早期腹腔置管引流治疗重症急性胰腺炎

目的 采用前瞻性随机对照临床研究,观察早期腹腔内留置导管引流对急性重症胰腺炎患者的治疗效果.方法 2007年1月至2009年1月综合ICU收治患者,符合SAP临床诊断标准,年龄≥18岁.排除24 h内死亡,Marshall评分≥20分,有明确腹腔感染,既往腹腔手术者.所有入选者均不参加其他可能影响胰腺炎病情的治疗研究,收集重症急性胰腺炎患者30例.按随机数字表随机分为A、B两组,入院时即经尿道膀胱插入Fod~y尿管,测定膀胱内压/腹内压,留置胃管,接胃肠减压,计量;呼吸衰竭者应用机械通气,记录呼吸机应用时间.A组为常规治疗组,16例,采用常规治疗;B组为引流组,14例,在常规治疗的基础上早期腹腔置管引流,计量.记录两组患者第0,3,7,10天腹内压、腹腔引流量、肠鸣音、胃肠减压量,相应时间点采血测定患者血浆前白蛋白(PA)、C反应蛋白(CPR)水平,评定急性生理及慢性健康状况评分(APACHEⅡ评分)和器官衰竭评分(Marshall评分).组问及组内数据进行方差分析,组间数据采用t检验,以P＜0.05为差异具有统计学意义.结果 入选时两组患者各指标差异无统计学意义,第3天起APACHEⅡ评分(25.36±12.58)vs.(16.81±13.19),P＜0.05]、Marshall评分(11.47±4.02)vs.(6.09±3.71),P＜0.05]、腹内压(22.5±5.1)v8.(12.7±6.3),P＜0.05]、CRP(304.16±86.51)vs.(198.65±94.37),P＜0.05]、胃肠减压量(1033±451)vs.(654±290),P＜0.05]均显著降低,引流组的呼吸机应用时间低于常规治疗组(7.13±2.22)d vs.(4.07±1.78)d)],28 d生存率提高(92.86%vs.81.25%).结论 胰腺炎相关性腹水在SAP病情进展过程中起重要作用,早期腹腔内置管引流可明显改善患者病情.减轻炎性反应,有利于肠功能和呼吸功能的恢复.

Early drainage of ascites for the treatment of severe acute pancreatitis

Objective To investigate the clinical effects of early drainage of ascites for the treatment of se-vere acute pancreatitis (SAP) . Method A total of 30 patients with ASP were enrolled depending on the criteria of ASP with age over 18 years admitted to ICU from Jan 2007 to Jan 2009. Patients, who died within 24 hours after ad-mission, and had Marshall Score over 20, definite infection in abdominal cavity and previous laparotomy,were ex-cluded. Intravesical pressure/intra-abdominal pressure was measured in all patients with a Forley' s catheter insert-ed through urethra into bladder. All patients were randomized to have either routine treatment alone (group A, n = 16) or routine treatment with early drainage of ascites (group B, n= 14). The scores of APACHE II and Mar-shall of all patients were recorded at admission and on the 3 rd, 7 th and 10th days. Concurrently, the measure-ments of the intra-abdominal pressure (1AP), the amount of aseites drained from abdominal cavity, the bowel sound, the volume of gastrointestinal decompression, and the days of mechanical ventilation employed were docu-mented, and the levels of plasma pre-albumin (PA) and C-reactive protein (CRP) were measured as well. The analyses of variance and t-test were used for the comparison of inter-and between groups. P ＜ 0.05 was consid-ered statistical significance. Results There was no statistical difference in all measurements between two groups at admission. From the 3rd day on, there were significant distinctions between two groups in the score of APACHE Ⅱ (16.81 ±3.19) vs. (25.36±12.58, P ＜0.05), the score of Marshall (6.09±3.71) vs. (11.47±4.02), P ＜0.05], the IAP (12.7±6.3) vs. (22.5±5.1), P ＜0.05], the level of CRP (198.65 ±94.37) vs. (304.16 ±86.51), P ＜0.05], and the volume of gastrointestinal decompression (654±290) mL vs. (1033±451) mL, P ＜0.05]. The time of mechanical ventilation employed in group B was obviously shorter than that in group A (4.07±1.78) days vs. (7.13±2.22) days]. The survival rate within 28 days in group B was obviously higher (92.86% vs. 81.25%, P ＜0.05). Conclusions The pancreatitis-associated ascites plays an important role in the course of the SAP. Early drainage of ascites can obviously blunt the inflammatory re-action of the ASP, benefiting the functional recovery of intestine and respiratory system, improving the general con-dition of patients with ASP, and increasing the survival rate.