摘要
目的探讨以小切口胰腺坏死组织清除术(非视频辅助)为核心的"四步法"治疗感染性胰腺坏死(IPN)的临床效果。方法回顾性分析2013年1月至2017年12月哈尔滨医科大学附属第一医院胰胆外科收治的207例IPN患者的临床资料,其中男性132例(63.8%),女性75例(36.2%);中位年龄45岁(范围:19~80岁)。重症急性胰腺炎158例(76.3%),中重症急性胰腺炎49例(23.7%)。所有患者均先接受经皮置管引流(PCD)治疗。Step-up组(173例):采用"四步法"治疗策略,PCD后接受微创小切口胰腺坏死清除术(MIAPN),对于术后残余感染灶进一步行经窦道内镜下坏死清除术和(或)PCD,最后行常规开放胰腺坏死清除术(OPN);OPN组(34例):PCD无效后直接行OPN。比较两组患者围手术期情况及预后。正态分布的计量资料采用t检验进行分析,偏态分布的计量资料采用Wilcoxon秩和检验进行分析;计数资料采用χ^2检验或Fisher确切概率法进行分析。结果Step-up组与OPN组患者基本特征的差异均无统计学意义(P值均>0.05)。OPN组的转诊率、术前3 d器官功能衰竭发生率高于Step-up组(47.1%比28.9%,χ^2=4.313,P=0.038;26.5%比9.2%,χ^2=2.819,P=0.011)。Step-up组MIAPN术前PCD次数、PCD管留置数量较OPN组明显减少[1(1)次比2(1)次;Z=-3.373,P=0.018;2(1)根比3(2)根;Z=-2.208,P=0.027]。与OPN组相比,Step-up组发病至手术时间缩短[29(15)d比36(17)d,Z=-0.567,P=0.008],MIAPN手术时间缩短[58(27)min比90(56)min;Z=-3.908,P<0.01];术后病死率降低(5.8%比17.6%;χ^2=4.070,P=0.044),术后总体并发症发生率降低(23.1%比55.9%;χ^2=14.960,P<0.01),术后新发器官功能衰竭比例降低(37.5%比47.4%;χ^2=7.133,P=0.007),但两组术后腹腔局部并发症(胰瘘、腹腔内出血、消化道瘘)发生率的差异均无统计学意义(P值均>0.05)。Step-up组术后需要ICU治疗的患者比例小于OPN组(22.0%比44.1%,χ^2=6.204,P=0.013);Step-up组总住院时间较OPN组明显缩短[46(13)d比52(13)d,Z=-1.993,P=0.046]。
Objective To examine the effect of the"four-steps"treatment on infectious pancreatic necrosis(IPN).Methods The data of 207 patients who were diagnosed with IPN from January 2013 to December 2017 at Department of Pancreaticobiliary Surgery,the First Affiliated Hospital of Harbin Medical University were analyzed retrospectively.Among 207 patients,132(63.8%)were males and 75(36.2%)were females.The median age was 45 years old(range:19 to 80 years old).One hundred and fifty-eight patients(76.3%)suffered severe acute pancreatitis and 49 patients(23.7%)suffered moderately severe acute pancreatitis.Percutaneous catheter drainage(PCD)was performed on all the patients(Step 1).Patients received"four-steps"minimally invasive treatment strategy in step-up group(173 patients).The following steps after PCD were mini-incision access pancreatic necrosectomy(MIAPN)(Step 2),sinus tract endoscopic debridement and(or)PCD for residual infections(Step 3)and finally conventional open pancreatic necrosectomy(OPN)(Step 4).Patients(34 cases)received conventional open pancreatic necrosectomy after invalided PCD in OPN group.The perioperative parameters and prognosis were compared between Step-up group and OPN group.Normally distributed quantitative variables were analyzed by t-test,non-normally distributed quantitative variables were analyzed by Wilcoxon chi-square test and categorical variables were analyzed byχ^2 test or Fisher exact test,respectively.Results The basic characteristics of the two groups of patients were similar,but the referral rate of patients and the rate of preoperative 3 days organ failure in the OPN group were significantly higher than those of step-up group patients(47.1%vs.28.9%,χ^2=4.313,P=0.038;26.5%vs.9.2%,χ^2=2.819,P=0.011).The frequency of PCD and the number of PCD tube(root)were less than those in the step-up group(1(1)vs.2(1),Z=-3.373,P=0.018;2(1)vs.3(2),Z=-2.208,P=0.027).Compared with the OPN group,the interval time from onset to surgery and the MIAPN operation time were significantly shorter in the step-
作者
张奇
李乐
吕新建
陈宏泽
陈华
孔瑞
王刚
姜洪池
孙备
Zhang Qi;Li Le;Lyu Xinjian;Chen Hongze;Chen Hua;Kong Rui;Wang Gang;Jiang Hongchi;Sun Bei(Department of Pancreatic and Biliary Surgery,the First Affiliated Hospital of Harbin Medical University,Key Laboratory of Hepatosplenic Surgery,Ministry of Education,Harbin 150001,China)
出处
《中华外科杂志》
CAS
CSCD
北大核心
2020年第11期858-863,共6页
Chinese Journal of Surgery
基金
国家自然科学基金(81670583、81871974)。
关键词
胰腺炎
急性坏死性
感染性胰腺坏死
经皮穿刺置管引流
小切口胰腺坏死组织清除术
创伤递升式
Pancreatitis,acute necrotizing
Infected pancreatic necrosis
Percutaneous catheter drainage
Mini-incision access pancreatic necrosectomy
Step-up approach.
