胆源性胰腺炎的手术时机探讨

目的探讨轻型急性胆源性胰腺炎的手术时机。方法回顾性分析我院2002年2月-2007年12月收治的49例胆源性胰腺炎的临床资料。将49例按入院后的手术时间分为早期手术组（A组）和延期手术组（B组）。结果早期手术组较延期手术组并发症发生率高;两组病死率无差别。早期手术和延期手术胆总管探查率分别为95．2％和39．3％,胆总管探查阳性率分别为45．0%和90．9％。结论早期手术和延期手术均是安全的。最佳手术时机是炎症发作消退、血清淀粉酶降至正常后首次住院期内。     

胆源性胰腺炎的手术时机探讨

目的 为提高急性且源性胰腺炎（ＡＧＰ）的治疗效果,探索ＡＧＰ早期手术适应证衣最佳手术时机。方法 通过回顾分析１４３例ＡＧＰ病人并将其生胆源笥胰腺炎９ＯＡＧＰ（及非梗阻性胆源笥胰腺炎（ＮＯＡＧＰ）２组。结果 ＯＡＧＰ组４９例作了交早期手术,４４例治愈,ＮＯＡＧＰ组９４例均先行非手术治疗,２周至３个月后再行延期胆道手术,结果死亡１例,余均治愈。结论 必须正确把握ＡＧＰ的手术时机,并认为：具有梗因素的Ａ     

胆源性重症急性胰腺炎手术时机探讨

我院于 1 996年 1月至 2 0 0 1年 1 2月共对 1 8例胆源性重症急性胰腺炎患者施行延期手术 ,取得较满意疗效 ,现报告如下。1　临床资料1 .1　一般资料　本组 1 8例 ,男性 1 2例 ,女性 6例 ,年龄 2 1～ 62岁 ,平均 40岁。诱因 :胆总管结石 1 6例 ,先天性胆总管囊状扩张 2例。全部患者均符合以下诊断标准 :Balthazar CT分级≥ 级 ,入院 48h内 Ranson分级≥ 3项和 (或 ) Apache 评分≥ 8分。均诊断为急性胆源性重症胰腺炎。1 .2　治疗方法　所有患者入院后均进行积极的内科治疗。包括 :1禁食、禁饮、持续胃肠减压 ;2积极抗休克、纠正水电解质…     

重症胆源性胰腺炎手术时机的选择

目的 探讨重症胆源性胰腺炎（ＳＧＰ）的最佳手术时机。方法 回顾性分析６７例ＡＳＧＰ的手术时机与并发平及死亡情况。结果 ＳＧＰⅠ级早期手术和延期手术的并发症率分别为５４．５４％和１０．００％（Ｐ〈０．０５），病死率分别为２７２７％和０（Ｐ〈０．０５）。ＳＧＰⅡ级早期手术与延期手术并发平率为８４．６２％和４１．６７％（Ｐ〈０．０５），病死率为５３．８５％和２５．００％（Ｐ〉０．０５）。结论 ＳＧＰⅠ级     

胆源性胰腺炎手术时机的选择及术后处理

目的 探讨胆源性胰腺炎(GP)的手术时机及术后处理。方法 分析30例GP的临床资料。结果 轻型 GP 24例采用非手术疗法治愈。24例轻型胰腺炎痊愈后,再行胆道手术 20例,无手术并发症。重型 GP 6例,其中4例急诊手术治疗,均治愈,但术后均有不同程度的并发症。另2例因全身情况不允许手术,行非手术治疗,治愈1例,死亡1例。结论 轻型GP应待急性发作缓解后手术,术后处理与一般的胆道疾病的相同。重型GP,若全身条件许可,应积极行外科手术治疗,并需重视术后处理。     

胆源性急性胰腺炎的手术治疗探讨

目的 探讨胆源性急性胰腺炎的手术治疗的指征和时机。方法 回顾性分析1991年-2000年收治的胆源性急性胰腺炎77例。结果 轻型胆源性急性胰腺炎69例，均予早期急诊手术解除胆道梗阻，均获得痊愈。重症胆源性急性胰腺炎8例，病情迅速恶化出现胰腺坏死，感染，均予以手术引流，痊愈4例。死亡4例。结论 对胆源性急性胰腺炎有胆道梗阻者应当早期急诊手术解除胆道梗阻，可获得良好预后。对重症胆源性急性胰腺炎出现坏死感染者应当及时手术引流，但预后不良。     

