重症急性胰腺炎合并盆腔腹膜后坏死组织感染的治疗

Management of retroperitoneal infected necrotic tissues in pelvic cavity in patients with severe acute pancreatitis

目的探讨重症急性胰腺炎（SAP）合并盆腔腹膜后坏死组织感染的治疗方法。方法回顾性分析2009年12月至2012年2月南京军区南京总医院收治的5例合并盆腔腹膜后坏死组织感染的SAP患者的临床资料，患者均采用全身综合治疗联合局部治疗。结果综合治疗：5例患者均行肠内营养支持，3例机械通气，3例持续血液滤过；针对小网膜囊、十二指肠旁、肾周间隙的胰腺坏死组织感染，5例患者均采用分步引流策略，先行CT或B超引导下经皮置管引流，然后中转开腹手术引流；合并胰腺坏死组织出血的4例患者经动脉栓塞止血和（或）“三明治”法填塞止血成功。局部治疗：针对盆腔腹膜后坏死组织感染，5例患者均在中转开腹后采取CT引导下经臀经皮置管引流治疗，穿刺距入院时间平均为38．4d，坏死组织CT密度值平均为24．4Hu（20～28Hu）。5例患者均在中转开腹手术后穿刺并一次性置管成功，引流管留置平均时间为21d。患者经臀经皮置管引流后体温及WBC计数均下降，复查CT示盆腔腹膜后坏死组织引流干净，患者痊愈出院。5例患者平均ICU治疗时间为（47±20）d，平均总住院时间为（884±34）d，平均住院费用为（1863424±15467）元。随访至2012年5月，患者一般情况良好，无复发。结论分步引流策略联合CT引导下经臀经皮置管引流是SAP合并盆腔腹膜后坏死组织感染的有效治疗方法。

Objective To investigate the management of retroperitoneal infected necrotic tissues in pelvic cavity in patients with severe acute pancreatitis （SAP）. Methods The clinical data of 5 patients with SAP complicated with retroperitoneal infected necrotic tissue in the pelvic carvity who were admitted to the General Hospital of Nanjing Military Area from December 2009 to February 2012 were retrospectively analyzed. Systemic comprehensive treatement combined with local management were applied to all the patients. Results Systemic comprehensive treatment： all the 5 patients were treated by enteral nutrition, 3 by mechanical ventilation and 3 by continuous blood purification. All the retroperitoneal infected necrotic tissues in the pelvic carvity were treated by computed tomography （CT）-guided percutaneous catheter drainage, and then the patients were converted to open surgery for further drainage. Four patients had complication of infected pancreatic necrosis bleeding, and they were treated by arterial embolism and （or） ＂sandwich＂ therapy. Local management： 5 patients with retroperitoneal infected necrotic tissues received CT-guided percutaneous catheter drainage via buttocks. The average time of puncturation after illness was 38.4 days, and the average CT density of infected necrotic tissue was 24.4 Hu （20-28 Hu）. Catheterization was successfully done in the open surgery for all the 5 patients, and the average time of abdominal drainage was 21 days. The body temperature and white blood cell count were decreased after puncturation. The average duration of intensive care unite stay, the average time of hospital stay and the average cost of hospitalization were （47 ± 20） days, （ 88 ±34 ） days and （ 186 342 ± 15 467） yuan. All the patients were followed up till May 2012, no recurrece of the retroperitoneal infected necrotic tissue was detected. Conclusion CT-guided percutaneous catheter drainage via buttocks is effective for the treatment of retroperitoneal infected necrotic tissue in the pelvic cavity in SAP patients.