中国实用外科杂志

中国实用外科杂志

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危重型急性胰腺炎外科治疗策略分析（附46例报告）

王    迪，申鼎成，周书毅，刘志勇，纪连栋，魏    伟，黄耿文   

  1. 中南大学湘雅医院胰胆外科，湖南长沙 410008
  • 出版日期:2017-10-01 发布日期:2017-10-11

  • Online:2017-10-01 Published:2017-10-11

摘要：

目的    总结危重型急性胰腺炎（critical acute pancreatitis，CAP）的病程特点和外科治疗策略。方法    回顾性分析2011年1月至2016年11月中南大学湘雅医院收治的46例CAP病人的临床资料，重点对器官功能衰竭、胰腺（胰周）引流液病原学结果、外科治疗方式及结局进行分析。结果    46例CAP病例中胆源性21例，高脂血症性14例，酒精性6例，原因不明5例。截至2017年1月，20例（43.5%）病人死亡。单器官功能衰竭和多器官功能衰竭病人的病死率差异有统计学意义［0（0/8） vs. 52.6%（20/38），P<0.05］。胰腺（胰周）引流液培养共检出病原菌129株，多重耐药菌77株。其中感染率最高的普通病原菌为大肠埃希菌［19.2%（10/52）］，感染率最高的多重耐药菌为鲍曼不动杆菌［22.1%（17/77）］；多重耐药菌感染病人的病死率高于普通细菌组［50.0%（20/40） vs. 0（0/6），P<0.05］。采取以经皮穿刺置管引流（PCD）为初始治疗方法的升阶梯策略病人的病死率为41.0%（16/39），而传统开放手术为初始治疗方法的降阶梯策略病人病死率为71.4%（5/7）。结论    多器官功能衰竭和胰腺（胰周）引流液中多重耐药菌感染与CAP病人的预后密切相关，外科治疗应首选以PCD为初始方法的升阶梯策略。

关键词: 危重型急性胰腺炎, 感染性胰腺坏死, 胰腺坏死组织清除术, 经皮穿刺置管引流

Abstract:

Surgical treatment strategies for critical acute pancreatitis: A report of 46 patients        WANG Di，SHEN Ding-cheng，ZHOU Shu-yi，et al. Department of Biliary and Pancreatic Surgery，Xiangya Hospital，Central South University，Changsha 410008，China
Corresponding author：HUANG Geng-wen，E-mail: 1466471168@qq.com
Abstract    Objective    To summarize clinical course and treatment strategy for critical acute pancreatitis（CAP）. Methods    A retrospective analysis was carried out using clinical data sourced from a database of patients with CAP admitted to the Xiangya Hospital，Central South University from January 2011 to November 2016. Organ failure, pancreatic and peri-pancreatic culture，interventions and outcomes were highlighted in the article. Results    Out of a total of 46 CAP patients，the most common cause was gallstones (n=21)，followed by hyperlipidemia (n=14), alcohol (n=6), and idiopathic acute pancreatitis（AP）(n=5). The overall mortality was 43.5% (20/46). Eight patients developed single organ failure and none of them died; 38 patients developed multiple organ failure and 20 of them died by January 2017 (mortality，52.6%) (P<0.05 ). There were 129 microbiological samples obtained from the necrotic tissue in 47 patients, 60.0% of which were MDRO infection (n=77). Escherichia coli (19.2%, 10/52) was the predominant common pathogen, whereas Acinetobacter baumannii (22.1%, 17/77) was the most frequent MDRO infection. The mortality rate in the MDRO infection group was higher  than that in the sensitive organism infection group (50.0% vs. 0，P<0.05). Step-up approach of percutaneous catheter drainage followed by necrosectomy was performed in 39 patients, and the mortality rate was 41.0% (16/39). The mortality rate of step-down approach based on necrosectomy was 71.4% (5/7). Conclusion    The prognosis of CAP patients is directly related to multiple organ failure and MDRO infection. Step-up approach based on PCD can be the first choice for surgeons.

Key words: critical acute pancreatitis, infected pancreatic necrosis, debridement of pancreatic necrosis, percutaneous catheter drainage