《中国实用外科杂志》2012年第7期重点内容介绍 重点选题:重症急性胰腺炎的诊断与治疗

重视重症急性胰腺炎多学科综合治疗(王春友)重症急性胰腺炎诊断及治疗的难点与争议(苗毅)重症急性胰腺炎相关诊治指南解读——基于全面考虑实施急性胰腺炎的治疗(雷若庆,王庆刚,张中文,等)     

WSES重症急性胰腺炎管理指南（2019）解读

近年来重症急性胰腺炎的研究取得了一些进展,对临床的诊治有较为明显的影响。2018年在意大利贝蒂诺罗举行的世界急诊外科大会上,专家协作小组基于循证提出了重症急性胰腺炎管理的国际共识(使用GRADE证据质量分级),并于2019年6月发表于世界急诊外科杂志。该指南主要包括以下5个主题:重症急性胰腺炎的诊断、抗生素治疗、重症监护室的管理、外科及手术处理和腹腔开放,全面地总结概括了重症急性胰腺炎的临床诊治原则,反映了当前重症急性胰腺炎的治疗现状和进展,值得参考、学习和借鉴。     

急性胰腺炎诊治的现状与进展

<正>21世纪以来,随着基础研究与临床实践的进步,急性胰腺炎(acute pancreatitis,AP)的诊断和治疗水平大大提高,国内外AP诊治指南得到更新~([1-4])。结合国际最新进展和我国国情,中华医学会外科学分会胰腺外科学组对我国2007年《重症急性胰腺炎诊治指南》进行增补和修订,颁布了《急性胰腺炎诊治指南(2014)》~([5]),以便于规范我国,AP诊治过程。本文结合我国最新的临床指南及国内外相关研究,对AP的诊治现状与进展阐述如下。     

对暴发性急性胰腺炎诊治的认识和理解

2007年中华医学会外科学分会胰腺外科学组制定并颁布了《重症急性胰腺炎诊治指南》。指南对重症急性胰腺炎（severe acute pancreatitis,SAP）的诊断、分类和治疗均有统一的明确定义,其颁布无疑对中国胰腺炎外科事业的发展具有里程碑的作用。笔者就临床工作中对暴发性急性胰腺炎（fulminant acute pancreatitis,FAP）的诊治谈一下自己的认识和理解,并就相关问题愿与同道共同商榷,以期抛砖引玉,进一步丰富和完善指南。     

重症急性胰腺炎并发毛细血管渗漏综合征的研究进展

重症急性胰腺炎(SAP)起病急、临床表现凶险、病死率高,在急性反应期常发生毛细血管渗漏综合征(CLS),CLS的出现又加快了重症急性胰腺炎病情恶化。目前针对重症急性胰腺炎诱发的毛细血管渗漏综合征的研究较少,在临床治疗上易被忽视,就重症急性胰腺炎诱发毛细血管渗漏综合征的发病机制、临床诊断及治疗等方面做一综述。     

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重症急性胰腺炎相关诊治指南制定的目的就是为了规范其诊治过程,在复杂多变的病程中能够选用相应的对策。解读基于临床的诊治指南,关键在于对其正确、正面地理解,这样才能对临床起至指导和帮助作用。实施急性胰腺炎的治疗应根据急性胰腺炎的特点,全面考虑。     

浅谈建立我国重症急性胰腺炎诊治指南的意义

重症急性胰腺炎的外科治疗经历了一个认识逐步加深、方案不断完善的过程。根据已经达成的共识,制定我国重症急性胰腺炎诊治指南十分必要,而且时机已经成熟。其必要性在于,我国幅员辽阔,重症急性胰腺炎的病因谱复杂,自然病程变异极大,因此在治疗上亟需一个相对统一的指南加以指导;     

《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。     

急性重症胰腺炎传统外科治疗的地位

正急性重症胰腺炎(SAP)在急性胰腺炎中的发病比例并不高,但因其并发严重感染和急性肺,肾功能衰竭的比例甚高,加之其病死率一直高居10%～20%,目前仍是临床治疗的难题,近50年来,随着我们对急性重症胰腺炎发病的病理生理过程的不断深入研究和了解,提出了众多的诊治指南和共识,这也是多学科针对同一种疾病,制定最多的专家共识和诊治指南,而且还在不断的更新,这也说明我们对SAP的诊治还在不断完善之中。     

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。     

An assessment of clinical guidelines for the management of acute pancreatitis.

