis had been made and the severity evaluated, patients presenting clinical or ultrasonographic signs of main biliary duct stones underwent ERCP within 72 hours of onset of symptoms. All patients then underwent a standard-technique laparoscopic cholecystectomy during the same hospital stay, and whenever ERCP had not been performed preoperatively, an intraoperative cholangiography was performed at the time of surgery. No intra- or postoperative complications were observed, with a mean hospital stay of 10.6 days (range: 5-25 days).     

Postoperative acute pancreatitis: our experience and review of the literature

AIM: Acute postoperative pancreatitis is a rare event, but, at the same time, it represents one of the most frightening complications, because it is associated with high mortality risk. METHODS: From January 1985 to December 2005, we observed 30 cases (12 males, 18 females) of acute postoperative pancreatitis. Twenty cases of low and medium gravity have been treated with only medical therapy, 10 cases, instead, have requested surgical therapy (necrosectomy and application of abdominal drains in 7 cases, necrosectomy and ileostomy in 1 case, necrosectomy and colostomy in 1 case, ligation of pancreatic vessels in 1 case of haemorrhagic pancreatitis). RESULTS: In the form of low and medium gravity, fast and pharmacological support (somatostatin and gabexate mesilate) are enough to resolve the event. In the form of high gravity the early surgical treatment has represented the clinical solution in 7 patients, while 3 others patients have died for septic and metabolic complication. CONCLUSIONS: Still today acute postoperative pancreatitis represents a frightening complication associated with high mortality risk that the surgeon has to treat with great care to avoid each bilio-pancreatic injury.     

内镜下双括约肌切开治疗急性胆源性胰腺炎

目的：探讨早期内镜下括约肌切开术（EST）联合内镜下胰管支架置入（ERPD）治疗急性胆源性胰腺炎（ABP）的疗效。方法：前瞻性研究,选取2009年1月至今于我院就诊的44例急性胆源性胰腺炎患者,对其行早期内镜下逆行性胰胆管造影（ERCP）、EST及必要的ERPD,评价疗效,并定期随访观察其长期疗效。结果：早期EST联合ERPD治疗急性胆源性胰腺炎尤其是重症胰腺炎,能有效的缓解腹痛、降低淀粉酶、促进胰腺恢复,降低复发率。结论：急性胆源性胰腺炎采用早期EST联合ERPD治疗是安全有效的,且有较好的长期疗效。     

Prediction of acute biliary pancreatitis

Authors propose mathematical model for prediction of acute biliary pancreatitis in patients with strangulated concrements of papilla Vateri. Values of α-amylase and lipase in blood and bile are used as main prognostic signs. It is estimated that blood lipase, bile α-amylase and lipase are main prognostic signs for development of acute biliary pancreatitis.     

重症急性胰腺炎102例临床分析

目的探讨重症急性胰腺炎的合理治疗方案。方法以1985年1月～2005年8月间收治的102例重症急性胰腺炎作研究对象，比较手术组与非手术组的主要并发症和死亡率。A组：1985年1月～1993年12月以手术治疗为主41例；B组：1994年1月～2005年8月以早期非手术治疗为主61例。结果手术组死亡率和并发症发生率明显高于非手术组，两组病死率及并发症发生率比较差异有显著性（P〈0．05）。结论重症急性胰腺炎采用早期非手术治疗能有效降低病死率和并发症发生率。大多数重症急性胰腺炎可经非手术治愈。     

重症急性胰腺炎84例治疗体会

目的探讨重症急性胰腺炎的合理治疗方案。方法以1999年1月～2004年12月间收治的84例重症急性胰腺炎作为研究对象,比较手术组与非手术组的主要并发症和死亡率。结果手术组死亡率和胰瘘的发生率明显高于非手术组。结论合理把握重症急性胰腺炎的手术适应证和手术时机是提高治愈率和降低死亡率的关键。     

