重症急性胰腺炎治疗方式与外科处理时机的选择(多中心回顾性研究)

Treatment of severe acute pancreatitis and the timing of surgical intervention:a multicenter retrospective study

目的探讨重症急性胰腺炎治疗方式的选择与外科处理的时机。方法回顾性分析北京大学第一医院、卫生部北京医院、北京大学深圳医院2001-2011年共收治的304例重症急性胰腺炎病人的临床资料。结果排除资料不全及自动出院者外,304例病人入组分析,其中男性203例,女性101例;年龄19～104(53.2±17.2)岁。入院时APACHEⅡ评分(12.4±4.5)分;总治愈率为87.5%(266/304),总病死率为12.5%(38/304)。其中非手术治疗组146例(48.0%),措施包括:ICU监护、液体治疗、抗感染、呼吸循环支持、抑制胰酶活性及分泌、营养支持等,非手术组治愈率为89.7%(131/146),病死率为10.3%(15/146)。外科干预组158例(52.0%),治疗方式包括内镜逆行胰胆管造影术(ERCP)+内镜下括约肌切开术(EST)、B超或CT定位穿刺置管引流、开腹胰腺坏死清除、其他局部并发症处理等,外科干预组治愈率为85.4%(135/158),病死率为14.6%(23/158)。结论针对重症急性胰腺炎全身或局部并发症应采取多学科及个体化的治疗方式。局部并发症如无合并感染,可保守支持治疗。外科介入有多种方式,介入时机视具体情况而定。对于合并腹腔间隔室综合征、胆道梗阻者应早期外科介入治疗;局部并发症的处理一般宜在发病4周以后进行。

Objective To explore the comprehensive treatment of severe acute pancreatitis （SAP） and investigate the proper time for surgery. Methods A multicenter retrospective study was done on 304 patients suffered from SAP from 2001 to 2011 in three major teaching hospitals （Peking University First Hospital, Beijing Hospital and Peking University Shenzhen Hospital）. Results There were 203 males and 101 females. The ages were from 19 to 104（53.2±17.2）years old. The mean APACHE Ⅱ score was 12.4±4.5. Patients with incomplete information and discharged automaticly were excluded. The overall curative rate and mortality were 87.5% （266/304）and 12.5% （38/304）. There were 146 patients （48.0%） treated conservatively （non-operation group） and 158 patients （52.0%） by surgical intervention （surgical group）. The conservative treatments include fluid resuscitation, nutritional support, inhibition of pancreatic enzyme activity and secretion, use of antibiotics and intensive care, etc. Surgical treatments include endoscopic retrospecitive eholangio-panereatography plus endoscopic sphincterectomy （ERCP＋EST）, B ultrasound or CT guided puncture and drainage or surgical debridement of necrosis and surgery for other local complications. The curative rate and mortality were 89.7% （131/146） and 10.3% （15/146） in non-operation group, 85.4% （135/158） and 14.6% （23/158） in surgical group. Conclusion Muhidiseiplinary and individual therapy are needed to treat the systemic or local complications of SAP. Conservative treatment is effective if local complication is sterile. Surgical intervention includes a variety of modalities and the surgical time depends on the patient＇ s conditions. For the patients with abdominal compartment syndrome （ACS） and biliary obstruction, surgical intervention should be done early. For the patients with infected localcomplications, the proper time is 4 weeks after onset.