Sakorafas George H, Lappas Christos, Mastoraki Aikaterini, Delis Spiros G, Safioleas Michael
4th Department of Surgery, Athens University, Medical School, Attikon University Hospital, Greece.
Infect Disord Drug Targets. 2010 Feb;10(1):9-14. doi: 10.2174/187152610790410936.
Severe acute pancreatitis is a potentially life-threatening disease. Pancreatic necrosis is associated with an aggravated prognosis, while superimposed infection is almost always lethal without surgery. Bacterial translocation mainly from the gut is the most widely accepted mechanism in the pathogenesis of infected pancreatic necrosis. Infected pancreatic necrosis should be suspected in the presence of the usual markers of systemic inflammation (i.e., fever and leukocytosis), organ failure, or a protracted severe clinical course. The diagnostic method of choice to confirm the diagnosis of pancreatic necrosis is contrast-enhanced computed tomography, where necrotic areas are evidenced as regions without enhancement. The presence of pancreatic necrotic infection should be based on a combination of clinical manifestations, results of laboratory investigation (mainly increased levels of CRP and / or procalcitonin), and can be confirmed by image-guided fine-needle aspiration and gram stain /culture of the aspirates. Surgery remains the treatment of choice for the management of infected pancreatic necrosis and involves open necrosectomy (debridement) and wide drainage of the peripancreatic areas, often in association with continuous irrigation. Planned reoperations may be required to achieve complete removal of the necrotic / infected material. The timing of surgery is of paramount importance; ideally, surgery should be performed after 2 or 3 weeks from the onset of pancreatitis. Recently, various minimally invasive approaches have been described, but they have not been compared in prospective trials with the classical open surgery. Antibiotic therapy is routinely used in patients with infected necrotizing pancreatitis, in conjunction with surgical debridement; its role, however, in the management of patients with sterile necrosis is recently questioned. Nutritional support should be taken into consideration in these patients; enteral nutrition should be preferred over total parenteral nutrition to improve the anatomical and functional integrity of the gut mucosa, thereby preventing bacterial translocation.
重症急性胰腺炎是一种可能危及生命的疾病。胰腺坏死与预后恶化相关，而叠加感染若不进行手术几乎总是致命的。细菌移位主要源于肠道，这是感染性胰腺坏死发病机制中最被广泛认可的机制。当出现全身炎症的常见指标（即发热和白细胞增多）、器官功能衰竭或病程迁延严重时，应怀疑存在感染性胰腺坏死。用于确诊胰腺坏死的首选诊断方法是增强计算机断层扫描，坏死区域表现为无强化的区域。胰腺坏死感染的诊断应基于临床表现、实验室检查结果（主要是CRP和/或降钙素原水平升高），并可通过影像引导下细针穿刺抽吸及抽吸物革兰氏染色/培养来确诊。手术仍然是治疗感染性胰腺坏死的首选方法，包括开放坏死组织清除术（清创）和胰腺周围区域的广泛引流，通常还伴有持续冲洗。可能需要计划性再次手术以彻底清除坏死/感染物质。手术时机至关重要；理想情况下，手术应在胰腺炎发病2或3周后进行。最近，已经描述了各种微创方法，但它们尚未在前瞻性试验中与经典开放手术进行比较。抗生素治疗常规用于感染性坏死性胰腺炎患者，与手术清创联合使用；然而，其在无菌性坏死患者管理中的作用最近受到质疑。这些患者应考虑营养支持；肠内营养应优于全胃肠外营养，以改善肠黏膜的解剖和功能完整性，从而预防细菌移位。
