重症急性胰腺炎的治疗方案选择与预后关系

Selection of therapeutic strategy in severe acute pancreatitis

目的 探讨重症急性胰腺炎的治疗方案选择与疗效的关系。方法 分析1996年1月至2000年12月共收治的重症急性胰腺炎271例,分析其病因、治疗方案选择与患者预后间的关系。结果重症胆源性胰腺炎手术治疗64例,治愈率92.2％,死亡病例平均生存天数29.0d,主要死亡原因是MODS和坏死感染;非手术治疗56例,治愈率85.7％,死亡病例平均生存天数6.2d,主要死亡原因为休克、严重感染、肾功能衰竭、胰性脑病和MODS。重症非胆源性胰腺炎下术治疗76例,治愈率75.0％,死亡病例平均生存天数52.9d,死亡原因有MODS、感染、DIC、消化道瘘和腹腔内出血;重症非胆源性胰腺炎非手术治疗75例,治愈率89.3％.死亡病例平均生存6.4d（1～54d）,早期死亡的病例发病急,迅速出现休克、肾功能衰竭、ARDS和腹内高压,后期死亡的病例有包裹性感染坏死病灶破裂、全身感染和MODS。结论 胆源性胰腺炎有胆道梗阻者应当行急诊手术或者行EST及ENBD,同时积极抗休克、防治肾功能衰竭,无胆道梗阻者先做积极的抗感染非手术治疗,后期作胆囊切除手术,是否探查胆总管根据病情决定。对来势急,经过积极的非手术治疗仍迅速出现休克、肾功能衰竭、ARDS、胰性脑病,或伴有腹膜炎或腹内高压者应及时手术引流。

Objective To compare the outcomes of patients with severe acute pancreatitis (SAP) treated with various methods and seek the optimal therapeutic strategy for SAP. Methods The clinical data of 271 patients with SAP treated in our hospital from January 1996 to December 2001 were reviewed, and the outcomes of the patients treated with various methods were analyzed. Results In 64 patients with biliary SAP who received surgical treatment, the survival rate was 92. 2% (59/64), Of them, six died from MODS and necrotic infection with the mean survival time of 29. 0 days. In 56 patients with biliary SAP who were treated nonsurgically, the survival rate was 85. 7% (48/56). Of them, eight died from septic shock, severe sepsis, acute renal failure, pancreatic encephalopathy and MODS, with the mean survival time of 6. 2 days. In 76 patients with nonbiliary SAP who received surgical treatment, the survival rate was 75. 0% (57/76), Of them, nine died from MODS, sepsis, DIC, fistula of the alimentary tract and intra-abdominal hemorrhage, with the mean survival time of 52. 9 days. In 75 patients with non-biliary SAP who received nonsurgical treatment, the survival rate was 89. 3%(67/75). Of them, eight died from shock, acute renal failure, ARDS, intra-abdominal hypertension, rupture of localized infected necrosis, sepsis and MODS, with the mean survival time of 6. 4 days. Conclusions (1) Surgical or endoscopic biliary drainage should be performed urgently for patients with biliary SAP accompanied with biliary obstruction. Furthermore, prophylactic antibiotics, anti-shock and anti-acute renal failure therapies should be emphasized in the treatment of such patients. For biliary SAP patients without biliary obstruction, cholecystectomy should be performed as soon as the patients recoved from the SAP; common bile duct exploration should be done if there is indication. (2) Should SAP exacerbated rapidly, intensive care therapy can never be too emphasized lest shock, acute renal failure, ARDS or pancreatic encephalophathy should occur, Surgical drainage should be done subsequently.