重症急性坏死性胰腺炎临床治疗流程研究

Retrospectives analysis of treatment strategy in severe acute pancreatitis(SAP) patients

目的探索重症急性胰腺炎的治疗流程,寻找最佳治疗方案。方法回顾性分析北京协和医院ICU1999年1月至2012年1月期间收治的57例重症急性胰腺炎病人的临床资料。结果 26例病人在治疗期间未接受任何介入或手术治疗,病死率为11.1%(3/26),1例出现肠穿孔,发生率为3.8%(1/26)。22例病人在治疗期间至少接受1次CT下经皮置管引流(PCD),其中19例(88.6%)在PCD术前后接受了手术治疗。所有接受PCD治疗病人3d后体温下降,有效率为77.3%(17/22),病死率为22.7%(5/22),1例PCD术后出现腹腔内出血,发生率为4.5%(1/22)。28例病人在治疗期间接受手术治疗,其中11例胆源性胰腺炎行胆囊切除、胆总管切开、T管引流术,1例胆源性胰腺炎行十二指肠乳头切开取石术(EST),16例因非手术治疗失败或PCD治疗7 d后仍发热,行外科坏死组织清除术。总的手术治疗病人病死率为35.7%(10/28),手术并发症发生率为46.4%(13/28)。逻辑回归分析提示,感染性休克和多脏器功能衰竭是影响重症急性胰腺炎预后的独立因素。结论重症急性坏死性胰腺炎治疗是综合性的。梗阻性胆源性胰腺炎应积极手术解除梗阻。非梗阻性胰腺炎早期应积极采取非手术治疗。在非手术治疗过程中出现持续高热、病情进展者,应采取PCD引流与手术相结合的治疗方案。

Objective To explore the optimal treatment strategy in SAP for improving patients outcome. Metheods Retrospective analysis of clinical data in 57 SAP patients from Jan. 1999 to Jan.2012 in department of critical care medicine of Peking Union Medical College Hospital. Result 26 patients did not receive any drainage therapy and operation during admission,their mortality were 11.1% （3/26）, intestinal perforation in 1 patient complication morbility was 3.8% （1/26）.2,2 patients received at least 1 pereutaneous catheter drainage（PCD） during admission,and 86.6% patients（19/22） received operation therapy before or after PCD. 77.3% patients （17/22）had a significant temperature decrement in 3 days after PCD therapy, overall mortality was 22.7% （5/22） , intraabdominal bleeding happened in 1 patient,morbility was 4.5% （1/22）.28 patients received operation therapy during admission, 11 patients were received cholecystectomy and common bile duct exploration T-tube choledochotomy, only 1 patient received Endoscopic Sphincterectomy）, 16 patients received surgical debridement of necrosis 7 patients because of continuous febrile after nonsurgieal therapy or PCD, overall mortally were 35.7% （10/28）,and complication morbility were46.4% （13/28）. Logistic analysis indicated,septic shock and MODS were independent risk factor for SAP outcome. Conclusion Strategy of SAP was comprehensive and combined. Common bile duct exploration should be taken in the beginning for comment bile duct obstruction patients. Comprehensive nonsurgical therapy was very important in the early stage, If febrile became continuous and organ function deteriorated, PCD and surgical intervention should be done alone or combined.