BACKGROUND: Recent guidelines have been issued for the management of acute pancreatitis. The aim of this study was to audit the management of acute pancreatitis in one district general hospital, to determine the problems and benefits associated with the implementation of such guidelines. METHODS: Data were collected over the period 1991-1995 for all patients diagnosed as having acute pancreatitis who were admitted to one district general hospital. Data regarding severity grading, determination of aetiology and treatment of mild and severe pancreatitis were analysed in conjunction with the recommendations issued by the British Society of Gastroenterology Working Party on the management of acute pancreatitis in 1995. RESULTS: A total of 210 patients were admitted on 263 occasions; 16% of cases were severe but severity prediction was inaccurate. 56.1% had gallstone pancreatitis and 20.9% had idiopathic pancreatitis. Definitive treatment of gallstones was within the recommended time limit in only 70.1%. 27 patients experienced recurrent attacks of pancreatitis before definitive treatment of their gallstones, due either to inadequate investigation for gallstones after suboptimal ultrasound examination (n = 12) or to inappropriate delay before definitive treatment of gallstones (n = 15). Recommendations for the management of severe cases with early ITU/HDU admissions and CT scanning were not followed. 28 day mortality was 6.3%, median age of those dying was 80.5 years. CONCLUSIONS: Acceptable mortality can be achieved for acute pancreatitis despite failure to implement BSG guidelines for the management of severe acute pancreatitis. Inadequate investigation and treatment of gallstone disease leads to an unacceptable incidence of recurrent acute pancreatitis.     

Variations in implementation of current national guidelines for the treatment of acute pancreatitis: implications for acute surgical service provision

OBJECTIVES: The aim of this study was to explore the implementation of the current national guidelines for the treatment of acute pancreatitis. By taking pooled data from all available individual and regional audits, the study aimed to identify areas of consistent variance from the 'best practice' stipulated in the guidelines. METHODS: All published audits of the management of acute pancreatitis where treatment was compared to the current British Society of Gastroenterology guidelines for the treatment of acute pancreatitis were identified from a search of MEDLINE and the published abstracts of relevant specialty meetings. RESULTS: Five audits providing pooled data on 545 patients were identified. Overall mortality from severe disease was 8% (range, 4-17%). Definitive treatment of gallstone disease within 4 weeks of index attack was performed in 49% (range, 16-65%). High dependency or intensive care facilities for severe disease were available in 52% (range, 20-100%). CONCLUSION: This study demonstrates the presence of striking variations in the implementation of the current national guidelines for the treatment of acute pancreatitis.     

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。     

An audit of the management of patients with acute pancreatitis against national standards of practice

BACKGROUND: The aim of this study was to audit the management of patients with acute pancreatitis against the standards of practice in the British Society of Gastroenterology guidelines. METHODS: The study assessed consecutive patients with acute pancreatitis over 5 years. Audit targets were overall mortality below 10 per cent, mortality for severe acute pancreatitis below 30 per cent, correct diagnosis and severity stratification within 48 h, aetiology determined in more than 80 per cent, availability of computed tomography and high-dependency or intensive therapy units when indicated and definitive treatment of gallstone pancreatitis within 2 weeks. RESULTS: Of 759 patients with acute pancreatitis, 219 (28.9 per cent) had severe acute pancreatitis (SAP). Overall mortality was 5.9 per cent, and 19.6 per cent in those with SAP. Acute pancreatitis was diagnosed within 48 h of presentation in 96.3 per cent of patients. The definitive aetiology was classified in 87.5 per cent. Of patients with SAP, 95.9 per cent underwent computed tomography within 6-10 days of admission. Of 93 patients with severe gallstone pancreatitis, 48 per cent had urgent endoscopic retrograde cholangiopancreatography, and 89.6 per cent of 359 patients with acute gallstone pancreatitis underwent definitive management within 2 weeks of admission. CONCLUSION: Patients with acute pancreatitis can be managed according to revised guidelines with a low associated mortality.     

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital

Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis. Sixteen patients underwent surgery: six patients for septic abdomen, four patients for pancreatic necrosis and two patients due to abdominal compartment syndrome. Four patients had a combination of surgical procedures for pancreatic necrosis and for abdominal compartment syndrome. Overall mortality was 9.1%. Severe acute pancreatitis represents a complex pathology that requires a multidisciplinary approach. Establishing best practice treatments and evidence-based guidelines for severe acute pancreatitis may improve outcomes in low-volume hospitals.     

