经皮穿刺引流术对急性胰腺炎不同时期的无菌性胰性液体积聚治疗作用的研究

发布时间：2018-07-05 14:38

本文选题：胰性液体积聚 + 经皮穿刺置管引流　；参考：《浙江大学》2016年博士论文

【摘要】：背景：胰性液体积聚(PFCs)在急性胰腺炎(AP)中很常见,由1992年亚特兰大会议(1992-AC)正式定义。2012年亚特兰大改良标准(2012-RAC)将PFCs分为：急性胰周液体积聚(APFCs),胰腺假性囊肿,急性坏死性积聚(ANC)和包裹性坏死(WON)四种类型。APFCs与ANC出现在AP早期阶段,而胰腺假性囊肿与WON则见于AP后期。PFCs对AP的预后产生不利影响。在AP早期,PFCs会加重局部及全身组织的炎症反应,导致腹腔内高压,引起或加重脏器功能衰竭(OF),使AP病情加重。而在AP后期,持续、进展的PFCs可压迫周围器官造成梗阻,以胃流出道梗阻(GOO)最为常见；还可造成假性动脉瘤、出血及门静脉、脾静脉栓塞等并发症。PFCs可无菌存在,亦可合并感染。自Freeny在1998年首次报道采用经皮穿刺置管引流术(PCD)成功治疗感染坏死性胰腺炎(INP)后,此项技术便逐渐推广起来。既往基于1992-AC观点,认为大部分无菌性PFCs能自行吸收,过早PCD干预会增加感染风险,因而不主张对PFCs行早期PCD治疗,但该观点缺乏临床依据。自2012-RAC对AP的类型、严重程度及PFCs定义改良后,以前大部分重症急性胰腺炎(SAP)均可纳入中重度急性胰腺炎(MSAP),从而使得SAP诊断更加准确。根据2012-RAC标准,SAP早期PFCs主要为ANC,而大于5cm的ANC很难自行吸收,因此,理论上我们可以对PFCs行PCD干预治疗。既往对于AP后期由PFCs压迫引起的GOO常行手术治疗,如果先行PCD治疗,其疗效如何,目前亦缺乏相关研究。目的：研究伴有无菌性PFCs的AP行早期PCD治疗的安全性及疗效；评估PCD对于AP后期由PFCs造成的GOO的缓解作用。方法：1、229例1992-AC标准的SAP患者纳入研究。按照2012-RAC严重程度标准及受累OF的数量和时间分为：SAP(a)+MOF, SAP(a)+SOF, SAP(b)+MOF, SAP(b)+ SOF, MSAP伴OF,MSAP不伴OF等六个亚组。162例伴有无菌性PFCs,其中105例2周内行PCD治疗,另外57例行保守治疗。比较各组的手术率、感染率及死亡率。2、自2010年7月-2013年7月,148例AP患者纳入研究。25例伴有胃排空障碍,其中12例由胃瘫引起,1例由胃内真菌丝梗阻造成,12例确诊为GOO。其中8例为胰腺假性囊肿引起,4例由WON引起,均给予PCD治疗。结果：1、大量的PFCs在SAP(a)与SAP(b)+MOF组中的发生率(80%)高于SAP(b)+SOF和MSAP组(60%)。在重症组中,PCD减少了SAP(a)的手术率,减少了SAP(a)+SOF和SAP(b)中的感染率和SAP(a)和SAP(b)+MOF组中的死亡率；相反,增加了MSAP组的手术率和感染率。2、12例GOO通过PCD治疗均得到缓解,PP组平均缓解时间为6天,WON组为37.25天；5例出现了囊腔内感染,通过PCD治疗后均得到有效控制；3例出现胰瘘,其中2例经PCD引流缓解,1例行囊肿空肠造口术治愈。结论：1、在AP中,PFCs的量与胰腺炎的严重程度和累及脏器功能衰竭的强度呈正相关；早期阶段的无菌性PFCs行PCD治疗可以缓解SAP的进展,但对MSAP没有益处。2、AP后期伴有假性囊肿或WON引起的GOO,行多部位,大口径的PCD治疗是一项安全、有效的微创方法。
[Abstract]:Background: pancreatic fluid accumulation (PFCs) is common in acute pancreatitis (AP), as defined by the 1992 Atlanta Conference (1992-AC). The 2012 Atlanta improved criteria (2012-RAC) classify PFCs into acute peripancreatic fluid accumulation (APFCs), pancreatic pseudocysts, and pancreatic pseudocysts. Four types of acute necrotic accumulation (ANC) and encapsulated necrosis (WON). APFCs and ANC appeared in the early stage of AP, while pancreatic pseudocyst and WON were found in the late stage of AP. PFCs had adverse effects on the prognosis of AP. In the early stage of AP, PFCs may aggravate the inflammatory reaction of local and systemic tissues, lead to intraperitoneal hypertension, cause or aggravate organ failure (of), and aggravate the condition of AP. In the later stage of AP, progressive PFCs can compress the surrounding organs to cause obstruction, especially gastric outflow tract obstruction (GOO), and may cause pseudoaneurysm, hemorrhage, portal vein embolism and other complications. PFCs may be sterile. It can also be combined with infection. Since Freeny first reported the successful treatment of infectious necrotizing pancreatitis (INP) with percutaneous catheter drainage (PCD) in 1998, this technique has been gradually popularized. According to 1992-AC view, most aseptic PFCs can be absorbed by themselves, and early PCD intervention will