重症急性胰腺炎并发深部真菌感染的病因分析和外科治疗

目的 分析重症急性胰腺炎患者并发深部真菌感染的主要易感因素并探讨防治措施。方法 回顾性分析1994年1月～2003年12月我院外科收治的10例重症急性胰腺炎(SAP)并发深部真菌感染患者的临床资料。结果 SAP并发深部真菌感染以念珠菌为主，病死率为50％。病情严重、病程长、全身性感染、长期使用抗生素和机体免疫力低下对真菌感染有重要影响。结论 深部真菌感染与SAP病情严重、全身性感染、长期使用抗生素密切相关。对SAP本身的综合治疗是防治深部真菌感染的关键。     

重症急性胰腺炎早期感染的危险因素分析

目的：探讨重症急性胰腺炎（ＳＡＰ）早期胰腺感染的易感因素。方法：将１９９８年１月～２０００年１２目间收治重症急性胰腺炎６８例,根据发病后２局内胰腺是否继发感染．分为感染组和非感染组,并分析其易感因素。结果：胰腺继发感染的总发主率为４１．２％;ＡＰＡＣＨＥ ＩＩ积分与胰腺感染发生之间呈明显的正相关性（ｒ＝０．３１,Ｐ＜０．０１）;放置胃管≥７天、肠切能障碍≥５天、施行腹腔灌洗手术、胰腺有坏死及胆源性胰腺炎等危险因素与 ＳＡＰ患者继发胰腺感染的发生率明显相关（Ｐ＜０．０５）;其余各影响因素与胰腺感染均无明显联系（Ｐ＞０．０５）。结论：胃肠道功能障碍≥５天、胆源性胰腺炎、早期胰腺明显坏死和腹腔灌洗引流等是ＳＡＰ自期胰腺感染的主要易感因素。     

重症急性胰腺炎的营养支持

目的探讨营养支持在重症急性胰腺炎治疗过程的作用。方法对４６例重症急性胰腺炎病人进行治疗的同时给予营养支持。在行全肠外营养２～３周后始加用肠内营养,同时减少肠外营养量;肠外营养加肠内营养１周后逐步改为全肠内营养,直到病人达到了或基本达到了正氮平衡。结果在营养支持期间,绝大多数病人达到了或基本达到了正氮平衡。结论只要使用和管理妥当,营养支持在重症胰腺炎治疗中将会达到良好的预期目的。     

重症急性胰腺炎合并真菌感染(文献综述)

感染是重症急性胰腺炎后期的主要死因。重症急性胰腺炎合并真菌感染的发生率近年明显上升 ,并已成为重症急性胰腺炎后期治疗的主要困难之一。本文重点介绍了重症急性胰腺炎合并真菌感染的发病趋势、危险因素、治疗及真菌感染对重症急性胰腺炎治疗结果的影响。     

重症急性胰腺炎合并真菌感染（文献综述）

感染是重症急性胰腺炎后期的主要死因。重症急性胰腺炎合并真菌感染的发生率近年明显上升，并已成为重症急性胰腺炎后期治疗的主要困难之一。本文重点介绍了重症急性胰腺炎合并真菌感染的发病趋势、危险因素、治疗及真菌感染对重症急性胰腺炎治疗结果的影响。     

重症急性胰腺炎并发结肠瘘的原因和治疗

目的 探讨重症生胰腺炎并发结肠瘘的原因及预防和治疗手段，方法 对１９８５年１月至１９９７年５月间收治的１２６例重症急性胰腺炎进行回顾性分析，并对可能导致肠瘘发生的危险因素和采用的治疗方法进行总结。结果 １２６例手术治疗的重症急性胰腺炎发生结肠瘘２５例，２５例结肠瘘均发生于术后２８天，有胰外感染的较无感染的发生率高（Ｐ〈０．０１）；晚期（两周后）手术较早期（两周内）手术发生率高（Ｐ〈０．０５），经后     