Comparative study on acute pancreatitis management

Background: Guidelines have been published regarding the management of acute pancreatitis by the British Society of Gastroenterology (BSG). The aim of the present paper is to compare the management of patients with acute pancreatitis in a tertiary referral medical centre and a regional health centre in Australia during 2001, evaluate compliance with the published BSG guidelines, and compare our data with those of a similar UK study. Methods: Patients with a primary diagnosis of acute pancreatitis were identified retrospectively. Eighty‐four admissions from the Austin Hospital (AH), a tertiary referral centre, and 83 from The Geelong Hospital (TGH), a regional health centre, were treated in these two hospitals. The histories were collected and examined for compliance with the guidelines recommended by the BSG. We compared our data with the data from the two UK hospitals in a previous study. Results: Only 38% of patients from these two centres had all the investigations performed for severity stratification as recommended by BSG. In other respects, AH and TGH managed these patients with acute pancreatitis according to the recommendations. The overall mortality rate from acute pancreatitis was 3.0%, and within the group of severe acute pancreatitis the mortality rate was 22.7%. 65.5% of patients from AH with gallstone related acute pancreatitis had a cholecystectomy or sphincterotomy and extraction of gallstones within 4 weeks of presentation. There were five re‐admissions to AH in 2001 due to non‐operated gallstone‐related acute pancreatitis. In contrast, 84.3% of patients from TGH had definitive treatment within 4 weeks and there were three re‐admissions to TGH. Conclusion: Overall, both a tertiary referral centre and smaller regional hospital in Australia managed acute pancreatitis according to recently published BSG guidelines. The guidelines emphasized the importance of expertise in hepatopancreatobiliary surgery, availability of intensive care unit/high dependency unit and dynamic CT scanning. The recommendations for definitive treatment of patients with gallstone‐related pancreatitis within 4 weeks of presentation reduced the morbidity and mortality in this group. Although compliance with the guidelines on investigation for severity stratification of acute pancreatitis was poor, this lack of formal severity assessment did not appear to influence the outcome.     

Management of severe acute pancreatitis

BACKGROUND: Acute pancreatitis is still associated with significant morbidity and mortality. Current management guidelines are sometimes equivocal, particularly in relation to the surgical treatment of severe disease. This review assesses available investigative and treatment strategies to allow the development of a formalized management approach. METHODS: A literature review of diagnosis, staging and management of acute pancreatitis was performed. RESULTS AND CONCLUSION: Recent evidence has helped to clarify the roles of computed tomography, endoscopic retrograde cholangiopancreatography, prophylactic antibiotics, enteral feeding and fine-needle aspiration for bacteriology in the management of acute pancreatitis. Despite a relative shortage of prospective randomized trials there has been a significant change in the surgical management of acute pancreatitis over the past 20 years. This change has been away from early aggressive surgical intervention towards more conservative management, except when infected necrosis is confirmed. A formalized approach, with appropriate use of the various non-surgical and surgical options, is feasible in the management of severe acute pancreatitis.     

Severe acute pancreatitis causes alterations in HLA-DR and CD14 expression on peripheral blood monocytes independently of surgical treatment.

OBJECTIVE: To find out if the severity of acute pancreatitis or the surgical treatment of severe acute pancreatitis influences HLA-DR and CD14 expression on peripheral blood monocytes. DESIGN: Prospective open study. SETTING: University hospital, Austria. SUBJECTS: 9 consecutive patients with severe acute pancreatitis in need of operative treatment, 5 patients with mild acute pancreatitis, and 7 healthy volunteers. INTERVENTIONS: Samples of 5 ml blood were taken daily into endotoxin free tubes at same time points. Surgical treatment for severe acute pancreatitis consisted of blunt necrosectomy, operative lavage, laparostomy, and open drainage. MAIN OUTCOME MEASURES: Correlation between HLA-DR and CD14 expression on peripheral blood monocytes on the one hand and the severity of acute pancreatitis and operative treatment of severe acute pancreatitis, on the other. RESULTS: In patients with severe acute pancreatitis expression of HLA-DR and CD14 was significantly downregulated both before and after operation (p < 0.0001; ANOVA), compared with patients with mild acute pancreatitis or healthy controls. However the expression of the two cell surface markers was not affected either by the first operation, or by the reoperations. CONCLUSION: These findings suggest that in acute pancreatitis the expression of cell surface markers on peripheral blood monocytes is related to the severity of disease but is not influenced by operative treatment.