中国实用外科杂志

中国实用外科杂志

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胰腺外伤单中心136例诊治报告

丁威威，王    凯，刘宝晨，习丰产，汪志明，李维勤，黎介寿   

  1. 中国人民解放军南京总医院（南京大学医学院附属金陵医院）普通外科，江苏南京 210002
  • 出版日期:2018-07-01 发布日期:2018-07-09

  • Online:2018-07-01 Published:2018-07-09

摘要：

目的    总结单中心10年胰腺外伤治疗经验。方法    回顾性分析2008年1月至2017年12月中国人民解放军南京总医院普通外科收治的136例胰腺外伤病人的临床资料，根据美国创伤外科协会（AAST）标准进行胰腺外伤分级，随访观察并发症发生情况及预后。结果    闭合伤131例，开放伤5例。腹部CT检查（64.0%）是胰腺外伤最主要的诊断方式。37例（27.2%）非手术治疗中，13例Ⅲ级或Ⅳ级胰腺外伤病人经保守治疗获得成功；99例（72.8%）病人行手术治疗。整体并发症发生率为49.3%，主要并发症包括腹腔内并发症［腹腔脓肿（27.9%）、胰瘘（25.0%）、肠瘘（14.7%）、腹腔出血（12.5%）、胰腺假性囊肿（5.9%）、创伤性胰腺炎（5.88%）］和全身并发症［肺部感染（11.8%）、休克（7.4%）、急性呼吸窘迫综合征（5.9%）、肾功能不全（5.2%）、多器官功能障碍综合征（6.6%）］。病死率为8.1%（11/136），胰腺坏死、胰瘘及感染所致的多器官功能衰竭是最主要的死亡原因。结论    大部分轻度胰腺外伤可行保守治疗，内镜下主胰管支架植入可应用于血流动力学稳定的Ⅲ、Ⅳ级胰腺外伤病人，手术引流适用于合并腹部其他器官损伤的低级别胰腺外伤。高级别胰腺外伤应遵循损伤控制外科理念，选择合理的手术方式。根据胰腺外伤的严重程度和全身情况，个体化选择治疗方案，加入多学科综合治疗协作组模式有助于降低病死率。

关键词: 胰腺外伤, 非手术治疗, 胰腺切除, 外科引流, 损伤控制

Abstract:

Management of pancreatic trauma: A report of 136 cases        DING Wei-wei，WANG Kai，LIU Bao-chen，et al. Research Institute of General Surgery，Jinling Hospital，Medical School of Nanjing University，Nanjing 210002，China
Corresponding author：LI Jie-shou，E-mail: lijieshounj@163.com
Abstract    Objective    To summarize experience of management of pancreatic trauma. Methods    A retrospective review was performed of all patients with pancreatic injury admitted to Nanjing General Hospital over a 10-year period between January 2008 and December 2017. Traumatic injuries of the pancreas were graded according to the American Association for the Surgery of Trauma (AAST) score. Complications and outcomes were also collected. Results    A total of 136 patients diagnosed with pancreatic trauma were included. Mechanism of injury included 131 of blunt trauma and 5 of penetrating trauma. Initial diagnosis was made by computed tomography in 87 patients (64.0%)，and CT scan was proposed as the first-line diagnosis method. Thirty-seven patients (27.2%) were managed non-operatively while 99 patients (72.8%) received surgical intervention. Overall complication rate was 49.3%. The most common intra-abdominal complication was intra-abdominal abscess (27.9%)，and pulmonary infection was considered as the most common systemic complication. In-hospital mortality was 8.1% (11/136)，of which MODS caused by pancreatic necrosis，pancreatic fistula and abdominal sepsis were the main cause of death. Conclusion Low-grade pancreatic injuries could be managed with NOM (non-operative management) successfully. Pancreatic duct stent placement procedure could be applied to those patients with hemodynamically stable. Surgical drainage was suitable for low-grade pancreatic injury patients with associated intra-abdomen injury. Damage control surgery was recommended for high grade pancreatic injuries. Individualized treatment options for pancreatic trauma according to AAST grade and location of injury were recommended. An individual-centered，multidisciplinary approach was recommended in the management of pancreatic trauma，which significantly reduces mortality.

Key words: pancreatic trauma, non-operative management, pancreatectomy, surgical drainage, damage control surgery