胆源性急性胰腺炎的临床分型与手术时机的选择

目的 探讨胆源性急性胰腺炎（GAP）的临床分型与手术时机的选择。方法 对109例GAP患者的临床资料进行回顾性分析。结果及结论 按壶腹部有无梗阻及胰腺炎的严重程度，将GAP分为4型并用不同方法处理：（1）轻症非梗阻型，以非手术治疗为主；（2）轻症梗阻型，自发病起观察约36h，如梗阻仍未解除需早期手术，如梗阻解除则继续非手术治疗；（3）重症非梗阻型，以非手术治疗为主，并按胰腺坏死是否并发感染决定其是否手术；（4）重症梗阻型，宜行EST及时解除梗阻，如无此条件，应在短期支持治疗后早期手术，注意；非手术治疗中如出现胆囊或胆道化脓性炎症宜早期手术；经非手术治疗度过急性期的患者，应限期手术解决胆石病。     

非结石性胆源性急性胰腺炎的病因及手术时机的探讨

目的：探讨非结石性胆源性急性胰腺炎的病因及手术时机。方法：总结38例非结石性胆源性急性胰腺炎的发病原因及治疗经验。结果：本组共行手术13例，早期手术6例，术后无并发症及死亡；中期重型急性胰腺炎手术5例，1例合并胰瘘，1例合并高位小肠瘘死亡；晚期手术2例，1列死亡。本组手术死亡率15％（2/13）。非手术治疗重型胰腺炎4例，早期死亡1例。轻型胰腺炎21例均经非手术治疗痊愈。结论：非结石性胆源性急性胰腺炎合并存在胆道感染时应早期手术，否则应先试行积极的支持治疗。     

30例重症胆源性胰腺炎延期手术探讨

目的　探讨重症胆源性胰腺炎 (GP)的手术时机。方法　对 1 995年 1月～ 1 999年 1 2月收治的 30例明确诊断为重症GP患者延期手术和病死率进行系统的回顾性分析。结果　 2例因梗阻性化脓性胆管炎早期急诊手术 ,术后 1例死于心衰。非手术治疗过程中 1例死于多器官功能衰竭。延期手术 2 7例 ,2例分别死于多器官功能衰竭和真菌性败血症。术后并发症 2例 ,分别是胰瘘和胰周残余脓肿。延期手术病死率和并发症发生率分别是 1 0 .0 %、6 .7%。结论　重症GP应首先行非手术治疗 ,待渡过急性期 ,一般于起病 3周后在同一住院期间延期手术 ,若非手术治疗过程中出现梗阻性化脓性胆管炎、胰腺坏死组织并发感染 ,应早期急诊手术。延期手术能保证较低的病死率     

急性胆源性胰腺炎的手术时机

目的 探讨急性胆源性胰腺炎的手术时机.方法 对2000年6月以来的急性胆源性胰腺炎病例57例进行回顾性分析.结果 36例轻型患者中,因胆囊颈管结石嵌顿导致慢性胆囊炎急性发作,于入院2～3 d内早期手术11例,其余25例在入院后6～11 d施行手术.21例重型患者中,因急性梗阻性胆管炎施行急诊手术13例,内科治疗2～3周症状缓解后施行手术7例,另1例暴发性胰腺炎患者入院时病情危重,失去手术时机,48 h死于多器官功能衰竭.本组治愈56例,死亡1例.结论 急性胆源性胰腺炎的手术时机应个体化,急性梗阻性胆管炎或胆囊颈管结石嵌顿导致急性发作应急诊手术,其余病人,尤其是重症患者,应尽可能在保守治疗症状完全缓解后择期手术.     

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)。     

The impact of timing of cholecystectomy following gallstone pancreatitis

IntroductionCurrent guidelines for the management of acute gallstone pancreatitis recommend cholecystectomy as definitive treatment during primary admission or within 2 weeks of discharge, with the aim of preventing recurrent pancreatitis. However, cholecystectomy during the inflammatory phase may increase surgical complication rates. This study aimed to determine whether adherence to the guidelines prevents recurrent pancreatitis while minimising surgical complications.MethodsMulti-centre review of seven UK hospitals, indentifying patients presenting with their first episode of gallstone pancreatitis between 2006 and 2008.ResultsA total of 523 patients with gallstone pancreatitis were identified, of which 363 (69%) underwent cholecystectomy (72 during the primary admission or within 2 weeks of discharge; 291 following this). Overall, 7% of patients had a complication related to cholecystectomy of which a greater proportion occurred when cholecystectomy was performed within guideline parameters (13% vs 6%; p = 0.07). 11% of patients were readmitted with recurrent pancreatitis prior to surgery, with those undergoing cholecystectomy outside guideline parameters being most at risk (p = 0.006).ConclusionThis study suggests cholecystectomy within guideline parameters significantly reduces recurrence of pancreatitis but may increase the risk of surgical complications. A prospective randomised study to assess the associated morbidity is required to inform future guidelines.     

