重症急性胰腺炎临床病理分期意义及治疗对策

目的：探讨重症急性胰腺炎（ＳＡＰ）临床病理分期和治疗措施。方法：从１９９０年１２月以来,我院对２３例ＳＡＰ病例采用早期手术,功口开放引流,观察胰腺病理形态改变。结果：通过对ＳＡＰ胰腺病理形态改变的观察,将ＳＡＰ的病理演变过程分为四期,即组织坏死合并急性生理率乱期、坏死组织液化继发感染期、胰腺感染坏死脱落及晚期并发症期和胰腺炎恢复期。结论：治疗以改善微循环、球死组织清除、充分引流和营养支持为主。     

急性坏死性胰腺炎合并感染的病原菌及耐药性分析

目的：研究急性坏死性胰腺炎（ANP）合并感染的病原菌分布及耐药性,并探讨其对ANP患者预后的影响。 方法：回顾性分析2010年10月—2014年10月收治的72例有明确病原学依据的ANP合并感染患者的临床资料。 结果： 72例ANP患者中,腹腔及腹膜后感染47例（65.28%）,呼吸道感染37例（51.39%）,血流感染32例（44.44%）,其中血流感染与患者死亡密切相关（P<0.05）。检出病原菌235株,其中革兰阴性细菌159株（67.66%）,革兰阳性细菌60株（25.53%）,真菌16株（6.81%）。获得的病原菌中排名前6位的依次是：鲍曼不动杆菌（24.68%）,铜绿假单胞菌（8.94%）,肺炎克雷伯菌（8.09%）,屎肠球菌/粪肠球菌（8.09%）,大肠埃希菌（7.66%）,金黄色葡萄球菌（4.68%）。耐药性分析显示,鲍曼不动杆菌和铜绿假单胞菌对亚胺培南耐药率分别达95.92%和52.63%,对头孢哌酮/舒巴坦的耐药率分别为59.26%和50.00%。肺炎克雷伯菌和大肠埃希菌产超广谱β-内酰胺酶（ESBLs）检出率分别为64.29%和80.00%,对头孢哌酮/舒巴坦的耐药率分别为31.58%和18.75%,而对亚胺培南的耐药率分别为23.08%和7.14%。19株屎肠球菌/粪肠球菌中仅1株对万古霉素耐药,对利奈唑烷尚未发现耐药菌株。耐甲氧西林金黄色葡萄球菌检出率为72.73%,对万古霉素、利奈唑烷和呋喃妥因尚未发现耐药菌株。16株真菌对常用抗真菌药物均未发现耐药菌株。 结论：血流感染是ANP患者死亡的重要原因。ANP患者的病原菌仍以革兰阴性菌为主,但革兰阳性菌和真菌的比例不容忽视。多重耐药菌已成为ANP合并感染的巨大的挑战。     

Acute necrotizing pancreatitis: therapeutic alternatives

The management of acute necrotizing pancreatitis has changed significantly over the last few years. Currently, most patients survive the early phases of the disease due to improvements in intensive care unit management. The most important risk factor for morbidity and mortality is infection of the pancreatic necrosis. Ideally, surgery should be delayed until 4 weeks after the onset of symptoms of pancreatitis, as it is at this time that the necrosis is most clearly demarcated. Advances in diagnostic imaging and minimally invasive techniques in surgery and radiology have revolutionized the surgical management of this disease. However, minimally invasive techniques should be limited to critically-ill patients unfit for conventional surgery.     

Acute necrotizing hemorrhagic pancreatitis

There is no etiologic treatment for acute necrotizing pancreatitis. Advances in intensive care resulted in a reduction in early death rate by a better control of systemic complications. Delayed death rate from infection is high (20-60%). Diagnostic problems are an important cause, in spite of the aid of computed tomography and echography. The prognosis will further be improved by earlier diagnosis, a better definition of surgical treatment when complications arise, and constant medicosurgical collaboration.     

Therapeutic strategy in acute necrotizing pancreatitis

We describe our therapeutic principles in connection with the treatment of 43 patients (30 male and 13 female) with acute necrotizing pancreatitis. The etiology of the disease was alcohol in 72.1%, gallstones in 23.3%, trauma, hyperlipidemia, ERCP and unknown in 4.7%. In all patients, the necrosis was proved by CT and histological examination. The patients were treated in intensive care unit. It involved prophylactic antibiotics (Imipenem) and early nasojejunal feeding. In each case, we endeavoured to delay surgery, which was a wide necrosectomy extending to the retroperitoneum. In 13 patients (30.2%) CT-guided percutaneous drainage was performed because of extensive peripancreatic fluid. Ten such patients were operated on at a later time. In 81.4% (35 patients) an average of 1.8 operations were performed. The first indications were acute abdomen, septic necrosis and multi-organ failure (MOF) unreactive to conservative therapy. Five patients (11.6%) were cured with conservative treatment and 3 patients (7%) were cured by treatment which included percutaneous drainage. Twenty-seven reoperations were performed in 12 patients because of sepsis, suspected peritonitis, abscess, bleeding and gastro-intestinal perforation. The average hospital stay was 44.5 days (3-120 days) long, and mortality was 16.2%. In our opinion in addition to intensive therapy, prophylactic antibiotics, early nasojejunal feeding and late, delayed surgery are important in the treatment of acute necrotizing pancreatitis. Percutaneous peripancreatic drainage is a useful way to delay operation. These therapeutic possibilities improve the survival rate of patients with pancreatic necrosis.     

