微创治疗急性坏死性胰腺炎：微创经腹膜后坏死组织清除术与内镜经胃坏死组织清除术的比较。

Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy.

机构信息

Department of General and Visceral Surgery, Universitätsklinikum Freiburg, Freiburg, Germany.

出版信息

Surgery. 2012 Sep;152(3 Suppl 1):S128-34. doi: 10.1016/j.surg.2012.05.021. Epub 2012 Jul 6.

DOI:10.1016/j.surg.2012.05.021

PMID:22770962

Abstract

BACKGROUND

A "step-up" approach is currently the treatment of choice for acute necrotizing pancreatitis. Our aim was to evaluate the outcome of minimally invasive retroperitoneal necrosectomy (MINE) and endoscopic transgastric necrosectomy (ETG) and to compare it to open necrosectomy (ONE).

METHODS

Patients with acute pancreatitis admitted to our institution from 1998 to 2010 (n = 334) were identified. From these, patients who underwent either ONE, MINE, or ETG were selected for further analysis. Statistical analysis employed 2-sided Fisher's exact test and Mann-Whitney U-test.

RESULTS

From 2002 to 2010, 32 patients with acute necrotizing pancreatitis were treated by minimally invasive procedures including MINE (n = 14) and ETG (n = 18) or with the classic technique of ONE (n = 30). Time from onset of symptoms to intervention was less for ONE than for MINE or ETG (median, 11 vs 39 vs 54 days; P < .05). The rate of critically ill patients with sepsis or septic shock was greatest in ONE (93%) and MINE (71%) compared with ETG (17%; P < .05). Problems after ONE and MINE were ongoing sepsis (ONE 73% vs MINE 29% vs ETG 11%) and bleeding requiring intervention (ONE 26% vs MINE 21% vs ETG 17%). A specific complication of ETG was gastric perforation into the peritoneal cavity during the procedure (28%), requiring immediate open pseudocystogastrostomy. Laparotomy was necessary in 21% after MINE and 28% after ETG owing to specific complications or persistent infected necrosis. Overall mortality was greatest after ONE (ONE 63% vs MINE 21% vs ETG 6%; P < .05).

CONCLUSION

Morbidity and mortality remains high in acute necrotizing pancreatitis. Operative procedures should be delayed as long as possible to decrease morbidity and mortality. Minimally invasive procedures can avoid laparotomy, but also introduce specific complications requiring immediate or secondary open operative treatment. Minimally invasive procedures require unique expertise and therefore should only be performed at specialized centers.

摘要

背景

目前，对于急性坏死性胰腺炎，“升阶梯”方法是治疗的首选。我们的目的是评估微创腹膜后坏死组织清除术（MINE）和内镜经胃坏死组织清除术（ETG）的结果，并将其与开腹坏死组织清除术（ONE）进行比较。

方法

从 1998 年到 2010 年，我们确定了在我们医院就诊的急性胰腺炎患者（n = 334）。从这些患者中，选择了接受 ONE、MINE 或 ETG 治疗的患者进行进一步分析。统计分析采用双侧 Fisher 确切检验和 Mann-Whitney U 检验。

结果

从 2002 年到 2010 年，32 例急性坏死性胰腺炎患者接受了微创治疗，包括 MINE（n = 14）和 ETG（n = 18）或经典的 ONE 技术（n = 30）。从发病到干预的时间 ONE 比 MINE 或 ETG 短（中位数分别为 11、39 和 54 天；P <.05）。ONE（93%）和 MINE（71%）的脓毒症或感染性休克重症患者比例高于 ETG（17%；P <.05）。ONE 和 MINE 后出现的问题是持续性脓毒症（ONE 73% vs MINE 29% vs ETG 11%）和需要干预的出血（ONE 26% vs MINE 21% vs ETG 17%）。ETG 的一个特定并发症是在手术过程中胃穿孔进入腹腔（28%），需要立即进行开腹假性囊肿胃吻合术。由于特定并发症或持续感染性坏死，MINE 后需要剖腹手术的比例为 21%，ETG 后为 28%。总体死亡率 ONE 最高（ONE 63% vs MINE 21% vs ETG 6%；P <.05）。