开放胰腺坏死组织清除术治疗感染性胰腺坏死的适应证及临床价值分析

Analysis of indications and clinical value of open pancreatic necrosectomy in treatment of infected pancreatic necrosis

背景与目的:随着近年来重症医学的进步、外科治疗理念和治疗手段的更新,各类微创升阶梯技术逐渐成为治疗感染性胰腺坏死(IPN)的主流手段。然而,传统的开放胰腺坏死组织清除术(OPN)仍占据着不可替代的地位。本研究旨在探讨微创时代下OPN治疗IPN的新特点及临床价值。方法:回顾2014年1月—2019年5月间中南大学湘雅医院连续收治的140例IPN患者,其中24例行OPN,116例行单纯微创治疗,重点对其中24例行OPN治疗的IPN患者的临床特点、手术时机、指针、方法及结局进行分析。全组IPN患者均遵循延迟外科干预的治疗原则,对于抗生素治疗无效的IPN,尽量保守治疗延迟至起病3~4周,待胰腺坏死充分包裹、液化后行外科干预。结果:24例OPN手术指征或原因包括无PCD穿刺路径1例(4.2%)、主动OPN 5例(20.8%)、微创手术无法控制的感染6例(25.0%)、合并严重并发症9例(37.5%)、外院已行腹腔开放感染仍无法控制3例(12.5%)。所有OPN患者均合并严重的腹膜后及血流感染,其中79.2%(19/24)为多重耐药菌感染,58.3%(14/24)合并血流感染,29.2%(7/24)合并胰周真菌感染,4.2%(1/24)合并真菌血症;肺炎克雷伯杆菌为最常见的胰周分离菌。与行单纯微创手术患者比较,行OPN患者重症比例高(87.5%vs.63.8%),平均ICU住院时间延长(26.9 d vs.17.7 d),干预后平均住院时间缩短(24.1 d vs.42.9 d)、病死率增高(45.8%vs.20.7%),差异均有统计学意义(均P<0.05);其他一般资料、手术距离起病的平均时间、术后主要并发症(出血、肠瘘、胰瘘)均无统计学差异(均P>0.05)。OPN患者术后主要死因包括感染性休克5例(45.5%)和失血性休克6例(54.5%)。结论:OPN在IPN的治疗中仍然占据着不可替代的地位,甚至有时候是唯一能够挽救患者生命的手段。在微创治疗的新的时代背景之下,合理选择OPN的适应证和手术时机,对于进一步改善重症胰腺炎的预后具有重要的意义。

Background and Aims:With the development of critical care medicine and the update of the surgical concepts and treatment modalities in recent years,the minimally invasive step-up approaches of different types have gradually become the mainstream methods for the treatment of infected pancreatic necrosis(IPN).However,traditional open pancreatic necrosectomy(OPN)still plays an irreplaceable role.This study was conducted to analyze the new characteristics and clinical value of OPN in treatment of IPN in the era of minimally invasive surgery.Methods:A total of 140 consecutive patients with IPN treated in Xiangya Hospital of Central South University from January 2014 to May 2019 were reviewed.Of the patients,24 cases underwent OPN and 116 cases were treated with purely minimally invasive approach,and the main attention was focused on the clinical characteristics,surgical timing,indications and outcomes of the 24 cases undergoing OPN.In the whole group of IPN patients,the therapeutic principle of delayed surgery was implemented.For those failed to antibiotic treatment,surgical intervention was performed after full encapsulation and liquefaction of the pancreatic necrosis by prolongation of the conservative treatment as maximal as possible at least 3 to 4 weeks after the onset.Results:The indications or reasons for OPN in the 24 patients included no route for PCD in one case(4.2%),aggressively performed OPN in 5 cases(20.8%),uncontrollable infection after minimally invasive surgery in 6 cases(25.0%),serious associated complications in 9 cases(37.5%)and uncontrollable infection after open surgery in other hospitals in 3 cases(12.5%).All patients undergoing OPN were complicated with severe retroperitoneal and bloodstream infections,of whom,79.2%(19/24)were multidrug-resistant infections,58.3%(14/24)were bloodstream infections,29.2%(7/24)were peripancreatic fungal infections,and 4.2%(1/24)were fungal bloodstream infection.Klebsiella pneumoniae was the most common microorganism isolated from the peripancreatic necrosis.In patients undergoing OPN compared with patients undergoing purely minimally invasive surgery,the proportion of cases with severe illness was high(87.5%vs.63.8%),the average length of ICU stay was prolonged(26.9 d vs.17.7 d),the average length of hospital stay after intervention was shortened(24.1 d vs.42.9 d),and the mortality rate was increased(45.8%vs.20.7%),and all the differences had statistical significance(all P<0.05);no significant differences in other general data,the interval between intervention and onset,and the main postoperative complications(massive bleeding,intestinal fistula and pancreatic fistula)were noted(all P>0.05).The main causes for postoperative death in patients undergoing OPN included septic shock in 5 cases(45.5%)and hemorrhagic shock in 6 cases(54.5%).Conclusion:OPN still plays an irreplaceable role in the treatment of IPN,and sometimes even the only way to save the life of the patients.In the era of minimally invasive surgery,appropriate selection of indications and timing for OPN has great importance in improving the prognosis of the patients with severe acute pancreatitis.