胰腺创伤的诊断与治疗经验(附48例回顾分析)

Diagnosis and management of pancreatic trauma:a retrospective analysis of 48 cases

目的探讨胰腺创伤诊断与治疗的经验和效果。方法回顾性分析1998年6月-2008年6月成都军区总医院全军普通外科中心收治的48例胰腺创伤患者的诊断、外科治疗情况及治疗效果。结果全组病例中,术前明确诊断32例(66.7%),术中确诊16例(33.3%)。根据胰腺损伤标准(AAST-OIS)分级:Ⅰ级9例(18.8%),Ⅱ级28例(58.3%),Ⅲ级5例(10.4%),Ⅳ级4例(8.3%),Ⅴ级2例(4.2%)。治愈44例(91.7%),死亡4例(8.3%)。近期并发症2例(4.2%),包括1例创伤性胰腺炎、1例膈下脓肿;远期并发症3例(6.3%),均为胰腺内分泌功能不足,发生于胰腺远端切除术后。术后并发症7例(14.6%),包括2例胰腺假性囊肿、1例胰瘘合并肠瘘、4例胰瘘。结论胰腺创伤的早期诊断需根据详尽的病史、周密的体格检查,结合血清淀粉酶指标、B超、CT扫描或逆行胰胆管造影(ERCP)及磁共振下胰胆管成像(MRCP)检查做出判断,并进行准确的胰腺损伤分级,必要时应及时剖腹探查。胰瘘仍是胰腺创伤后最常见的并发症,多发生于胰腺受严重损伤后。术中应尽可能避免对胰腺本身实行较大范围的操作,正确判断主胰管损伤、彻底清创、有效的外引流和良好的胰肠吻合是防止术后胰瘘的关键。

Objective To summarize the experiences on the diagnosis of pancreatic trauma and to explore the strategy of its manage ment. Methods The clinical data of 48 patients with pancreatic trauma, who were admitted and treated in the Center for General Surgery, General Hospital of Chengdu Command of PLA from June 1998 to June 2008, were retrospectively studied, and the diagnosis, surgical management, and the therapeutic effects were analyzed. Results Of the 48 patients, 32 patients （66. 7%） were diagnosed as pancreatic injury before operation, and in 16 （33. 3%） the final diagnosis was confirmed intraoperatively. For these 48 patients, the degree of pancreatic injury was graded according to AAST-OIS as follows： Grade 1 9 cases, Grade Ⅱ 28 cases, Grade Ⅲ 5 cases, Grade Ⅳ 4 cases and Grade Ⅴ 2 eases. Of the 48 patients, 44 （91.7%） recovered and 4 （8. 3%） died. Early complications occurred in 2 cases （4.2%）, one with traumatic pancreatitis and another subphrenic abscess. Late complication such as pancreatic secretion insufficiency occurred in 3 patients （6. 3%） in whom resection of distal portion of pancreas was done 7 patients （14. 6%） had postoperative complications, including 2 cases of pancreatic pseudocyst, 4 cases of pancreatic fistula and 1 case of pancreatic fistula combined with intestinal fistula. Conclusions The early diagnosis of pancreatic trauma should be based on a comprehensive patiant history and scrupulous physical examination, aided by auxiliary examinations including serum amylase level, ultrasound, CT scanning, endoscopic retrograde cholangio-pancreatography （ERCP） or magnetic resonance cholangio-pancreatography （MRCP）, and laparotomy if necessary. Pancreatic fistula is the main complication following pancreatic trauma and often occurs in the patients with severe pancreatic injury. Aggressive operation on the pancreas is not recommended, while correct judgement of injury to the main duct, a good debridement, effective drainage and flawless pancreatieoenterostomy are the key factors to avoid postoperative fistula.