vancom 发表于 2016-8-25 11:17:47

[CCM]:腹腔穿刺引流术用于经皮置管引流之前,可使急性胰腺炎伴液体积聚患者受益


Clinical Investigations | CARING FOR THE CRITICALLY ILL PATIENTAbdominal Paracentesis Drainage Ahead of Percutaneous Catheter Drainage Benefits Patients Attacked by Acute Pancreatitis With Fluid CollectionsA Retrospective Clinical Cohort Study*Wei-hui Liu, MD; Li-na Ren, MD; Tao Chen, MD; Li-ye Liu, MD; Jin-heng Jiang, MD;Tao Wang, MD; Chuan Xu, MD; Hong-tao Yan, MD; Xiao-bo Zheng, MD; Fu-qiang Song, MD;Li-jun Tang, MDCrit Care Med. 2015 Jan;43(1):109-19. doi: 10.1097/CCM.0000000000000606. IMPORTANCE | 背景Based on the optional existed treatments, inspired by the revised Atlanta classification of AP, we are trying a novel step-up approach in which PCD is carried out after abdominal paracentesis drainage (APD) and necrosectomy is performed using a minimally invasive approach (endoscopic necrosectomy).APD is totally different from PCD in various aspects .First, different puncturation sites are used: APD is performed from the right paracolic sulci or left paracolic sulci into the abdominal cavity or pelvic cavity, whereas PCD is mainly performed in the (peri)pancreatic region, left pararenal region, or right pararenal region. Second, the puncturations have distinct purposes: in APD, puncturation is used to remove seroperitoneum; in contrast, PCD is used to eliminate (peri)pancreatic collections. Third, the timing of the puncturation varies: APD is carried out as early as possible (within 4 wk from the onset of AP), and PCD is started later (after 4 wk).


受胰腺炎的《亚特兰大分类标准( 修订版) 》的启发,基于现有可选择的治疗手段,我们尝试一种新的升阶梯治疗方法,即在经皮穿刺置管(PCD)之前行腹腔穿刺引流术(APD),并且采用微创的方法实施坏死组织清除术(经内镜坏死组织清除术)。APD与PCD存在以下不同之处:1.穿刺管置入部位不同:APD常放置入腹腔或盆腔,位于左、右结肠旁沟附近,PCD主要放置在胰腺周围、左肾区或右肾区。2.穿刺的目的不同:APD常用于引流腹腔积液,而PCD常用于引流胰腺周围的液体积聚。3.穿刺时机不同:APD实施要尽早进行(在急性胰腺炎发病后4周内),而PCD开始的时间较晚(在发病4周后)。


OBJECTIVE | 目的The efficacy and safety of ultrasound-guided abdominal paracentesis drainage ahead of percutaneous catheter drainage as the new second step of a step-up approach are evaluated.
评价在经皮置管引流(PCD)之前经超声引导下行腹腔穿刺引流术(APD)的有效性及安全性。

DESIGN, SETTING, AND PARTICIPANTS | 设计,场景及研究人群This retrospective study included 102 consecutive patients with acute pancreatitis from June 2009 to June 2011. In this retrospective study were all patients with SAP and moderately severe acute pancreatitis (MSAP), admitted to the General Surgery Center, Postdoctoral Working Station,China.
这项回顾性研究入选了自2009年6月至2011年6月在中国一个普外科治疗中心(博士后工作站)住院治疗的102名急性胰腺炎患者,所有患者均为重症急性胰腺炎(SAP)和中度急性胰腺炎(MSAP)。

INTERVENTIONS | 干预措施The patients were separated into two groups according to whether or not they had APD before PCD. The patients in the APD + PCD group underwent APD treatment in preparation of PCD intervention, and the patients in the PCD-alone group did not undergo APD before PCD.
按照是否在PCD之前实施APD治疗而将患者分为两组,即APD+PCD组(PCD之前接受APD治疗)和单独PCD组(在PCD之前未接受APD治疗)。

