微创技术在重症急性胰腺炎病程各阶段的应用(附101例报道)

Application of Minimally Invasive Technique to Every Stage of Severe Acute Pancreatitis(Report of 101 Cases)

目的总结重症急性胰腺炎(SAP)病程的不同阶段微创技术的应用。方法对我院1995年1月至2008年12月期间收治的101例SAP患者治疗过程进行回顾性分析,分别在SAP早期采用ERCP取石+EST+ENBD,同时放置营养管灌注大黄液,B超下腹腔置管引流以及连续性肾脏替代治疗(CRRT);亚急性期行腹腔镜胆囊切除术(LC);后期经B超、CT穿刺置管引流和胆道镜直视下对胰周坏死灶进行清创。结果 101例SAP患者中75例行ERCP和(或)EST取石并行ENBD,31例放置营养管灌注大黄液,8例危重患者行CRRT;48例患者在亚急性期行LC,腹腔置引流管1～6根;后期36例经B超、CT检查发现胰周积液、坏死,经胆道镜清创3～14次。5例并发严重多器官衰竭和急性呼吸窘迫征死亡;胆道镜清创操作中发生出血2例,经直视下电凝止血成功;3例发生肠瘘,经引流后治愈;3例后期发生假性胰腺囊肿择期行囊肿空肠吻合。住院时间9～132d(平均24d),共治愈96例。结论微创技术适时地应用于SAP各阶段,方法简单、灵活、安全,最大程度减少了对机体的干扰和损伤,提高了治愈率。

Objective To explore and summarize the application of minimally invasive technique to every stage of severe acute pancreatitis （SAP）. Methods The treatment of 101 SAP patients admitted to our hospital between January 1995 and December 2008 were retrospectively analyzed. After calculi were removed by endoscopic retrograde cholangiopancreatograpy （ERCP） and endoscopic sphincterotomy （EST）,endoscopic nasobiliary drainage （ENBD） were applied,then rhubarb liquid was perfused into gut with a nutrient canal and ultrasound-guided abdominal drainage tube were simultaneously placed at the early stage. Some patients received continuous renal replacement therapy （CRRT） at the same time. Laparoscopic cholecystectomy （LC） was performed at the subacute stage,and choledochoscope was introduced to remove parapancreatic necrotic tissues at the late stage of SAP. Results Of all the 101 cases treated by the method mentioned above,75 cases received ERCP （or EST） and ENBD,and 31 cases underwent rhubarb liquid perfusion with a nutrient canal. Eight cases underwent continuous renal replacement therapy （CRRT）. Forty-eight cases underwent LC and ultrasound-guided abdominal drainage. Thirty-six cases with infected peripancreatic tissue or abscess underwent debridement under choledochoscope 3 to 14 times at the later stage. Five cases died of multiple organ failure （MOF） and acute respiratory distress syndrome （ARDS）. The hemobilia ocurred in 2 patients during choledochoscopy and was cured under direct visualization by electric coagulation. Intestinal fistula happened in 3 cases and cured by drainage. Pancreatic pseudocyst was latterly seen in 3 cases and treated by the anastomosis of cyst with jejunum through selective operation. After the hospitalization of 9-132 d （mean 24 d）,96 cases completely recovered. Conclusion Timely application of minimally invasive technique to every stage of SAP can avoid the defects of traditional operations,decrease the injury and interference to the maximum,and raise the cure rate.