CRRT联合超声引导下PTGD在治疗重症急性胆源性胰腺炎中的临床评价

clinical evaluation of CRRT coupled with ultrasound-guided percutaneous transhepatic gallbladder Fainage for the treatment of severe acute biliary pancreatitis

目的探讨CRRT联合超声引导下经皮经肝微创胆囊穿刺置管引流（PTGD）在治疗重症急性胆源性胰腺炎中的临床应用价值。方法纳入2010年6月至2015年6月青岛大学附属医院重症医学科收治的重症急性胆源性胰腺炎患者，分为常规CRRT组和CRRT＋PTGD组（各30例），分别比较两组患者治疗后临床指标变化的差异（腹痛缓解时间、胃肠减压时间）、实验室检测指标（WBC、PLT、PCT、CRP、AMS、TBIL、ALT、ALB、Lac）、危重病相关评分（APACHEⅡ评分、Balthazar CT评分、MODS评分）的差异，并观察并发症发生情况（ARDS、ARF、MODS、腹腔感染；胆漏、腹腔出血、肠道损伤、导管易位，导管滑脱），比较两组患者呼吸机治疗时间、ICU住院时间及病死率的差异。结果与常规CRRT组比较，CRRT＋PTGD组患者治疗后临床症状明显缓解，腹痛缓解时间及胃肠减压时间明显缩短（P〈0.05）；实验室检测指标（WBC、PLT、PCT、CRP、AMS、TBIL、ALT）变化明显，两组之间差异具有统计学意义（P〈0.05）；危重病相关评分（APACHEⅡ评分、Balthazar CT评分、MODS评分）差异具有统计学意义（P〈0.05）；两组患者呼吸机治疗时间[（6.1±1.3）d vs.（9.5±1.4）d]、ICU住院时间[（15.7±1.1）d vs.（21.1±2.5）d]比较，差异具有统计学意义（P〈0.05）。结论CRRT联合PTGD治疗重症急性胆源性胰腺炎，可在有效清除患者致炎介质和毒素的基础上，通过胆囊穿刺置管引流使胆道减压，改善肝功能，有效缓解患者临床症状，改善临床指标及相关危重病评分，从而改善患者预后。

ObjectiveTo investigate the value of continuous renal replacement therapy （CRRT） coupled with minimally invasive ultrasound-guided percutaneous transhepatic gallbladder drainage （PTGD） for the treatment of severe acute biliary pancreatitis.MethodsHospitalized patients with severe acute biliary pancreatitis were recruited from the intensive care unit （ICU） of the Affiliated Hospital of Qingdao University from June 2010 to June 2015, and divided into conventional CRRT alone group （n = 30） and CRRT ＋ PTGD group （n = 30）. Comparisons of postoperatively symptoms （time required for abdominal pain relief, time consumed for, gastrointestinal decompression）, laboratory findings （WBC, PLT, PCT, CRP, AMS, TBIL, ALT, ALB, Lac） and acute physiology and chronic health evaluation score （APACHE Ⅱ, Balthazar CT, MODS） were carried out between two groups. The occurrence of complications （ARDS, abdominal infection, bile leakage, abdominal hemorrhage, intestinal injury, catheter translocation, catheter dislocation） was observed. The differences in duration of ventilator support, the length of stay in ICU, and fatality rate were compared between the two groups.ResultsCompared with the conventional CRRT alone group, the postoperative symptoms were significantly relieved, and time required for abdominal pain relief and time consumed for gastrointestinal decompression were evidently shortened in the CRRT ＋ PTGD group （P 〈 0.05）. There were statistically significant differences in laboratory findings （WBC, PLT, PCT, CRP, AMS, TBIL, ALT） between two groups （P 〈 0.05）. The differences in APACHE Ⅱ, Balthazar CT and MODS score between the two groups also presented statistical significance （P 〈 0.05）. The comparisons of the duration of ventilator support [（6.1 ± 1.3） d vs. （9.5 ± 1.4） d] and the length of stay [（15.7 ± 1.1） d vs. （21.1 ± 2.5） d] between the two groups revealed statistical significance （P 〈 0.05）.ConclusionsCRRT coupled with PTGD for the treatment of severe acute biliary pancreatitis can effectively eliminate the inflammatory mediators and toxins from patients. On this basis, the coupled therapy with gallbladder puncture and drainage is capable of decompressing the biliary tract, improving liver function, effectively relieving clinical symptoms, minimizing the changes of laboratory findings and APACHE II score, and thereby optimizing the prognosis of patients.