不同类型胆石性胰腺炎不同病程中的手术处理

Treatment of different clinical types of gallstone pancreatitis at different clinical phases

目的探讨手术在不同临床类型胆石性胰腺炎不同病程中所起的作用。方法分析273例胆石性胰腺炎的早期手术、延期手术以及恢复期手术的临床资料。结果（1）13例Ⅲ型病人采用早期手术治疗，病死4例；8例Ⅰ型病人和所有经早期手术治疗的轻型病人全部治愈。（2）共有4例重型病人行延期手术治疗，其中2例因并发坏死组织继发感染，1例病死，1例治愈；1例假性囊肿伴出血和另1例巨大假性囊肿。（3）120例经非手术方法治愈，15例Ⅲ型病人得到随访，2例复发，2例在住院后期行胆囊切除，9例再入院行胆囊切除，尚有2例未行胆囊切除；9例Ⅳ型病人在住院后期行手术治疗；其余病例失访。结论（1）Ⅰ型、Ⅱ型病人是早期手术的绝对适应证，手术目的在于解除胆道梗阻，Ⅲ型病人不适合早期手术；（2）Ⅰ型或Ⅲ型病人在病变后期出现胰腺局部并发症需要延期手术，其关键在于胰周间隙的通畅引流；（3）对于保守成功的Ⅲ型病人应尽早开展针对胆石病变的恢复期手术以防止胰腺炎复发；（4）Ⅳ型病人可采用早期手术，也可采用愈合期手术治疗。

Objective To investigate the effects of operation on different clinical types of gallstone pancreatitis （GP） at various clinical phases. Methods The clinical data of operation in the early, late and healed stages in 273 patients with GP were analyzed. Results 1） Of the 13 patients with type Ⅲ GP surgically treated in the early stage, 4 died. Eight cases of type Ⅰ GP and all of the cases of mild type treated by operation in the early stage were cured. 2） Of the 4 cases of GP of severe type were surgically treated in the late stage, 2 were complicated with secondary infection of necrotizing tissues. One of the 2 died. Meanwhile, 1 case was complicated by pseudo-cyst accompanied with bleeding the other by huge pseudo-cyst. 3） A total of 120 cases were cured by conservative methods. Fifteen patients with type Ⅲ GP were followed up. It was that GP recurred in 2 cases. The cholecystectomy was performed in 2 patient in their first hospitalization and 9 in their second one. The other 2 cases have cholecystolithiasis now. Nine patients with type Ⅳ GP were operated on in their first hospitalization. The other cases were not followed up. Conclusions 1） GP of type Ⅰ and Ⅱ is the indica- tion of operation in the early stage and the aim of the operation is to settle biliary obstruction. GP of type Ⅲ should not be surgically treated in the early stage. 2） The pancreatic local complications of GP of type Ⅰ or Ⅲ which emerge in the late stage should not be surgically treated. The key of operation lies in unobstructed drainage of peri-pancreatic gap. 3） As for GP of type Ⅲ cured by conservative methods, the cholecystolithiasis should be surgically managed in the healed stage as soon as possible to prevent recurrence of pancreatitis. 4） GP of type Ⅳ might be surgically treated in the early or healed stage.