合理营养支持对重症急性胰腺炎治疗作用的研究

目的　探讨合理营养支持对重症急性胰腺炎治疗的作用。方法　将 96例重症急性胰腺炎病人随机分为全胃肠外营养组和肠内与肠外营养结合组。分别检测血清内毒素、尿L/M值、CD4 /CD8比值和IgG水平以监测肠黏膜通透性和免疫状态的改变 ,同时观察TNF α和IL 6血清病人感染率和死亡率。结果　肠内与肠外结合营养组病人血清IgG和CD4 /CD8明显高于全胃肠外营养组 (P <0 0 5 ) ,而内毒素、尿L/M值以及TNF α、IL 6水平则明显低于全胃肠外营养组 (P <0 0 5 ) ,病人感染率和死亡率亦明显降低 (P <0 0 5 )。结论　合理应用肠外与肠内营养相结合的营养支持方式可缓解炎性细胞因子及炎性介质的释放 ,从而对重症急性胰腺炎具有积极的治疗作用。     

肠内营养对重症胰腺炎患者免疫功能的影响

目的 研究肠内营养对重症胰腺炎患者免疫功能的影响。方法 对我院自2001～2002年32例重症胰腺炎病人行肠内营养(EN)的免疫球蛋白、细胞因子和红细胞免疫功能进行检测。并与30例采用肠外营养(TPN)的病人进行比较。结果 EN组应用1周后IgA浓度明显提高，IL-6明显提高，IL-10显著下降。红细胞C3b受体花结率(RRCR)明显提高。结论 肠内营养对重症胰腺炎病人免疫功能有增强作用。     

抗菌药物对预防重症急性胰腺炎感染的作用

为探讨抗菌药物对预防重症急性胰腺炎感染的作用，作者对１９９０年１０月至１９９５年３月收治的１０７例重症急性胰腺炎给予预防性使用环丙沙星加甲硝唑。方法：重症胰腺炎诊断明确后即经静脉给环丙沙星０．２ｇ加甲硝唑０．５ｇ，每１２小时一次，以后根据病情或药敏试验选用有效治疗性抗菌药物。结果：发生胰腺及胰同感染１１例（１０．３％），均为重症Ⅱ型及ＢａｌｔｈａｚａｒＤ、Ｅ级，细菌种类包括大肠杆菌、肠球菌、假单胞菌属及念珠菌等。肺及泌尿系感染１６例（１％），肠道菌群紊乱及真菌感染２７例（２５．２％）。死亡１２例，死亡率１１．２％。提示对重症急性胰腺炎预防性使用抗菌药物能降低继发胰腺感染的发生率及死亡率。抗菌药物应用时间不宜太长；若伴真菌感染，应给予抗真菌药物。     

重症胰腺炎合并急性肾功能衰竭相关因素分析

目的分析重症急性胰腺炎(SAP)合并急性肾功能衰竭(ARF)的临床特点及防治措施。方法回顾分析我院2000年1月至2006年12月收治SAP合并ARF的46例病人的临床资料,并用直线回归方法,对影响SAP合并ARF病死率的相关因素进行分析。结果病人的年龄、全身炎症反应综合征(SIRS)持续时间、病情严重程度(APACHEⅡ评分),急性呼吸窘迫综合征(ARDS)、多器官功能障碍综合征(MODS)、腹腔间室综合征(ACS)、感染及局部并发症等因素对预后有显著的影响。46例中死亡28例(60.9%),同时合并ARDS和MODS是病死率增加的重要原因。结论早期液体复苏、控制病情发展、积极有效的引流及早期重要脏器功能的支持是预防SAP并发ARF,改善预后的重要手段。     

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近年来重症急性胰腺炎(severe acute pancreatitis,SAP)的营养模式发生了显著的变化,大致分为3个阶段:全胃肠外营养模式、阶段性营养支持模式和早期肠内营养模式。21世纪初期开始的早期肠内营养,即在SAP的急性期内,血流动力学和内稳态稳定后,立即建立空肠营养通道,开始肠内营养,只有当肠内营养不能实施时,才考虑用肠外营养。早期肠内营养不仅仅单纯作为"营养",而是同时作为调节过度炎性反应和预防肠源性感染的手段。越来越多的证据表明,早期肠内营养能够明显改善SAP预后,降低胰腺坏死组织感染发生率。     

Temporal assessment of Candida risk factors in the surgical intensive care unit.

