Long peritoneal lavage decreases pancreatic sepsis in acute pancreatitis.

Late infection of devitalized pancreatic and peripancreatic tissue has become the major cause of morbidity in severe acute pancreatitis. Previous experience found that peritoneal lavage for periods of 48 to 96 hours may reduce early systemic complications but did not decrease late pancreatic sepsis. A fortunate observation led to the present study of the influence of a longer period of lavage on late sepsis. Twenty-nine patients receiving primary nonoperative treatment for severe acute pancreatitis (three or more positive prognostic signs) were randomly assigned to short peritoneal lavage (SPL) for 2 days (15 patients) or to long peritoneal lavage (LPL) for 7 days (14 patients). Positive prognostic signs averaged 5 in both groups but the frequency of five or more signs was higher in LPL (71%) than in SPL (47%). Eleven patients in each group had early computed tomographic (CT) scans. Peripancreatic fluid collections were shown more commonly in LPL (82%) than in SPL (54%) patients. Longer lavage dramatically reduced the frequency of both pancreatic sepsis (22% LPL versus 40% SPL) and death from sepsis (0% LPL versus 20% SPL). Among patients with fluid collections on early CT scan, LPL led to a more marked reduction in both pancreatic sepsis (33% LPL versus 83% SPL) and death from sepsis (0% LPL versus 33% SPL). The differences were even more striking among 17 patients with five or more positive prognostic signs. In this group the incidence of pancreatic sepsis was 30% LPL versus 57% SPL and of death from sepsis 0% (LPL) versus 43% (SPL) (p = 0.05). In these patients, overall mortality was also reduced (20% LPL versus 43% SPL). When 20 patients treated by LPL were compared with 91 other patients with three or more positive prognostic signs who were treated without lavage or by lavage for periods of 2 to 4 days, the frequency of death from pancreatic sepsis was reduced from 13% to 5%. In those with five or more signs, the incidence of sepsis was reduced from 40% to 27% (p = 0.03) and of death for sepsis from 30% to 7% (p = 0.08). These findings indicate that lavage of the peritoneal cavity for 7 days may significantly reduce both the frequency and mortality rate of pancreatic sepsis in severe acute pancreatitis.     

超声引导经皮置管引流在重症急性胰腺炎治疗中的应用价值

目的探讨超声引导经皮置管引流在重症急性胰腺炎治疗中的应用价值。方法自2002年1月至2004年6月对9例重症急性胰腺炎采用了包括超声引导经皮置管引流在内的多种非手术治疗手段,其中对6例腹腔渗液较多者,实施超声引导下经皮穿刺置管引流和腹腔灌洗;对4例合并胰腺周围积液并感染者,实施超声引导下经皮穿刺置管引流。结果9例病人全部治愈,包括1例暴发性急性胰腺炎,无一例需手术治疗,腹腔引流管留置时间为5～7d,胰周引流管留置时间为7～60d(平均为30d),住院时间32～152d,平均68d。结论超声引导经皮置管引流对于重症急性胰腺炎腹腔积液较多者以及胰腺周围积液合并感染者能够进行简便、安全、有效的治疗,它的成功应用为非手术治疗重症急性胰腺炎提供了有益的经验。     

The Role of Peritoneal Lavage in Severe Acute Pancreatitis

Encouraged by reports of the therapeutic efficacy of peritoneal lavage in small series of five or six patients with acute pancreatitis, we have evaluated this treatment in 24 patients with "severe" pancreatitis. One hundred and three patients with "severe" pancreatitis (28% mortality) were separated from 347 with "mild" pancreatitis (0.9% mortality) by previously described early objective signs. Early treatment (Day 0-7) of "severe" pancreatitis included peritoneal lavage through catheters placed nonoperatively in 18 (Group A) and by catheters placed at laparotomy in six (Group C). Early treatment of nonlavaged patients with "severe" pancreatitis was by standard nonoperative measures in 61 (Group B) and included early operation in 18 (Group D). Lavage was continued for 48-96 hours, usually using 36-48 L/24 hours of balanced isotonic dialysate fluid, and was uncomplicated. Lavage led to striking immediate clinical improvement and no lavaged patient (Groups A and C) died during the first 10 days of treatment of pancreatitis. By contrast, 45% of deaths in nonlavaged patients (Group B and D) occurred during this early period, usually from cardiovascular or respiratory failure. Although lavage reduced mortality in subgroups of patients, ultimate overall survival was no affected (Group A, 83%; B, 84%; C, 33%; D,33%). Late peripancreatic abscesses caused most deaths in lavaged patients. These data show that peritoneal complications of severe acute pancreatitis and dramatically reduces early mortality. Lavage does not prevent the late local sequelae of peripancreatic necrosis.     

