Ranson J H, Berman R S
Department of Surgery, New York University School of Medicine, NY 10016.
Ann Surg. 1990 Jun;211(6):708-16; discussion 716-8. doi: 10.1097/00000658-199006000-00009.
Late infection of devitalized pancreatic and peripancreatic tissue has become the major cause of morbidity in severe acute pancreatitis. Previous experience found that peritoneal lavage for periods of 48 to 96 hours may reduce early systemic complications but did not decrease late pancreatic sepsis. A fortunate observation led to the present study of the influence of a longer period of lavage on late sepsis. Twenty-nine patients receiving primary nonoperative treatment for severe acute pancreatitis (three or more positive prognostic signs) were randomly assigned to short peritoneal lavage (SPL) for 2 days (15 patients) or to long peritoneal lavage (LPL) for 7 days (14 patients). Positive prognostic signs averaged 5 in both groups but the frequency of five or more signs was higher in LPL (71%) than in SPL (47%). Eleven patients in each group had early computed tomographic (CT) scans. Peripancreatic fluid collections were shown more commonly in LPL (82%) than in SPL (54%) patients. Longer lavage dramatically reduced the frequency of both pancreatic sepsis (22% LPL versus 40% SPL) and death from sepsis (0% LPL versus 20% SPL). Among patients with fluid collections on early CT scan, LPL led to a more marked reduction in both pancreatic sepsis (33% LPL versus 83% SPL) and death from sepsis (0% LPL versus 33% SPL). The differences were even more striking among 17 patients with five or more positive prognostic signs. In this group the incidence of pancreatic sepsis was 30% LPL versus 57% SPL and of death from sepsis 0% (LPL) versus 43% (SPL) (p = 0.05). In these patients, overall mortality was also reduced (20% LPL versus 43% SPL). When 20 patients treated by LPL were compared with 91 other patients with three or more positive prognostic signs who were treated without lavage or by lavage for periods of 2 to 4 days, the frequency of death from pancreatic sepsis was reduced from 13% to 5%. In those with five or more signs, the incidence of sepsis was reduced from 40% to 27% (p = 0.03) and of death for sepsis from 30% to 7% (p = 0.08). These findings indicate that lavage of the peritoneal cavity for 7 days may significantly reduce both the frequency and mortality rate of pancreatic sepsis in severe acute pancreatitis.
失活胰腺及胰周组织的晚期感染已成为重症急性胰腺炎发病的主要原因。既往经验发现，持续48至96小时的腹腔灌洗可减少早期全身并发症，但并未降低晚期胰腺感染。一次幸运的观察促使开展本研究，以探讨更长时间灌洗对晚期感染的影响。29例接受重症急性胰腺炎（三个或更多阳性预后指标）初次非手术治疗的患者被随机分为两组，15例患者接受为期2天的短程腹腔灌洗（SPL），14例患者接受为期7天的长程腹腔灌洗（LPL）。两组患者的阳性预后指标平均均为5个，但LPL组（71%）五个或更多指标的出现频率高于SPL组（47%）。每组11例患者进行了早期计算机断层扫描（CT）。LPL组患者（82%）胰周积液的显示比SPL组患者（54%）更常见。更长时间的灌洗显著降低了胰腺感染的频率（LPL组为22%，SPL组为40%）和感染性死亡的频率（LPL组为0%，SPL组为20%）。在早期CT扫描发现有积液的患者中，LPL组在胰腺感染（LPL组为33%，SPL组为83%）和感染性死亡（LPL组为0%，SPL组为33%）方面的降低更为显著。在17例有五个或更多阳性预后指标的患者中，差异更为明显。在该组中，胰腺感染的发生率LPL组为30%，SPL组为57%；感染性死亡的发生率LPL组为0%，SPL组为43%（p = 0.05）。在这些患者中，总体死亡率也有所降低（LPL组为20%，SPL组为43%）。将20例接受LPL治疗的患者与91例其他有三个或更多阳性预后指标、未接受灌洗或接受2至4天灌洗治疗的患者进行比较时，胰腺感染性死亡的频率从13%降至5%。在有五个或更多指标的患者中，感染的发生率从40%降至27%（p = 0.03），感染性死亡的发生率从30%降至7%（p = 0.08）。这些发现表明，为期7天的腹腔灌洗可能显著降低重症急性胰腺炎胰腺感染的频率和死亡率。