1033例重症急性胰腺炎治疗经验总结

目的 总结重症急性胰腺炎的治疗经验.方法 1997年1月至2009年3月,南京军区南京总医院全军普通外科研究所共收治重症急性胰腺炎患者1033例,男性622例,女性411例;年龄13～98岁,平均51岁.APACHEⅡ评分(12.0±4.3)分.所有患者的治疗均由ICU、外科、内镜、影像和血液净化等专业医师组成的治疗小组完成.患者早期均在ICU内进行监测治疗,其中机械通气365例,气管切开218例,行床旁持续大流量血液滤过159例,行鼻胆引流179例,早期肠内营养513例,CT引导下经皮胰周穿刺引流477例次,因胰周坏死感染行胰周坏死组织清除引流术438例.结果 1033例患者中,975例治愈出院(94.4%),38例患者死亡,其中手术患者病死率7.1%(31/438).结论 多专业医生组成的治疗小组可能更有利于重症急性胰腺炎的治疗.     

内镜胆管减压治疗急性胰腺炎20年探索与思考

目的分析内镜胆管减压(EBD)治疗急性胰腺炎(AP)的疗效和临床应用价值。方法20年来分两个阶段共用EBD法治疗AP病人260例。1985～1994年为前瞻性随机对照研究阶段,观察对象为轻型AP(MAP)及早期重症急性胰腺炎(SAP),均为胆源性AP,共152例。治疗组78例行内镜治疗,方法是先行ENBD,若插管失败,再行EST后ENBD。对照组74例行常规内科保守治疗。1995～2005年为扩大临床应用阶段,观察对象为胆源性AP98例,非胆源性AP84例。治疗方法有所改进,行EST的比例增加。结果第一阶段治疗组AP治愈率为87.2%,重型化率为3.8%,与对照组(71.6%,14.9%)相比差异显著;病死率为1.3%,与对照组5.4%相比差异无显著性。第二阶段胆源性轻型AP操作成功率为97.1%,治愈率为92.9%,重型化率为2.9%。胆源性重型AP操作成功率为64.3%,治愈率为60.7%,病死率为5.6%。非胆源性轻型AP操作成功率为98.6%,治愈率为69.6%;非胆源性重型AP操作成功率为43.8%,病死率为17.2%。结论EBD对于胆源性AP病人能迅速阻断MAP向SAP进展,有效地降低了重型胰腺炎的发生率;同时应严格掌握EBD治疗AP的适应证和时机,不宜选择进展期SAP病人,早期治疗效果好。     

Diagnosis of acute destructive biliary pancreatitis

The article presents an analysis of results of examinations and treatment of 98 patients and an assessment of the clinical picture, laboratory and instrumental findings. The significance of USI as a method of screening diagnosis is stressed. The indications and possible endoscopic and videolaparoscopic interventions for the diagnosing and treatment of acute destructive biliary pancreatitis (ADP) are determined. The author proposes an algorithm of the diagnosing and treatment of ADP. The use of the algorithm allowed the postoperative lethality after ADP to be decreased from 20.8% to 14%.     

急性胆源性胰腺炎外科治疗

目的 总结胆源性胰腺炎手术治疗经验,探讨胆源性胰腺炎的手术时机和方法.方法 回顾分析2004年9月至2007年5月江苏吴江市第三人民医院普外科收治的54例急性胆源性胰腺炎临床治疗.结果 全组手术46例,早期手术9例,延期手术37例,均获痊愈,平均术后住院时间8.4 d,术后随访无复发.非手术8例,死亡1例,随访有2例复发.结论 外科手术在胆源性胰腺炎治疗中具有重要地位.ABP手术时机的选择应采用个体化和延期手术相结合的处理方针.     

Treatment of acute biliary pancreatitis in the aged in the endolaparoscopic era

BACKGROUND: Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial to clearly assess the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and to establish the severity in order to plan the appropriate treatment. METHODS: In this study we have considered 61 patients divided into 2 groups. Group 1 had 29 ABP patients aging less than 65 years, group 232 patients aging more than 65 years; the diagnosis was made by ultrasound and serological values in 78.5% of cases, while in the remaining 21.5% was only serological. Following Ranson and APACHE II scoring 18 cases (29.5%) were classified as severe [6 (20.6%) in group 1; 12 (37.5%) in group 2: p < 0.01], 43 (70.4%) as mild. All patients with severe ABP had emergency ERCP + ES (within 24-48 hrs) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. RESULTS: In severe cases operative endoscopy cured pancreatic inflammation in 13 cases. Subsequent LC never showed serious morbidity, apart subcutaneous emphysema in one case. In 5 cases laparotomy was required since pancreatic necrosis was present, with 60% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 6.9% morbidity. IOC showed choledochal stones in 32.5% of cases, while in severe cases stones in the biliary tree were showed in 88.8% of cases. No significant differences were detected between group 1 and 2. CONCLUSIONS: In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hrs as well as in mild cases (LC + IOC) when surgery is done within 10 days, independently from the age of the patients.     