Hemorrhagic pancreatitis.

An experience with 68 patients with hemorrhagic pancreatitis identified at operation or autopsy is reported. Sixteen of the patients were subjected to operation, and 6 survived after celiotomy and peritoneal irrigation. There were no survivors in the unoperated group. Death when the pancreas is hemorrhagic and due to pancreatitis occurs an average of 10 days after the onset of symptoms or within 7 days of hospitalization. In eight patients who presented in coma, the diagnosis was not established before death. Early recognition of patients with hemorrhagic pancreatitis can be facilitated by the routine use of amylase and methemalbumin determinations and peritoneal lavage. Translocation of large volumes of albumin-rich fluid from the intravascular compartment to the retroperitoneum and pleural and abdominal cavities is in part responsible for many of the signs, symptoms, and complications of hemorrhagic pancreatitis. These include hemoconcentration, hypotension, tachycardia, tachypnea, ascites, abdominal distress, respiratory insufficiency, and renal failure. Adequate initial resuscitation and intensive follow-up are probably the most important elements in the management of patients with hemorrhagic pancreatitis. Careful monitoring of fluid and electrolytes and blood gases is required to avoid shock and renal and pulmonary failure. The need for careful monitoring is emphasized by the number of our patients in whom inadequacies of fluid replacement and ventilation were often not appreciated until the patient was in extremis from shock or respiratory or renal failure. Antibiotics are indicated in patients with biliary tract disease and penetrating ulcer in whom the risk of secondary infection is considerable. Associated diseases that initiated pancreatitis and that in themselves may be life-threatening, such as acute cholecystitis or cholangitis, should be promptly treated by operation. Diagnostic and therapeutic lavage are justified in the treatment of hemorrhagic pancreatitis. Resection of the necrotic pancreas should be considered when the patient fails to improve after lavage and nonoperative resuscitation.     

腹腔灌洗术治疗74例重症急性胰腺炎体会

目的总结腹腔灌洗术治疗重症急性胰腺炎的经验。方法74例重症胰腺炎患中，56例单纯行腹腔灌洗术，18例中转或术后再次开腹行胰包膜切开引流术。合并胆道感染同时行胆总管切开引流术。结果单纯腹腔灌洗死亡4例(7．1％)，中转开腹死亡3例(16．7％)，总死亡率为9．5％。结论腹腔灌洗术治疗重症胰腺炎方法简便、疗效确切，适于基层医院应用。     

Intraoperative use of isosulfan blue in the treatment of persistent lymphatic leaks

BACKGROUND: Lymphatic leaks are a major source of morbidity after lower extremity vascular surgery. We determined the ability of isosulfan blue (Lymphazurin) use to identify and help ligate offending lymphatics, and compared postoperative complication rates and length of stay versus nonoperative therapy alone. METHODS: From January 1993 through March 2002, we identified 15 patients with lymphatic leaks. The first group consisted of 5 patients treated nonoperatively. The second group was 10 patients (11 explorations) treated operatively aided by isosulfan blue, after a trial of nonoperative therapy. RESULTS: Isosulfan blue identified the leak in 10 of 11 cases. Mean drainage time for the nonoperative group was 47.6 days versus 1.8 days for the operative group (P = 0.036). Within the operative group, the mean drainage time during their initial conservative treatment phase was 15 days versus 1.8 days after surgery (P < 0.01). Complications were significantly less in the operative group (P < 0.05). Postoperative length of stay was a mean of 4.7 days versus 8.1 days for nonoperative patients (P = not significant). CONCLUSIONS: Intraoperative isosulfan blue use accurately identifies disrupted lymphatic channels and helps ensure definitive ligation. This simple procedure is associated with fewer complications, and a trend toward shorter hospital stay.     