Acute necrotizing pancreatitis following abdominal trauma

We present 11 cases of acute necrotizing pancreatitis following abdominal trauma operated in our clinic during the last five years. All patients except one were male. All of them had obvious symptoms of acute diffuse peritonitis when they came to hospital. The diagnosis was established by CT scan in four observations. All operations were performed during 12-36 hours after they came. During surgery, there was complete pancreatic necrosis in seven cases and incomplete in the other four cases. Associated injuries following trauma were represented by: hemothorax--two cases, spleen injury--one case, lesion of mesentery--one case, intestinal lesion--one case. In all cases we performed a wide opening of the lesser sac, pancreatic capsulectomy, necrosectomy and multiple drainage of the pancreatic side (behind the peritoneum) and peritoneal cavity. The postoperative outcome was difficult in all cases. Postoperative morbidity recorded pancreatic leakage (three cases), pseudocysts (two cases) and a perforation of gastric wall. There were 10 cases cured and one patient died.     

Acute necrotizing pancreatitis and post-operative irrigation-lavage

A series of 62 operated cases of acute necroto-hemorrhagic pancreatitis is presented along with discussion of the four principle objectives of surgical treatment: exposure, evaluation and selective resection of the lesions followed by close observation. Based on peroperative determination of anatomic site and macroscopic character, a double codification for each lesion is proposed. This codification provides the surgeon an objective basis for his choice of the type of procedure to be done. The surgery itself has a dual purpose: to eradicate frank necrosis and to protect the remaining tissue from autodigestion by installing one or more drains for irrigation and lavage of the lesion site. In the case of stage 3 necrosis, the procedure must include a left pancreatectomy of varying extent.     

Evolving treatment of necrotizing pancreatitis

Background

Over the past decade, the treatment of necrotizing pancreatitis (NP) has incorporated greater use of minimally invasive techniques, including percutaneous drainage and endoscopic debridement. No study has yet compared outcomes of patients treated with all available techniques. We sought to evaluate the evolution of NP treatment at our high volume pancreas center. We hypothesized that minimally invasive techniques (medical only, percutaneous, and endoscopic) were used more frequently in later years.

Fungal infection in acute necrotizing pancreatitis

BACKGROUND: Anecdotal reports suggest that patients with fungal infection of necrotizing pancreatitis (NP) have worse outcomes than those with bacterial infection. Our aim was to compare the clinical course and outcomes of patients with NP infected with fungal versus nonfungal organisms. STUDY DESIGN: Prospectively collected data on 57 patients with infected NP (1983-1995) were reviewed. RESULTS: Seven patients (12%) developed fungal infection, and 50 (88%) developed bacterial infection. Groups had similar mean ages (60 versus 63 years) and APACHE-II scores on admission (9 each). The cause of NP was ERCP-induced in 3 of 7 with fungal infection versus 3 of 50 with bacterial infection. Patients with fungal infection had been treated with a mean of 4 different antibiotics for a mean of 23 days, and 4 of 7 (57%) required mechanical ventilation preoperatively. In addition, postoperative ICU stays were longer (20 versus 10 days), as were total hospital stays (59 versus 41 days). Mortality was higher with fungal infection; 3 of 7 patients (43%) died versus 10 of 50 patients (20%). CONCLUSIONS: Although NP presents with similar initial severity, patients with fungal infection of NP tend to have a more complicated course and worse outcomes compared with those with bacterial infection. Low-dose antifungal prophylaxis should be added to early management of NP.     

Acute necrotizing pancreatitis after distal splenorenal shunt

World Journal of Surgery - Two cases of fatal acute necrotizing pancreatitis shortly after distal splenorenal shunt are presented. Instrumental injury to the pancreas during operation may have...     

