Dua Monica M, Worhunsky David J, Malhotra Lavina, Park Walter G, Poultsides George A, Norton Jeffrey A, Visser Brendan C
Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
J Surg Res. 2017 Nov;219:11-17. doi: 10.1016/j.jss.2017.05.089. Epub 2017 Jun 21.
The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described.
Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality.
Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort.
Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.
坏死性胰腺炎的最佳手术策略仍存在争议。传统的外科坏死组织清除术会带来较高的发病率；内镜和经皮治疗策略需要反复干预且住院时间延长。我们开发了一种经胃途径的胰腺坏死组织清除术，以克服上述其他技术的缺点。
回顾性分析2009年至2016年在某学术中心接受治疗的坏死性胰腺炎患者。如果坏死区域已包裹形成并在横断面成像中位于胃后位置，则进行开放或腹腔镜经胃坏死组织清除术。研究终点包括术后并发症和死亡率。
46例患者接受了经胃坏死组织清除术（9例开放手术，37例腹腔镜手术）。术前急性生理与慢性健康状况评估II（APACHE II）评分的中位数（四分位间距）为6（3 - 12）。70%的患者术前影像学显示坏死面积>30%；35%存在感染性坏死。中位总住院时间为6（3 - 12）天。没有患者需要二次手术清创；4例患者（9%）术后因残留积液接受了短期经皮引流。中位随访时间为1年；未出现瘘管或伤口并发症。6例患者（13%）术后出血；5例患者接受了影像引导下的栓塞治疗。该队列中有1例死亡。
经胃胰腺坏死组织清除术通过单次确定性手术即可实现有效的清创。在解剖结构合适时，这种手术策略可加快恢复并避免与瘘管和长期引流相关的长期发病率。
