Cribari Chris, Tierney Joshua, LaGrone Lacey
Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA.
Trauma and Acute Care Surgery, University of Colorado Health, Loveland, Colorado, USA.
Trauma Surg Acute Care Open. 2025 Apr 14;10(Suppl 1):e001798. doi: 10.1136/tsaco-2025-001798. eCollection 2025.
Acute pancreatitis (AP) is a heterogeneous inflammation of the pancreas, most frequently attributable to gallstones or alcohol. AP accounts for an estimated 300 000 patients admitted each year in the USA, and an estimated US$2.6 billion/year in hospitalization costs. Disease severity is classified as mild, moderate, or severe, dependent on the presence or degree of concomitant organ failure. Locally, pancreatitis may be complicated by fluid collections, necrosis, infection, and hemorrhage. Infection of necrotizing pancreatitis (NP) is associated with a doubling of mortality risk. The modern management of AP is evolving. Recent data suggest a shift from normal saline to lactated Ringer's solution, and from aggressive to more judicious volume resuscitation. Similarly, while historical wisdom advocated keeping patients nothing by mouth to 'rest the pancreas', recent data convincingly show fewer complications and reduced mortality with early enteral nutrition, when tolerated by the patient. The use of antibiotics in NP is controversial. Current recommendations suggest reserving antibiotics for cases with highly suspected or confirmed infected necrosis, as well as in patients with biliary pancreatitis complicated by acute cholecystitis or cholangitis. Regarding the management of local complications, control of acute hemorrhage can be attained either endovascularly or via laparotomy. Abdominal compartment syndrome is associated with a mortality risk of 50%-75%. Routine monitoring of intra-abdominal pressure is recommended in patients at high risk. Pancreatic pseudocysts require intervention in symptomatic patients or those with infection or other complications. Endoscopic transmural drainage may be considered as the first step when technically feasible. Necrotizing pancreatitis without suspicion of infection is often managed medically, while the delay, drain, debride approach remains the standard of care for the vast majority of infected pancreatic necrosis. Robotic surgery, in appropriately selected patients, allows for a one-step approach, and merits further study to explore its initially promising results.
急性胰腺炎（AP）是一种胰腺的异质性炎症，最常见的病因是胆结石或酒精。在美国，每年估计有30万名患者因AP住院，住院费用估计每年达26亿美元。根据是否存在伴随器官功能衰竭及衰竭程度，疾病严重程度分为轻度、中度或重度。在局部，胰腺炎可能并发液体积聚、坏死、感染和出血。坏死性胰腺炎（NP）感染会使死亡风险加倍。AP的现代治疗方法正在不断发展。最近的数据表明，治疗液体已从生理盐水转向乳酸林格氏液，液体复苏策略也从积极补液转变为更审慎的补液。同样，虽然过去一直主张让患者禁食以“让胰腺休息”，但最近的数据令人信服地表明，在患者能够耐受的情况下，早期肠内营养可减少并发症并降低死亡率。NP中抗生素的使用存在争议。目前的建议是，仅在高度怀疑或确诊感染性坏死的病例以及并发急性胆囊炎或胆管炎的胆源性胰腺炎患者中使用抗生素。关于局部并发症的处理，急性出血的控制可通过血管内介入或剖腹手术实现。腹腔间隔室综合征的死亡风险为50%-75%。建议对高危患者进行腹腔内压力的常规监测。胰腺假性囊肿在有症状的患者或伴有感染或其他并发症的患者中需要进行干预。在技术可行的情况下，内镜经壁引流可作为首选方法。无感染怀疑的坏死性胰腺炎通常采用内科治疗，而对于绝大多数感染性胰腺坏死，“延期、引流、清创”方法仍是标准治疗方案。对于经过适当选择的患者，机器人手术可实现一步治疗法，其初步取得的有前景的结果值得进一步研究探索。
