Division of Surgical Gastroenterology, Department of General Surgery, Post Graduate Institute of Medical Education Research, Chandigarh 160012, India.
Ann Surg. 2013 Apr;257(4):737-50. doi: 10.1097/SLA.0b013e318269d25d.
Initial management of severe acute pancreatitis (SAP) is conservative. As a step-up approach, percutaneous catheter drainage (PCD) with saline irrigation is reported to be effective. Factors leading to surgery are unclear.
In this ongoing prospective study, 70 consecutive patients with SAP were recruited. As a step-up approach, all patients initially received medical management and later underwent PCD and surgery as per the indication.
Of the 70 consecutive patients with SAP, 14 were managed medically, 29 managed with PCD alone, whereas 27 required surgery after initial PCD. Sepsis reversal was achieved with PCD alone in 62.5%. The curative efficacy of PCD alone was in 27 patients (48%). Overall mortality in the whole group was 24%. On univariate analysis, factors significantly affecting surgical intervention included initial acute physiology and chronic health evaluation (APACHE) II score, APACHE II score at first intervention, sepsis reversal by PCD within a week, number of organs failed, organ failure within a week of the onset of disease, number of bacteria isolated per patient, renal failure, respiratory failure, Escherichia coli, computerized tomography severity index score at admission, parenteral nutrition requirement before or after radiological intervention, maximum extent of necrosis of more than 50% of the pancreas, and extrapancreatic necrosis. On multivariate analysis, renal failure (P = -0.03), APACHE II score at first intervention (P = -0.006), and the number of bacteria isolated per patient (P = -0.01) remained independent predictors of surgery. An APACHE II score of more than 7.5 at first intervention (PCD) had the ability to predict surgery with a sensitivity of 88.9% and a specificity of 69%.
PCD reversed sepsis in 62% and avoided surgery in 48% of the patients. Reversal of sepsis within a week of PCD, APACHE II score at first intervention (PCD), and organ failure within a week of the onset of disease could predict the need for surgery in the early course of disease.
急性重症胰腺炎（SAP）的初始治疗为保守治疗。作为一种递进治疗方法，经皮穿刺导管引流（PCD）联合盐水灌洗已被证实有效。但目前仍不清楚哪些因素会导致需要手术治疗。
本研究为一项正在进行的前瞻性研究，共纳入 70 例 SAP 患者。所有患者均首先接受内科治疗，随后根据指征行 PCD 或手术治疗。
70 例 SAP 患者中，14 例仅接受内科治疗，29 例仅行 PCD 治疗，27 例 PCD 后行手术治疗。62.5%的患者通过单纯 PCD 可逆转脓毒症。单纯 PCD 治疗有效率为 27 例（48%）。全组死亡率为 24%。单因素分析显示，影响手术干预的因素包括初始急性生理学与慢性健康状况评分系统（APACHE）Ⅱ评分、首次干预时的 APACHE Ⅱ评分、1 周内 PCD 逆转脓毒症、器官衰竭数量、疾病发病后 1 周内器官衰竭、每位患者分离的细菌数量、肾衰竭、呼吸衰竭、大肠杆菌、入院时计算机断层扫描严重指数评分、放射介入前后肠外营养需求、胰腺坏死超过 50%的最大范围和胰外坏死。多因素分析显示，肾衰竭（P=-0.03）、首次干预时的 APACHE Ⅱ评分（P=-0.006）和每位患者分离的细菌数量（P=-0.01）是手术的独立预测因素。首次 PCD 时的 APACHE Ⅱ评分超过 7.5 分（PCD）可预测手术，其敏感度为 88.9%，特异度为 69%。
PCD 使 62%的患者的脓毒症得到逆转，并使 48%的患者避免了手术。PCD 后 1 周内脓毒症的逆转、首次 PCD 时的 APACHE Ⅱ评分和疾病发病后 1 周内的器官衰竭可预测疾病早期的手术需求。
