急性胆源性胰腺炎不同治疗方法的疗效分析

目的:探讨治疗急性胆源性胰腺炎（acute biliary pancretitis,ABP）的优化方案。
方法:回顾性分析5年余收治的159例ABP患者的临床资料,根据疾病严重程度及有无胆道梗阻分为轻症非梗阻型（68例）、轻症梗阻型（43例）、重症非梗阻型（27例）、重症梗阻型（21例）。所有患者入院后先给予非手术治疗。对于伴有胆道梗阻的64例,根据解除梗阻的不同术式,分为内镜治疗组和开腹手术组,对比使用不同治疗方案的各组患者腹痛缓解时间、血清淀粉酶恢复时间、住院时间、治愈率、并发症发生率、病死率等指标。
结果:不伴梗阻的95例患者均经非手术治疗治愈,且轻症组与重症组各指标比较,差异无统计学意义(P＞0.05);伴有梗阻的64例中,入院后24 h内均行手术治疗。开腹手术组（26例）各指标与内镜治疗组（38例）比较,治疗效果差异有统计学意义,前者差于后者(P＜0.05)。
结论:胆源性胰腺炎应分型而治。非梗阻型ABP(轻型和重症)早期非手术治疗效果好;梗阻型ABP在非手术治疗的基础上早期解除胆道梗阻,通畅引流是治疗关键。内镜途径解除胆道梗阻与开腹手术比较,具有创伤小,安全性高,疗效更满意,是治疗梗阻型ABP的首选途径。

     

重症急性胰腺炎的个体化诊治体会

目的:探讨重症急性胰腺炎的临床特点及个体化治疗方法,以提高诊治水平,降低病死率。
方法:回顾性分析63例重症急性胰腺炎患者的临床资料。
结果:保守治疗46例,手术治疗17例;总治愈率为88.9%（56/63）,其中非手术组治愈率为91.3%（42/46）,手术组治愈率82.4%（14/17）。
结论:正确把握重症急性胰腺炎的个体化诊治原则可提高治愈率。

     

妊娠合并胰腺炎的临床诊断与治疗

目的：探讨妊娠合并胰腺炎的临床诊断与治疗特点。
方法：回顾性分析16例（18次）妊娠合并胰腺炎患者的临床资料。
结果：中期妊娠3例次,晚期妊娠15例次。重症急性胰腺炎5例。合并高脂血症6例,胆道疾病1例。血或/和尿淀粉酶升高者14例次（77.8%,14/18）。B超提示胰腺炎12例次（66.7%）。16例患者给予保守治疗,其中1例转手术清创引流。13例终止妊娠。产妇无死亡,胎儿死亡3例（18.8%）。
结论：妊娠期合并胰腺炎以中晚期妊娠为主。高脂血症是主要病因。以保守治疗及保证孕妇安全为首选;及时终止妊娠,母婴分科协作抢救有利于提高疗效。

     

老年急性胰腺炎的诊断治疗

目的:探讨老年急性胰腺炎（AP）的诊断和治疗。
方法:回顾性分析5年间住院治疗的老年急性胰腺炎患者254例（老年组,年龄≥60岁）的临床资料。并与同期住院的非老年急性胰腺炎患者(对照组,年龄＜60岁)258例进行比较。
结果:老年组,男∶女=1.00∶1.27。胆源性因素占发病原因的70.9%。其中轻症（MAP）218例,治愈216例,死亡2例（0.92%）;重症（SAP）36例,治愈23例,死亡13例（36.11%）。病死率与年龄、轻重程度有关（P＜0.01）。对照组,男∶女＝1.00∶1.00。胆源性发病因素占46.1%。MAP 216例,均治愈,SAP　22例治愈19例,死亡3例（13.6%）。老年组血淀粉酶（1 054.97±775.60）U/L及总胆红素(40.97±37.11)μmol/L升高大于对照组,差异有统计学意义（P＜0.05）。全组CT检查的阳性符合率（68.9%）明显高于B超（22.8%）（P＜0.01）。老年组行手术治疗65例,ERCP 46例占70.8%,常规手术治疗26例,对照组手术治疗51例,其中ERCP　28例,常规手术治疗23例。老年组有35例发生不同种类并发症(13.8%)多于对照组的20例(78%)（P＜0.05）。
结论:老年AP胆源性因素居多。血淀粉酶及总胆红素升高明显;并发症多;病死率高。CT是AP首选的辅助检查。治疗上以综合治疗为主。ERCP对于胆道梗阻、感染引起的老年急性胰腺炎患者较为适用。老年重症急性胰腺炎病死率高,且随年龄的增加而上升。

     

