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小切口微创入路治疗感染性胰腺坏死的临床研究

Clinical analysis of small incision minimally invasive approach in treatment of infected pancreatic necrosis

摘要:

目的 探讨小切口微创入路胰腺坏死组织清除术治疗感染性胰腺坏死的安全性和效果.方法 回顾性分析2012年1月至2016年12月哈尔滨医科大学附属第一医院胰胆外科收治的164例因感染性胰腺坏死实施小切口微创入路胰腺坏死组织清除术的患者资料,男性102例,女性62例;中位年龄46岁(范围:19~79岁).重症急性胰腺炎101例(61.6%),中重症急性胰腺炎63例(38.4%),遵循step-up approach原则首先行经超声引导下经皮穿刺置管引流术(PCD)治疗后行小切口微创入路胰腺坏死组织清除术治疗者131例(79.9%),未行PCD而直接行小切口微创入路胰腺坏死组织清除术治疗者33例(20.1%).依据术前CT影像确定病灶位置,于PCD穿刺点或脓腔距离体表最近处逐层切开进入脓腔,行小切口微创入路胰腺坏死组织清除术.结果 所有患者从发病至首次手术的中位时间为32 d(范围:23~45 d),住院时间46 d(范围:29~103 d),术中平均放置引流管中位数为4枚(范围:2~8枚).微创腹膜后入路胰腺坏死组织清除术者92例(56.0%),微创小网膜囊胰腺坏死组织清除术者36例(22.0%),微创腹膜后入路联合微创小网膜囊胰腺坏死组织清除术者36例(22.0%).微创手术治愈者148例(90.2%),转为常规开放手术治愈者8例(4.9%),治愈率为95.1%(156/164).术后主要并发症包括术后胰瘘(25例)、腹腔内出血(10例)、胃瘘(2例)、十二指肠瘘(4例)、结肠瘘(3例),并发症发生率为26.8% (44/164).院内死亡8例,病死率为4.9%(8/164).结论 针对感染性胰腺坏死患者,小切口微创入路胰腺坏死组织清除术是清除坏死组织、通畅引流、降低并发症的有效治疗手段.

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abstracts:

Objective To investigate the safety and efficiency of small incision minimally invasive approach pancreatic necrosectomy in the treatment of infected pancreatic necrosis.Methods The data of 164 patients who underwent small incision minimally invasive approach pancreatic necrosectomy for infected pancreatic necrosis at Department of Pancreatic and Biliary Surgery,the First Affiliated Hospital of Harbin Medical University from January 2012 to December 2016 were analyzed retrospectively.Among 164 patients,there were 102 male and 62 female patients.The median age was 46 years(ranging from 19 to 79 years).One hundred and one patients (61.6%) suffered from severe acute pancreatitis and 63 patients (38.4%) suffered from moderately severe acute pancreatitis.Following step-up approach principle,the surgical procedures were performed for 131 patients(79.9%) who suffered from sepsis which could not be alleviated via percutaneous catheter drainage (PCD).The other 33 patients (20.1%) who did not undergo PCD directly took small incision minimally invasive approach pancreatic necrosectomy.Preoperative CT images were used to determine the location of the lesion.The PCD puncture points or the points where the abscess was closest to the skin were chosen as the incision.Gradually,the small incision minimally invasive approach pancreatic necrosectomy were performed via cutting all layers into the abscess.Results The median time from the onset of symptom to first operation was 32 days(ranging from 23 to 45 days).The average hospital stay was 46 days(ranging from 29 to 103 days).The average number of drainage tubes placed was 4 pieces(ranging from 2 to 8 pieces).Ninety-two patients (56.0%) underwent minimal access retroperitoneal pancreatic necrosectomy.Thirty-six patients (22.0%) underwent minimal invasive approach lesser omentum sac pancreatic necrosectomy.Thirty-six patients(22.0%) underwent minimal invasive approach lesser omentum sac pancreatic necrosectomy combined with minimal access retroperitoneal pancreatic necrosectomy.A total of 148 cases(90.2%) were cured via minimally invasive approach pancreatic necrosectomy,8 cases (4.9%) were cured after transfering to open pancreatic necrosectomy.The cure rate was 95.1% (156/164).The mainly postoperative complications included pancreatic fistula (25 cases),intra-abdominal hemorrhage (10 cases),gastric fistula (2 cases),duodenal fistula (4 cases) and colonic fistula (3 cases).The overall incidence rate of complications was 26.8% (44/164).Eight cases were dead after surgery and the in-hospital mortality was 4.9% (8/164).Conclusion In summary,small incision minimally invasive approach pancreatic necrosectomy is an effective way to clean up necrotic tissue,improve the drainage,reduce complications in dealing with infected pancreatic necrosis.

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作者: 吕新建 [1] 孙备 [1] 李乐 [1] 陈华 [1] 孔瑞 [1]
第一作者: 吕新建
期刊: 《中华外科杂志》2018年56卷9期 687-692页 MEDLINEISTICPKUCSCD
栏目名称: 论著
DOI: 10.3760/cma.j.issn.0529-5815.2018.09.009
发布时间: 2018-09-25
基金项目:
国家自然科学基金资助项目(81670583)National Natural Science Foundation of China
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