美国胃肠病协会关于急性胰腺炎胰腺坏死处理临床实践专家共识更新解读  

Interpretation of American Gastroenterological Association Clinical Practice update: management of pancreatic necrosis in acute pancreatitis patients

作　　者：皋林 童智慧[1] 李维勤[1] GAO Lin;TONG Zhi-hui;LI Wei-qin(Medical School of Nanjing University,Severe Acute Pancreatitis Treatment Center,General Hospital of Eastern Theater Command,Nanjing 210002,China)

机构地区：[1]南京大学医学院东部战区总医院重症胰腺炎治疗中心

出　　处：《中国实用外科杂志》2019年第12期1257-1259,1264,共4页Chinese Journal of Practical Surgery

基　　金：江苏省重点研发计划(社会发展)项目(No.BE2016749);国家自然科学基金(No.81670588)

摘　　要：美国胃肠病协会(AGA)于2019年8月在Gastroenterology(《胃肠病学》)杂志上发表了针对胰腺坏死处理的临床实践专家共识的更新,归纳并总结了当前的临床证据与专家意见,旨在为胰腺坏死这一复杂临床情况的最佳干预提供指导建议。近年来,随着临床实践的不断深入,急性胰腺炎胰腺坏死的处理经历了较大的变革。从一开始的以手术为主的清创策略过渡到现阶段较为成熟的升阶梯治疗模式。针对胰腺坏死的治疗主要包含两个方面:非手术治疗和有创干预。其中,非手术治疗主要包括抗菌治疗和营养支持等。一旦坏死组织发生感染或无菌性坏死使病人产生显著临床症状,提示有强烈干预指征时,此时更多地依赖于有创干预。升阶梯治疗模式的主要内容为:以经皮引流或透壁内镜引流为首要手段,对于引流无法处理的大量固体坏死,可进行经皮微创或经内镜下坏死清除,若微创手段干预无效可进行开放手术清创。关于选择经皮微创阶梯治疗还是经内镜阶梯治疗,目前尚无研究显示两者之间对病死率等主要临床结局产生影响,不同治疗中心可根据各中心的专业特长和医疗资源,合理选择治疗方案。American Gastroenterological Association(AGA)has published the latest clinical practice update in Gastroenterology in August 2019.The purpose of this AGA clinical practice update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition.In recent decades,with the improvement in clinical practice,the management of pancreatic necrosis in patients with acute pancreatitis(AP)has undergone great changes.The well-defined step-up approach has been more advocated rather than the traditional open surgery.The treatment of pancreatic necrosis mainly includes two aspects,conservative methods,which consist of antimicrobial therapy as well as nutrition support,and invasive interventions.Drainage and/or debridement of pancreatic necrosis is best indicated in patients with infected necrosis or patients with sterile pancreatic necrosis and persistent clinical symptoms,which need proactive management.A step-up approach consists of percutaneous drainage or endoscopic transmural drainage,followed by direct endoscopic/percutaneous minimally invasive necrosectomy,and then surgical debridement is reasonable.As for the comparison between percutaneous surgical or endoscopic step-up approach,no studies have shown that there are differences between the two in the main clinical outcomes,for instance,mortality.Hence,the choice of specific treatment strategy in different AP centers depends mainly on their available clinical expertise and medical resources.

关 键 词：胰腺坏死 升阶梯模式 内镜清创 外科微创 

分 类 号：R6[医药卫生—外科学]