双入路小切口坏死组织清除术联合持续灌注引流治疗感染性坏死性胰腺炎的临床疗效

Clinical efficacy of bilateral route minimal-incision necrosectomy combined with continuous lavage for the treatment of infected necrotizing pancreatitis

目的探讨双入路小切口坏死组织清除术联合持续灌注引流治疗感染性坏死性胰腺炎(INP)的临床疗效。方法采用回顾性描述性研究方法。收集2016年4月至2019年7月陆军军医大学大坪医院收治的20例INP病人的临床资料;男11例,女9例;年龄为(42±9)岁。20例病人均行双入路小切口坏死组织清除术,联合术后脓腔持续灌注引流。观察指标:(1)手术情况。(2)术后情况。(3)随访情况。采用门诊及电话方式进行随访,了解病人发热、腹痛、腹胀、腹泻等临床表现及胰腺周围残余组织感染和生存情况。随访时间截至2020年1月。正态分布的计量资料以x±s表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数表示。结果(1)手术情况:20例病人均顺利完成手术,其中14例手术入路为腹上区+左侧腹膜后入路,1例为腹上区+右侧腹膜后入路,5例为腹上区+双侧腹膜后入路。20例病人中,14例行附加手术,其中10例行空肠造瘘术、2例行胃造瘘及空肠造瘘术、1例行腹腔镜胆囊切除及空肠造瘘术、1例行胆囊造瘘术。20例病人手术时间为(228±41)min,术中出血量为100 mL(50~700 mL)。(2)术后情况:20例病人术后开始行0.9%氯化钠溶液脓腔持续灌注引流时间为2 d(1~14 d)。20例病人中,6例发生术后并发症,其中1例为术后胃瘘合并腹腔出血(于术后13 d行剖腹探查止血+胃造瘘术)、1例为术后十二指肠瘘(于术后111 d行胃肠吻合+空肠造瘘术)、1例为术后腹膜后残余组织坏死感染(于术后11 d再次行胰腺周围坏死组织清除引流术)、1例为术后胆囊瘘(于术后71 d行胆囊切除术)、2例为术后胰瘘(经保守治疗后痊愈)。20例病人第1次手术后住院时间为42 d(20~178 d)。(3)随访情况:20例病人均获得术后随访,随访时间为6.0~45.0个月,中位随访时间为14.5个月。随访期间,1例病人继发糖尿病;无病人出现发热、腹痛、腹胀、腹泻等临床表现。20例病人胰腺周围残余组织吸收良好,无病人死亡。结论双入路小切口坏死组织清除术联合持续灌注引流治疗INP安全、可行。

Objective To investigate the clinical efficacy of bilateral route minimal-incision necrosectomy combined with continuous lavage for the treatment of infected necrotizing pancreatitis(INP).Methods The retrospective and descriptive study was conducted.The clinical data of 20 patients with IPN who were admitted to Daping Hospital,Army Medical University from April 2016 to July 2019 were collected.There were 11 males and 9 females,aged(42±9)years.All the 20 patients underwent bilateral route minimal-incision necrosectomy,and then be continuous perfused and drainage within the purulent cavity postoperatively.Observation indicators:(1)surgical situations;(2)postoperative situations;(3)follow-up.Follow-up using outpatient examination and telephone interview was performed to detected patients fever,abdominal pain,abdominal distension,diarrhea,peripancreatic residual infection and survival up to January 2020.Measurement data with normal distribution were represented as Mean±SD,and measurement data with skewed distribution were represented as M(range).Count data were described as absolute numbers.Results(1)Surgical situations:of the 20 patients who underwent surgery successfully,14 patients underwent upper abdomen combined with left retroperitoneal approach,1 patient underwent upper abdomen combined with right retroperitoneal approach,and the other 5 patients underwent upper abdomen combined with bilateral retroperitoneal approach.Fourteen of the 20 patients underwent additional surgery including 10 cases undergoing jejunostomy,2 cases undergoing gastrostomy combined with jejunostomy,1 case undergoing laparoscopic cholecystectomy combined with jejunostomy,and 1 case undergoing cholecystectomy.The operation time and volume of intraoperative blood loss of 20 patients were(228±41)minutes and 100 mL(range,50-700 mL),respectively.(2)Postoperative situations:20 patients began continuous perfused with 0.9%sodium chloride solution within the purulent cavity at postoperative day 2(range,day 1-14).Six of the 20 patients had postoperative complications including 1 case with postoperative gastric fistula combined with intraperitoneal hemorrhage who underwent laparotomy hemostasis combined with gastrostomy at day 13 postoperatively,1 case with postoperative duodenal fistula who underwent gastrointestinal anastomosis and jejunostomy at day 111 postoperatively,1 case with postoperative retroperitoneal residual tissue necrosis and infection who underwent peripancreatic necrotic tissue debridement and drainage at day 11 postoperatively,1 case with postoperative gallbladder fistula who underwent cholecystectomy at day 71 postoperatively,and 2 cases with postoperative pancreatic fistula who were cured with conservative treatment.The duration of hospital stay after 1st operation of the 20 patients were 42 days(range,20-178 days).(3)Follow-up:all 20 patients were followed up for 6.0 to 45.0 months,with a median follow-up time of 14.5 months.During the follow-up,1 case developed secondary diabetes,and none of patient showed clinical manifestation such as fever,abdominal pain,abdominal distension and diarrhea.The peripancreatic residual tissue of all 20 patients absorbed well,and none of patient died.Conclusion Bilateral route minimal-incision necrosectomy combined with continuous lavage is safe and feasible for the treatment of INP.