Predictors of Surgery in Patients With Severe Acute Pancreatitis Managed by the Step-Up Approach
Predictors of Surgery in Patients With Severe Acute Pancreatitis Managed by the Step-Up Approach
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DOI：
10.1097/sla.0b013e318269d25d
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发表时间：
2013-04-01
影响因子：
9
通讯作者：
Singh, Rajinder
中科院分区：
文献类型：
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作者：
Babu, Raghavendra Yalakanti;Gupta, Rajesh;Singh, Rajinder
背景：重症急性胰腺炎(SAP)的初始治疗是保守的。作为一种循序渐进的方法，经皮导管引流(PCD)加生理盐水冲洗据报道是有效的。导致手术的因素尚不清楚。方法：在这项正在进行的前瞻性研究中，纳入了70名连续的SAP患者。结果：在连续70例SAP患者中，14例内科治疗，29例单纯PCD治疗，27例在首次PCD后需要手术治疗。仅用PCD逆转败血症的比例为62.5%。单纯PCD治疗有效27例(48%)。整个组的总死亡率为24%。单因素分析显示，影响手术干预的因素有急性生理学与慢性健康评估(APACHE)II评分、首次介入时APACHE II评分、1周内PCD逆转败血症、器官衰竭个数、发病1周内器官衰竭、每例患者分离出的细菌数、肾功能衰竭、呼吸衰竭、大肠杆菌、入院时CT严重程度指数评分、放射干预前后肠外营养需求、胰腺最大坏死率超过50%及胰腺外坏死。在多因素分析中，肾功能衰竭(P=-0.006.0 3)、首次干预时APACHE II评分(P=-0.0 1)和每例患者分离的细菌数(P=-0.0 1)仍是手术治疗的独立预测因素。首次介入(PCD)时APACHE II评分>7.5预测手术的敏感性为88.9%，特异性为69%。结论：PCD逆转脓毒症的发生率为62%，避免手术的发生率为48%。PCD后一周内脓毒症逆转，首次干预时APACHE II评分(PCD)，以及发病后一周内器官衰竭可预测疾病早期是否需要手术治疗。
Background: Initial management of severe acute pancreatitis (SAP) is conservative. As a step-up approach, percutaneous catheter drainage (PCD) with saline irrigation is reported to be effective. Factors leading to surgery are unclear.Methods: In this ongoing prospective study, 70 consecutive patients with SAP were recruited. As a step-up approach, all patients initially received medical management and later underwent PCD and surgery as per the indication.Results: Of the 70 consecutive patients with SAP, 14 were managed medically, 29 managed with PCD alone, whereas 27 required surgery after initial PCD. Sepsis reversal was achieved with PCD alone in 62.5%. The curative efficacy of PCD alone was in 27 patients (48%). Overall mortality in the whole group was 24%. On univariate analysis, factors significantly affecting surgical intervention included initial acute physiology and chronic health evaluation (APACHE) II score, APACHE II score at first intervention, sepsis reversal by PCD within a week, number of organs failed, organ failure within a week of the onset of disease, number of bacteria isolated per patient, renal failure, respiratory failure, Escherichia coli, computerized tomography severity index score at admission, parenteral nutrition requirement before or after radiological intervention, maximum extent of necrosis of more than 50% of the pancreas, and extrapancreatic necrosis. On multivariate analysis, renal failure (P = -0.03), APACHE II score at first intervention (P = -0.006), and the number of bacteria isolated per patient (P = -0.01) remained independent predictors of surgery. An APACHE II score of more than 7.5 at first intervention (PCD) had the ability to predict surgery with a sensitivity of 88.9% and a specificity of 69%.Conclusions: PCD reversed sepsis in 62% and avoided surgery in 48% of the patients. Reversal of sepsis within a week of PCD, APACHE II score at first intervention (PCD), and organ failure within a week of the onset of disease could predict the need for surgery in the early course of disease.