72例胰腺損傷診治分析

高云瀚,王 燦,楊 錢

(重慶市急救醫(yī)療中心普外科 400014)

72例胰腺損傷診治分析

高云瀚,王 燦,楊 錢

(重慶市急救醫(yī)療中心普外科 400014)

目的探討胰腺損傷的診斷和治療方法?方法 對近10年間該院手術(shù)治療的胰腺損傷72例作回顧性分析?主要診斷技術(shù)為CT,MRI,內(nèi)鏡逆行胰膽管造影(ERCP)等;手術(shù)方法包括修補加引流術(shù)?遠(yuǎn)端胰腺切除術(shù)?空腸與遠(yuǎn)端胰腺Roux-en-Y吻合術(shù)?胰十二指腸修補術(shù)加廣泛引流?胰十二指腸修補術(shù)加憩室化術(shù)和“損傷控制外科(DCS)”術(shù)等術(shù)式?結(jié)果52例腹內(nèi)臟器合并傷中,穿透傷13例(25%),鈍性傷39例(75%),二者比較差異無統(tǒng)計學(xué)意義(χ2=0.000,P0.05);49例腹以外部位合并傷中,穿透傷6例(12.24%),鈍性傷43例(87.76%),二者比較差異有統(tǒng)計學(xué)意義(χ2=13.310,P0.01)?72例患者中死亡9例(12.5%),合并傷?失血總量?傷后至手術(shù)時間等因素與患者死亡具有相關(guān)性(P0.05)?術(shù)后并發(fā)癥共18例(25%),Ⅰ～Ⅱ級傷3例,Ⅲ～Ⅴ級傷15例,二者比較差異有統(tǒng)計學(xué)意義(χ2=10.667,P0.01)?術(shù)后并發(fā)癥包括出血?胰瘺?胰腺假性囊腫?胰腺膿腫?創(chuàng)傷性胰腺炎?胰腺內(nèi)外分泌功能障礙等?72例患者中存活63例?34例胰腺損傷級別為Ⅲ～Ⅴ級的患者,傷后隨訪6個月至22年(中位數(shù)隨訪時間2年),情況良好?結(jié)論避免胰腺損傷早期漏診,手術(shù)時迅速控制合并傷大出血,按胰腺損傷分級采用不同術(shù)式,可明顯減少并發(fā)癥和病死率?

胰腺;創(chuàng)傷和損傷;診斷;外科手術(shù)

近年來,胰腺損傷的發(fā)病率在中國呈明顯增高的趨勢,這與車輛逐年增多有關(guān)?而車禍中方向盤損傷是導(dǎo)致胰腺損傷的重要原因?胰腺損傷容易發(fā)生早期漏?誤診,帶來嚴(yán)重后果;同時,手術(shù)治療方法的不恰當(dāng),也會增加并發(fā)癥的發(fā)生率和致死率[1-4]?因此,對早期診斷和正確的手術(shù)方式需加強認(rèn)識?現(xiàn)結(jié)合本院2002年1月至2011年12月手術(shù)治療的胰腺損傷患者72例,進(jìn)行回顧性分析?

1 資料與方法

1.1 一般資料 本組72例患者中男61例,女11例;年齡17～82歲,平均32.8歲?穿透傷18例,鈍性傷54例;39例交通事故傷中,35例為方向盤損傷?受傷至入院時間小于1h者36例,≥1～6h者28例,>6h者8例?42例患者入院時有失血性休克?除20例患者單一胰腺損傷(穿透傷5例,鈍性傷15例)外,其余52例患者均合并腹內(nèi)其他臟器損傷?52例合并傷中,49例還合并腹以外部位傷;35例方向盤所致胰損傷中,28例合并心肌挫傷?

1.2 胰腺損傷診斷 術(shù)前診斷24例(33.3%),包括CT確診22例,內(nèi)鏡逆行胰膽管造影(ERCP)確診2例;術(shù)中診斷48例(66.7%),18例穿透傷患者和30例鈍性傷患者系急診剖腹術(shù)中確診胰腺損傷?全組均有腹部體征,18例血清淀粉酶增高,11例腹腔穿刺液淀粉酶增高,44例腹腔穿刺抽出不凝血?胰腺損傷部位:胰頭17例,胰頸7例,胰體25例,胰尾23例?美國創(chuàng)傷外科學(xué)會器官損傷分級(AAST-OIS)[5]:Ⅰ級8例,Ⅱ級28例,Ⅲ級19例,Ⅳ級11例,Ⅴ級6例?主胰管損傷共占全組的50.0%?

