急性坏死性胰腺炎外科治疗20年经验总结

A 20-year Experience in Surgical Management of Acute Necrotizing Pancreatitis

总结了1974年8月～1994年11月243例急性坏死性胰腺炎外科治疗的经验.按治疗观点及治疗方式分为三个阶段.第一阶段1974年8月～1987年12月为针对胰腺坏死作早期彻底切除坏死组织手术,辅以“三造瘘”、“创口敞开”、“局部灌洗”等措施.治愈率为61.3%.第二阶段1988年1月～1991年6月以坏死是否伴有感染为指征,对有感染者作手术治疗,治愈率67.1%;对非感染者作保守治疗,治愈率85.7%,总治愈率提高到68.5%.第三阶段1991年7月～1994年11月治疗有二特点.第一是在手术时间上强调后期手术,如在严密的治疗观察下感染能缓解控制、可延缓到后期手术;对于有恶化倾向、或对阻塞性胆源性胰腺炎及胰腺脓肿穿破致腹膜炎等病例则作早期或急诊手术.第二是建立综合治疗体系,依靠多学科的参与使患者渡过诸如全身细菌、霉菌感染、深部脓肿的处理、以及全身严重消耗的纠正等、使手术治愈率提高到80%、非手术治愈率达到100%、总治愈率为83.1%.

From 1974 to 1995, 243 patients with ANP proved by operation or CT scanning were hospitalized. The severity of the disease had been evaluated by CT scoring system. The overall survival rate was 70.4%. Based on the understanding of the development of ANP with our own experimental work, the strategy of treatment had been changed twice. In the first period (1974 - 1987), the strategy of treatment was resection of necrosis as radical and as early as possible, and the main type of operationwas subtotal pancreatectomy. The survival rate in this period was 61.3% (49/80). In the second period (1988 - 1991), inspired by our own experimental work, we recognized the importance of infection. The strategy of the treatment had been changed into 'Individualization' i.e. in cases of sterile pancreatic necrosis, conservative treatment was the first choice while in cases of infected pancreatic necrosis necrosectomy was performed early. In this period, the survival rate of conservative treatment was 85.7% (6/7), that of operative treatment was 67.1% (57/85) and the overall survival rate in this period was 68.5% (63/92). In the third period (1991-1994), we insisted on 1. late operation for the patients with necrosis infected, 2. comprehensive management for all the patients with ANP. The survival rate of conservative treatment in this period was 100% (11/11), that of operative treatment was 80% (48/60), and the overall survival rate was 83.1% (59/71). We conclude that comprehensive management combined with late operation for the patients with necrosis infected is a better strategy for the treatment of ANP.