闭合性胰腺损伤保守治疗的病例选择

Case Selection for Conservative Treatment of Closed Pancreatic Injury

目的:探讨闭合性胰腺损伤保守治疗的临床特点和病例选择。方法:回顾性分析2001年10月—2018年12月天津市第三中心医院分院普外科收治的42例闭合性胰腺损伤保守治疗患者的临床资料。男性35例,女性7例,中位年龄52岁。均符合美国创伤外科协会(American association for the surgery of trauma,AAST)胰腺损伤分级标准中的Ⅰ~Ⅱ级。保守治疗措施包括:(1)呼吸循环功能及血氧饱和度监护。(2)肝肾功能及凝血功能监测。(3)禁食水及有效的胃肠减压。(4)全胃肠外营养,维持水电解质平衡。(5)足量应用广谱抗生素。(6)给予H受体阻滞剂或质子泵抑制剂,保护胃黏膜。(7)及时的影像学复查。(8)结合患者具体情况积极治疗并发症和合并症。结果:42例患者中1例死于颅脑损伤术后并发症,其余41例患者经保守治疗后均无胰瘘。腹腔脓肿2例,在B超引导下穿刺引流。胰腺假性囊肿4例,直径3~4cm,经继续保守治疗,1个月后均消失。其余均无腹部相关并发症。随访6个月~3年,1例患者2年后因饮酒出现急性胰腺炎,经保守治疗好转,其余饮食情况及复查B超、CT、血尿淀粉酶均正常。结论:Ⅰ、Ⅱ级闭合性胰腺损伤保守治疗效果满意,随着监测手段和药物的快速发展,保守治疗应引起高度重视。

Objective: To explore the clinical characteristics and case selection of conservative treatment of closed pancreatic injury. Methods: The clinical data of 42 patients with closed pancreatic injury treated conservatively in the hospital from October 2001 to December 2018 were retrospectively analyzed. There were 35 males and 7 females, with a median age of 52 years. All of them met grades Ⅰ-Ⅱ in the American Society for Traumatology Surgery(AAST) classification of pancreatic injury. Conservative treatment measures included:(1) Respiratory and circulatory function and blood oxygen saturation monitoring.(2) Monitoring of liver and kidney function and coagulation function.(3) Fasting water and effective gastrointestinal decompression.(4) Total parenteral nutrition to maintain water and electrolyte balance.(5) Use of broad-spectrum antibiotics in sufficient quantities.(6) Give Hreceptor blockers or proton pump inhibitors to protect the gastric mucosa.(7) Timely imaging review.(8) Actively treat complications and comorbidities in combination with the specific situation of the patient. Results: 1 of the 42 cases died of postoperative complications of craniocerebral injury, and the remaining 41 cases had no pancreatic fistula after conservative treatment. Two cases of abdominal abscess were punctured and drained under the guidance of B-ultrasound. There were 4 cases of pancreatic pseudocyst with a diameter of 3-4 cm, which disappeared after 1 month after continuing conservative treatment. The rest had no abdominal-related complications. During the follow-up period of 6 months to 3 years, 1 patient developed acute pancreatitis due to drinking after 2 years, which was improved after conservative treatment. The rest of the patients’ diet, B-ultrasound, CT, and blood and urine amylase were normal. Conclusion: The results of conservative treatment of grade I and II closed pancreatic injury are satisfactory. With the rapid development of monitoring methods and drugs, conservative treatment should be highly valued.