1.3 治療方法

1.3.1 胰腺損傷治療 胰腺損傷手術(shù)方式見表1?其中4例實施“損傷控制外科(damage control surgery,DCS)”術(shù),具體方法是將治療分3階段,(1)初期簡化手術(shù):僅暫時止血(結(jié)扎?填塞)和阻斷污染(鉗閉或結(jié)扎斷裂腸管等),并作腹腔引流;(2)ICU復(fù)蘇:糾正血流動力學(xué)障礙,改善通氣,治療“致死三聯(lián)征”;(3)48～72h后行確定性手術(shù)[2,6-10]?4例初期手術(shù)僅止血?阻斷污染和引流,ICU復(fù)蘇成功的2例在48～72h行保脾遠(yuǎn)端胰切除術(shù)?采用任何術(shù)式均同時作充分的腹腔引流,并在術(shù)后給予抑分泌治療,包括禁食?胃減壓?腸外營養(yǎng)和使用分泌抑制藥?術(shù)后無胰瘺者,使用奧曲肽0.1mg皮下注射,每日3次,3～5d停藥;腹腔引流管在手術(shù)1～2周后拔除,并停止胃減壓和開始流質(zhì)飲食?發(fā)生胰瘺者,連續(xù)使用奧曲肽;漏量大于300mL/d者,改用生長抑素6mg/d,靜脈泵持續(xù)輸入,并繼續(xù)胃減壓和腸外營養(yǎng)(3例在術(shù)后7～10d經(jīng)鼻腸管做空腸營養(yǎng))?所有患者均使用預(yù)防性抗生素?

表1 72例胰腺損傷急診手術(shù)方式(n)

1.3.2 合并傷治療 腹內(nèi)臟器合并傷均在急診剖腹術(shù)同時處理;腹以外部位傷,除心肌挫傷行心肌保護(hù)?限液和藥物等治療外,需手術(shù)者在急診剖腹術(shù)后血流動力學(xué)已穩(wěn)定情況下,施行相應(yīng)手術(shù),手術(shù)方式見表2?

表2 合并傷手術(shù)方式(n)

1.4 統(tǒng)計學(xué)處理 使用SPSS17.0統(tǒng)計軟件進(jìn)行統(tǒng)計學(xué)處理,計數(shù)資料采用χ2檢驗,以P0.05為差異有統(tǒng)計學(xué)意義?

2 結(jié) 果

2.1 合并傷損傷分類結(jié)果 52例腹內(nèi)臟器合并傷中,穿透傷13例(25.0%),鈍性傷39例(75.0%),二者比較差異無統(tǒng)計學(xué)意義(χ2=0.000,P0.05);49例腹以外部位合并傷中,穿透傷6例(12.2%),鈍性傷43例(87.8%),二者比較差異有統(tǒng)計學(xué)意義(χ2=13.310,P0.01)?

2.2 患者死亡相關(guān)因素分析結(jié)果 72例患者中死亡9例(12.5%)?其中8例患者死于血管損傷或其他實質(zhì)臟器大出血;另1例患者合并有單純肋骨骨折和小量血胸,術(shù)中對主胰管損傷只做了修補和引流,術(shù)后出現(xiàn)大量胰漏和胰腺膿腫,繼發(fā)大出血和腸瘺,最后該患者死于全身炎癥反應(yīng)綜合征?72例患者死亡相關(guān)因素分析見表3?

表3 72例患者死亡相關(guān)因素分析

2.3 并發(fā)癥發(fā)生情況 術(shù)后并發(fā)癥共18例(25%),Ⅰ～Ⅱ級傷3例,Ⅲ～Ⅴ級傷15例,二者比較差異有統(tǒng)計學(xué)意義(χ2=10.667,P0.01)?術(shù)后并發(fā)癥包括出血?胰瘺?胰腺假性囊腫?胰腺膿腫?創(chuàng)傷性胰腺炎?胰腺內(nèi)外分泌功能障礙等?

2.4 隨訪結(jié)果 72例患者中存活63例?34例胰腺損傷級別為Ⅲ～Ⅴ級的患者,傷后隨訪6個月至22年(中位數(shù)隨訪時間2年),情況良好?

