早期超声引导下盆腔积液PCD可改善中-重症急性胰腺炎病程

Ultrasound guided early PCd of pelvic effusion can improve the progression of moderate and severe acute pancreatitis

目的探讨中-重症急性胰腺炎早期(发病7 d内)超声引导下经皮穿刺引流(percutaneous catheter drainage,PCD)盆腔游离积液的可行性及其对病情进展和预后的影响。方法回顾分析2014年4月至2017年12月上海交通大学医学院附属瑞金医院急诊科与重症医学科收治的伴有早期盆腔积液的中-重症急性胰腺炎患者,进行盆腔PCD的归为早期PCD组(n=31),未进行盆腔PCD的归为未PCD组(n=60),对比分析两组病情进展情况、后期并发症发生率和预后情况等。结果早期PCD组平均引流量为(1561.3±776.7)mL,平均留管时间为(5.1±1.3)d,引流液微生物培养均为阴性,未出现任何并发症。早期PCD组比未PCD组:腹腔内高压缓解时间[(4.5±2.9)d vs (5.6±2.2)d]、平均机械通气时间[(7.5±6.6)d vs (11.4±5.7d)]和半量肠内营养(EN)达标时间[(6.7±3.8)d vs (8.4±4.2)d]均显著短于未PCD组(P<0.05);早期PCD组后期进行胰周PCD(22.6%vs 35.1%)、继发感染(22.6%vs 41.7%)及清创手术率(19.4%vs 38.3%)均低于未PCD组,但无统计学差异(P>0.05);早期PCD组后期多部位/区域PCD的发生率显著低于未PCD组(3.2%vs 20.0%,P<0.05);出院时(非手术患者)>100 mL包裹性坏死/积液区域数量显著低于未PCD组[(1.68±0.84) vs (2.36±1.42),P<0.05);此外,早期PCD组住ICU时间[(20.48±20.63)d vs (25.76±26.21)d]和总住院时间[(36.58±23.44)d vs (41.43±28.26)d]以及总死亡率都低于未PCD组,但缺乏统计学差异(P>0.05)。结论在技术支持和强化导管管理的前提下,早期超声引导下PCD引流盆腔游离积液是安全可行的,并对缓解早期腹腔内高压,缩短机械通气时间、提早实现半量EN、减少后期多部位/区域PCD具有显著帮助,也可明显减少病程后期较大体积坏死或积液残留。

Objective To evaluate the feasibility of ultrasound-guided PCD of pelvic fluid collection in the early stage (7 days after onset) of moderate-severe acute pancreatitis and its effect on the disease progression and prognosis. Methods Patients who were admitted to the emergency surgery and/or the intensive care unit of Ruijin Hospital from Apr. 2014 to Dec. 2017 were retrospectively analyzed. The patients with early pelvic effusion were selected by ultrasonic monitoring and divided into early PCD group ( n =31) and non PCD group ( n =60). The effects of early PCD on progression, complications and prognosis were analyzed. Results The average of drainage volume in the early PCD group was (1 561.3±776.7)mL and the average retention time was (5.1±1.3) days. The microbiological cultures of the drainage fluid were all negative. No complications occurred. In the early PCD group, the average time to relieve high intra-abdominal pressure [(4.5±2.9)d vs (5.6±2.2)d], mechanical ventilation time [(7.5±6.6)d vs (11.4±5.7)d] and waiting time of half volume EN application [(6.7±3.8)d vs (8.4±4.2)d] were significantly shorter than those in the non PCD group ( P <0.05). Though the incidence of peri-pancreatic PCD (22.6% vs 35.1%), secondary infection (22.6% vs 41.7%) and surgical debridement (19.4% vs 38.3%) in the late stage was lower than those in the non PCD group, there was no statistical difference ( P >0.05). There was no difference in the CT score of pancreatic necrosis in two groups (3.2% vs 20.0%, P <0.05), but the residual wall-off necrosis/fluid collection over 100 mL was significantly less than those in the non PCD group [(1.68±0.84) vs (2.36±1.42), P <0.05]. In addition, the ICU and total hospitalization time [(20.48±20.63)d vs (25.76±26.21)d] and total mortality [(36.58±23.44)d vs (41.43±28.26)d] in early PCD group were lower than those in the non PCD group, but there was no statistical difference ( P >0.05). Conclusion With the technical support and enhanced catheter management, ultrasonic guided early PCD of pelvic effusion is safe and feasible, which can help to relieve high intra-abdominal hypertension, shorten mechanical ventilation time and realize early half volume EN in the early stage, and significantly reduce the residues of larger volume necrosis/fluid collection in the later stage.