中国医科大学学报  2018, Vol. 47 Issue (3): 244-246

文章信息

谢锋, 朱芳, 王红岩, 刘峥嵘, 赵晓丹, 樊小刚, 韩宏民
XIE Feng, ZHU Fang, WANG Hongyan, LIU Zhengrong, ZHAO Xiaodan, FAN Xiaogang, HAN Hongmin
经皮胆囊穿刺引流术辅助治疗重症急性胰腺炎的临床应用价值
Clinical Application of Percutaneous Gallbladder Drainage in Severe Acute Pancreatitis
中国医科大学学报, 2018, 47(3): 244-246
Journal of China Medical University, 2018, 47(3): 244-246

文章历史

收稿日期:2017-10-18
网络出版时间:2018-03-02 17:38
经皮胆囊穿刺引流术辅助治疗重症急性胰腺炎的临床应用价值
1. 中国医科大学人民医院核医学科, 沈阳 110016;
2. 中国医科大学人民医院心功能科, 沈阳 110016;
3. 中国医科大学人民医院普外科, 沈阳 110016;
4. 沈阳出入境检验检疫局国际旅行卫生保健中心, 沈阳 110016
摘要目的 探讨采用经皮胆囊穿刺引流术辅助治疗重症急性胰腺炎的临床应用价值。方法 回顾性分析65例重症胰腺炎患者的临床资料。将患者分为胆囊穿刺组和对照组。随访至少6个月,观察2组的死亡率及胰腺脓肿、假性囊肿、肾功能不全、呼吸衰竭、心功能衰竭、消化道出血、败血症、弥漫性血管内凝血(DIC)等并发症的发生率,并进行统计学分析比较。结果 胆囊穿刺组死亡率低于对照组,差异有统计学意义(P < 0.05);胆囊穿刺组全身并发症(肾功能不全、呼吸衰竭、心力衰竭、消化道出血、败血症)的发生率低于对照组(P < 0.05);胆囊穿刺组局部并发症(胰腺脓肿及假性囊肿)的发生率与对照组无统计学差异(P > 0.05);另外,胆囊穿刺组DIC的发生率低于对照组,但差异无统计学意义(P > 0.05)。结论 经皮胆囊穿刺引流术能够有效降低重症胰腺炎的肾功能不全、呼吸衰竭、心功能衰竭、消化道出血、败血症等全身并发症的发生率,降低死亡率。但对于局部并发症胰腺脓肿和假性囊肿及DIC的发生率没有帮助。
Clinical Application of Percutaneous Gallbladder Drainage in Severe Acute Pancreatitis
1. Department of Nuclear Medicine, The People's Hospital of China Medical University, Shenyang 110016, China;
2. Department of Cardiac Function, The People's Hospital of China Medical University, Shenyang 110016, China;
3. Department of General Surgery, The People's Hospital of China Medical University, Shenyang 110016, China;
4. Shenyang Entry-exit Inspection and Quarantine Bureau International Travel Health Care Center, Shenyang 110016, China
Abstract: Objective To investigate the clinical value of percutaneous gallbladder drainage in the treatment of severe acute pancreatitis (SAP).Methods A total of 65 patients treated for SAP in our hospital between January 2014 and April 2017 were analyzed retrospectively. The patients were divided into a gallbladder puncture group and a control group. Follow-up was performed for at least 6 months to monitor mortality and the incidence of complications, including pancreatic abscess, pseudocyst, renal failure, respiratory failure, heart failure, gastrointestinal bleeding, sepsis, and disseminated intravascular coagulation (DIC). The differences in mortality and complication rates between the two groups were statistically analyzed.Results Mortality in the gallbladder puncture group was significantly lower than in the control group (P < 0.05);the incidence of renal failure, respiratory failure, heart failure, gastrointestinal bleeding, and sepsis in the gallbladder puncture group was lower than in the control group (P < 0.05);the incidence of pancreatic abscess and pseudocyst in the gallbladder puncture group was similar to that in the control group, showing no significant difference (P > 0.05);the incidence of DIC in the gallbladder puncture group was lower than in the control group, but the difference was not statistically significant (P > 0.05).Conclusion Percutaneous gallbladder drainage can effectively reduce the incidence of renal failure, respiratory failure, heart failure, gastrointestinal bleeding, and sepsis in SAP, thereby reducing mortality. However, the incidence of DIC, pancreatic abscess, and pseudocyst is not reduced.