increase the risk of infection. Therefore, it is not recommended to treat PFCs with early PCD therapy, but this view lacks clinical basis. Since the classification, severity and PFCs definition of AP were improved by 2012-RAC, most severe acute pancreatitis (SAP) were included in MSAP, which made the diagnosis of SAP more accurate. According to the 2012-RAC standard, the early stage of 5cm is mainly ANC, but it is difficult to absorb 5cm by itself. Therefore, we can use PCD intervention therapy in theory. In the past, GOO caused by PFCs compression in the later stage of AP is often treated by surgery. If PCD is used first, what is the curative effect, and there is a lack of relevant research at present. Aim: to study the safety and efficacy of early PCD therapy for AP with aseptic PFCs, and to evaluate the effect of PCD on the remission of goo caused by PFCs in the later stage of AP. Methods one hundred and twenty-nine SAP patients with 1992-AC criteria were included in the study. According to the severity criteria of 2012-RAC and the number and time of involved of, the patients were divided into six subgroups: SAP (a) mof, SAP (a) SOF, SAP (b) MOF, SAP (b) SOF, MSAP with OFN MSAP without of 6 subgroups. Among them, 105 cases received PCD treatment within 2 weeks, and 57 cases received conservative treatment. From July 2010 to July 2013, 148 patients with AP were included in the study. There were 25 patients with gastric emptying disorder, 12 patients with gastric mycelium obstruction caused by gastroparesis and 12 patients diagnosed as goo. Among them, 8 cases were caused by pancreatic pseudocyst, 4 cases were caused by WON, all of them were treated with PCD. Results the incidence of massive (a) in SAP (a) and SAP (b) MOF group (80%) was higher than that in SAP (b) SOF and SAP (b) group (60%). In the severe group, PCD reduced the rate of operation, the infection rate in SAP (a) and (b) and the mortality rate in SAP (a) and SAP (b) MOF groups. The rate of operation and the infection rate in MSAP group were increased. 12 cases of goo were treated with PCD. The average remission time of PP group was 6 days and that of WON group was 37.25 days. There were 5 cases with intracystic infection and 3 cases with pancreatic fistula were effectively controlled after PCD treatment. Among them, 2 cases were relieved by PCD drainage and 1 case was cured by cyst jejunostomy. Conclusion: the amount of PFCs in AP is positively correlated with the severity of pancreatitis and the intensity of organ failure, and the early stage of aseptic PFCs treatment with PCD can alleviate the progression of SAP. However, there is no benefit to MSAP. 2Goo caused by pseudocyst or WON in late stage of MSAP. It is a safe and effective minimally invasive method to treat MSAP with multi-site and large-caliber PCD.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R657.51

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