Cholangitis score: a scoring system to predict severe cholangitis in gallstone pancreatitis

Abstract. Background/Purposes: Emergency biliary decompression and stone extraction are mandatory for patients with gallstone pancreatitis who have ampullary stone impaction or persistent stones and pus in the bile duct (severe cholangitis). The aim of this study was to devise a simple scoring system for the prediction of complicating severe cholangitis in gallstone pancreatitis. Methods: Clinical signs, laboratory data, and ultrasonography (US) findings at the time of admission, and the bile duct pathology at the time of bile duct exploration, were reviewed in 66 patients with gallstone pancreatitis. Variables which discriminated 26 patients with bile duct stones from 40 without were defined as predictive factors of bile duct stones. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff values of numerical variables. One point was allocated to each predictive factor, and the total score was defined as the cholangitis score (CS). Bile duct pathology identified at the time of bile duct exploration was graded into three categories: mild, moderate, and severe cholangitis. A threshold value of the CS, claimed to be predictive of severe cholangitis, was determined by using the ROC curve. Results: The scoring system consisted of four predictive factors: (1) pyrexia (temperature ≧38 °C), (2) elevated serum bilirubin (≧2.2 mg/dl), (3) dilated bile duct (≧11 mm maximum diameter on US), and (4) bile duct stones detected on US. The scoring system predicted severe cholangitis with 92% sensitivity and 98% specificity in patients with scores of three or four points. Conclusions: Patients with gallstone pancreatitis who meet three or four of the above predictive factors at the time of admission are likely to have severe cholangitis, and should be rapidly treated by biliary decompression and stone extraction. Received: July 13, 2001 / Accepted: November 16, 2001     

不同类型胆石性胰腺炎不同病程中的手术处理

目的探讨手术在不同临床类型胆石性胰腺炎不同病程中所起的作用。方法分析273例胆石性胰腺炎的早期手术、延期手术以及恢复期手术的临床资料。结果（1）13例Ⅲ型病人采用早期手术治疗，病死4例；8例Ⅰ型病人和所有经早期手术治疗的轻型病人全部治愈。（2）共有4例重型病人行延期手术治疗，其中2例因并发坏死组织继发感染，1例病死，1例治愈；1例假性囊肿伴出血和另1例巨大假性囊肿。（3）120例经非手术方法治愈，15例Ⅲ型病人得到随访，2例复发，2例在住院后期行胆囊切除，9例再入院行胆囊切除，尚有2例未行胆囊切除；9例Ⅳ型病人在住院后期行手术治疗；其余病例失访。结论（1）Ⅰ型、Ⅱ型病人是早期手术的绝对适应证，手术目的在于解除胆道梗阻，Ⅲ型病人不适合早期手术；（2）Ⅰ型或Ⅲ型病人在病变后期出现胰腺局部并发症需要延期手术，其关键在于胰周间隙的通畅引流；（3）对于保守成功的Ⅲ型病人应尽早开展针对胆石病变的恢复期手术以防止胰腺炎复发；（4）Ⅳ型病人可采用早期手术，也可采用愈合期手术治疗。     

急性胆源性胰腺炎41例外科治疗临床体会

目的探讨急性胆源性胰腺炎(acute biliary pancreatitis ABP)外科治疗的时机与方法。方法 41例ABP患者均采用外科手术治疗。结果本组41例患者均获治愈。结论对ABP的治疗应根据其病情与类型而定,对伴有胆总管下端梗阻或胆道感染的重症ABP应急诊或早期(72 h)手术,对不伴胆道完全梗阻、胆管炎的重症ABP患者,早期采取保守治疗,手术尽量延至病情稳定后。对急性水肿性ABP可经保守治疗,病情稳定后2～4周行胆道手术,但保守治疗期间若出现胆管炎、胆囊坏疽或穿孔应急诊手术。     

Surgeons provide definitive care to patients with gallstone pancreatitis

Background

The optimal management of patients with gallstone pancreatitis (GP) remains a matter of debate. There are wide variations in the use of diagnostic testing and same-stay cholecystectomy. We hypothesize that a general surgery service (SURG) will deliver more efficient, definitive care for patients with GP.

