重症急性胰腺炎合并非感染性胰腺坏死手术时机的选择

目的 探讨急性胰腺炎合并无明显感染征象的胰腺坏死的手术时机。方法 回顾分析27例坏死性胰腺炎术中所见及病理改变。结果 发病3周内行手术治疗的6例患者，见坏死胰腺与未坏死胰腺组织之间分界不十分清楚；腹腔内粘连严重，水肿明显，均未合并感染。发病后3～4周行手术治疗的14例患者，9例坏死胰腺与周围未坏死胰腺组织之间分界清楚，无明显感染征象，大网膜及横结肠系膜与胰床粘连明显；3例有程度不一的胰腺坏死情况；另2例胰腺坏死合并感染。其余7例患者分别于发病后5～7周施行手术，其中3例发现胰腺坏死区域有不同程度的坏死感染，甚至形成局部胰腺脓肿；周围脂肪组织及肠系膜根部脂肪组织大片坏死。结论 坏死性胰腺炎胰腺坏死组织清除术宜在发病3～4周施行；发病3周内手术，坏死组织与未坏死组织尚未完全分离，术中易出血，增加手术难度和再次手术的机会；发病5周以上手术，坏死组织多已合并感染，腹腔内感染严重，需再次手术甚至多次手术。

The reasonable timing of operation for the patients with non-infectious pancreatic necrosis of severe acute pancreatitis

Objective To investigate the reasonable operation timing for patients with acute pancreatitis without obvious infectious manifestation. Methods The findings during the operation and pathological changes in 27 pantients with necrotic pancreatitis were analysed retrospectively.Results Six patients underwent surgical treatment with in 3 weeks. The delimitation between non-necrotic pancreas and necrotic pancreas was not very clear, and the abdominal adhesion and edema were serious. Other 14 cases were subjected to the surgical treatment 3-4 weeks after the onset of illness. The delimitation was clear in 9 cases without obviously infectious signs, but the adhesion of the pancreas bed to the greater omentum or the transverse mesocolon was evident. Various degrees of necrosis was found in 3 cases, and the infection together with pancreatic necrosis developed in the other 2 cases. The rest 7 patients were operated on 5-7 weeks after the disease onset, different degrees of infection and necrosis developed in 3 cases, and local pancreatic abscess formation could be observed.There was a lot of necrosis of fatty tissues on the peri-pancreas and the root of mesentery. Conclusions Clear away of necrotic pancreatic tissue is suitable in 3-4 weeks after the onset of illness in patients with non-infectious necrosis of pancreas.If operation is performed in the initial 3 weeks, intraoperative bleeding may be severe because the detachment between the non-necrotic tissues and necrotic tissues of pancreas was not yet formed completely, which may lead to hard to do the operation and result in increasing intraoperative bleeding and even increasing reoperation .If operation was done after 5 weeks, the infection of the necrotic pancreatic tissues can be seen in most of the cases, and the infection degree in the abdominal cavity may also be serious, which may need more operations to treat.