重型急性非胆源性胰腺炎治疗决策的反思：附54例报告

目的：探讨急性非胆源性重症型胰腺炎治疗方法。
方法：回顾分析近10年间收治的54例急性非胆源性重症型胰腺炎患者的临床资料。将其分为3组：Ⅰ组为急诊手术组15例(系前5年收治入院保守治疗72 h手术者);Ⅱ组为简捷手术+非手术治疗(针对并发症治疗者)24例;Ⅲ组为简捷手术+后期手术治疗组（并发胰腺脓肿者15例）。
结果：54例患者治愈51例（94.5％）,其中24例并发胰腺囊肿2期手术治愈,3例死亡（5.5％）（均系急诊手术组）,1例死于急性呼吸窘迫综合征（ARDS）,1例死于感染中毒性休克,1例死于术后多器官系统衰竭（MOSF）。Ⅱ和Ⅲ组均无死亡病例。
结论：急性非胆源性重症型胰腺炎早期强化全身支持治疗,维护脏器功能和内环境稳定甚为关键,应该针对其并发症进行序贯性治疗,炎症反应高峰期采用简捷手术（局麻下腹腔置管引流处理）,可延缓胰腺病变进程,对形成胰腺脓肿者及时手术治疗,术后持续腹腔灌洗,可明显提高治愈率。     

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     

重症急性胰腺炎手术治疗：附72例分析

目的:探讨重症急性胰腺炎(SAP)的手术治疗。
方法:回顾性分析1998年1月—2009年9月间经手术治疗的72例SAP患者的临床资料。
结果:72例根据接受手术时间早晚及是否进行肠内营养(EN）,分为:早期+全胃肠外营养（TPN）组,早期+TPN+EN组,延期+TPN组,延期+TPN+EN组。全组发生术后并发症72例,死亡23例,延期+TPN+EN组在病死率、住院时间及费用方面较其他组有明显降低,而在术后并发症与其他组无区别。
结论:在早期维持SAP患者生命体征及内环境稳态的情况下,延期行创伤小的手术方式,充分引流,尽早进行肠内营养可明显降低患者病死率、并发症、住院时间及费用。

     

肝包虫病85例治疗体会

目的：探讨肝包虫的诊断和治疗。
方法：回顾性分析收治的肝包虫病85例的临床资料。
结果：85例术前均诊断为肝包虫病。均采取手术治疗,全组均治愈。
结论：B超及CT检查,血清卡松尼试验阳性,即可确诊。 外科手术仍是治疗本病的最佳方式。

     

胆石性肠梗阻的诊断及治疗：附18例报告

目的：探讨胆石性肠梗阻的诊断及外科治疗方法。
方法：回顾性分析18例胆石性肠梗阻患者的临床特点、诊治方法及随访结果。
结果：18例平均年龄64.3岁,男女比例为1∶5。术前诊断率为77.8%。18例均经手术治疗,其中3例行一期肠切开取石手术,8例行一期行肠切开取石及二期胆囊切除加胆肠内瘘修补术,6例行一期手术解决肠道梗阻同时处理病变胆囊及胆肠内瘘,1例既往有胆肠内引流手术史患者一期行肠切开取石、胆肠吻合口切开取石、原胆肠吻合口整形术。术后并发症发生率38.9%,主要并发症为切口感染及肺部感染;死亡1例(5.5%),为术后第4天死于心肌梗塞。
结论：胆石性肠梗阻以老年女性患者为主,有效的影像学检查可及时诊断并为治疗提供可靠依据。胆石性肠梗阻应尽早外科干预,并根据患者具体情况选择合适的手术方式。

     

重症急性胆源性胰腺炎内镜治疗时机探讨

目的探讨内镜治疗重症急性胆源性胰腺炎的时机。方法选择上海市第一人民医院1995年4月至2005年5月59例经内镜治疗的重症急性胆源性胰腺炎病例,分为早期治疗组(A组,<48h)31例,延迟治疗组(B组,>48h)28例。分别比较两组病例腹痛缓解时间、血淀粉酶恢复正常时间、平均住院天数及并发症发生情况。结果A组病例腹痛缓解时间、血淀粉酶恢复正常时间及平均住院天数均短于B组(P<0.05)。A组发生并发症5例,B组为9例。结论重症急性胆源性胰腺炎应尽早行内镜治疗。     

