Timmerhuis Hester C, van Dijk Sven M, Hollemans Robbert A, Umans Devica S, Sperna Weiland Christina J, Besselink Marc G, Bouwense Stefan A W, Bruno Marco J, van Duijvendijk Peter, van Eijck Casper H J, Issa Yama, Mieog J Sven D, Molenaar I Quintus, Stommel Martijn W J, Bollen Thomas L, Voermans Rogier P, Verdonk Robert C, van Santvoort Hjalmar C
Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands.
Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Ann Surg. 2023 Aug 1;278(2):e284-e292. doi: 10.1097/SLA.0000000000005624. Epub 2022 Jul 22.
The aim of this study was to explore the incidence, risk factors, clinical course and treatment of perforation and fistula of the gastrointestinal (GI) tract in a large unselected cohort of patients with necrotizing pancreatitis.
Perforation and fistula of the GI tract may occur in necrotizing pancreatitis. Data from large unselected patient populations on the incidence, risk factors, clinical outcomes, and treatment are lacking.
We performed a post hoc analysis of a nationwide prospective database of 896 patients with necrotizing pancreatitis. GI tract perforation and fistula were defined as spontaneous or iatrogenic discontinuation of the GI wall. Multivariable logistic regression was used to explore risk factors and to adjust for confounders to explore associations of the GI tract perforation and fistula on the clinical course.
A perforation or fistula of the GI tract was identified in 139 (16%) patients, located in the stomach in 23 (14%), duodenum in 56 (35%), jejunum or ileum in 18 (11%), and colon in 64 (40%). Risk factors were high C-reactive protein within 48 hours after admission [odds ratio (OR): 1.19; 95% confidence interval (CI): 1.01-1.39] and early organ failure (OR: 2.76; 95% CI: 1.78-4.29). Prior invasive intervention was a risk factor for developing a perforation or fistula of the lower GI tract (OR: 2.60; 95% CI: 1.04-6.60). While perforation or fistula of the upper GI tract appeared to be protective for persistent intensive care unit-admission (OR: 0.11, 95% CI: 0.02-0.44) and persistent organ failure (OR: 0.15; 95% CI: 0.02-0.58), perforation or fistula of the lower GI tract was associated with a higher rate of new onset organ failure (OR: 2.47; 95% CI: 1.23-4.84). When the stomach or duodenum was affected, treatment was mostly conservative (n=54, 68%). Treatment was mostly surgical when the colon was affected (n=38, 59%).
Perforation and fistula of the GI tract occurred in one out of six patients with necrotizing pancreatitis. Risk factors were high C-reactive protein within 48 hours and early organ failure. Prior intervention was identified as a risk factor for perforation or fistula of the lower GI tract. The clinical course was mostly affected by involvement of the lower GI tract.
本研究旨在探讨在一大群未经挑选的坏死性胰腺炎患者中，胃肠道穿孔和瘘管的发生率、危险因素、临床病程及治疗情况。
胃肠道穿孔和瘘管可能发生于坏死性胰腺炎。目前缺乏来自大量未经挑选患者群体关于发生率、危险因素、临床结局及治疗的数据。
我们对一个全国性的包含896例坏死性胰腺炎患者的前瞻性数据库进行了事后分析。胃肠道穿孔和瘘管定义为胃肠道壁的自发性或医源性中断。采用多变量逻辑回归分析来探究危险因素，并对混杂因素进行校正，以探讨胃肠道穿孔和瘘管与临床病程之间的关联。
在139例（16%）患者中发现了胃肠道穿孔或瘘管，其中23例（14%）位于胃，56例（35%）位于十二指肠，18例（11%）位于空肠或回肠，64例（40%）位于结肠。危险因素包括入院后48小时内高C反应蛋白[比值比（OR）：1.19；95%置信区间（CI）：1.01 - 1.39]和早期器官衰竭（OR：2.76；95%CI：1.78 - 4.29）。既往侵入性干预是发生下消化道穿孔或瘘管的危险因素（OR：2.60；95%CI：1.04 - 6.60）。而上消化道穿孔或瘘管似乎对持续入住重症监护病房具有保护作用（OR：0.11，95%CI：0.02 - 0.44）以及对持续器官衰竭具有保护作用（OR：0.15；95%CI：0.02 - 0.58），下消化道穿孔或瘘管与新发器官衰竭的发生率较高相关（OR：2.47；95%CI：1.23 - 4.84）。当胃或十二指肠受累时，治疗大多为保守治疗（n = 54，68%）。当结肠受累时，治疗大多为手术治疗（n = 38，59%）。
六分之一的坏死性胰腺炎患者发生了胃肠道穿孔和瘘管。危险因素为48小时内高C反应蛋白和早期器官衰竭。既往干预被确定为下消化道穿孔或瘘管的危险因素。临床病程大多受下消化道受累的影响。
