急性坏死性胰腺炎的外科干预:时机比技术更重要

目前,围绕急性坏死性胰腺炎的手术和非手术治疗、早期手术还是后期手术、微创干预还是开放手术等问题,仍在探索中不断取得进步并逐步形成共识。进一步探索清除胰腺坏死组织最佳手术时机及手术技术、实施微创与开放相结合的外科干预策略、提高针对胰腺坏死组织延期一次性手术清除的成功率,是降低急性坏死性胰腺炎后期病死率的关键。近20年来,对急性坏死性胰腺炎局部并发症病理转归多样性认识的深化,划时代改变了急性坏死性胰腺炎后期的治疗模式。从20世纪末的早期开腹手术引流减压到计划性多次手术清创,再到延期一次性手术,以及近年来探索实施的创伤递进式手术策略,随着治疗理念的变革,逐步实现了疗效的突破。相较于坏死组织的清除技术,手术时机的选择对治疗成功更具重要意义。根据现有针对急性坏死性胰腺炎循证医学研究结果,鉴于急性坏死性胰腺炎病情的复杂性、个体间的差异性、以及有限的多中心研究结果,目前尚不能确定外科技术对改善预后的优势;而手术时机的正确把握,对提高急性坏死性胰腺炎手术治疗效果的地位不容置疑。笔者回顾性分析其团队收治的1000余例外科治疗急性坏死性胰腺炎患者的临床资料,探讨针对急性坏死性胰腺炎后期局部并发症外科干预时机及技术对改善预后的临床意义。

Surgical intervention of acute necrotizing pancreatitis:timing is more important than technology

At present,around the surgical and non-surgical treatment of acute necrotic pancreatitis,early surgery or late surgery,minimally invasive intervention or open surgery,consensus is gradually formed.Further exploring the optimal surgical timing and surgical techniques for the debridement,combination of the surgical and minimally invasive intervention strategies,and improving the success rate of delayed one-time surgical intervention is the key to further reduce the mortality rate of acute necrotic pancreatitis of the late stage.In the past two decades,the treatment mode of the late stage of acute necrotic pancreatitis had been changed extremely as the understanding of the pathology of local complications of acute necrosis pancreatitis has been deepened.From the early open surgery for abdominal decompression in the late 20th century to the planned multiple surgical debridement,and then to the postponement one-time surgery,as well as the development of step-up approach procedures in recent years,changement in the concept of treatment gradually achieved a breakthrough in efficacy.Compared with the techniques of different procedures for necrotic tissues,the choice of surgical timing is more important to the success of treatment.From the evidence-based results of existing studies of acute necrotic pancreatitis,it is not possible to determine the advantages of surgical techniques to improve the prognosis due to the complexity of acute necrotic pancreatitis,individual differences and limited results from multicenter research.The proper timing of surgery is indisputable in the role of improving the surgical effect of acute necrosis pancreatitis.The author reviews the clinical data of more than 1,000 patients treated by the analytical team for the treatment of acute necrotic pancreatitis,and discusses the timing of surgical intervention and the clinical significance of technology for improving prognosis for the late stage of acute necrotic pancreatitis.