超声引导经皮置管引流治疗重症胰腺炎的护理探讨

目的探讨超声引导经皮置管引流治疗重症胰腺炎的护理方法.方法自2002年1月至2004年6月对9例重症胰腺炎采用了包括超声引导经皮引流在内的多种非手术治疗的全面护理,尤其是生命体征及腹部体征的监测,引流管的护理及应用施他宁的护理等.结果9例病人全部治愈.腹腔引流管留置时间为5-7天,胰周引流管留置时间为7-60天(平均为30天).住院时间32-152天,平均68天.无一例发生脱管现象及其他并发症.结论超声引导经皮置管引流对于重症急性胰腺炎腹腔积液较多者以及胰腺周围积液合并感染者能够进行简便、安全、有效的治疗.加强病情的观察,做好引流管的管理以及药物的应用是急重症胰腺炎在非手术中的重要的护理环节.     

Influence of peritoneal lavage on objective prognostic signs in acute pancreatitis.

In 39 patients with severe attacks of acute pancreatitis, a longitudinal study was done with respect to the influence of peritoneal lavage on objective prognostic signs (WBC, blood-glucose, serum-calcium, hematocrit, serum-creatinine, arterial pO2, base deficit); amylase activities in peritoneal fluid, serum, and urine; serum-hemoglobin, serum-Na, serum-K, and plasma-insulin. In addition to standard care in the ICU, half of the patients (N = 19) were randomly treated with peritoneal lavage. Peritoneal lavage did not influence overall mortality (13%), incidence of major complications (36%), or hospital stay (23 +/- 7 days). None of the prognostic signs was significantly influenced by lavage. Amylase concentration in peritoneal fluid was significantly reduced in the lavaged group after 6 hours compared to 24 hours in controls. Serum and urinary amylase decreased 12 hours earlier in the lavaged group, indicating an efficiency of the lavage procedure per se. Still, this study did not reveal any beneficial clinical effects of peritoneal lavage in acute pancreatitis.     

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.     

Diagnostic peritoneal lavage in acute pancreatitis--the value of microscopy of the lavage fluid

In only 2 of 98 cases with a clinical diagnosis of acute pancreatitis submitted to peritoneal lavage in order to assess severity was the diagnosis found to be wrong. These two cases (one was biliary peritonitis and the other mesenteric infarction) were not differentiated from severe pancreatitis by clinical examination, measurement of plasma amylase, the appearance of the lavage fluid or its amylase or white cell count. One case was exceptional in that the lavage fluid had a faecal odour, and both cases were found to have large numbers of intestinal organisms which were clearly visible on routine microscopy. Scanty commensals (? contaminants) were seen in the lavage fluid of 2 of the 96 patients with acute pancreatitis but no intestinal organisms were found. If peritoneal lavage is used in the management of acute pancreatitis, microscopy of the lavage fluid, carried out as an emergency investigation, might help to detect the occasional case with a false diagnosis.     

遏制轻型急性胰腺炎向重症转化的非手术 治疗策略

目的 ：探讨遏制急性胰腺炎向重症转化的非手术治疗策略。方法 ：将4年间收治的286例轻型急性胰腺炎分为对照组和治疗观察组。对照组采取常规非手术治疗措施;观察组加用改善胰腺微循环，防治细胞钙超载和抑制胰酶的治疗方法。结果 ：对照组144轻型有20例转化为重症胰腺炎，14例发生全身性并发症;观察组142例轻型有8例转化为重症，2例出现全身性并发症。观察组重症患者血C-反应蛋白和Balthazar CT严重度指数在治疗后各时点较对照组明显降低。结论 ：在常规治疗的基础上加用改善胰腺微循环，防治细胞钙超载和抑制胰酶的治疗措施可能有助于阻止轻型急性胰腺炎向重症化发展。     