HYPOTHESIS: Risk factors for Candida infection in surgical intensive care units (SICUs) change over time. Risk factor progression may influence Candida colonization and infection. DESIGN: Multicenter cohort survey. SETTING: Three urban teaching institutions. PATIENTS: A total of 301 consecutively admitted patients in SICUs for 5 or more days. MAIN OUTCOME MEASURES: Assessment of patients on SICU days 1, 3, 4, 6, and 8 and SICU discharge for risk factors, Candida colonization, and antifungal use. Candida colonization status was categorized as noncolonized (NC), locally colonized (LC) if 1 site was involved, and disseminated infection (DI) if 2 or more sites or candidemia were involved. RESULTS: The most frequent risk factors in the 301 patients enrolled were presence of peripheral and central intravenous catheters, bladder catheters, mechanical ventilation, and lack of enteral or intravenous nutrition. Early risk factors included total parenteral nutrition or central catheter at SICU day 1 and previous SICU admissions or surgical procedures. Peak number of risk factors (mean +/- SD) were as follows: 7.2 +/- 2.6 in NC (n = 229), 9.2 +/- 2.3 in LC (n = 45), and 9.2 +/- 2.6 in DI (n = 27). These numbers were reached at day 8 in the NC and LC groups and day 4 in the DI group. The LC and DI groups had more risk factors on each SICU day than the NC group and longer median SICU length of stay (28 days in the DI group vs 11 and 19 days in the NC and LC groups, respectively). Antifungal therapy, while used most frequently in the DI group, was initiated later for this group than in NC and LC groups. CONCLUSIONS: Risk factors for Candida infection in SICU patients change over time. Patients with DI demonstrate a greater number of and more rapid increase in risk factors than patients in the LC and NC groups. Presence of early risk factors at the time of SICU admission, a high incidence of risk factors, or a rapid increase in risk factors should prompt clinicians to obtain surveillance fungal cultures and consider empirical antifungal therapy.     

重症急性胰腺炎早期肠内营养的影响因素分析

目的 研究重症急性胰腺炎早期肠内营养(enteral nutrition,EN)应用的相关影响因素.方法 回顾上海交通大学医学院附属瑞金医院SICU收治的57例SAP(severe acute panereati tis)患者,以入科后EN开始时间分为A组(≤5 d)和B组(>5 d),比较组间相关影响因素差异.以不同营养途径分组比较EN开始时间及相关影响因素.结果 A组患者入科APACHEⅡ评分、Ranson评分和Bahhazar CT评分均显著低于B组(P<0.05),EN开始时A组患者APACHE Ⅱ评分低于B组,但无统计学意义.在并发症比较中,B组多脏器功能障碍综合征(multiple organ dysfunction of syndrome,MODS)、休克和腹腔间隔室综合征(abdominal compartment syndrome,ACS)的发病率明显高于A组(P<0.05),而其他并发症在两组间无统计学意义;鼻空肠管组患者入科时APACHE Ⅱ评分、Ranson评分和Balthazar CT评分均低于空肠造瘘管组,EN开始时间也显著提前(P<0.05).结论 SAP患者EN的应用受胰腺炎病情的严重度、严重并发症(休克、MODS与ACS)及喂养途径等多因素影响.早期EN的标准应当以病情评估为基础,以内环境稳定、胃肠功能开始恢复为起始标志,在≤5d内启用EN是可行的.APACHE Ⅱ评分对EN开始时机的把握可能具有指导意义.     