Endoscopic ultrasonography in acute biliary pancreatitis

Conclusions EUS appears to be a very accurate test for diagnosing CBD stones in a relatively large number of studies using a variety of methodologic approaches, mostly in patients with a moderate-to-high suspicion of gallstones, however. Whether these results can be transferred to patient groups with low stone prevalence, and to other examiners outside the centers of excellence, is not fully known. In the setting of acute pancreatitis, the same seems to be true, but the evidence is based on only two studies, each with a rather small number of patients. In our opinion, the biggest competitor for EUS is MRCP, and further comparative studies will shed some more light on the relative value and cost-effectiveness of both tests in the setting of acute biliary pancreatitis.     

胆源性胰腺炎的腹腔镜胆囊切除术及手术时机

目的 :回顾分析腹腔镜胆囊切除术 (LC)在急性胆源性胰腺炎治疗中的资料。方法 :对 14例急性胆源性胰腺炎患者在综合治疗的支持下 ,早期应用LC。结果 :所有病例全部治愈 ,疗效满意 ,随访 3～2 8个月 ,无手术并发症和 /或胰腺炎复发。结论 :LC可用于急性胆源性胰腺炎的早期治疗。     

急性胆源性胰腺炎胆道疾病的外科处理

目的:探讨急性胆源性胰腺炎(ABP)患者胆道疾病手术治疗的方法及时机。方法:回顾性分析206例ABP行胆道疾病处理的患者临床资料,其中轻型192例,中重型2例,重型12例;手术方式包括胆囊切除术、胆总管切开取石T管引流术、ERCP、肝叶部分切除术等。结果:中重型及重型ABP患者均在非手术治疗后早期行外科处理;轻型ABP患者中与早期手术者(起病2周内)抗生素使用时间、总住院时间、住院费用较延期手术者(起病2周后)明显减少,同期手术者抗生素使用时间、总住院时间、总费用较择期手术者明显减少(P0.05)。结论:ABP患者胆道手术方式需根据患者情况选择,轻型患者应在同次住院期间且起病早期行胆道手术治疗;重型患者应在非手术治疗整体情况缓解后尽早行手术治疗;如有胆道梗阻或胆管炎无论轻重均应急诊手术或ERCP。     

Treatment of rectal carcinoma: our experience

Authors' experience with 53 patient operated on for adenocarcinoma of the rectum in Oncologic Surgery Department--University of Messina (Italy) was analysed. The development of mechanical devices has allowed surgeons to perform sphincter-saving in patients with medium-lower tumors of the rectum. In this experience abdominoperineal amputation was performed in cases of distal rectal tumors, local transanal excision was performed in 6 cases. There were no statistically significant differences between low anterior resection and abdomino-perineal resection with respect to local (17% vs 16.6%) and distant (16% vs 16%) recurrence.     

Minimally invasive treatment of acute biliary pancreatitis

Background: Stones of the common bile duct are the most important factor in acute pancreatitis (AP). Endolaparoscopic surgery plays a well-recognized role in the treatment of this pathology. Methods: From January 1992 to December 1995 we observed 62 cases of acute biliary pancreatitis (ABP). In 57 cases (= 93.4%) we proposed a minimally invasive treatment, based on performance of endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES) and then of laparoscopic cholecystectomy (LC). Results: ERCP was attempted in emergency in 40/57 cases and successfully done in 34 cases. An ES was performed in all but two cases. In 51 patients we performed LC. The overall morbidity was 8.9% with no mortality. Conclusions: In the case of ABP early treatment can achieve the restoration of patency of the papilla, reducing the risk of associated cholangitis and the development of pancreatic necrosis. The cholecystectomy prevents the risk of relapse of ABP.