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。     

内镜微创保胆取石术与胆囊切除术后综合征

目的:探讨胆囊切除术后综合征的病因、预防及处理。
方法:对收治的胆石症患者进行随机抽样调查,共调查253例,其中微创保胆取石术133例,腹腔镜胆囊切除术25例,开腹胆囊切除术95例。
结果:120例胆囊切除术后发生非器质性胆囊切除后综合征11例（9.2%）,133例保胆术后发生非器质性保胆术后综合征11例（8.3%）。
结论:胆囊是否切除与胆囊手术后综合征的发生无直接关系,胆道压力变化及长期清淡饮食导致的胆道顺应性下降可能是发生胆囊切除或保胆术后综合征的病因;胆囊功能的保留对缓冲与维持正常的胆道压力至关重要;胆道功能康复训练将有效降低上述症状的发生率。

     

腹腔镜联合十二指肠镜早期治疗轻型急性胆源性胰腺炎57例报告

目的 探讨运用腹腔镜联合十二指肠镜早期治疗胆囊结石继发细径胆总管结石和轻型急性胆源性胰腺炎的手术方法及疗效.方法 分析在发病7 d内(早期手术组)同期行腹腔镜胆囊切除术(LC)联合十二指肠镜下乳头切开术(EST)40例患者资料,并与在胰腺炎治疗2周后(延期手术组)同期行LC联合EST 17例患者资料,观察两组的疗效.结果 同期行LC联合EST手术成功率早期手术组为92.5%,延期手术组为94.1%,两组差异无统计学意义(P>0.05).两组术后均无胆管残留结石、胰腺炎加重.无胃肠穿孔、胆管穿孔、胆漏、大出血等手术并发症,无死亡.但延期手术组的住院时间和住院费用明显高于早期手术组.(P<0.05).结论 只要选择合适的轻型急性胆源性急性胰腺炎病例,于发病7 d内同期行腹腔镜胆囊切除术及十二指肠镜下乳头切开术是安全、有效的.     

内镜治疗急性胆源性胰腺炎的疗效评价

目的　探讨内镜治疗急性胆源性胰腺炎的临床效果。方法　将 3 6例急性胆源性胰腺炎患者分成两组治疗 ,其中 2 0例于 2 4h内行逆行胰胆管造影术 (ERCP )、内镜下乳头括约肌切开 (EST )后用网篮取石或碎石网篮碎石后气囊取石术及内镜下鼻胆管引流术 (内镜治疗组 ) ;另 16例行保守或急诊外科手术治疗 (对照组 )。结果　内镜组治疗的成功率为 95 .2 4% ,未发生与内镜操作有关的严重并发症 ,与对照组相比 ,内镜组术后腹痛缓解时间、住院时间明显低于对照组 (P <0 .0 1) ,术后第 2天血及尿淀粉酶明显降低 (P <0 .0 5 ) ,第 3天降低更为明显 (P <0 .0 1)。结论　内镜治疗直接针对胆源性胰腺炎的发病原因 ,解除胆胰管开口的梗阻 ,通畅了胆胰液的引流 ,降低胆胰管内压 ,可有效治疗胆源性胰腺炎 ,该方法微创、安全、有效 ,是治疗急性胆源性胰腺炎的理想方法。     

胰十二指肠切除术后腹腔内迟发性出血的原因与处理

目的：探讨胰十二指肠切除术后迟发性腹腔内出血的原因与处理方法。
方法:回顾性分析168例施行胰十二指肠切除术的患者中术后腹腔内出血的情况。
结果:168例患者中有38例出现腹腔内迟发性出血,发生率为22.6%（38/168）;因大出血而再次手术止血11例,发生率6.5%（11/168）;再手术的病死率27.3%（3/11）;出血的主要原因是合并胰瘘或腹腔感染。
结论:胰十二指肠切除术后腹腔内出血与胰瘘或腹腔感染密切相关。完善围手术期的处理,预防与及时发现、积极处理胰瘘和腹腔感染可以减少腹腔内迟发性出血的发生。

     

Pancreatographic findings in idiopathic acute pancreatitis

Background/purpose Despite extensive evaluation based on clinical history, biochemical tests, and noninvasive imaging studies, the cause of acute pancreatitis cannot be determined in 10 to 30% of patients, and a diagnosis of idiopathic acute pancreatitis is made. The purpose of this study was to clarify the pancreatographic findings in patients with idiopathic acute pancreatitis.Methods Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 34 patients with idiopathic acute pancreatitis, and the pancreatographic findings were examined. Patency of the accessory pancreatic duct was examined by dye-injection endoscopic retrograde pancreatography (ERP) in 16 of the 34 patients.Results In 11 patients (32%), the following anatomic abnormalities of the pancreatic or biliary system were demonstrated: complete pancreas divisum (n = 5), incomplete pancreas divisum (n = 2), high confluence of pancreaticobiliary ducts (n = 2), choledochocele (n = 1), and giant periampullary diverticulum (n = 1). Pancreatographic findings were normal in 17 patients. Eleven of these patients were examined by dye-injection ERP, and all were found to have nonpatent accessory pancreatic duct.Conclusions Anatomic abnormality of the pancreatic or biliary system is one of the major causes of idiopathic acute pancreatitis. Closure of the accessory pancreatic duct may play a role in the development of idiopathic acute pancreatitis in patients with a normal pancreaticobiliary ductal system.     