内镜联合腹腔灌洗治疗早期急性重症胆源性胰腺炎

目的探讨内镜联合腹腔穿刺灌洗治疗早期重症胆源性胰腺炎的效果.方法将急性重症胆源性胰腺炎患者62例随机分为2组,即内镜联合腹腔灌洗组(简称内镜组)32例和保守治疗组(对照组)30例.内镜组在入院3     

Evaluation of specific treatment for severe acute pancreatitis based on the results of the cooperative national survey in Japan

A cooperative national survey on acute pancreatitis in Japan was conducted by the Research Committee for Intractable Diseases of the Pancreas. Between January 1952 and December 1986, 2533 cases of acute pancreatitis, including 1219 severe and 1285 moderate cases, diagnosed according to the criteria of the Ministry of Health and Welfare of Japan, were collected from 523 institutions. Peritoneal lavage, plasma exchange, and artifical kidney therapy, that is, hemodialysis and hemofiltration, were employed as specific treatments for severe acute pancreatitis. We have attempted to evaluate the efficacy of these treatments based on the results of this survey. Peritoneal lavage, employed to treat 57 patients, was effective when performed within 3 days of the onset of symptoms and more than six times a day. Plasma exchange, employed in 20 patients, was effective when performed within 5 days of the onset of symptoms. Artificial kidney therapy, performed in 76 patients, was effective when continued for more than 7 days. These findings suggest that accurate and rapid diagnosis, and intensive care to maintain the cardiovascular system are crucial if these specific treatments for severe acute pancreatitis, are to succeed.     

非梗阻性胆源性重症急性胰腺炎的治疗

目的探讨非梗阻性胆源性重症急性胰腺炎的早期治疗方法。方法对收治的非梗阻性胆源性重症急性胰腺175例采用不同的治疗方案,其中63例3d内接受手术治疗,112例2周内行非手术治疗,对两组的临床治疗效果进行回顾性分析和总结。结果3d内手术治疗组中出现严重并发症者21例(33.3%),死亡16例(25.4%)。2周内接受非手术治疗组中出现严重并发症者19例(16.9%),死亡14例(12.5%);两组间差异均有显著性(P均<0.05)。结论非梗阻性胆源性重症急性胰腺炎2周内宜行非手术综合治疗,不宜过早手术。     

急性非梗阻性胆源性胰腺炎的腹腔镜手术时机探讨

目的:探讨急性非梗阻性胆源性胰腺炎患者施行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的可行性及手术时机。方法:回顾分析2004年4月至2008年2月37例急性非梗阻性胆源性胰腺炎患者实施LC的临床资料。结果:37例经非手术保守治疗2～11d后,血、尿淀粉酶恢复正常,成功实施了LC,术后均恢复顺利,当日或次日下床活动,36～72h后进食,无并发症发生。住院10～24d,平均13d。随访3～12个月,均无复发。结论:急性非梗阻性胆源性胰腺炎经非手术治疗病情控制后如能慎重选择病例,做好必要的围手术期处理,实施LC是安全的。     

Peritoneal Lavage for Severe Acute Pancreatitis: A Systematic Review of Randomised Trials

Background

The use of peritoneal lavage in patients with acute pancreatitis remains controversial. While recent guidelines do not make a positive recommendation for its use, there continues to be reports of clinical benefits from peritoneal lavage in this setting. The aim of this study was to systematically review the available randomized controlled trials of peritoneal lavage in patients with severe acute pancreatitis.

Methods

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and four major Chinese biomedical databases were searched. A random effects model was used in meta-analysis. The summary estimates were reported as risk ratios (RR) with corresponding 95% confidence interval.

Results

Ten randomized controlled trials, encompassing a total of 469 patients, were included. When compared with conservative treatment, the use of peritoneal lavage did not result in a statistically significant difference in the risk of mortality (RR = 0.82; 95% CI 0.32–1.79; p = 0.69) and complications (RR = 1.33; 95% CI 0.99–2.12; p = 0.06). The use of peritoneal lavage with antiproteases, in comparison with peritoneal lavage only, also did not result in a statistically significant difference in the risk of mortality and complications.

Conclusion

The lavage of the peritoneal cavity in patients with severe acute pancreatitis does not appear to confer a clinical benefit. Whether lavage of the pancreatic bed after necrosectomy is beneficial has yet to be determined.     

