经皮穿刺置管引流与直接开腹手术引流治疗胰腺坏死组织感染的疗效比较

摘要

目的 比较经皮穿刺置管引流和直接开腹手术引流治疗重症急性胰腺炎(SAP)合并胰腺坏死组织感染的临床效果.方法 回顾性分析2008年1月至2009年12月治疗的90例合并胰腺坏死组织感染的SAP患者的临床资料,根据针对感染的胰腺坏死组织首先采取的治疗方法的不同将患者分为经皮穿刺置管引流组和直接开腹手术引流组,其中经皮穿刺置管引流组27例,直接开腹手术引流组63例.经皮穿刺置管引流组首先在彩色超声或CT引导下穿刺置管引流,冲洗3 d后评价引流效果,无明显改善则中转开腹手术引流.直接开腹手术引流组在确诊胰腺坏死组织感染后直接开腹手术引流.结果 经皮穿刺置管引流组的避免开腹手术引流率(48.1%比0,P＜0.05)和一次开腹手术引流成功率(92.9%比85.7%,P＜0.05)均明显高于直接开腹手术引流组,而术后残余脓肿(7.1%比28.6%,P＜0.05)、术后新发单脏器功能障碍(7.4%比28.6%,P＜0.05)、新发消化道瘘(7.4%比27.0%,P＜0.05)、远期并发症(3.7%比22.2%,P＜0.05)的发生率均低于直接开腹手术引流组.此外,经皮穿刺置管引流组的平均ICU治疗时间[(21.2±9.7)d比(28.7±12.1)d,P＜0.01],平均住院时间[(48.2±12.5)d比(59.6±17.5)d,P＜0.05]和住院费用[(191 762±5892)元比(341 689±10 854)元,P＜0.05]均低于直接开腹手术引流组.结论 经皮穿刺置管引流能有效降低多次开腹手术引流率和术后残余脓肿发生率,治疗后近期和远期并发症的发生率均明显下降,并且平均ICU治疗时间、平均住院时间、平均住院费用明显下降.%Objective To compare the clinical effectiveness of percutaneous US- or CT- guided drainage and laparotomy for patients with infective pancreatic necrosis. Methods Data of 90 infective pancreatic necrosis patients admitted from January 2008 to December 2009 were included. They were divided into two groups by the different treatment choices. Twenty-seven patients in the percutaneous group received percutaneous US- or CT- guided drainage as first choice. After that a sump suction apparatus was applied for controlled drainage. If no improvement was achieved after 3 days, they would received operation soon. While patients in the laparotomy group received surgical drainage at the time when the diagnosis of infected pancreatic necrosis was confirmed. Continous drainage was also applied for these ones. Results The percutaneous group had a significant low rate of reoperation(7.1% vs. 14. 3% ,P ＜0. 05) and postoperative residual abscesses ( 7.1% vs. 28. 6%, P ＜ 0. 05 ). Furthermore, 48. 1% of patients in percutaneous group successfully avoid laparotomy. In the regard of complications, the percutaneous group presented lower incidence of both single organ dysfunction ( 7.4% vs. 28.6%, P ＜ 0.05 ), intestinal fistula ( 7.4% vs.27.0%, P ＜ 0. 05 ) and long-term complications ( 3.7% vs. 22.2% , P ＜ 0. 05 ) . In addition, the percutaneous group costed less medical resources as evidenced by shorter ICU duration (21.2 ± 9. 7 vs.28. 7 ± 12. 1, P ＜ 0. 01 ), shorter hospital duration ( 48. 2 ± 12. 5 vs. 59. 6 ± 17.5, P ＜ 0. 05 ) and less expenditure( 191 762 ± 5892 vs. 341 689 ± 10 854, P ＜ 0. 05 ). Conclusions Percutaenous drainage can effectively lower the surgical rates and the rates of complications and reoperations in patients with infective pancreatic necrosis. Besides that, it could also reduce the cost of medical resources.