Timing of surgical intervention in necrotizing pancreatitis
Timing of surgical intervention in necrotizing pancreatitis
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DOI：
10.1001/archsurg.142.12.1194
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发表时间：
2007-12-01
影响因子：
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通讯作者：
Gooszen, Hein G.
中科院分区：
文献类型：
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作者：
Besselink, Marc G. H.;Verwer, Thomas J.;Gooszen, Hein G.
目的：探讨手术干预时机对坏死性胰腺炎的影响。设计：对53例患者进行回顾性研究并进行系统评价。环境：三级转诊中心。主要结局指标：死亡率。结果：干预的中位时间为28天。83%的患者有感染性坏死，55%的患者术前有器官衰竭。死亡率为36%。入院14天内手术16例，15 ~ 29天手术11例，30天及以后手术26例。后一组患者术前使用抗生素的时间较长（P < 0.001），假丝酵母菌和耐药菌多来自胰腺或胰腺周围坏死（P = 0.02）。30天组的死亡率也最低（8% vs 1 ~ 14天组的75%，15 ~ 29天组的45%，P < 0.001）；当术前器官衰竭的结果分层时，这种差异仍然存在。在研究的后半段，坏死切除术进一步推迟（43天vs 20天，P = 0.06），死亡率下降（22% vs 47%, P = 0.09）。我们还回顾了11项研究，共1136例患者。手术患者中位数为每年8.3例（范围5.3-15.6），手术干预的中位时间为26天（范围3-31），中位死亡率为25%（范围6%-56%）。我们观察到干预时间与死亡率之间存在显著相关性（R = -0.603； 95%可信区间，-2.10至-0.02;P = 0.05）。结论：将坏死性切除术推迟至首次入院后30天与死亡率降低、抗生素使用时间延长以及念珠菌和耐药菌的发生率增加有关。
Objective: To determine the effect of timing of surgical intervention for necrotizing pancreatitis.Design: Retrospective study of 53 patients and a systematic review.Setting: A tertiary referral center.Main Outcome Measure: Mortality.Results: Median timing of the intervention was 28 days. Eighty-three percent of patients had infected necrosis and 55% had preoperative organ failure. The mortality rate was 36%. Sixteen patients were operated on within 14 days of initial admission, 11 patients from day 15 to 29, and 26 patients on day 30 or later. This latter group received preoperative antibiotics for a longer period (P < .001), and Candida species and antibiotic-resistant organisms were more often cultured from the pancreatic or peripancreatic necrosis in these patients (P = .02). The 30-day group also had the lowest mortality (8% vs 75% in the 1 to 14-days group and 45% in the 15 to 29 days group, P < .001); this difference persisted when outcome was stratified for preoperative organ failure. During the second half of the study, necrosectomy was further postponed (43 vs 20 days, P = .06) and mortality decreased (22% vs 47%, P = .09). We also reviewed 11 studies with a total of 1136 patients. Median surgical patient volume was 8.3 patients per year (range, 5.3-15.6), median timing of surgical intervention was 26 days (range, 3-31), and median mortality was 25% (range, 6%-56%). We observed a significant correlation between timing of intervention and mortality (R = -0.603; 95% confidence interval, -2.10 to -0.02; P = .05).Conclusion: Postponing necrosectomy until 30 days after initial hospital admission is associated with decreased mortality, prolonged use of antibiotics, and increased incidence of Candida species and antibiotic-resistant organisms.