重症胰腺炎(severe acute pancreatitis,SAP)是一种常见的急腹症,临床表现为从局部炎症累及胰周组织到全身性病理状态的进展过程,易并发胰腺脓肿、假性囊肿等局部并发症及肾功能不全、呼吸衰竭、心力衰竭、消化道出血、败血症等全身并发症,从而导致患者死亡。目前SAP的治疗仍以内科治疗为主,有创的操作为辅[1-2],临床上急需寻找一种能够降低SAP致死性并发症的发生率从而降低死亡率的有效的微创治疗方式。经皮胆囊穿刺引流术是一种微创的简单的穿刺技术,能将胆汁从胆道内直接引出至体外,最大限度地降低胆汁与胰液混合的概率。本研究回顾性分析了经皮胆囊穿刺引流术对于SAP的并发症的治疗效果,旨在探讨该治疗方式在SAP治疗中的临床应用价值。

1 材料与方法 1.1 研究对象

收集2014年1月至2017年4月中国医科大学人民医院收治的65例SAP患者的病历资料。其中,男49例,女16例,平均年龄(44±28)岁。纳入标准为具备急性胰腺炎的临床表现和生化改变,且符合下列条件之一者:影像学检查发现胰腺坏死;发生器官衰竭;Ranson评分≥3;APACHEⅡ评分≥8;CT分级为D、E。

1.2 研究方法

将患者分为胆囊穿刺组(44例)和对照组(21例),自出现腹痛开始72 h内接受经皮胆囊穿刺引流术者纳入胆囊穿刺组,未接受本项治疗者纳入对照组。患者入院后均给予补液、抗炎、镇痛、营养支持、抑制胰酶分泌等常规治疗。随访至少6个月,观察2组的死亡率及在治疗中出现胰腺脓肿、假性囊肿、肾功能不全、呼吸衰竭、心功能衰竭、消化道出血、败血症、弥漫性血管内凝血等并发症的发生率。

经皮胆囊穿刺引流术由从事介入工作的影像科医生完成。手术适应证为CT检查胆囊最大横截面积不小于8 cm2,凝血酶原时间 < 30 s。术前30 min预防性应用抗生素,局部麻醉采用2%利多卡因,术中应用地佐辛10 mg加250 mL生理盐水持续缓慢静脉滴入(30滴/min)。采用美国COOK公司21G引流套管针穿刺,导丝采用日本泰尔茂公司0.035英寸的泥鳅导丝,引流管采用美国波士顿科学公司8F猪尾引流管。

1.3 统计学分析

采用SPSS 17.0软件进行统计学分析。采用χ2检验对2组的并发症发生率及死亡率进行比较。P < 0.05为差异有统计学意义。

2 结果

胆囊穿刺组全部患者手术均获成功,未出现并发症。胆囊穿刺组死亡率(13.64%)低于对照组(38.10%),差异有统计学意义(P < 0.05)。胆囊穿刺组肾功能不全发生率(27.27%)低于对照组(57.14%)(P < 0.05);胆囊穿刺组呼吸衰竭发生率(22.73%)低于对照组(52.38%)(P < 0.05);胆囊穿刺组心力衰竭发生率(11.36%)低于对照组(42.86%)(P < 0.05);胆囊穿刺组消化道出血发生率(4.55%)低于对照组(23.81%)(P < 0.05);胆囊穿刺组败血症发生率(18.18%)低于对照组(42.86%)(P < 0.05);弥漫性血管内凝血发生率胆囊穿刺组(9.09%)低于对照组(23.81%),但差异无统计学意义(P > 0.05);胆囊穿刺组胰腺脓肿发生率(22.73%)低于对照组(33.33%),但差异无统计学意义(P > 0.05);胆囊穿刺组假性囊肿发生率(18.18%)低于对照组(28.57%),但差异无统计学意义(P > 0.05)。见表 1

表 1 胆囊穿刺组和对照组死亡率和并发症发生率的比较(%) Tab.1 Mortality and incidence of the complications in gallbladder puncture and control groups (%)
Group Mortality Pancreatic abscess Pseudocyst Renal insufficiency Respiratory failure Heart failure Gastrointestinal hemorrhage Septicemia DIC
Gallbladder puncture group 13.64 22.73 18.18 27.27 22.73 11.36  4.55 18.18  9.09
Control group 38.10 33.33 28.57 57.14 52.38 42.86 23.81 42.86 23.81
P  0.030  0.381  0.353  0.028  0.024  0.008  0.031  0.037  0.135

