内镜下乳头括约肌切开术后严重并发症的外科治疗策略

Surgical treatment of severe complications after endoscopic papillary sphincterotomy

目的总结内镜下乳头括约肌切开术(EST)及相关操作后消化道大出血、穿孔及胰周坏死伴感染等严重并发症的外科处理措施。方法回顾性分析战略支援部队特色医学中心和民航总医院2012年1月至2019年12月收治的EST后出现严重并发症的28例患者的临床资料,其中6例发生消化道大出血,10例发生十二指肠穿孔,12例发生重症胰腺炎导致的胰周坏死伴感染或腹膜后广泛积液积脓。28例患者均进行外科手术治疗。对患者的术中引流、营养管放置情况及术后恢复情况等进行归纳和总结。结果本组28例患者均放置胃肠减压,24例放置空肠营养管;10例行十二指肠造瘘,10例行T管引流。消化道大出血患者术后血红蛋白含量明显上升,十二指肠穿孔及胰周坏死伴感染患者C-反应蛋白及白细胞迅速回落。结论严格掌握手术适应证、术中充分引流及尽早开始肠内营养支持是治疗消化道大出血的重要措施。消化道大出血手术关键在于确切止血,十二指肠穿孔手术需给予穿孔部位充分引流,而胰周坏死伴感染在充分清除坏死组织的同时也需要充分引流。

Objective To summarize the surgical treatment of massive gastrointestinal hemorrhage,perforation,peripancreatic necrosis accompanied by infection after endoscopic papillary sphincterotomy and related operations.Methods The clinical data of 28 patients with severe complications after EST who were admitted into Strategic Support Force Characteristic Medical Center and Civil Aviation General Hospital from January 2012 to December 2019 were retrospectively analyzed,including 6 patients with massive gastrointestinal tract bleeding,10 patients with duodenal perforation,and 12 patients with pancreatic necrosis accompanied by infection or extensive retroperitoneal effusion and empyema due to severe pancreatitis.All of the 28 patients received surgical treatment.The intraoperative drainage,placement of nutrient tubes and postoperative recovery of the patients were summarized.Results In this study,all the 28 patients were placed for gastrointestinal decompression,and 24 patients were placed for jejunal nutrition.Duodenal fistula was performed in 10 patients and T-tube drainage was performed in 10 patients.In patients with massive gastrointestinal bleeding,hemoglobin increased significantly,and C-reactive protein and white blood cells decreased rapidly in patients with duodenal perforation and peripancreatic necrosis accompanied by infection.Conclusion It is important to master the operative indications strictly,and to give adequate intraoperative drainage and early initiation of enteral nutritional support in the treatment of massive gastrointestinal bleeding.The key to the operation of massive gastrointestinal bleeding is the accurate hemostasis.Duodenal perforation should be performed with sufficient drainage in perforated site.Peripancreatic necrosis accompanied by infection requires adequate drainage as well as adequate clearance of necrotic tissue.