早期胰管支架置入治疗急性坏死性胰腺炎的疗效:附57例报告

Efficacy of early pancreatic duct stent placement in treatment of acute necrotizing pancreatitis:a report of 57 cases

背景与目的:急性坏死性胰腺炎(ANP)的病情复杂多变,病理进展迥异,继发感染时病死率可达20%~30%。目前对于ANP的治疗主要是早期给予禁食、补液、镇痛、抑酸、抑酶等对症治疗,后期形成并发症时,进行外科干预的升阶梯治疗。而ANP后期局部并发症发生率和病死率较高,预后较差。相关研究表明,胰管高压和胰管梗阻在急性胰腺炎(AP)的发病过程中起着重要作用,AP合并胰液渗漏的概率可高达90%以上。因此,本研究探讨早期胰管支架置入治疗ANP的有效性和安全性。方法:回顾性收集宁夏医科大学总医院2019年6月1日—2021年12月30日期间入院后48 h之内行胰管支架置入术治疗的ANP患者临床资料。结果:按照纳入标准和排除标准,共纳入57例患者,其中中度重症34例,重症23例。所有患者入院到手术等待时间为8(3~21)h,均成功完成胰管支架置入。18例患者在手术中可见胰管蛋白栓,其中中度重症8例(23.53%)、重症10例(43.48%)。患者手术后腹痛、腹胀等症状均有不同程度的缓解;患者入院48 h后,白细胞、血淀粉酶、血脂肪酶、血糖水平及APACHEⅡ评分均较入院时明显降低(均P<0.05)。患者首次经口进食时间和住院时间的中位数分别为72(48~144)h和9(6~16.5)d。进一步分析显示,中度重症转入ICU患者数量、首次经口进食时间、住院时间、住院费用和CT严重程度指数方面均明显优于重症患者(均P<0.05)。大部分患者入院时有严重的胰周渗出,胰管支架置入后,胰周渗出都有不同程度的吸收。无严重手术相关不良事件发生,后期形成感染性坏死8例、包裹性坏死7例,其中5例通过胰管支架引流后治愈,其余10例行经皮穿刺置管引流,未进行开腹清创等其他外科干预。结论:早期胰管支架置入治疗ANP可以快速缓解患者的症状,降低局部并发症的发生率,减少后期反复的外科干预,是临床有效的治疗方法和策略。

Background and Aims:Acute necrotizing pancreatitis(ANP)is a complex and variable condition with diverse pathological progressions,and the mortality rate can reach 20%to 30%when secondary infections occur.Currently,the treatment for ANP mainly involves early symptomatic management,such as fasting,fluid infusion,pain relief,acid suppression,and enzyme inhibition,followed by a step-up approach involving surgical interventions when complications develop in the later stages.Late-stage local complications of ANP are associated with a high incidence complications and poor prognosis.Studies have suggested that pancreatic duct hypertension and obstruction play crucial roles in the pathogenesis of acute pancreatitis(AP),with a probability of pancreatic fluid leakage exceeding 90%.Therefore,this study investigated the efficacy and safety of early pancreatic duct stent placement in treating ANP.Methods:Clinical data of ANP patients who underwent pancreatic duct stent placement within 48 h of admission at Ningxia Medical University General Hospital from June 1,2019,to December 30,2021,were retrospectively collected.Results:According to the inclusion and exclusion criteria,57 patients were included,including 34 with moderately severe disease and 23 with severe disease.The median time from admission to surgery for all patients was 8(3-21)h,and all patients successfully underwent pancreatic duct stent placement.Pancreatic protein plugs were observed in 18 patients during surgery,including 8 cases(23.53%)with moderately severe disease and 10 cases(43.48%)with severe disease.Patients had varying degrees of relief from symptoms such as abdominal pain and bloating after surgery.On 48 h after admission,the white blood cell count,amylase,lipase,blood glucose levels,and APACHEⅡscores were significantly reduced compared to admission values(all P<0.05).The median time to the first oral intake and length of hospital stay were 72(48-144)h and 9(6-16.5)d,respectively.The analysis further revealed that patients with moderately severe disease had significantly better outcomes in terms of ICU admission,time to first oral intake,hospital stay,hospital costs,and CT severity index compared to patients with severe disease(all P<0.05).Most patients had significant peripancreatic fluid collections at admission,and after pancreatic duct stent placement,these collections showed varying degrees of absorption.No severe surgery-related adverse events occurred.Late-stage complications included infected necrosis in 8 cases and walled-off necrosis in 7 cases,of whom 5 cases were cured through pancreatic duct stent drainage,while the remaining 10 cases underwent percutaneous drainage without the need for open surgical debridement or other surgical interventions.Conclusion:Early pancreatic duct stent placement in the treatment of ANP can rapidly alleviate symptoms,reduce the incidence of local complications,and decrease the need for subsequent surgical interventions.It is an effective clinical treatment strategy.