早期腹部CT检查在制定急性胆源性胰腺炎诊疗方案中的作用

Early abdominal CT examination in decision making on diagnosis and treatment of acute biliary pancreatitis

目的:研究早期腹部CT检查在制定急性胆源性胰腺炎诊疗方案中的作用。方法:2013年1月1日至2016年12月30日,对连续收治的急性胆源性胰腺炎病人在发病48 h内行腹部CT检查,以明确有无胰周积液、胆囊结石、胆总管结石。CT检查无胰周积液(Balthazar CT分级轻症)、无器官功能障碍(Marshall评分<2分)的急性胆源性胰腺炎病人,分为早期腹腔镜胆囊切除术(early laparoscopic cholecystomy,ELC)组和后期腹腔镜胆囊切除术(late laparoscopic cholecystomy,LLC)组。ELC组腹痛缓解,实验室指标好转,仍处于禁食期,发病7 d内行腹腔镜胆囊切除术(laparoscopic cholecystomy,LC)。LLC组发病后经非手术治疗无腹痛,实验室指标正常,进食流质2 d无不适,发病7 d后行LC。影像检查发现胆总管结石,在LC术前行内镜逆行胆胰管造影(endoscopic retrograde cholangiopancreatography,ERCP)。结果:115例纳入本研究,ELC组56例,LLC组59例。腹部CT检查诊断胆囊结石、胆总管结石的灵敏度均>85%,特异度均为100%。44例行ERCP取石、鼻胆管引流。所有病人均治愈出院,无腹腔出血、腹腔感染、胆漏等并发症发生,无术后胰腺炎病情加重。ELC组平均住院时间、入院至手术时间、LC手术时间,均显著短于LLC组(P<0.05)。两组术中出血量差异无统计学意义(P>0.05)。无胆管损伤,LLC组1例中转开腹。结论:早期腹部CT检查对急性胆源性胰腺炎治疗方案的制定具有指导意义。对有胆总管结石的病人,及时行ERCP取石。对无胰周积液和无器官功能障碍者,可早期行LC,安全并缩短住院时间。

Objective To study the effect of early abdominal CT examination in decisions making on diagnosis and treatment of acute biliary pancreatitis (ABP). Methods From January 1, 2013 to December 30, 2016, consecutively admitted ABP patients within 48 hours of onset were enrolled and abdominal CT scan was performed to diagnose peripancreatic fluid collection, gallbladder stones, and common bile duct stones. ABP patients with neither peripancreatic fluid collection (mild type of Balthazar CT grade) nor organ dysfunction (Marshall score <2 ) were divided into 2 groups: early laparoscopic cholecystectomy (ELC) group and late laparoscopic cholecystectomy (LLC) group. Patients in ELC group had laparoscopic cholecystectomy (LC) during the period of 7 days after onset when abdominal pain was relieved and laboratory tests improved, but still in the fasting period. Patients in LLC group had LC at the onset 7 days later when no abdominal pain and normal laboratory test after treatment were found and fluid food at least 2 days without discomfort. If common bile duct stones was diagnosed by CT, endoscopic retrograde cholangiopancreatography (ERCP) with stone removal was done before LC. Results A total of 115 cases were eligible for inclusion in this study. There were 56 cases in ELC group and 59 cases in LLC group. Sensitivity of abdominal CT scan for diagnosis of gallbladder stones and common bile duct stones was >85%, and specificity 100%. ERCP with stone removal was performed for 44 cases combined endoscopic nasal bile duct drainage. All patients were cured and discharged without any complications including abdominal hemorrhage or infection, bile leakage, and no postoperative exacerbation of pancreatitis. Length of hospital stay, days before LC and LC operative time in ELC group were significantly less than those in LLC group, P<0.05. There were no significant differences in operative blood loss between 2 groups and no bile duct injuries occurred. One case was converted to open surgery in LLC group. Conclusions Early abdominal CT would be instructive for the treatment options of ABP. ERCP with stone removal should be performed timely for the patients with common bile duct stones and ELC could be safely performed for the patients with neither peripancreatic fluid collection nor organ dysfunction to shorten hospital stay significantly.