3 讨论

SAP属于急性胰腺炎的特殊类型,是一种病情险恶、并发症多、病死率高的急腹症,占全部急性胰腺炎的10%~20%。SAP肾脏损害的主要病理特征是肾小管坏死及间质水肿,是由于体内某些炎性细胞因子相互作用,导致免疫功能紊乱所致[3-4]。本研究结果提示胆囊穿刺可以降低SAP肾功能不全的发生率,分析原因可能是由于经皮胆囊穿刺引流术将大多数胆汁引流至体外,使胰液与胆汁混合的机会减少,胰腺自身消化的能力降低,从而炎性细胞因子分泌减少所致。另外,约50%~70%的胰腺炎是胆源性的,胆囊穿刺引流可以有效控制胆系感染,改善肝脏功能,从而进一步避免并发症的发生[5]。呼吸衰竭也是SAP常见的并发症,主要病理特征为肺泡水肿或出血、间质增厚及微小肺不张。研究[6-7]表明这是由于胰酶的降解产物、炎性细胞因子入血,激活补体系统,引发变态反应所致。本研究结果提示胆囊穿刺可以降低SAP患者呼吸衰竭的发生率,这可能是由于胆囊穿刺通过胆胰分流减轻了胆系感染,使胰酶降解减少,炎性细胞因子分泌减少所致。心肌损害也是SAP的并发症之一,其主要的发生机制是胰酶的降解产物和炎性细胞因子入血,除直接对心肌造成损伤外,还可通过收缩冠状动脉引发心肌缺血,从而导致心力衰竭或心律失常[8]。本研究结果提示胆囊穿刺可有效降低SAP患者心功能衰竭的发生率,考虑其原因也是通过胆胰分流,减少胰酶降解,降低炎性细胞因子分泌实现的。消化道出血也是SAP较常见的并发症,主要的出血血管包括脾动脉、门静脉及胰周血管,多由于严重感染侵蚀血管所引起,大出血多伴有严重坏死,死亡率为37.9% [9],本研究中SAP死亡率为42.86%,与之相符。本研究结果显示,胆囊穿刺可降低SAP患者全身败血症及消化道出血的风险,这可能也与减少炎症介质分泌,减轻血管侵蚀有关。通过减少以上全身并发症的发生,经皮胆囊穿刺引流术可有效提高SAP患者的存活率,本研究也证实了这一点。

弥漫性血管内凝血也是SAP的并发症之一,发生原因可能是由于凝血因子大量消耗,引起的凝血功能异常所致[10]。本研究提示胆囊穿刺并不能有效降低弥漫性血管内凝血的发生率,提示胆胰分流并不能减少凝血因子在疾病中的消耗。另外,本研究显示胆囊穿刺并不能降低胰腺脓肿及假性囊肿这2种局部并发症的发生率,提示胆汁引流并不能对胰腺周围局部病灶的发展构成影响。

综上所述,经皮胆囊穿刺引流术能够有效降低重症胰腺炎的肾功能不全、呼吸衰竭、心力衰竭、消化道出血、败血症等全身并发症的发生率,从而降低死亡率;但对于减少胰腺脓肿和假性囊肿这2种局部并发症及弥漫性血管内凝血的发生并没有帮助。

参考文献
[1]
BOUMITRI C, BROWN E, KAHALEH M. Necrotizing pancreatitis:current management and therapies[J]. Clin Endosc, 2017, 50(4): 357-365. DOI:10.5946/ce.2016.152
[2]
HARTWIG W, WERNER J, UHL W, et al. Management of infection in acute pancreatitis[J]. J Hepatobiliary Pancreat Surg, 2002, 9(4): 423-428. DOI:10.1007/s005340200052
[3]
PETEJOVA N, MARTINEK A. Acute kidney injury following acute pancreatitis:a review[J]. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub, 2013, 157(2): 105-113.
[4]
FROST L, PEDERSEN RS, OSTQAARD SE, et al. Prognosis in acute pancreatitis complicated by acute renal failure requiring dialysis[J]. Scand J Urol Nephrol, 1990, 24(4): 257-260.
[5]
YU W, LI W, WANG Z, et al. Early percutaneous transhepatic gallbladder drainage compared with endoscopic retrograde cholangiopancreatography and papillotomy treatment for severe gallstone associated acute pancreatitis[J]. Postgrad Med J, 2007, 83(977): 187-191. DOI:10.1136/pgmj.2006.047746
[6]
ZHANG X, WU D, JIANG X. Icam-1 and acute pancreatitis complicated by acute lung injury[J]. JOP, 2009, 10(1): 8-14.
[7]
SIEBIQ S, LESALNIEKS, BRUENNLER T, et al. Recovery from respiratory failure after decompression laparotomy for severe acute pancrertitis[J]. World J Gastroenterol, 2008, 14(35): 5467-5470. DOI:10.3748/wjg.14.5467
[8]
HSU PC, LIN TH, SU HM, et al. Acute necrotizing pancreatitis complicated with ST elevation acute myocardial infarction:a case report and literature review[J]. Kaohsiung J Med Sci, 2010, 26(4): 200-205. DOI:10.1016/S1607-551X(10)70029-2
[9]
FLATI G, ANDREN-SANDBERG A, LA PM, et al. Potentially fatal bleeding in acute pancreatitis:pathophysiology, prevention, and treatment[J]. Pancreas, 2003, 26(1): 8-14. DOI:10.1097/00006676-200301000-00002
[10]
SAIF MW. DIC secondary to acute pancreatitis[J]. Clin Lab Haematol, 2005, 27(4): 278-282. DOI:10.1111/j.1365-2257.2005.00697.x