重症急性胰腺炎死亡的高危因素分析

目的探讨与重症急性胰腺炎（SAP）死亡相关的高危因素。方法回顾性分析2001年1月至2005年10月收治的141例SAP患者的临床资料。将患者分为死亡组和生存组,对可能影响SAP预后的15个因素采用Logistic回归分析。结果141例SAP患者中死亡34例（24．1％）。死亡组患者在年龄、体重指数、住院时间、APACHEⅡ评分和并发多器官功能障碍综合征（MODS）、腹腔室隔综合征（ACS）等方面与生存组相比差异有统计学意义（P〈0．05）。多因素分析显示,MODS（OR=67．358,P〈0．01）、APACHEII评分（OR=9．716,P〈0．01）和ACS（OR=5．775,P〈0．05）是早期影响SAP预后的独立危险因素;胰腺感染（OR=9．652,P〈0．01）、MODS（OR=5．212,P〈0．05）和腹腔出血（OR=4．707,P〈0．05）则是后期影响SAP预后的独立危险因素。结论SAP早期死亡的主要原因是MODS,特别是呼吸功能障碍和肾功能障碍,而后期死亡的主要原因是感染、MODS和腹腔出血。对高危因素进行早期预防和及时处理是降低SAP病死率的关键。     

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??Perioperative supplementary parenteral nutrition support therapy ZHU Ming-wei.Department of General Surgery, Beijing Hospital, National Center for Geriatrics, Beijing 100730??China
Abstract The incidence of malnutrition is high in surgical patients. Inadequate intake and gastrointestinal dysfunction are the main causes, which can lead to increased postoperative complications and prolonged hospitalization. Standardized nutritional support can improve the clinical outcome. Enteral nutrition is preferred as perioperative support to protect the intestinal barrier and immune function. Intolerance is the main reason of enteral nutrition which is difficult to implement. The insufficient supply of energy and protein for longer periods of time can lead to increased mortality and complications. The combined with PN on the basis of EN is the core of parenteral nutrition which is to maintain intestinal barrier function, quickly reach the target amount to meet the metabolic needs and improve the clinical outcome. The target patient of perioperative parenteral nutrition is that enteral nutrition can not provide more than 60% energy needs. The start of enteral nutrition in patients with low nutrition risk (NRS2002 ≤??or Nutric score ≤ 5 ) will start after 7 days; and start at 48-72 hours after operation for high preoperative nutritional risk (NRS2002 ≥5 or Nutric score≥6). Supplement of parenteral nutrition with glutamine and ω-3 fatty acids can optimize the clinical outcomes of surgical patients. The application of multichamber bags can reduce bloodstream infections and is suitable for short-term supplementary parenteral nutrition after surgery.     

