Mier J, León E L, Castillo A, Robledo F, Blanco R
Department of General and Gastrointestinal Surgery, Hospital de Especialidades, Centro Médico Nacional Siglo XXI (IMSS), Mexico City, Mexico.
Am J Surg. 1997 Feb;173(2):71-5. doi: 10.1016/S0002-9610(96)00425-4.
Debate as to whether surgery in severe necrotizing pancreatitis (SNP) should be done early or late has been present ever since the disease was described. There are no prospective, randomized studies addressing this specific issue.
Patients with SNP, documented clinically, with Ranson's criteria, and dynamic pancreatography (DP) findings were randomly allocated in two groups for treatment. Group A included early necrosectomy (within 48 to 72 hours of onset) and group B, late necrosectomy (at least 12 days after onset). Both groups continued with open packing and staged necrosectomies. Cultures were obtained at each laparotomy and necrosis was verified histologically in all instances.
During a 36-month study period, 150 patients with unequivocal acute pancreatitis were admitted for treatment. Forty-one with SNP initially entered the study; there were 5 drop outs. Patients in group A (25) and group B (11) had no difference in distribution by gender or mean age, etiology, mean Ranson's signs (4 versus 3.8), DP findings, rate of infected necrosis, or necrosectomies required per patient. Although the mortality rate (58% versus 27%) did not reach statistical significance, the odds ratio for mortality was 3.4 times higher in group A, which made us finish the study.
This prospective, randomized study from a single institution clearly demonstrates that early intensive conservative treatment with late necrosectomy for selected cases is the current rationale approach for SNP.
自坏死性胰腺炎被描述以来，关于重症坏死性胰腺炎（SNP）手术应早期进行还是晚期进行的争论就一直存在。目前尚无针对这一具体问题的前瞻性随机研究。
临床诊断为SNP、符合兰森标准且有动态胰腺造影（DP）检查结果的患者被随机分为两组进行治疗。A组为早期坏死组织清除术（发病后48至72小时内），B组为晚期坏死组织清除术（发病后至少12天）。两组均继续采用开放填塞和分期坏死组织清除术。每次剖腹手术时进行培养，所有病例均经组织学证实坏死。
在36个月的研究期间，150例明确诊断为急性胰腺炎的患者入院治疗。41例SNP患者最初进入研究，5例退出。A组（25例）和B组（11例）患者在性别分布、平均年龄、病因、平均兰森体征（4比3.8）、DP检查结果、感染性坏死发生率或每位患者所需的坏死组织清除术方面无差异。虽然死亡率（58%对27%）未达到统计学显著性，但A组的死亡比值比高3.4倍，这促使我们提前结束研究。
这项来自单一机构的前瞻性随机研究清楚地表明，对于选定病例，早期强化保守治疗并在后期进行坏死组织清除术是目前治疗SNP的合理方法。
