重症急性胰腺炎并发胰腺坏死感染经阶梯式引流模式治疗的患者病死原因及临床特点分析  

Causes of death and clinical characteristics of severe acute pancreatitis patients with infected pancreatic necrosis treated by the step-up approach

作　　者：杨栋梁[1] 童智慧[1] 柯路[1] 李刚[1] 周晶[1] 董杰[1] 陈意喆 张敬柱[1] 李维勤[1] 

机构地区：[1]南京大学医学院附属金陵医院(南京军区南京总医院)解放军普通外科研究所,南京医学硕士210002

出　　处：《医学研究生学报》2016年第11期1197-1201,共5页Journal of Medical Postgraduates

基　　金：江苏省重点研发计划(社会发展)项目(BE2016749)

摘　　要：目的重症急性胰腺炎(severe acute pancreatitis,SAP)是ICU中常见的重症急症。文中分析经阶梯式引流模式治疗的SAP并发胰腺坏死组织感染(infected pancreatic necrosis,IPN)患者的病死原因及临床特点。方法回顾性分析2014年1月至2015年12月南京军区南京总医院普通外科重症胰腺炎治疗中心收治的243名IPN患者的临床资料。所有患者均采取阶梯式引流模式治疗IPN。根据患者临床结局分为病死组及存活组,比较2组患者的临床特点,并通过多因素回归分析探索IPN患者病死的危险因素。结果 2年内共纳入243名IPN患者,死亡32例,IPN整体病死率为13.17%。病死患者相比于存活患者,急性期器官功能障碍、急性肾功能损伤以及休克发生率明显增高,分别为(81.25%vs 50.23%)、(46.87%vs27.49%)、(90.62%vs 21.80%)。APACHEⅡ评分更高(13 vs 17),感染时间更早(52 d vs 23 d);感染期腹腔大出血、消化道瘘等并发症的发生率增高,开腹手术比例更高(59.37%vs 19.43%)。手术距发病时间更短[34(28,40)d vs 62(22,64)d]、ICU(11 d vs 54 d)及住院总天数更长(31 d vs 59 d),差异均有统计学意义(P<0.05)。多因素回归分析发现,病死危险因素包括急性期器官功能障碍、感染时间、感染期并发症、开腹手术、ICU天数及住院天数。结论急性期器官功能障碍、感染及感染期并发症仍是阶梯式引流模式中IPN患者的主要病死原因,临床治疗中应加以重视。Objective Severe acute pancreatitis( SAP) is a common disease in the ICU. The aim of this study was to explore the causes of death and clinical characteristics of SAP patients complicated with infected pancreatic necrosis( IPN) managed by the step-up approach. Methods We retrospectively reviewed the clinical data of 243 IPN patients admitted to Jinling Hospital from January 2014 to December 2015,all treated by the step-up approach. We compared the clinical characteristics and outcomes between the dead( n = 32)and survived( n = 211) patients and investigated the risk factors of death by logistic regression analysis. Results Of the 243 IPN patients,32( 13.17%) died. Compared with the survivors,the dead patients showed higher incidence rates of organ dysfunction( ARDS: 50.23% vs 81.25%,AKI: 27.49% vs 46.87%,shock: 21.80% vs90.62%) in the acute phase,a higher APACHEⅡ score( 13 vs 17),earlier infection( 52 d vs 23 d),higher rates of complications,such as intra-abdominal hemorrhage and gastrointestinal fistula,and open necrosectomy( 19. 43% vs 59. 37%),shorter duration from onset to operation( 62 d vs 34 d),and longer stay in ICU( 11 d vs 54 d) and hospital( 31 d vs 59 d)( all P<0.05). Based on the results of logistic regression analysis,the independent risk factors of death included higher incidence of organ dysfunction in the acute phase,earlier infection,higher rates of complications and open necrosectomy,and prolonged ICU and hospital stays. Conclusion Organ dysfunction in the acute phase,early infection,and complications are the major risk factors of death in the step-up approach to IPN.

关 键 词：胰腺坏死组织感染 阶梯式引流 器官功能 并发症 病死原因 临床特点 危险因素 

分 类 号：R657.5[医药卫生—外科学]