多切口入路坏死组织清除术治疗重症急性胰腺炎的临床分析  

Clinical analysis of subcostal and post-waist combining approach of pancreatic necrosectomy

作　　者：郭佐铭 孙备[2] Guo Zuom-ing;Sun Bei(Department of Hepatopancreatobiliary Surgery,Harbin Medical University Cancer Hospital,Harbin 150040,China)

机构地区：[1]哈尔滨医科大学附属肿瘤医院肝胆胰外科,哈尔滨150040 [2]哈尔滨医科大学附属第一医院胰腺胆道外科

出　　处：《腹部外科》2018年第5期326-331,共6页Journal of Abdominal Surgery

摘　　要：目的探讨"联合肋缘下后腰入路胰腺坏死组织清除术"在治疗腹膜后广泛坏死型胰腺炎方面的疗效。方法回顾性分析2015年1月至2017年12月,因腹膜后广泛坏死型胰腺炎接受多切口入路手术的8例病人的临床资料,入院时CT检查均显示Balthazar C级或D级。治疗方案遵循"创伤递进"原则,并进行相应调整。定期复查CT以评估疾病进展和治疗效果。所有病人术前均接受经皮穿刺置管引流,引流液常规进行细菌培养。发病4周内,尽可能延迟手术时间;如发病超过4周,且非手术治疗无法缓解病情,则进行手术治疗。结果所有病人的坏死部位均累及胰周和腹膜后大片区域,需要多切口入路方可达到所有病变部位。中位手术时间为发病后26d(16～76d),平均接受手术2.3次。6例病人因腹膜后感染迁延不愈而接受手术,1例病人于术后80d死于脓毒症,其余5例病人未发生手术相关并发症,痊愈。1例病人因腹腔出血接受手术,未发生手术相关并发症,痊愈。1例病人因进行性多器官功能障碍综合征接受手术,无手术相关并发症发生,术后40d死于脓毒症。结论在"创伤递进"原则下,多切口入路手术治疗广泛坏死型胰腺炎具有安全性和有效性。即使一般状态较差的病人也可以承受多次手术所产生的打击。Objective To introduce outcome using subcostal and post-waist combining approach of pancreatic necrosectomy to treat extensive necrotizing pancreatitis.Methods This retrospective study included 8 patients with extensive necrotizing pancreatitis undergoing subcostal and post-waist combining approach of pancreatic necrosectomy from Jan.2015 to Dec.2017 in our hospital.All patients were diagnosed C or D degree in Balthazar＇s CT Grade.The treating strategy followed the＂step-up approach＂with some modifications.CT was performed routinely to evaluate the regions of lesions and the progression of disease.All patients received percutaneous catheter drainage（PCD）for varied reasons,and drainage-fluid was tested by bacteria culture to identify infection.The debridement was delayed as long as possible,unless the disease lasted more than 4 weeks of non-surgical therapies failed to maintain general conditions.Results In all patients the regions of necrosis involved both superior and inferior abdomen which needed combining approach necrosectomy to debride total lesions.Six patients underwent debridement due to constant retroperitoneal infection,medium delay from disease onset to debridement was 26 days（16 to 76 days）,average surgical times was 2.3,one patient died from sepsis on the 80 th day from disease onset,and no surgery related complication occurred on other 5 patients who were cured.One patient underwent debridement due to intra-abdominal hemorrhage,and no surgery related complication occurred.One patient due to aggravating multiple organ dysfunction syndrome（MODS）died from sepsis on the 40 th day from disease onset,and no surgery related complication occurred.Conclusions Following the＂step-up approach＂policy,combining approach of pancreatic necrosectomy was safe and effective in treating extensive necrotizing pancreatitis. Most patients were able to handle repeated operations even in poor conditions.

关 键 词：坏死型胰腺炎 创伤递进 多切口入路 胰腺坏死组织清除术 

分 类 号：R657.51[医药卫生—外科学]