Therapeutic intervention and surgery of acute pancreatitis
Therapeutic intervention and surgery of acute pancreatitis
复制标题
DOI：
10.1007/s00534-009-0211-6
复制
发表时间：
2010-01-01
影响因子：
3
通讯作者：
Arata, Shinju
中科院分区：
文献类型：
--
作者：
Amano, Hodaka;Takada, Tadahiro;Arata, Shinju
急性胰腺炎的临床病程有轻有重。对急性胰腺炎的严重程度和病因的评估对于确定急性胰腺炎的治疗策略是重要的。急性胰腺炎按其形态分为水肿性胰腺炎和坏死性胰腺炎。水肿性胰腺炎占急性胰腺炎的80%-90%，大多数患者无需接受任何特殊治疗即可缓解。坏死性胰腺炎占急性胰腺炎的10-20%，死亡率为14-25%。合并胰腺坏死组织细菌感染的感染性胰腺坏死的死亡率尤其高(Widdison和Karanjia在BR J Surg 80：148-154,1993；Ogawa等人)。在研究急性胰腺炎的实际情况。由厚生劳动省主办的特定可伸缩疾病研究小组、特定疾病测量研究工作。《平成12研究报告》，2001年第17-33页)。另一方面，无菌胰腺坏死的死亡率据报道为0-11%，且不伴有细菌感染(Ogawa等人)。2001年；Bradely和Allen in Am J Surg 161：19-24,1991；Rattner等人。载于《外科杂志》163：105-109,1992)。日本(JPN)指南旨在为具有不同临床特征的患者的急性胰腺炎的治疗提供建议。本文介绍了急性胰腺炎的外科治疗和介入治疗指南，将急性胰腺炎治疗的最新证据纳入2010年日语版的JPN指南。提出11个临床问题(CQ)：(1)临床表现和血液学资料恶化，血细菌培养试验阳性，血内毒素试验阳性，CT扫描胰腺内及周围有气泡是感染性胰腺坏死的间接征象；(2)细针吸取细菌学检查有助于明确感染性胰腺坏死的诊断；(3)无菌胰腺坏死应保守治疗；(4)感染性胰腺坏死是介入治疗的指征。但一般情况稳定的患者也可给予抗生素保守治疗；(5)坏死性胰腺炎不宜早期手术，应尽可能延长手术时间；(6)感染坏死者建议行胰腺切除术；(7)术后需长期随访，注意胰腺功能及并发症，包括胆管、胰管狭窄；(8)胰腺脓肿需行经皮、内窥镜、外科手术等引流；(9)经皮引流或内窥镜引流不能改善胰腺脓肿的临床表现，应行外科引流；(10)对出现症状、伴发并发症或囊肿直径增大的假性胰腺囊肿，应进行介入治疗；(11)应根据具体情况选择经皮引流、内窥镜引流或手术治疗。
The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163: 105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.