重症急性胰腺炎并发感染处理的争议与对策

Debates and countermeasures in the management of infection secondary to severe acute pancreatitis

现代外科治疗重症急性胰腺炎(SAP)并发感染以创伤递升式分阶段治疗理念为指导,呈现微创化、阶段化、多学科化、专业化和多元化5大新特点。创伤递升式分阶段治疗SAP并发感染遵循3D原则:外科干预应相对延迟至SAP发病后4周左右;首选引流;若引流效果不佳,则干预升级为清创。早期判断或筛选感染及疑似感染者应注重准确读片、综合分析,并考虑到其他系统感染的可能。对于确诊或疑似感染者,若病情稳定、无明显脓毒症或器官功能衰竭征象,可单纯予以抗生素治疗。影像学引导下经皮穿刺置管引流术(PCD)作为微创化的干预方式,可相对较早地开展。多器官功能衰竭及囊实混合性病灶是相对明确的外科清创必要性的独立危险因素。创伤递升式分阶段治疗SAP并发感染应根据病变位置及分布、术者的特长与偏好选择具体实施方案,其底线是尽量避免出血及肠瘘。创伤递升式分阶段治疗序列中的开放性清创应在合理的指征及时机下开展,其安全有效,也无法取代。当前SAP并发感染的治疗中凸显外科干预相对不足的问题,外科医师在多学科团队中应主动树立自身的主导性地位,勇于担当、敢于出手,努力为SAP并发感染病人争取良好预后。

There are five emerging characteristics present in the modern surgical management of infection secondary to severe acute pancreatitis （SAP） under the guidance of step-up approach： minimal invasive, staged, multi-disciplinary, specialized and diversified. The administration of step-up approach conforms to 3D principle： surgical interventions should be relatively delayed to the end of the 4th week approximately, the first choice of intervention is drainage and debridement is warranted if drainage failed. A favorable evaluation of documented and/or suspected infection places emphasis on a precise imaging reading and a comprehensive analysis in combination with other clinical findings, taking a possibility of infections in other system /organs into account. Medical therapy alone is only suitable for documented/suspected patients whose illness is stable and with no obvious signs of sepsis and/or organ failure. As a minimal invasive intervention, imaging-guided PCD could be relatively conducted early. Multiple organ failure and heterogeneous lesion are explicit risk factors independently associated with the requirement of debridement for patients with secondary infection. A specific step-up protocol in the management of infection secondary to SAP is determined by location and distribution of the lesion as well as preference of the surgeon in charge, under the ultimate consideration of avoiding hemorrhage and intestinal fistula. The open debridement in the step-up approach is performed at the appropriate timing under the right indication, so it is safe, available and irreplaceable. There is a prominent insufficiency in the surgical management of infection secondary to SAP, surgeons thus should endeavor to establish their predominant role in the multiple disciplinary therapy and fight for a favorable prognosis for the patients.