胰腺坏死的外科治疗：东部创伤外科学会的实践管理指南
Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma.
作者信息
Mowery Nathan T, Bruns Brandon R, MacNew Heather G, Agarwal Suresh, Enniss Toby M, Khan Mansoor, Guo Weidun Alan, Cannon Jeremy W, Lissauer Matthew E, Duane Therese M, Hildreth Amy N, Pappas Peter A, Gries Lynn M, Kaiser Meghann, Robinson Bryce R H
机构信息
From the Department of Surgery, Wake Forest University (N.T.M., A.N.H.), Winston-Salem, North Carolina; Department of Surgery, University of Maryland (B.R.B.), Baltimore, Maryland; Memorial University Medical Center, Mercer University School of Medicine (H.G.M.), Savannah, Georgial; University of Wisconsin (S.A.), Madison, Wisconsin; University of Utah (T.E.), Salt Lake City, Utah; Imperial College Healthcare NHS Trust (M.K.), London, England; SUNY-University at Buffalo (W.A.G.), Buffalo, New York; University of Pennsylvania (J.W.C.), Philadelphia, Pennsylvania; Rutgers-Robert Wood Johnson Medical School (M.L.), New Brunswick, New Jersey; JPS Health Network (T.M.D.), Fort Worth, Texas; University of Central Florida (P.P.), Holmes Regional Medical Center, Melbourne, Florida; University of Arizona (L.G.), Tucson, Arizona; Greenville Health System (M.K.), Greenville, South Carolina; and University of Washington (B.R.), Seattle, Washington.
出版信息
J Trauma Acute Care Surg. 2017 Aug;83(2):316-327. doi: 10.1097/TA.0000000000001510.
BACKGROUND
Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients.
METHODS
A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation.
RESULTS
Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality.
CONCLUSION
Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach.
LEVEL OF EVIDENCE
Systematic review/guideline, level III.
背景
胰腺或胰腺周围组织坏死会导致严重的发病率和死亡率。新的治疗方式使得坏死性胰腺炎的干预方法和时机出现了很大差异。随着急性护理外科的发展，其从业者越来越多地被要求管理这些复杂的患者。
方法
使用PubMed对MEDLINE数据库进行系统回顾。纳入1980年至2014年关于胰腺坏死的英文文章。排除给编辑的信、病例报告、书籍章节和综述文章。研究主题包括手术时机、辅助治疗的使用以及手术修复的类型。推荐分级、评估、制定和评价方法应用于问题提出、结果优先级确定、证据质量评估和推荐制定。
结果
纳入88项研究并进行全面审查。在评估的每个时间段（72小时、12 - 14天、30天），增加手术干预时间均能改善结局，若手术延迟30天，结局有显著改善。经皮和内镜手术的使用被证明可推迟手术并可能具有确定性。使用微创手术进行清创和引流已被证明是安全的，且与发病率和死亡率降低相关。
结论
急性护理外科医生因其在重症监护和伴有持续性休克的复杂手术方面的培训，在护理胰腺坏死患者方面接受了独特的训练。在成年胰腺坏死患者中，我们建议将胰腺坏死切除术推迟至至少第12天。在出现症状的前30天内，对于感染性坏死灶，仅在患者经放射学或内镜引流后无改善时，我们有条件地推荐手术清创。最后，即使有记录显示存在感染性坏死，我们建议患者采用逐步升级的手术干预方法作为首选手术方式。
证据水平
系统回顾/指南，三级。
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