Zhang Q, Li L, Lyu X J, Chen H Z, Chen H, Kong R, Wang G, Jiang H C, Sun B
Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University; Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin 150001, China.
Zhonghua Wai Ke Za Zhi. 2020 Nov 1;58(11):858-863. doi: 10.3760/cma.j.cn112139-20200429-00348.
To examine the effect of the "four-steps" treatment on infectious pancreatic necrosis(IPN). The data of 207 patients who were diagnosed with IPN from January 2013 to December 2017 at Department of Pancreaticobiliary Surgery, the First Affiliated Hospital of Harbin Medical University were analyzed retrospectively. Among 207 patients, 132(63.8%) were males and 75(36.2%) were females. The median age was 45 years old (range: 19 to 80 years old). One hundred and fifty-eight patients(76.3%) suffered severe acute pancreatitis and 49 patients(23.7%) suffered moderately severe acute pancreatitis. Percutaneous catheter drainage(PCD) was performed on all the patients(Step 1). Patients received "four-steps" minimally invasive treatment strategy in step-up group(173 patients). The following steps after PCD were mini-incision access pancreatic necrosectomy(MIAPN) (Step 2), sinus tract endoscopic debridement and(or) PCD for residual infections(Step 3) and finally conventional open pancreatic necrosectomy(OPN) (Step 4). Patients(34 cases) received conventional open pancreatic necrosectomy after invalided PCD in OPN group. The perioperative parameters and prognosis were compared between Step-up group and OPN group. Normally distributed quantitative variables were analyzed by t-test, non-normally distributed quantitative variables were analyzed by Wilcoxon chi-square test and categorical variables were analyzed by χ(2) test or Fisher exact test, respectively. The basic characteristics of the two groups of patients were similar, but the referral rate of patients and the rate of preoperative 3 days organ failure in the OPN group were significantly higher than those of step-up group patients(47.1% . 28.9%, χ(2)=4.313, 0.038; 26.5% . 9.2%, χ(2)=2.819, 0.011). The frequency of PCD and the number of PCD tube (root) were less than those in the step-up group(1(1) . 2(1), -3.373, 0.018; 2(1) . 3(2), -2.208, 0.027). Compared with the OPN group, the interval time from onset to surgery and the MIAPN operation time were significantly shorter in the step-up group(29(15) days . 36(17)days, -0.567, 0.008; 58(27)minutes . 90(56)minutes, -3.908, 0.01); postoperative mortality was lower(5.8% .17.6%, χ(2)=4.070, 0.044); the overall incidence of postoperative complications was reduced(23.1% . 55.9%, χ(2)=14.960, 0.01) and the incidence of new-onset organ failure was decreased after operation in the step-up group(37.5% .47.4%, χ(2)=7.133, 0.007). The incidence of local abdominal complications (pancreatic fistula, intra-abdominal hemorrhage, gastrointestinal fistula) showed no significant difference between the two groups (0.05). Fewer patients required ICU treatment after operation in the step-up group compared with OPN group(22.0% . 44.1%, χ(2)=6.204, 0.013). Patients in the Step-up group has shorter hospital stay than patients in OPN group (46(13) days . 52(13)days, 1.993, 0.046). The clinical effects of "four-steps" exhibited the superiority of minimally invasive treatment of IPN.And MIAPN is a simple, safe and effective procedure to remove pancreatic necrotic tissue and decrease complications.
探讨“四步法”治疗感染性胰腺坏死（IPN）的效果。回顾性分析2013年1月至2017年12月在哈尔滨医科大学附属第一医院肝胆胰外科确诊为IPN的207例患者的数据。207例患者中，男性132例（63.8%），女性75例（36.2%）。中位年龄为45岁（范围：19至80岁）。158例患者（76.3%）患有重症急性胰腺炎，49例患者（23.7%）患有中度重症急性胰腺炎。所有患者均行经皮导管引流（PCD）（第一步）。逐步治疗组（173例患者）采用“四步法”微创治疗策略。PCD术后的后续步骤依次为小切口入路胰腺坏死组织清除术（MIAPN）（第二步）、窦道内镜清创和（或）针对残余感染的PCD（第三步），最后为传统开放性胰腺坏死组织清除术（OPN）（第四步）。OPN组34例患者在PCD无效后接受传统开放性胰腺坏死组织清除术。比较逐步治疗组和OPN组的围手术期参数及预后。正态分布的定量变量采用t检验分析，非正态分布的定量变量采用Wilcoxon秩和检验分析，分类变量分别采用χ²检验或Fisher确切概率法检验。两组患者的基本特征相似，但OPN组患者的转诊率和术前3天器官衰竭发生率显著高于逐步治疗组患者（47.1%对28.9%，χ² = 4.313，P = 0.038；26.5%对9.2%，χ² = 2.819，P = 0.011）。PCD的频次及PCD管（根）数少于逐步治疗组（1（1）对2（1），t = -3.373，P = 0.018；2（1）对3（2），t = -2.208，P = 0.027）。与OPN组相比，逐步治疗组从发病到手术的间隔时间及MIAPN手术时间显著缩短（29（15）天对36（17）天，t = -0.567，P = 0.008；58（27）分钟对90（56）分钟，t = -3.908，P = 0.01）；术后死亡率较低（5.8%对17.6%，χ² = 4.070，P = 0.044）；术后并发症的总发生率降低（23.1%对55.9%，χ² = 14.960，P = 0.01），逐步治疗组术后新发器官衰竭的发生率下降（37.5%对47.4%，χ² = 7.133，P = 0.007）。两组局部腹部并发症（胰瘘、腹腔内出血、胃肠道瘘）的发生率差异无统计学意义（P＞0.05）。与OPN组相比，逐步治疗组术后需要ICU治疗的患者较少（22.0%对44.1%，χ² = 6.204，P = 0.013）。逐步治疗组患者的住院时间比OPN组患者短（46（13）天对52（13）天，t = 1.993，P = 0.046）。“四步法”的临床效果显示了IPN微创治疗的优越性。并且MIAPN是一种简单、安全、有效的清除胰腺坏死组织及减少并发症的手术方式。
