摘要目的 探讨创伤递升式分阶段处理重症急性胰腺炎(SAP)的可行性及临床应用价值.方法 回顾性分析2002年1月至2006年12月直接开腹胰腺坏死组织清除及2007年1月至2011年12月分阶段处理的SAP患者临床资料.其中,直接开腹组58例,男性37例,女性21例,年龄20～72岁,平均47.6岁；分阶段组63例,男性42例,女性21例,年龄19 ～78岁,平均46.2岁.分阶段处理首先行B超引导下经皮穿刺置管引流术,根据病情进展进一步选择沿穿刺管小切口胰腺坏死组织清除.比较两组术后并发症发生率、病死率、医疗费用、住院时间等.结果 分阶段组术后总体并发症发生率、器官功能不全、消化道漏及切口疝发生率明显低于直接开腹组(31.7％比62.1％,14.3％比37.5％,6.3％比19.0％,9.5％比29.3％；x2=4.43 ～ 11.17,P=0.001 ～0.035).其他并发症两组差异无统计学意义(P＞0.05).分阶段组输血率更低(44.4％比70.7％,x2=8.488,P=0.004),输血费用及住院费用减少[(2525±4573)元比(4770±6867)元,t=2.131,P=0.035;(171 213±50917)元比(237 874±67 832)元,t=2.496,P=0.014].两组患者住院时间及病死率差异无统计学意义(P＞0.05).结论 创伤递升式分阶段处理SAP能降低并发症发生率、减少输血及降低住院费用,具有临床可行性及应用价值.

abstractsObjective To investigate the feasibility and clinical value of the step-up approach for severe acute pancreatitis (SAP).Methods Clinical data of 121 SAP patients admitted between January 2002 and December 2011 were retrospectively analyzed.Fifty-eight patients (37 males and 21 females,aged from 20 to 72 years,mean 47.6 years) in the group of direct open necrosectomy from January 2002 to December 2006 were performed laparotomy through removal of all necrotic tissue.Sixty-three patients (42 males and 21 females,aged from 19 to 78 years,mean 46.2 years) of step-up approach from January 2007 to December 2011 underwent percutaneous catheter drainage through retroperitoneum or omental bursa guided by B-type ultrasonography for the first therapy,and then,according to the pathogenetic condition,if necessary,followed by a small incisional necrosectomy along the drainage tube.The two groups were compared for the rates of postoperative complications,death,transfusion and length of stay,medical costs.Results The rates of total postoperative complications,organ dysfunction,alimentary tract fistula and incisional hernia in step-up approach group were significantly lower than those of direct open necrosectomy group (31.7％ vs.62.1％,14.3％ vs.37.5％,6.3％ vs.19.0％,9.5％ vs.29.3％; x2=4.43 to 11.17,P =0.001 to 0.035).The other complications had no significant differences between the two groups (P ＞ 0.05).Patients in step-up approach group had a lower rates of transfusion (44.4％ vs.70.7％,x2 =8.488,P =0.004),fewer medical costs of transfusion and hospital stay,compared with those in direct open necrosectomy group ((2525 ± 4573) yuan vs.(4770 ± 6867) yuan,t =2.131,P =0.035 ; (171 213 ±50 917) yuan vs.(237 874 ±67 832) yuan,t =2.496,P =0.014).There were no significant differences of length of stay and mortality between two groups (P ＞ 0.05).Conclusion Step-up approach for SAP which can reduce the rates of postoperative complications,transfusion and medical costs has significant feasibility and great clinical value.