Methods

A retrospective cohort study of consecutive GP patients in an urban hospital from 2006 to 2009. Differences between groups were assessed by the two-tailed Student t test for continuous variables and the Fisher exact test for ordinal data.

Results

One hundred twenty-four patients with GP were admitted, 79 to medicine (MED) and 45 to surgery (SURG). In the MED group, 21 patients (27%) underwent same-stay cholecystectomy, and 7 patients (9%) returned with recurrent biliary pancreatitis. In the SURG group, 44 patients had definitive surgery, and none returned with recurrent disease (P < .01 and .09, respectively). The SURG group had fewer laboratory tests, antibiotics, and consultations.

Conclusions

For patients with GP, admission to surgery results in definitive treatment with same-stay cholecystectomy. This is a more efficient approach with fewer readmissions for the same disease process.     

重症急性胰腺炎的手术治疗

本文对近８年来９１例重症急性胰腺炎病例进行了回顾性研究，根据ＣＴ影像或术中所见胰腺坏死的程度将病例分为轻度，中度和重度。本组资料提示：轻度和中度病例宜以保守治疗为主，重度病例应以手术治疗为主。手术病人术前需纠正休克或成人呼吸窘迫综合征，术中应充分游离胰腺，十二指肠造瘘对阻止胰腺炎的发展和防止胰腺或胰周脓肿的形成有重要作用。     

A practical cost-effective management strategy for gallstone pancreatitis

Background

The purpose of this study was to evaluate the outcomes of various surgeon strategies used to evaluate and treat common duct stones (CDSs) in patients presenting with mild to moderate gallstone pancreatitis (GP).

Methods

We performed a retrospective review of patients admitted for mild to moderate GP. Data variables included laboratory values and radiology images, indications for and findings of intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP), length of stay (LOS), and hospital charges. Data were stratified by 2 different management strategies: preoperative ERCP and then laparoscopic cholecystectomy (LC) or LC with IOC followed by selective postoperative ERCP.

Results

During this time period, 80 patients met the study criteria, 56 were treated by LC with IOC, and 24 had a preoperative ERCP performed. The incidence of CDS was 33% (n = 26). The presence of CDSs correlated with an elevated total bilirubin at admission (CDSs 3.5 mg/dL vs 2.1 mg/dL no CDSs, P < .01) and 24 hours after admission (CDS 3.2 mg/dL vs 1.5 mg/dL no CDS, P < .01). Patients who had an IOC compared with those who had preoperative ERCP had a shorter LOS (4.6 vs 5.9 days, P = .04) and lower hospital charges (US $28,510 vs US $38,620; P < .01).

Conclusions

Elevated total bilirubin at admission and 24 hours after admission may predict a patient's risk for CDS. We found that the management of uncomplicated GP with early LC and IOC results in decreased LOS and total hospital charges when compared with preoperative ERCP.     

Endoscopic sphincterotomy permits interval laparoscopic cholecystectomy in patients with moderately severe gallstone pancreatitis

Patients with moderately severe gallstone pancreatitis with substantial pancreatic and peripancreatic inflammation, but without organ failure, frequently have an open cholecystectomy to prevent recurrent pancreatitis. In these patients, prophylactic endoscopic retrograde cholangiography (ERC) with endoscopic sphincterotomy (ES) may prevent recurrent pancreatitis, permit laparoscopic cholecystectomy, and decrease risks. The medical records of all patients with pancreatitis undergoing cholecystectomy from 1999–2004 at the University of North Carolina Memorial Hospital were reviewed. Data regarding demographics, clinical course, etiology of pancreatitis, operative and endoscopic interventions, and outcome were extracted. Moderately severe gallstone-induced pancreatitis was defined as pancreatitis without organ failure but with extensive local inflammation. Thirty patients with moderately severe gallstone pancreatitis underwent ERC and ES and were discharged before cholecystectomy. Mean interval between ES and cholecystectomy was 102 ± 17 days. Cholecystectomy was performed laparoscopically in 27 (90%) patients, open in three (10%) patients, and converted to open in two (7%) patients, with a morbidity rate of 7% (two patients). No patient required drainage of a pseudocyst or developed recurrent pancreatitis. Interval complications resulted in hospital readmission in seven (23%) patients. In conclusion, recurrent biliary pancreatitis in patients with moderately severe gallstone pancreatitis is nil after ERC and ES. Hospital discharge of these patients permits interval laparoscopic cholecystectomy, but close follow-up is necessary in these potentially ill patients. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).