重症急性胰腺炎早期非手术治疗的再认识

目的: 探讨重症急性胰腺炎的早期治疗方法. 方法: 对80例急性重症胰腺炎资料分别采用早期手术治疗和早期非手术治疗的两种方法进行回顾分析,并对病死率及主要并发症进行总结. 结果: 1992年1月~1994年12月的29例患者经早期手术治疗,病死率和并发症发生率分别为55.2%和93.1%,1995年1月~2000年12月的51例经早期非手术治疗,病死率和并发症发生率分别为23.5%和51.0%.两组比较差异有显著性(P<0.01). 结论: 对急性重症胰腺炎患者采用早期非手术治疗能降低病死率和并发症发生率.     

Severe acute pancreatitis--diagnostic and therapeutic strategy

To establish the optimal diagnosis and therapeutical strategy in severe acute pancreatitis. 94 (56.9%) severe acute pancreatitis (79 males and 15 females, aged between 26 and 81), selected from 165 acute pancreatitis admitted in the last 5 years (2000-2004) were analyzed. The disease was assigned as severe when one or more of the following criteria were present: Ranson score >3 on admission or at 48 hours, APACHE II score >8, visceral failures, Balthazar CT score C, D or E and local complications (infected necrosis, pseudocyst or pancreatic abscess). Medical treatment (aggressive supportive intensive care therapy, minimizing pancreatic secretion and antibiotic therapy) was the first therapeutical step in all cases. 49 (52.1%) patients were operated on: 20 as early surgery imposed by biliary sepsis (16 cases) or by an acute abdomen with uncertain etiology and unfavourable evolution, and 22 as late surgery (at least 12 days after onset), imposed by the presence of the infected pancreatic necrosis, visceral failures or other local complications, the necrosectomy being the main surgical procedure for infected necrosis. 77 (81.9%) cases had a fair evolution. The conservative treatment led to a complete recovery in 37 (37.2%) cases. We registered an overall mortality rate of 12.7% and postoperative mortality rate of 14%; we also registered 5 (10.2%) postoperative complications: 4 pancreatic and 1 colonic fistulae. (1) The treatment of the severe acute pancreatitis must be performed only in the specialized multidisciplinary well equipped centers with very well trained staff. (2) Medical conservative treatment (aggressive supportive intensive care therapy and antibiotic therapy) is the main therapeutical method within the acute phase (first two weeks). (3) Very restrictive surgical indications within the acute phase. (4) Necrosectomy is the main surgical procedure for the infected necrosis.     

重症急性胰腺炎腹腔感染治疗方法的探讨

目的探讨重症性胰腺炎并腹腔感染治疗方法。方法回顾性分析1995年1月～2006年1月重症急性胰腺炎患者87例,其中51例采用常规方法治疗作为对照。研究组36例在常规治疗的基础上根据具体情况分别加用微创或开腹方法进行腹腔清创,持续灌洗疗法以及肠内营养。结果研究组36例中,5例出现感染,脓肿1例,真菌感染1例,死亡2例,对照组51例中,26例出现感染,胰腺脓肿6例,真菌感染5例,死亡6例。结论早期应用抗生素,腹腔灌洗清除腹腔毒性物质,缓解腹腹腔内高压症状以及肠内营养是SAP患者治疗的关键。     

The role of peritoneal lavage in the surgical treatment of acute necrotizing pancreatitis

Treatment of patients for acute pancreatitis is reported in this paper, with particular reference being made to the effectiveness of peritoneal lavage. Aetiological factors as well as surgical indications and techniques are communicated against the background of ten years of experience. Results are separately reported for two periods under review, with no peritoneal lavage used in the first phase. Results improved, and lethality rates dropped in the second five-year period, despite growing numbers of severe courses. Effects of peritoneal lavage are considered possible in the latter cases. However, mortality in the wake of early surgery has continued to be high, that is in connection with most severe forms of pancreatitis (when surgical action had been taken in the first week of manifest illness). No improvement appeared to be obtainable in such cases from postoperative peritoneal lavage.