3 討 論

本組鈍性傷占75.0%,與 Ahmed和 Vernick[2]及Stawicki和Schwab[9]報道的穿透傷占多數(shù)相反?本組中方向盤所致胰腺損傷占48.6%,其中80.0%還合并鈍性心臟損傷?交通事故中方向盤損傷時,應(yīng)高度警惕胰腺和心臟損傷的發(fā)生?急診剖腹術(shù)時應(yīng)剪開胃結(jié)腸韌帶仔細(xì)探查胰腺,尤其注意有無主胰管損傷?本組2例雖術(shù)中發(fā)現(xiàn)胰腺挫裂傷,但漏診主胰管傷,手術(shù)方式不到位,術(shù)后并發(fā)胰瘺,經(jīng)螺旋CT和ERCP證實主胰管斷裂?因此,即使胰腺小血腫也要剪開包膜探查,仔細(xì)顯露腺體破裂處主胰管,擠壓胰腺觀察有無胰液從破口溢出?未行急診剖腹探查術(shù)者應(yīng)采用新一代CT?MRI等檢查,以明確胰腺損傷情況,ERCP是發(fā)現(xiàn)主胰管損傷最可靠的方法[11-18]?Velmahos等[14]和Phelan等[15]指出,CT診斷胰腺損傷靈敏度不夠高,但對主胰管傷的診斷具特異性?

胰腺損傷手術(shù)方式的選擇取決于有無主胰管損傷[4,16]?無主胰管損傷(Ⅰ～Ⅱ級傷)時,只須引流或加修補;雖然Pata等[19]對Ⅲ級胰腺損傷嘗試非手術(shù)治療,但多數(shù)作者指出主胰管損傷(Ⅲ～Ⅴ級)均應(yīng)手術(shù),并按部位選擇術(shù)式;無論何種術(shù)式,均應(yīng)同時行充分的腹腔引流[4,8-9]?體尾部主胰管損傷應(yīng)行遠(yuǎn)端胰切除術(shù),既妥善止血?確切結(jié)扎主胰管,又清除了失活組織,避免壞死組織感染后繼發(fā)性出血?胰瘺?假性囊腫和膿腫等并發(fā)癥的發(fā)生?無脾傷或脾傷輕者可采用保脾切胰措施[3-4,11,18],本組8例保脾切胰,其中 3例結(jié) 扎脾動脈,無并發(fā)癥?結(jié)扎脾動脈的保脾切胰,注意保留胃短動脈?胰頭頸部的主胰管損傷(Ⅳ～Ⅴ級),行遠(yuǎn)端胰與空腸的Roux-en-Y吻合,胰頭端主胰管結(jié)扎并妥善縫閉和大網(wǎng)膜覆蓋?本組4例遠(yuǎn)端胰空腸端端套入,未置支撐,采用彭淑牖和何小偉[6]推薦的捆綁式吻合,無胰瘺發(fā)生?胰十二指腸聯(lián)合傷時,實施 Whipple手術(shù)病死率高達(dá)31%～36%,除非胰頭和十二指腸降段失活被迫采用此術(shù)式,即使壺腹部破裂仍宜采取多處修補加胰管?膽管和十二指腸腔內(nèi)外充分引流[7]?本組6例中,4例分別采用修復(fù)胰頭和十二指腸加多處引流(壺腹傷置支撐管經(jīng)十二指腸引流,十二指腸減壓引流?膽道“T”管引流和胰床充分引流);僅2例行Whipple手術(shù),6例患者均存活?瀕死患者可采用DCS術(shù),指征主要為患者出現(xiàn)“致死三聯(lián)征”(凝血障礙?低溫?酸中毒)[10],本組中4例初期手術(shù)均為填塞和結(jié)扎止血,同時充分腹腔引流,ICU復(fù)蘇成功的2例,48～72h間行保脾遠(yuǎn)端胰切除術(shù),順利康復(fù)?Seamon等[8]指出,在嚴(yán)重胰腺損傷實施DCS術(shù)時,不加引流的填塞會增加病死率,應(yīng)避免?

本組統(tǒng)計顯示,無論穿透傷和鈍性傷均大多合并腹內(nèi)其他臟器傷,而鈍性傷比穿透傷更易合并腹以外部位多發(fā)傷?單一胰腺損傷甚少引起患者死亡,合并血管和實質(zhì)臟器傷大出血?多發(fā)傷是主要死亡原因,其次為術(shù)后并發(fā)癥[11,13,20]?本組死于合并傷8例,并發(fā)癥1例?因此,首先控制合并傷大出血是提高患者生存率的關(guān)鍵?另外,腎臟損傷15例中累及左腎12例,說明胰腺損傷時易累及左腎,術(shù)中應(yīng)仔細(xì)探查?本組有28例(38.89%)合并心肌挫傷,方向盤損傷時更須特別警惕,并做相應(yīng)的檢查,如心肌酶譜?肌鈣蛋白和超聲心動圖,經(jīng)食管超聲心動圖(TEE)可提高診斷靈敏度?

