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《中华消化外科杂志》2019年10月第18卷第10期论著

腹膜后入路胰腺坏死组织清除术治疗感染坏死性胰腺炎的临床疗效

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引用本文:
周伟,崔静,勾善淼,等.腹膜后入路胰腺坏死组织清除术治疗感染坏死性胰腺炎的临床疗效[J].中华消化外科杂志,2019,18(10):946-950.DOI:10.3760/cma.j.issn.1673-9752.2019.10.010.
【摘要】

目的:探讨腹膜后入路胰腺坏死组织清除术(MARPN)治疗感染坏死性胰腺炎(IPN)的临床疗效。
方法:采用回顾性队列研究方法。收集2014年1月至2017年12月华中科技大学同济医学院附属协和医院收治的61例IPN患者的临床资料,男39例,女22例;中位年龄为49岁,年龄范围为36~67岁。61例患者中,40例采用开腹手术治疗,设为开放组;21例采用MARPN治疗,设为MARPN组。两组患者均按照《重症急性胰腺炎诊治指南(2014)》进行规范化的非手术治疗后行手术治疗。观察指标:(1)术中和术后情况。(2)随访情况。采用电话或门诊方式进行随访,了解患者体质量下降、血糖异常及脂肪泻、肠梗阻、胰源性门静脉高压症情况,随访时间终点设置为术后1年,随访时间截至2017年12月。 正态分布的计量资料以Mean±SD表示,组间比较采用t检验。计数资料以绝对数或百分比表示,组间比较采用χ2检验。
结果:(1)术中和术后情况:开放组患者手术时间、首次下床活动时间、首次进食时间、再次手术例数、术后发生多器官功能障碍综合征例数、术后并发症发生率、病死率、引流管拔除时间、住院时间、治疗费用分别为(77±20)min、(13.0±3.6)d、(9.0±2.7)d、8例、9例、45.0%(18/40)、7.5%(3/40)、(37.0±6.3)d、(49±8)d、(84 321±8 872)元;MARPN组上述指标分别为(59±20)min、(2.7±0.9)d、(1.9±0.4)d、6例、2例、19.0%(4/21)、0、(21.0±2.7)d、(39±6)d、(58 594±3 576)元;两组患者再次手术例数比较,差异无统计学意义(χ2=0.69,P>0.05);两组患者其余指标比较,差异均有统计学意义(t=4.24,9.61,15.34, χ2=23.76,4.02,36.03,t=11.07,5.93,8.43,P<0.05)。开放组患者中18例术后发生并发症,其中消化道出血、腹腔出血、胰液漏、肠瘘分别为2、3、9、4例;MARPN组患者中4例术后发生并发症,上述并发症发生情况分别为0、0、3、1例。两组发生并发症患者,针对病因分别采用内镜、介入、放置空肠营养管、回肠造瘘等方法治疗。开放组患者死亡3例,MARPN组患者均痊愈。(2)随访情况:61例患者中,47例获得术后1年随访(开放组31例、MARPN组16例)。随访期间开放组患者中体质量下降4例、血糖异常11例、脂肪泻5例、不全性肠梗阻4例、胰源性门静脉高压症5例;MARPN组患者中上述并发症发生情况分别为2、6、2、0、3例。两组患者上述指标比较,差异均无统计学意义(χ2=0.18,0.02,0.01,0.03,0.90,P>0.05)。
结论:MARPN是一种安全可靠的治疗IPN方法,能够有效降低患者术后并发症发生率、病死率和缩短住院时间。

【Abstract】

Objective:To investigate the clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy (MARPN) for infected pancreatic necrosis (IPN).
Methods:The retrospective cohort study was conducted. The clinical data of 61 patients with IPN who were admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 2014 and December 2017 were collected. There were 39 males and 22 females, aged 36-67 years, with a median age of 49 years. Of 61 patients, 40 undergoing open surgery were allocated into open group, and 21 undergoing MARPN were allocated into MARPN group. All the patients underwent surgical treatments after standard non-surgical treatments according to the Guidelines for the diagnosis and treatment of severe acute pancreatitis (2014 edition). Observation indicators: (1) intraoperative and postoperative situations; (2) follow-up. Follow-up using telephone interview or outpatient examination was performed to detect weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension for one year after surgery up to December 2017. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was done using the chi-square test. |
Results:(1) Intraoperative and postoperative situations: operation time, time to out-of-bed activity, time to initial food intake, cases with reoperation, cases with postoperative multiple organ dysfunction syndrome (MODS), incidence rate of postoperative complications, mortality, time to drainage-tube removal, duration of hospital stay, and hospital expenses were (77±20)minutes, (13.0±3.6)days, (9.0±2.7)days, 8, 9, 45.0%(18/40), 7.5%(3/40), (37.0±6.3)days, (49±8)days, (84 321±8 872)yuan in the open group, and (59±20)minutes, (2.7±0.9)days, (1.9±0.4)days, 6, 2, 19.0%(4/21), 0, (21.0±2.7)days, (39±6)days, (58 594±3 576)yuan in the MARPN group, respectively, showing no significant difference in the cases with reoperation (χ2=0.69, P>0.05) but significant differences in the other indices between the two groups (t=4.24, 9.61, 15.34, χ2=23.76, 4.02, 36.03, t=11.07, 5.93, 8.43, P<0.05). There were 18 patients with postoperative complications in the open group, including 2 with digestive hemorrhage, 3 with abdominal hemorrhage, 9 with pancreatic leakage, and 4 with intestinal leakage. There were 4 patients with postoperative complications in the MARPN group, including 3 with pancreatic leakage, and 1 with intestinal leakage. Patients with complications were treated by endoscopy, interventional therapy, placement of jejunal nutrition tube, and ileum stoma. Three patients in the open group died, and all the patients in the MARPN group were cured. (2) Follow-up: 47 of 61 patients were followed up for one year, including 31 in the open group and 16 in the MARPN group. During the follow-up, weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension were detected in 4, 11, 5, 4, 5 patients of the open group and in 2, 6, 2, 0, 3 patients of the MARPN group, showing no statistically significant difference between the two groups (χ2=0.18, 0.02, 0.01, 0.03, 0.90, P>0.05).
Conclusion:MARPN for IPN is safe and reliable, with certain efficacy, which can effectively reduce incidence of postoperative complication, motality and shorten hospital stay.

DOI:10.3760/cma.j.issn.1673-9752.2019.10.010
基金项目:国家自然科学基金(81302115),武汉协和医院院内基金(000004827)
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