坏死性胰腺炎并发胃肠道瘘的诊断与治疗  

Diagnosis and treatment of necrotizing pancreatitis complicated with gastrointestinal fistula

作　　者：王革非 任建安 WANG Ge-fei;REN Jian-an(Department of General Surgery,Affiliated Jinling Hospital,Medical School of Nanjing University,Nanjing,210002,China)

机构地区：[1]南京大学医学院附属金陵医院(中国人民解放军东部战区总医院)、解放军普通外科研究所,江苏南京210002

出　　处：《中国实用外科杂志》2024年第5期544-547,共4页Chinese Journal of Practical Surgery

基　　金：国家自然科学基金面上项目(No.81870396,No.82170581);江苏省自然科学基金面上项目(No.BK20211133);东部战区总医院院管课题项目(No.2023JSYXMS152)。

摘　　要：胃肠道瘘是坏死性胰腺炎常见的严重并发症,病死率高。内脏静脉血栓形成、胰液和坏死组织对邻近肠壁的直接腐蚀、侵入性操作及手术均是胃肠道瘘发生的原因。多器官功能衰竭、感染坏死严重程度和手术干预率是并发胃肠道瘘的危险因素,早期肠内营养是保护因素。当坏死性胰腺炎病人出现脓毒症加重、消化道出血或器官功能恶化时,应怀疑并发胃肠道瘘,CT是诊断坏死性胰腺炎并发胃肠道瘘的重要手段,消化道增强CT可以提高诊断准确率,消化道造影、窦道造影或胃肠镜等检查可进一步确诊。坏死性胰腺炎并发胃肠道瘘的感染特点是胰周坏死组织感染与胃肠道瘘导致的感染并存,实施感染源控制时应兼顾两者,根据病情选择“step-up”或“step-jump”策略。上消化道瘘多数可通过非手术治疗而自行愈合,而结肠瘘往往需要造口手术转流消化液来控制感染,后期再行确定性手术治疗。Gastrointestinal fistula is a common and serious complication of necrotizing pancreatitis,with high mortality.The formation of visceral venous thrombosis,direct corrosion of adjacent intestinal walls by pancreatic juice and necrotic tissue,and invasive procedures or surgeries are the causes of gastrointestinal fistulas.Multiple organ failure,severity of infection and necrosis,and surgical intervention rate are risk factors for concurrent gastrointestinal fistula,and early enteral nutrition is a protective factor.When sepsis worsens,gastrointestinal bleeding or organ function deteriorates in patients with necrotizing pancreatitis,it is necessary to suspect the occurrence of gastrointestinal fistula.CT is an important means of diagnosing NP complicated with gastrointestinal fistula,and intestinal contrast enhancement CT can improve diagnostic accuracy.Further diagnosis still depends on examinations such as gastrointestinal imaging,sinography,or endoscopy.The infection characteristics of necrotizing pancreatitis complicated with gastrointestinal fistula are the coexistence of peripancreatic necrotic tissue infection and intra-abdominal infection caused by gastrointestinal fistula.When implementing source control of infection,both should be taken into account,and the“step-up”or“step-jump”strategy can be selected according to the condition.Most upper gastrointestinal fistulas can self-heal through conservative therapy,while colon fistulas often require enterostomy to divert digestive fluid to control infection,followed by definitive surgical treatment in the later stage.

关 键 词：胰腺炎 胃肠道瘘 外科手术 微创性 创伤递增式治疗 

分 类 号：R6[医药卫生—外科学]