重型非胆道梗阻性急性胆石性胰腺炎的外科处理

目的探讨重型非胆道梗阻性急性胆石性胰腺炎的外科处理要点。方法分析47例重型非胆道梗阻性急性胆石性胰腺炎病人的临床资料。结果(1)1999年8月以前,13例采用早期手术,4例死于早期多脏器功能衰竭,病死率为30.8%;存活者平均住院时间为51.5d、平均医疗费用为9.53万元。(2)1999年8月以后,22例采用早期区域动脉灌注治疗,1例死于后期感染并发症,病死率为4.5%;存活者平均住院时间为31.3d,平均医疗费用为4.64万元。(3)12例采用传统保守治疗,4例病情较重者3例死于早期多脏器功能障碍;其余8例病情较轻者无并发症治愈。结论(1)在急性反应期内,作好复苏治疗的同时,推荐应用区域动脉灌注治疗重型非梗阻性胆石性胰腺炎;(2)重视临床类型的鉴别和转化,发现胆道梗阻及时手术治疗;(3)病变后期出现胰腺局部并发症需要适时的择期手术;(4)非手术治疗成功者应适时手术解除胆石病变以防止胰腺炎复发。     

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目的探讨胆源性胰腺炎(GP)病人胆道结石的处理方式和时机。方法回顾性分析1998年5月至2003年6月期间89例GP病人的处理方式和时机结果腹腔镜胆囊切除术(LG)的比例逐渐增加(48％)，剖腹胆道手术却逐渐减少(52％)，尤其是剖腹胆总管探查术(12％)，但胆总管结石探查的阳性率却明显增加(100％)。术前进行ERCP检查的比例仅0～4％，但MRCP的比例增加到32％。极少数病人(0～8％)需要行内镜括约肌切开(Ⅸ汀)治疗。结论采用微创技术处理GP病人胆道结石的方式逐渐增加。GP病人胆道结石的最佳处理时期是胆道和胰腺的炎症得到控制后，大多数病人需要1～3周。对B超不能确诊的胆总管结石，应首选脉CP检查，慎用逆行性胰胆管造影术(ERCP)。     

内镜治疗急性胆源性胰腺炎的临床价值

目的探讨内镜治疗急性胆源性胰腺炎的疗效。方法对我院1998年7月~2004年10月行ERCP、EST、ENBD等方法治疗急性胆源性胰腺炎43例的临床资料进行回顾性分析。结果本组43例经内镜治疗后疗效均满意。术后发生出血1例、形成胰腺假性囊肿2例、死亡1例。无因病情恶化而中转手术治疗者。结论ERCP对急性胆源性胰腺炎的诊断有重要价值;内镜是治疗急性胆源性胰腺炎安全、有效的方法之一。     

Sulindac-induced acute pancreatitis mimicking gallstone pancreatitis

Two patients with sulindac-induced acute pancreatitis presented clinically with abdominal pain, right upper-quadrant tenderness, markedly increased serum amylase values, and hyperbilirubinemia, findings initially suggestive of gallstone pancreatitis. Ultrasound examinations were negative for gallstones. One patient was inadvertently treated two years later with sulindac with recurrence of abdominal pain, marked hyperamylasemia, and jaundice. Clinical resolution was rapid with each episode following discontinuation of sulindac.     

Operations upon the biliary tract in patients with acute pancreatitis: aims, indications and timing

The management of gallstones in patients with acute pancreatitis (AP) is controversial. This paper reports an analysis of 171 attacks of AP associated with gallstones. Whilst awaiting elective cholecystectomy 56% of patients had further symptoms and 1 died. Non-urgent operations during the same admission as the pancreatitis (n = 34) resulted in 2 deaths and 7 septic complications, but prediction of complications may be possible. Urgent surgery (n = 5) was followed by 3 deaths. This study suggests that in most patients, cholecystectomy should be performed as soon as the patient is adequately fit. Urgent removal of an impacted ampullary stone (preferably by endoscopic papillotomy) may be required in a small minority if severe pancreatitis fails to respond to medical treatment, or if cholangitis supervenes .     

胆囊结石并发胆源性重症急性胰腺炎行腹腔镜胆囊切除术手术时机的探讨

目的 探讨胆囊结石合并胆源性重症急性胰腺炎(acute biliary servere pancreatitis,ABSP)应用腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗的可行性及手术时机.方法 回顾性分析我院2008年7月至2011年6月16例胆囊结石合并胆源性重症急性胰腺炎患者应用LC治疗的临床资料.结果 16例患者在保守治疗12～27d后均成功行LC术,无中转开腹,手术时间30～145min,平均63min.术中出血量20～330ml,平均80ml.6例放置腹腔引流管,均于术后24～72h拔除腹腔引流管,无胆漏及出血.住院15～31d,平均19d.16例术后随访4～36个月均无复发病例.结论 对于胆囊结石合并胆源性重症急性胰腺炎患者,在临床症状和体征基本消失,可进低脂饮食后,可安全实施LC术.     

Endoscopic therapy for aged patients with biliary acute pancreatitis

目的 探讨高龄胆源性急性胰腺炎(biliary acute pancreatitis,BAP)病人早期内镜治疗的疗效及安全性.方法 将100例BAP病人分为高龄组(80岁及以上)22例,对照组(80岁以下)78例,观察两组内镜治疗的疗效和安全性.结果 高龄组22例均顺利完成了内镜下逆行胰胆管造影(ERCP)操作,与对照组比较,治疗后血淀粉酶、白细胞计数、肝功能恢复正常时间、腹痛缓解时间、腹部体征消失时间及体温恢复正常时间、并发症发生率等差异均无统计学意义.结论 治疗性ERCP对于治疗高龄BAP具有微创、安全、有效等优点.     

