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介入超声穿刺引流联合胆道镜清创:胰周坏死感染的微创化解决方案

Ultrasound-guided percutaneous tube drainage combined with directly-viewed debridement with choledochoscopy: a mini-invasive strategy for peripancreatic necrotizing infection

摘要:

目的 以微创技术手段建立胰周坏死感染引流和清创的一体化治疗模式,并探讨其临床应用价值.方法 2006年3月至2008年1月,共对17例患者施行介入超声穿刺引流联合胆道镜清创.其中男性13例,女性4例.采用超声引导对胰周坏死感染经皮穿刺引流;以Cook筋膜扩张器(8~30 F)对穿刺窦道由细到粗逐级扩张,并将穿刺引流管(6~8 F)更换为较大口径引流管(22~24F),改善引流效果;胆道镜经扩张成型窦道进入病灶内部,直视下完成坏死组织的清创;通过持续有效引流和反复清创促进愈合.结果 本组17例患者,15例采用此方法治愈,治愈率88.2%,2例因技术原因中转开腹手术;15例患者平均治愈时间73 d,平均住院时间57 d;并发窦道和腹腔出血各1例,消化道瘘2例,均经非手术治愈;所有患者随访至今健在,无胰周感染坏死残留或复发.结论 介入超声穿刺引流联合胆道镜清创在达到胰周坏死感染目标化治疗的同时,实现了"损伤控制"的现代外科理念.

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abstracts:

Objective To establish "an integrative therapy" of drainage and debridement on peripancreatic necrotizing infection (PPNI) with minimally invasive technique, and to detect its clinical effects. Methods There were 17 patients who accepted ultrasound-guided percutaneous tube drainage combined with directly-viewed debridement with choledechoscapy from March 2006 to January 2008. Percutaneous puncture and catheter(6-8 F)drainage were adopted on the patients suffering from PPNI with B-us guidance,then the drainage sinus was expanded progressively from 8 F to 24 F in diameter with Cook fascia dilator by degrees, and the 22 F or 24 F tube was easily placed into the interior of PPNI instead of the prior catheter. So a better drainage effect was achieved. One week later, the necrotizing tissue of PPNI could be observed and debrided with choledochoscope under a directly-viewed way through the enlarged new sinus. Thus, with the continuous tube drainage and repeated debridement, the focus was absorbed and covered gradually. Results Seventeen cases accepted the mini-invasive therapy, 15 cases were saved finally with cure rate of 88.2%, and 2 cases conversion to laparotomy because of some technical reasons. The mean healing time was 73 days, and the mean hospitalization time was 57 days. Bleeding was occurred in 2 cases localized in sinus and the inside of PPNI, digestive tract fistula was detected in 2 cases, and these patients with the complications were cured under nonoperative management. All the patients were still alive with following-up,neither remains nor recurrence of the PPNI was found in our group. Conclusions Ultrasound-guided percutaneous tube drainage combined with directly-viewed debridement with choledochoscape, as a mini-invasive therapy, could complete the goal-directed therapy of PPNI, meanwhile, realize the modern surgery ideal of damage control

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