Rau B, Pralle U, Uhl W, Schoenberg M H, Beger H G
Department of General Surgery, University of Ulm, Germany.
J Am Coll Surg. 1995 Oct;181(4):279-88.
The clinical management of sterile pancreatic necrosis is still a matter of debate. In this study we analyzed the clinical course and outcome of patients with sterile necrotizing pancreatitis treated surgically versus nonsurgically.
Between May 1982 and December 1993, 249 patients with necrotizing pancreatitis (NP) entered this study, of which 172 (69 percent) had intraoperatively or fine needle aspiration-proven sterile NP. One hundred seven of 172 patients underwent surgery (S group) with necrosectomy and continuous postoperative closed lavage and 65 of 172 were treated by nonsurgical means (NS group).
Median Ranson and admission APACHE II scores were 4.7 (range, 1 to 10) and 11 (range, 1 to 29) in the S group, significantly higher than those in the NS group with 3.0 (range, 0 to 6) (p = 0.022) and 8 (range, 1 to 23) (p = 0.036). After 48 hours of intensive care treatment, APACHE II scores persisted at 10.5 (range, 1 to 29) in the S group and decreased to 6 (range, 0 to 15) (p = 0.013) in the NS patients. Median C-reactive protein (CRP) levels on admission were 179 mg/L and 68.5 mg/L (p = 0.023), respectively. Within 72 hours, 61 (94 percent) of 65 NS-managed patients responded to intensive care therapy, whereas organ complications persisted or increased and thus led to surgery in the S group. Mortality rates were 13.1 percent in the surgically treated patients and 6.2 percent in the nonsurgically treated patients (p = NS).
Most patients with limited and sterile pancreatic necrosis respond to intensive care treatment. Indication for surgery in sterile NP should be based on persisting or advancing organ complications despite intensive care therapy. APACHE II scores and admission CRP levels represent a helpful tool in decision making for surgical or nonsurgical management of NP.
无菌性胰腺坏死的临床管理仍存在争议。在本研究中,我们分析了接受手术治疗与非手术治疗的无菌性坏死性胰腺炎患者的临床病程和结局。
1982年5月至1993年12月期间,249例坏死性胰腺炎(NP)患者进入本研究,其中172例(69%)经术中或细针穿刺证实为无菌性NP。172例患者中有107例接受了手术(S组),进行了坏死组织清除术及术后持续闭式灌洗,172例中有65例采用非手术方法治疗(NS组)。
S组的Ranson评分中位数和入院时APACHE II评分分别为4.7(范围1至10)和11(范围1至29),显著高于NS组的3.0(范围0至6)(p = 0.022)和8(范围1至23)(p = 0.036)。经过48小时的重症监护治疗后,S组的APACHE II评分维持在10.5(范围1至29),而NS组患者的评分降至6(范围0至15)(p = 0.013)。入院时C反应蛋白(CRP)水平中位数分别为179 mg/L和68.5 mg/L(p = 0.023)。72小时内,65例接受非手术治疗的患者中有61例(94%)对重症监护治疗有反应,而S组的器官并发症持续存在或加重,因此导致了手术。手术治疗患者的死亡率为13.1%,非手术治疗患者的死亡率为6.2%(p =无显著性差异)。
大多数局限性无菌性胰腺坏死患者对重症监护治疗有反应。无菌性NP的手术指征应基于尽管进行了重症监护治疗但器官并发症仍持续存在或进展。APACHE II评分和入院时CRP水平是NP手术或非手术管理决策中的有用工具。