Lyu X J, Sun B, Li L, Chen H, Kong R
Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, China.
Zhonghua Wai Ke Za Zhi. 2018 Sep 1;56(9):687-692. doi: 10.3760/cma.j.issn.0529-5815.2018.09.009.
To investigate the safety and efficiency of small incision minimally invasive approach pancreatic necrosectomy in the treatment of infected pancreatic necrosis. The data of 164 patients who underwent small incision minimally invasive approach pancreatic necrosectomy for infected pancreatic necrosis at Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University from January 2012 to December 2016 were analyzed retrospectively.Among 164 patients, there were 102 male and 62 female patients.The median age was 46 years(ranging from 19 to 79 years). One hundred and one patients(61.6%) suffered from severe acute pancreatitis and 63 patients(38.4%) suffered from moderately severe acute pancreatitis.Following step-up approach principle, the surgical procedures were performed for 131 patients(79.9%) who suffered from sepsis which could not be alleviated via percutaneous catheter drainage(PCD). The other 33 patients(20.1%) who did not undergo PCD directly took small incision minimally invasive approach pancreatic necrosectomy.Preoperative CT images were used to determine the location of the lesion.The PCD puncture points or the points where the abscess was closest to the skin were chosen as the incision.Gradually, the small incision minimally invasive approach pancreatic necrosectomy were performed cutting all layers into the abscess. The median time from the onset of symptom to first operation was 32 days(ranging from 23 to 45 days). The average hospital stay was 46 days(ranging from 29 to 103 days). The average number of drainage tubes placed was 4 pieces(ranging from 2 to 8 pieces). Ninety-two patients(56.0%) underwent minimal access retroperitoneal pancreatic necrosectomy. Thirty-six patients(22.0%) underwent minimal invasive approach lesser omentum sac pancreatic necrosectomy.Thirty-six patients(22.0%) underwent minimal invasive approach lesser omentum sac pancreatic necrosectomy combined with minimal access retroperitoneal pancreatic necrosectomy.A total of 148 cases(90.2%) were cured via minimally invasive approach pancreatic necrosectomy, 8 cases(4.9%) were cured after transfering to open pancreatic necrosectomy.The cure rate was 95.1%(156/164). The mainly postoperative complications included pancreatic fistula(25 cases), intra-abdominal hemorrhage(10 cases), gastric fistula (2 cases), duodenal fistula(4 cases) and colonic fistula(3 cases). The overall incidence rate of complications was 26.8%(44/164). Eight cases were dead after surgery and the in-hospital mortality was 4.9%(8/164). In summary, small incision minimally invasive approach pancreatic necrosectomy is an effective way to clean up necrotic tissue, improve the drainage, reduce complications in dealing with infected pancreatic necrosis.
探讨小切口微创入路胰坏死组织清除术治疗感染性胰腺坏死的安全性及有效性。回顾性分析2012年1月至2016年12月在哈尔滨医科大学附属第一医院肝胆胰外科行小切口微创入路胰坏死组织清除术治疗感染性胰腺坏死的164例患者的资料。164例患者中，男性102例，女性62例。中位年龄46岁（19～79岁）。101例（61.6%）为重症急性胰腺炎，63例（38.4%）为中度重症急性胰腺炎。遵循逐步递进原则，对131例（79.9%）经皮导管引流（PCD）无法缓解脓毒症的患者实施手术。另外33例（20.1%）未行PCD直接行小切口微创入路胰坏死组织清除术。术前CT图像用于确定病变部位。选择PCD穿刺点或脓肿距皮肤最近点作为切口。逐步行小切口微创入路胰坏死组织清除术，逐层切开进入脓肿。症状出现至首次手术的中位时间为32天（23～45天）。平均住院时间46天（29～103天）。平均放置引流管数量为4根（2～8根）。92例（56.0%）行微创腹膜后胰坏死组织清除术。36例（22.0%）行微创小网膜囊胰坏死组织清除术。36例（22.0%）行微创小网膜囊胰坏死组织清除术联合微创腹膜后胰坏死组织清除术。共148例（90.2%）通过微创入路胰坏死组织清除术治愈，8例（4.9%）转为开放胰坏死组织清除术后治愈。治愈率为95.1%（156/164）。主要术后并发症包括胰瘘（25例）、腹腔内出血（10例）、胃瘘（2例）、十二指肠瘘（4例）和结肠瘘（3例）。并发症总发生率为26.8%（44/164）。8例术后死亡，住院死亡率为4.9%（8/164）。综上所述，小切口微创入路胰坏死组织清除术是清理坏死组织、改善引流、减少感染性胰腺坏死并发症的有效方法。