急性坏死性胰腺炎的非手术治疗

目的探讨非手术方法治疗急性坏死性胰腺炎,以提高疗效。方法非手术治疗急性坏死性胰腺炎１５８例,病例选择为全身情况稳定或经短期纠正后基本好转。其中无菌性胰坏死１３７例,感染性胰坏死２１例。有４种治疗方案：１．用善得定;２．介入疗法;３．用中药;４．善得定与中药结合。结果１５８例中治愈１５１例（９５．６％）,死亡７例（４．４％）,疗效明显高于同期手术组（Ｐ＜０．０１）。结论急性坏死性胰腺炎有选择地采用非手术治疗,效果满意。     

Surgical treatment of acute necrotizing pancreatitis

Between January 1980 and June 1986, 21 patients required surgery for acute necrotizing pancreatitis. Four patients had been transferred from other hospitals; the remaining 17 patients had been treated from the outset at Glasgow Royal Infirmary, representing 3.7 per cent of the 456 patients treated for acute pancreatitis during this time. Necrosectomy was performed on 14 patients and 7 patients were treated by pancreatic resection, with 4 deaths in each group; thus 8 patients (38 per cent) died at a median time of 22 days from onset of their attack. Three of the four patients transferred to our care died, giving a mortality in our own patients of 29 per cent. Of the survivors, all but three had a prolonged and complicated hospital course. Our data confirm that acute necrotizing pancreatitis is still associated with a considerable mortality and morbidity. Early multi-organ failure, advanced age, underlying medical illness and the presence of infected necrosis were associated with a poor outcome. Necrosectomy delayed until the second or subsequent week appeared to be a suitable procedure for the majority of our patients, but shortcomings were apparent with the traditional methods of closed drainage of the pancreatic bed postoperatively. The many demands imposed by this small group of patients suggests that their management is best undertaken in centres in which there is special expertise and this should contribute to a further reduction in the mortality from this condition.     

Surgical treatment of acute necrotizing pancreatitis

The purpose of this work is to summarize the experience in treatment of patients with acute destructive pancreatitis and to carry out comparative analysis of the results of "open" and "closed" types of the treatment for this disease. 233 patients of the study group underwent surgery which demanded parietal deperitonization and mobilization of the pancreas from the retroperitoneal space, drainage of all parts of retropancreatic bat and drainage of biliary tracts, total continuous retroperitoneal neuro-vegetative blockade, local hypothermia and omentobursostomy with further regular elective pancreosequesf8p4omies and sanation of the cavity of the omental bursae with local sorbtion--dehydration therapy. The number of the days of inhospital stay in the study group made up 43.5 +/- 3.3, and in the control group--64.2 +/- 4.1 (p < 0.05). The level of postoperative complications in the study group made up 36.6%, in control group--85.1%, lethality being 18.2 and 50.0%, respectively. In the study group long-term unfavourable follow-up results were obtained only in 2.9% of patients, whereas in control group--in 31.6%.     

Acute pancreatitis: management of complicating infection

Acute pancreatitis develops precipitously, changing the patient's condition from apparent good health to a critically ill status. Of patients who succumb, 80 per cent die from secondary infection in the pancreas-peripancreatic area. Infection supervenes in the second week or later after onset. Prophylactic antibiotic(s) appear to be helpful in avoiding, delaying, and/or lessening secondary sepsis. Once infection develops, treatment requires open debridement of necrotic material, drainage, and appropriate antibiotic therapy; or mortality will approach 100 per cent. Infecting organisms are commonly Escherichia coli, Klebsiella, Staphylococcus, Enterococcus, Bacteroides, and/or fungi. Antibiotics felt to be preferable for prophylactic therapy include 1) imipenem-cilastatin, 2) a quinolone + metronidazole, and 3) possibly an extended-spectrum penicillin. Treatment should be continued for 2 weeks or until recovery. Because fungus infections are occurring more often, prophylaxis with fluconazole may be warranted.     

Acute necrotizing tubulointerstitial nephritis due to systemic adenoviral infection

To date, all the reported cases of acute necrotizing tubulointerstitial nephritis (TIN) secondary to systemic adenovirus infection have occurred in individuals with primary or secondary immunodeficiency, and have resulted in renal failure and death. We present the case of a 12-year-old, immunologically competent girl who developed acute necrotizing TIN with acute renal failure (ARF), hepatitis and meningoencephalitis secondary to a systemic adenoviral infection who completely recovered with supportive care. Received: 11 February 2000 / Revised: 6 July 2000 / Accepted: 18 August 2000     