Obstructive jaundice in patients with pancreatitis without associated biliary tract disease.

Jaundice occurring in patients with pancreatitis is usually due to hepatocellular injury or to associated biliary tract disease. Common duct obstruction is occasionally caused by pancreatic fibrosis, edema or pseudocyst in patients who have neither hepatocellular injury nor biliary tract disease. We have studied 7 patients with obstructive jaundice due to pancreatitis who demonstrated no other known cause for jaundice. The difficulty in making the differential diagnosis between benign and malignant disease in these patients, particularly when no pain is associated with obstructive jaundice, is discussed. In view of the fact that the terminal common duct traverses the pancreas, it is uncertain why obstructive jaundice associated with chronic pancreatitis does not occur more often unless the condition is sometimes transient and overlooked. Operative intervention is required in those patients in whom jaundice is persistent. Operation is intended to decompress the biliary tract and the pancreas. The approach used will be dictated by the operative findings in each patient.     

Lymphoplasmacytic chronic cholecystitis and biliary tract disease in patients with lymphoplasmacytic sclerosing pancreatitis

Lymphoplasmacytic sclerosing pancreatitis (LPSP) represents a distinctive form of chronic pancreatitis characterized by diffuse fibroinflammatory infiltrates that can involve both the pancreatic ducts and acinar parenchyma. Several cases of inflammatory infiltrates within the gallbladder have been reported in association with LPSP, but the spectrum of gallbladder pathology in patients with LPSP has not been systematically reviewed. Many patients with LPSP have distal CBD fibrosis, strictures, and inflammation, features that overlap somewhat with primary sclerosing cholangitis (PSC). In PSC, a pattern of gallbladder pathology termed "diffuse acalculous lymphoplasmacytic chronic cholecystitis" has been previously described as showing a triad of diffuse, mucosal-based, plasma cell-rich inflammatory infiltrates. We studied 20 gallbladders from patients with LPSP and compared them with 20 gallbladders in PSC, 20 gallbladders with chronic cholelithiasis, and 10 gallbladders from patients with benign (non-LPSP) pancreatic disease. The following features were evaluated: degree and composition of mucosal inflammation and deep (mural) inflammation, lymphoid nodules, metaplasia, dysplasia/neoplasia, fibrosis, muscular hypertrophy, Rokitansky-Aschoff sinuses, and cholesterolosis. The majority (60%) of gallbladders in LPSP contained moderate or marked inflammatory infiltrates and lymphoid nodules, frequencies similar to PSC but significantly higher than in chronic cholelithiasis and benign non-LPSP pancreatic disease. LPSP gallbladders received the highest scores for deep inflammation of all groups, and 35% of LPSP gallbladders showed transmural chronic cholecystitis. Overall, "diffuse lymphoplasmacytic chronic cholecystitis" was present in 50% of PSC cases and 25% of LPSP cases, but in only 5% of chronic cholelithiasis and none of non-LPSP benign pancreatic disease. Mucosal inflammation in LPSP gallbladders correlated significantly with the presence of inflammation in the extrapancreatic portion of the CBD. These findings suggest that inflammatory pathology of the gallbladder is frequently associated with LPSP and that it is part of the spectrum of biliary tract disease in these patients, rather than a simple reflection of the pancreatitis itself.     

Acute gallstone pancreatitis: best timing for biliary surgery

The timing of biliary surgery in patients who have pancreatitis secondary to cholelithiasis is debatable. Of 523 patients admitted for acute pancreatitis between 1969 and 1978, 114 had gallstones for which an operation was performed, early and late operation respectively in 98 patients. Complications occurred in 12 of the 114 patients and 7 patients died. Significantly more deaths occurred in the group who had an immediate operation (n = 5). In the group who had an operation more than 7 days after the amylase returned to normal, recurrent pancreatitis developed in 5 patients, 1 of whom died. It is concluded that immediate operation does increase mortality, and so may delay longer than 7 days after the amylase returned to normal.     

Minimally invasive approach in gallstone disease complicated with acute pancreatitis

We have evaluated the minimally invasive approaches (laparoscopy, endoscopy) in the management of the gallstone disease complicated with acute pancreatitis. Hypothesis. Emergency ERCP in gallstone pancreatitis (GSP) associated with jaundice or angiocholitis has a beneficial effect on pancreatic inflammation, eventually favoring laparoscopic cholecystectomy. We have compared 18 cases of emergency ERCP for GSP associated with jaundice or angiocholitis (Group 1) with 72 cases of GSP where ERCP was indicated on a selective basis (Group 2). Laparoscopic cholecystectomy was done after the acute bout of pancreatitis subsided. The minimally invasive approaches were completed in 89% cases in Group1 and in 90% cases in Group 2, respectively. Pancreatic morbidity was better in Group 1 (0% vs. 15.2%), but without statistical significance. General morbidity was significantly lower (0% vs. 23.6%) as well as the mean hospital stay (13 +/- 5.5 days vs. 17 +/- 10.4 days). Only the lower general morbidity and the shorter hospital stay assert the hypothesis that emergency ERCP in GSP associated with jaundice or angiocholitis has a beneficial effect on pancreatic inflammation, eventually favoring laparoscopic cholecystectomy.