本組并發(fā)癥發(fā)生率28.13%,與文獻(xiàn)報告相近[14]?并發(fā)癥治療常需聯(lián)合使用介入?內(nèi)鏡和手術(shù)治療[9]?與胰腺損傷直接相關(guān)的并發(fā)癥主要為出血?胰瘺?胰腺假性囊腫?胰腺膿腫?創(chuàng)傷性胰腺炎?胰腺內(nèi)外分泌功能障礙等?最危急者為出血,可為繼續(xù)出血和繼發(fā)性出血,前者多因手術(shù)不當(dāng)?止血不善,術(shù)后立即出現(xiàn);后者原因有化學(xué)性和感染性,即胰液腐蝕性出血和胰腺損傷組織壞死感染后出血,多在手術(shù)2d后出現(xiàn)?胰瘺在主胰管損傷時發(fā)生率增高,故應(yīng)妥善結(jié)扎或內(nèi)外引流,引流物至少保留1～2周;術(shù)后抑分泌治療,包括禁食,引出胃液和使用注射用生長抑素,可減少胰瘺發(fā)生或促進(jìn)愈合?假性囊腫除迅速增大者急診外引流,一般先行非手術(shù)治療?超聲引導(dǎo)下穿刺置管引流?ERCP下鼻胰管引流?腹腔鏡下置管引流等方法,都是近年來日漸用于臨床的有效非手術(shù)治療技術(shù)?作者不贊成用胃鏡經(jīng)胃后壁開窗,此法非但引流不暢,反而會增加囊腫感染概率?通常保守治療2個月無效再引流,此時囊壁增厚利于吻合?胰腺膿腫應(yīng)及時再手術(shù)引流,拖延將導(dǎo)致繼發(fā)性出血?胃腸瘺和全身炎癥反應(yīng)綜合征等更嚴(yán)重的并發(fā)癥?為避免胰功能障礙,胰切除量不超過80.0%,否則選擇遠(yuǎn)端胰與空腸的Roux-en-Y吻合?漏診再手術(shù)和術(shù)式不當(dāng)使并發(fā)癥發(fā)生概率大增,甚至導(dǎo)致不應(yīng)有的死亡[1,2,4,20]?本組1例手術(shù)主胰管損傷卻只做了修補和引流,未行遠(yuǎn)端胰切除,術(shù)后出現(xiàn)胰瘺和胰腺膿腫,繼發(fā)大出血和腸瘺,患者死于全身炎癥反應(yīng)綜合征,實為深刻教訓(xùn)?

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Analysis of dignosis and treatment of 72 cases with pancreatic injures

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ObjectiveTo explore diagnostic and therapeutic modalities of pancreatic trauma.MethodsThe dates of 72patients with pancreatic injuries treated operatively during the past 10years in chongqing emergency medical center(CEMC)were studied retrospectively.The diagnosticMethodswere mainly CT,MRI,and ERCP etc.Various surgical procedures included simple suture or drainage,distal pancreatectomy,distal pancreaticojejunostomy,pancreaticoduodenal repair plus a diverticularization and multiple drainage,Whipple′s procedure,and damage control surgery(DCS),etc.Results52patients had associated injuries of other viscera in the abdomen;of them 13(25%)were penetrating injury,and 39(75%)blunt(χ2=0.000,P0.05).49patients sustained simultaneity extra-abdominal injuries;of them 6(12.24%)were penetrating,and 43(87.76%)blunt(χ2=13.310,P0.01).The overall mortality rate was 12.5%(9/72).Relatively lethal factors were associated injuries,the amount of blood loss,and preoperative time,etc.Postoperative morbidity was 25%(18/72)including bleeding,pancreatic fistula,pancreatic pseudocyst,pancreatic abscess,traumatic pancreatitis,and disfunction of internal and external secretion of the pancreas,etc.There was a significant difference of the incidence of postoperative complication between gradeⅢ-Ⅴ(15/18)and gradeⅠ-Ⅱ(3/18,χ2=10.667,P0.01).Of 63survivors,34with pancreatic injury of gradeⅢ-Ⅴ were followed up from 6months to 22years(medium was 2years),the patients′conditions were well.ConclusionTo decrease obviously the morbidity and mortality in the patients with pancreatic injuries,it is critical that initially missed diagnosis of pancreatic injuries is avoided,massive hemorrhage from associated injuries is ceased expeditiously during the operation,and a corresponding surgical procedure is selected exactly based on the classification of pancreatic injury.

pancreas;wounds and injuries;diagnosis;surgical procedures,operative

10.3969/j.issn.1671-8348.2012.18.008

A

1671-8348(2012)18-1808-03

2012-01-08

2012-03-01)

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