Results of surgical treatment of necrotizing pancreatitis

In 205 patients with necrotizing pancreatitis, surgery was carried out following failure of medical treatment. Intraoperatively, according to the size of the necrotic area and the weight of the surgically removed necrotic tissue, 79 patients showed a limited pancreatic necrosis, and 126 patients an extended necrotizing process. In 40.4% of 138 patients with bacteriological reports, a bacterial contamination of the pancreatic necrosis was found. The main objective of surgical management was the removal of the necrotic tissue. This was performed with 2-way drainage and postoperative continuous peritoneal and/or local lavage, in a smaller group of patients with inner drainage of the necrosis cavity, and in a few patients with drainage alone. The overall hospital mortality rate was 24.4%. The lowest mortality was achieved in patients treated with necrosectomy and postoperative continuous local lavage (6.0%). In patients with necrosis of approximately 30% of the pancreas, mortality was lower (7.6%) than in patients with a 50% necrosis (24.0%) or in patients with a subtotal/total necrosis (51.0%) (p<0.0001). Formation of extrapancreatic necrosis resulted in a significantly increased mortality rate (p<0.02). In patients with bacterially contaminated necrosis, a mortality rate of 32.1% was found, whereas in patients with a sterile necrosis, mortality was down to 9.8% (p<0.01). Based on the results of this study, we conclude that the clinical course of necrotizing pancreatitis depends essentially on the extent of the necrosis in the pancreas itself, the development of extrapancreatic necrosis, and the bacteriological status of the necrotic area. Adequate surgical management leads to a considerably increased survival rate of patients with necrotizing pancreatitis.

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Resumen Tratamiento quirÚrgico fué realizado en 205 pacientes con pancreatitis necrosante, una vez que el manejo médico hubo fallado. Intraoperatoriamente, y en relación con el tamaño del área necrótica y con el peso del tejido necrótico removido, 79 pacientes exhibieron necrosis pancreática limitada y 126 pacientes exhibieron un extenso proceso necrosante. En el 40.4% de 138 pacientes con informes bacteriológicos se encontró contaminación bacteriana de la necrosis pancreática. El propósito principal del tratamiento quirÚrgico fue la remoción del tejido necrótico. Esto fue realizado mediante drenaje de doble vía y lavado peritoneal y/o local post-operatorio continuo, en un grupo menor de pacientes con drenaje interno de la cavidad necrótica y, en unos pocos pacientes, con drenaje solamente. La tasa global de mortalidad hospitalaria fue de 24.4%. La mortalidad minima fue lograda en los pacientes tratados con necrosectomía y lavado local postoperatorio (6.0%). En los pacientes con necrosis de alrededor de un 30% del páncreas la mortalidad fue menor (7.6%) que en los pacientes con un 50% de necrosis (24.0%) o con necrosis subtotal/total (51.0%) (p<0.0001). El desarrollo de necrosis extrahepática resultó en un incremento significativo de la tasa de mortalidad (p<0.02). En los pacientes con necrosis bacteriológicamente contaminada se halló una tasa de mortalidad de 32.1%, en tanto que en los pacientes con necrosis estéril la mortalidad se redujo a 9.8% (p<0.01).Con base en los resultados de este estudio hemos llegado a la conclusión de que la evolución de la pancreatitis necrosante depende esencialmente de la extensión de la necrosis del páncreas, del desarrollo de la necrosis extrapancreática y del estado bacteriológico del area necrótica. Un manejo quirÚrgico adecuado da lugar a una mayor tasa de supervivencia en pacientes con pancreatitis necrosante.

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Résumé Deux cent cinq malades atteints de pancréatite nécrotique qui avait résisté au traitement médical ont été opérés. Au cours de l'intervention en fonction de l'étendue et du poids du tissu nécrotique furent découverts 126 cas de lésions étendues et 79 cas de lésions limitées. Chez 40.4% des 138 opérés chez qui fut recherchée une surinfection bactérienne, celle-ci fut constatée. Le but essentiel du traitement fut de pratiquer l'exérèse de la nécrose, la nécrosectomie étant complétée soit par la mise en place de deux drains permettant en postopératoire le lavage et le drainage de la cavité péritonéale et/ou celui de la cavité nécrotique, soit par la constitution d'une dérivation interne, soit encore par le drainage simple de la zone affectée. La mortalité globale s'est élevée à 24.4%. La mortalité la plus faible (6%) fut observée lorsque la nécrosectomie fut complétée par le lavage local continu. Chez les malades dont la nécrose répondait à 30% du pancréas le taux de la mortalité fut inférieur à 7.6%, il s'élèva à 24% lorsque la nécrose affectait la moitié du parenchyme pancréatique, il atteignit 51.0% en cas de nécrose presque totale ou totale de la glande (p<0.0001). L'extension de la nécrose au-delà des limites de la loge pancréatique s'est accompagnée d'une augmentation significative du taux de la mortalité (p<0.02). Celui-ci s'est élevé à 32.1% en cas de surinfection bactérienne alors qu'il n'a pas dépassé 9.8% (p<0.01) lorsque la nécrose est restée stérile. En se référant aux résultats de leur étude les auteurs affirment que l'évolution de la nécrose pancréatique dépend de son importance initiale, de son extension au-delà de la loge pancréatique et de la surinfection de la nécrose. Ils affirment également que le traitement chirurgical adéquat de la nécrose accroÎt les chances de guérison des malades atteints de pancréatite nécrotique.