Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
Intensive Care Unit (ICU), Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, People's Republic of China.
Surg Endosc. 2017 Nov;31(11):4603-4616. doi: 10.1007/s00464-017-5522-0. Epub 2017 Apr 14.
Step-up approach consisting of multiple minimally invasive techniques has gradually become the mainstream for managing infected pancreatic necrosis (IPN). In the present study, we aimed to compare the safety and efficacy of a novel four-step approach and the conventional approach in managing IPN.
According to the treatment strategy, consecutive patients fulfilling the inclusion criteria were put into two time intervals to conduct a before-and-after comparison: the conventional group (2010-2011) and the novel four-step group (2012-2013). The conventional group was essentially open necrosectomy for any patient who failed percutaneous drainage of infected necrosis. And the novel drainage approach consisted of four different steps including percutaneous drainage, negative pressure irrigation, endoscopic necrosectomy and open necrosectomy in sequence. The primary endpoint was major complications (new-onset organ failure, sepsis or local complications, etc.). Secondary endpoints included mortality during hospitalization, need of emergency surgery, duration of organ failure and sepsis, etc.
Of the 229 recruited patients, 92 were treated with the conventional approach and the remaining 137 were managed with the novel four-step approach. New-onset major complications occurred in 72 patients (78.3%) in the two-step group and 75 patients (54.7%) in the four-step group (p < 0.001). For other important endpoints, although there was no statistical difference in mortality between the two groups (p = 0.403), significantly fewer patients in the four-step group required emergency surgery when compared with the conventional group [14.6% (20/137) vs. 45.6% (42/92), p < 0.001]. In addition, stratified analysis revealed that the four-step approach group presented significantly lower incidence of new-onset organ failure and other major complications in patients with the most severe type of AP.
Comparing with the conventional approach, the novel four-step approach significantly reduced the rate of new-onset major complications and requirement of emergency operations in treating IPN, especially in those with the most severe type of acute pancreatitis.
阶梯式治疗方案，即多种微创技术的联合应用，已逐渐成为治疗感染性胰腺坏死（IPN）的主流方法。本研究旨在比较新型四步方案与传统方案治疗 IPN 的安全性和疗效。
根据治疗策略，将符合纳入标准的连续患者分为两个时间间隔进行前后比较：传统组（2010-2011 年）和新型四步组（2012-2013 年）。传统组对任何经皮引流感染性坏死失败的患者均行开放性坏死切除术。新型引流方案包括经皮引流、负压灌洗、内镜坏死切除术和开放性坏死切除术四个不同步骤。主要终点是主要并发症（新发器官衰竭、脓毒症或局部并发症等）。次要终点包括住院期间死亡率、急诊手术需求、器官衰竭和脓毒症持续时间等。
共纳入 229 例患者，92 例采用传统方法治疗，其余 137 例采用新型四步方法治疗。两步组有 72 例（78.3%）患者发生新发主要并发症，四步组有 75 例（54.7%）患者发生新发主要并发症（p<0.001）。对于其他重要终点，虽然两组死亡率无统计学差异（p=0.403），但四步组需要急诊手术的患者明显少于传统组[14.6%（20/137）比 45.6%（42/92），p<0.001]。此外，分层分析显示，四步组新发器官衰竭和其他主要并发症的发生率在急性胰腺炎最严重类型的患者中明显较低。
与传统方法相比，新型四步方案可显著降低 IPN 治疗中新发主要并发症和急诊手术的发生率，尤其是在急性胰腺炎最严重类型的患者中。