MAIN OUTCOMES AND MEASURES | 主要预后指标The primary endpoint was mortality rate.The secondary endpoints were as:1. Rate of intervention-related complications, including bleeding, fistula, and discomfort. 2. Severity scores (APACHE II and CTSI) of patients before and after APD. 3. Differences in levels of inflammatory cytokines—C-reactive protein (CRP), interleukin (IL)-6, IL-10, tumor necrosis factor (TNF)-α—before and after APD. 4. Prevalence of pneumonia, bacteremia, or sepsis before APD and reversal of sepsis after APD. 5. Difference in leukocyte counts before and after APD. 6. Prevalence of organ failure before and after APD (transient or persistent). 7. Details of PCD (interval from onset of AP to initial PCD,number of PCD interventions, initial catheter size of PCD,and complications with PCD). 8. Necrosectomy indexes (proportion of patients requiring necrosectomy after initial PCD, time from initial PCD to first necrosectomy, and number of necrosectomies) .
主要观察终点指标为死亡率。次要观察终点指标包括:
1.干预治疗的相关并发症(出血、瘘、不舒适感)。
2.APD前后病情严重程度评分(APACHE II 和 CTSI)的变化。
3.APD前后炎症因子水平的变化(C反应蛋白、IL-6、IL-10、TNF-α)。
4.APD前肺炎、菌血症、脓毒症的发生率以及APD后脓毒症的好转情况。
5.APD前后白细胞计数的变化情况。
6.APD前后器官功能衰竭(一过性或持续性的)的发生率。
7.PCD的详细资料(急性胰腺炎发病至首次行PCD的时间、PCD置管次数、首次PCD的导管尺寸、PCD的并发症)。
8.坏死组织清除术的相关指标(首次PCD后仍需要坏死组织清除术的患者比例、从首次PCD到首次坏死组织清除术的间隔时间、坏死组织清除术的次数)。

RESULTS | 结果The mortality rate in the PCD-alone group was 4 of 49 patients (8.0%), and disease-specific mortality was 4 of 49 patients; in contrast, the mortality rate in the APD + PCD group (2/53 patients, 3.8%) was lower than in the PCD-alone group (p < 0.05) (Table 2).The APACHE II scores, Ranson scores, and Marshall scores were significantly lower in the APD + PCD group compared with the PCD-alone group (p < 0.05) (Table 3). The laboratory variables decreased more rapidly in the APD + PCD group than in the PCD-alone group (p < 0.05) (Table 3). The mean WBC count in the APD + PCD group (14 ± 2.3 × 10E9/L) was close to that of the PCD-alone group (14 ± 1.7 × 10E9/L); however, WBC recovery took longer in most of the patients in PCD-alone group than in those in the APD + PCD group (p >0.05). The prevalence of sepsis was a little higher in the PCD-alone group (19/49, 38%) compared with the APD + PCD group (16/53, 30%), but not pneumonia or bacteremia. There were significant differences in frequency of organ failure developing at different periods from the onset of the disease between the two groups (p < 0.05) (Table 5). The interval between the onset of symptoms and the first PCD insertion was a little longer in the APD + PCD group than in the PCD-alone group (p < 0.05).The rates of total PCD complications were 28.6% and 30.2% in the PCD-alone group and the APD+PCD group, respectively. After initial PCD, 20 patients (40.8%) in the PCD-alone group underwent necrosectomy, compared with 15 patients (28.3%) in the APD + PCD group (p < 0.05). The interval between the initial PCD and the first necrosectomy was similar between two groups. The number of both endoscopic and open procedures was much higher in the PCD-alone group (n = 40) than in the APD + PCD group (n = 27) (p < 0.05) (Table 6).
单独PCD组的49例患者中有4例死亡,死亡率为8%,并且4例患者均死于胰腺炎;而APD+PCD组患者的死亡率(2/53,3.8%)明显低于单独PCD组(P < 0.05)(表2)。两组之间的APACHE II评分、Ranson评分以及Marshall评分比较结果显示:APD+PCD组要明显低于单独PCD组(P < 0.05)(表3)。APD+PCD组患者的各项实验室指标的下降速度也快于单独PCD组(P < 0.05)(表3)。


白细胞平均值比较显示APD+PCD组(14 ± 2.3 × 10E9/L)与单独PCD组(14 ± 1.7 × 10E9/L)相似,单独PCD组白细胞恢复正常的时间长于APD+PCD组(P >0.05)。单独PCD组的脓毒症发生率(19/49, 38%)略高于APD+PCD组(16/53, 30%),但是肺炎及菌血症的发生率在两组之间无显著统计学差异。在疾病发展的不同时期,两组患者器官功能衰竭的发生率都有统计学差异(P < 0.05)(表5)。


APD+PCD组患者从发病到首次行PCD的时间要略长于单独PCD组患者(P < 0.05)。单独PCD组和APD+PCD组患者的PCD相关并发症发生率分别为28.6%和30.2%。在首次PCD术后,单独PCD组中有20名患者(40.8%)需要进一步实施坏死组织清除术,而APD+PCD组有15名患者(28.3%)需行坏死组织清除术(P < 0.05)。两组患者从实施首次PCD术到首次坏死组织清除术的间隔时间是相似的。经内镜和开腹手术的例数在单独PCD组(n = 40)要明显高于APD+PCD组(n = 27)(P < 0.05)(表6)。



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