急诊ERCP在急性胆源性胰腺炎治疗中的应用

目的探讨急诊ERCP在急性胆源性胰腺炎(ABP)急性反应期中的作用与地位。方法回顾分析92例ABP患者,根据是否早期接受急诊ERCP分为ERCP组(ERCP组,52例)和非ERCP组(N-ERCP组,40例)。观察ERCP组中胆总管微小结石或胆泥发生率;比较两组重症胰腺炎发生率、腹痛缓解时间、血清淀粉酶及肝功能变化。结果 ERCP组中49例急诊ERCP治疗成功,成功率达94.2%。ERCP组中,胆总管微小结石及胆泥共6例,占胰腺炎病因11.5%(6/52);ERCP组重症胰腺炎发生率[5.8%(3/52)]明显低于N-ERCP组[20%(8/40)](P<0.05)。ERCP组腹痛缓解时间(3.5±1.1 d vs 5.0±1.5 d)、血清淀粉酶下降速度(50±135 U/L vs 201±120 U/L)、肝功能(TBIL:125±114μmol/L vs 250±140μmol/L;ALT:210±183 U/L vs 452±215 U/L;GGT:241±198 U/L vs 450±285 U/L)改善情况均优于N-ERCP组(P<0.05)。结论急诊治疗性ERCP可显著缓解临床症状和降低重症胰腺炎发生率。     

Early versus delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis

Background

The recommended treatment for patients presenting with mild acute biliary pancreatitis is early cholecystectomy performed during the index admission. However, the data are less clear in regards to patients who undergo endoscopic sphincterotomy prior to surgery. While it has been shown that these patients still benefit from cholecystectomy, the optimal timing of this intervention is not well defined. We hypothesized that delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis is associated with significant preventable morbidity.

Methods

A retrospective chart review was performed at two academic hospitals for patients diagnosed with biliary pancreatitis who underwent endoscopic sphincterotomy followed by cholecystectomy. Patients aged 18 and over admitted from 2006 to 2011 were included, while those with severe pancreatitis were excluded. The primary outcome was biliary complications experienced during the waiting period for cholecystectomy. Secondary outcomes included length of stay, operative complications, and conversion rate. Student t test was used to compare continuous data and Fischer’s exact test was used for categorical data.

Results

80 patient charts were reviewed. Time to cholecystectomy was 3.3 days (range 0.5–10) in the early group and 141.6 (range 18–757) in the delayed group. The groups were comparable in terms of age and American Society of Anesthesiologists (ASA) classification. 21 of 35 patients (60 %) in the delayed group experienced biliary complications compared with 1 of 45 (2 %) in the early group (p < 0.001). 14 patients in the delayed group required re-admission (40 %) and 5 (14 %) required additional procedures. Secondary outcomes were not statistically significant.

Conclusions

The data demonstrate a significantly increased biliary complication rate associated with delayed cholecystectomy in this patient population. Early cholecystectomy should be strongly considered for patients with mild biliary pancreatitis even when endoscopic sphincterotomy has been performed pre-operatively.     

Clinical Diversity in Biliary Pancreatitis — Classification of Two Types

One hundred and seven patients with biliary pancreatitis undergoing operation from 1976 to 1989 were reviewed. To clarify the reason for failure to respond to conventional supportive therapy, 73 patients (68%) who underwent emergency surgery were retrospectively divided into two groups according to the severity of the pancreatitis evaluated at laparotomy and compared. Sixty-two had minimal or mild pancreatitis (Group I), among whom 44 (71%) had life-threatening acute biliary tract disease. All underwent biliary surgery and 4 (6%) subsequently died, 2 due to acute obstructive suppurative cholangitis. Eleven had hemorrhagic necrotizing pancreatitis (Group II), among whom 7 had complications of acute pancreatitis such as pancreatic ascites or abscess. These underwent pancreatic and/or biliary surgery and 3 (27%) died of multi-organ failure.There appears to be two types of biliary pancreatitis refractory to conventional supportive therapy, which differ in the extent of surgery required and in mortality: (1) minimal or mild pancreatitis with persistent life-threatening acute biliary tract disease (biliary type), and (2) more severe pancreatitis (pancreas type) early in the course of the disease.