急性重症胰腺炎合并腹内高压32例治疗研究

Treatment of severe acute pancreatitis with intra-abdominal hypertension：a report of 32 cases

目的 探讨急性重症胰腺炎（SAP）合并腹内高压（IAH）的治疗.方法 对我院2002年12月至2009年8月间收治的32例SAP合并IAH患者的临床资料进行回顾性分析.结果 32例患者中腹内压分级为：Ⅰ级者10例,Ⅱ级8例,Ⅲ级7例,级7例;早期均行内科治疗,包括：（1）疏通肠道,增强胃肠蠕动和早期经胃、肠管予肠内营养疗法;（2）腹腔、后腹膜有积液者均于B超、CT定位下行穿刺置管引流术;（3）补充血容量基础上达到负水平衡;（4）继发胰周脓肿经穿刺引流无效者,转外科手术治疗.经上述治疗后,所有患者均治愈;腹内压Ⅰ、Ⅱ、Ⅲ级者无1例形成胰周脓肿;腹内压Ⅳ级者6例继发胰周感染,其中1例经多次穿刺引流后治愈,5例经外科手术干预后治愈.结论 SAP合并IAH患者应遵循：疏通肠道、腹腔和/或后腹膜穿刺引流、负水平衡、外科干预的治疗原则.早期的胰周感染可在使用足量、敏感抗生素的情况下,于B超或CT定位下穿刺置管引流;外科手术时间可推迟至发病后的第3～4周,待感染形成局限后,可缩小手术范围、减少手术创伤.

Objective To review the treatment of severe acute pancreatitis with intra-abdominal hypertension. Methods Total 79 patients with severe acute pancreatitis were treated in our department from Dec 2002 to Aug 2009, including 32 with intra-abdominal hypertension; the clinical data of the patients were retrospectively reviewed. Results Among 32 cases of acute severe pancreatitis with intra-abdominal hypertension, 10 cases were classified as class Ⅰ, 8 as class Ⅱ, 7 as class Ⅲand 7 as class Ⅳ. The medical treatment included： enhancing peristalsis of gastrointestinal tract, early enteral nutrition;puncturing and draining peritoneal or post-peritoneal effusion guided by ultrasonography or CT scan ; achieving negative water balance with plasma, albumin and diuretics; puncturing and draining for secondary peri-pancreatic abscess, if ineffective surgery was required. There was no case fatality, all patients recovered. Six patients in class IV developed peri-pancreatic abscess, one of them cured by repeated puncture and draining, the remaining 5 cases were treated by surgery. Conclusion Early medical treatment is usually effective for severe acute pancreatitis with intra-abdominal hypertension, surgical intervention can be postponed to 3 - 4 weeks after disease onset to restrain surgical range and to reduce surgical trauma.