Importance of a clinical protocol in the treatment of severe acute pancreatitis

BACKGROUND: Selection of the optimal treatment strategy in severe acute pancreatitis (SAP) is a serious clinical challenge largely due to difficult differential diagnosis of patients with early SAP. The aim of this study is a retrospective evaluation of the first experiences in the treatment of patients with SAP and early SAP according to a new complex clinical protocol (CCP). METHODS: A total of 210 patients complied with Atlanta recommendations for SAP and were included in the retrospective study. Patients were stratified into two groups according to the diagnostic and treatment strategy. Non-protocol (NP) group comprised 154 patients who had received their treatment based on previous clinical routine and subjective decision of physicians in charge. 56 patients who were managed according to the new CCP developed for SAP comprised the CCP group. CCP included:- Early assessment of the severity of acute pancreatitis (APACHE II score, presence of SIRS and/or organ dysfunction); - Immediate ICU monitoring including routine measurement of the intraabdominal pressure; - Conservative treatment including early enteral nutrition, colloids, antibacterial prophylaxis and early continuous venovenous hemofiltration (CVVHF) when indicated; - Surgical treatment when conservative treatment was not effective (progression of the organ dysfunction) or presence of infection was evident. Hospital, ICU stays and outcomes were analysed. Statistical comparison was done by Mann-Whitney U-test and Chi-square test. RESULTS: The age structure and severity of the disease were similar in both groups with mean of 51.3 (15.6) vs. 46.8 (15.2) years and 9.7 (5.1) vs. 9.8 (4.4) APACHE II points in groups NP and CCP, respectively. Male/female ratio was 2 : 1, and alcohol was the main etiologic factor in about 55 % of cases in both groups. Early SAP was diagnosed in 33 % to 46 % of patients according to the results of the SOFA scoring. The results of the conservative therapy considerably improved after implementation of the CCP treatment. Surgical intervention was done in 46-52 % of patients. MODS was the main cause of death in both groups. Remarkable decrease in early mortality (within the first week from admission) was a real advantage of CCP treatment comprising 1.8 % vs. 22.1 % in NP patients, p < 0.01. Mortality from early SAP was reduced by CCP treatment to 3.8 % compared to 33 % in NP group, p < 0.01. There was a considerable reduction in postoperative mortality with CCP treatment comprising 10.3 % vs. 32.7 % in patients who did not receive CCP treatment, p < 0.05. Overall mortality associated with CCP treatment ranged to 5 %, compared to 34 % mortality in the NP treatment group, p < 0.01. Due to the considerable number of early deaths among NP patients, there was statistically longer ICU and hospital stay in CP group with mean of 14.1 (14.1) vs. 9.6 (15.2) days and 37.9 (26.7) vs. 23.4 (21.8) days, compared to NP group, p < 0.01. CONCLUSIONS: Timely recognition and complex therapy of SAP including ICU monitoring, colloids, antibacterial prophylaxis, early enteral nutrition, and CVVHF is the most effective way how to manage this category of patients. Implementation of a specialised treatment protocol considerably improves outcome and reduces the number of deaths associated with surgery and early SAP.     

膳食纤维肠内营养对大鼠急性重症胰腺炎肠屏障功能的影响

目的探讨早期添加膳食纤维（dietary fiber，DF）、肠内营养（enteral nutrion，EN）对急性重症胰腺炎（severe acute pancreatitis，SAP）大鼠肠屏障功能的影响。方法SD大鼠32只，随机分成4组（n=8）：SAP组（A组），EN组（B组），膳食纤维肠内营养（fiber enteral nutrion，FEN）组（C组）和对照组即假手术组（D组）。采用逆行胰胆管注射3．5％牛磺胆酸钠溶液制成重症胰腺炎大鼠模型。A组和D组术后36h开始自由饮葡萄糖盐水；C组和B组术后36h开始空肠营养管分次注射肠内营养液。5d后再次麻醉大鼠，收集组织及血液标本；检测指标包括细菌移位率、胰腺病理评分、结肠组织形态学变化、血浆D-乳酸以及小肠黏膜固有层CD4^＋，CD8^＋和CD4^＋／CD8^＋比值等。结果SAP大鼠结肠黏膜萎缩，黏膜腺体稀疏。FEN组结肠黏膜形态变化好于EN组。FEN组细菌培养阳性率明显低于SAP组。FEN组血浆D-乳酸水平明显低于EN组。FEN组与EN组比较，胰腺病理学评分、CD4^＋、CD8^＋淋巴细胞数和CD4^＋／CD8^＋比值差异无统计学意义。结论添加DF的EN在维护SAP肠黏膜屏障、改善肠道免疫功能、防止细菌易位方面作用优于单纯EN。DF尚不能提高小肠局部免疫功能。     

围手术期补充性肠外营养支持治疗

外科病人营养不良的发生率常较高,摄入不足和胃肠功能减退是主要原因,可导致术后并发症增加和住院时间延长,规范的营养支持治疗可改善临床结局。围手术期营养支持首选肠内营养（EN）,以维护肠屏障和免疫功能,耐受性问题是导致EN难以实施或供给不足的主要原因,较长时间能量和蛋白质供给不足可导致病死率和并发症发生率升高,补充性肠外营养（PN）的核心是在EN的基础上联合PN,既维护肠屏障功能,又能较快到达目标喂养量,满足机体代谢需求,进而达到改善临床结局的目标。围手术期补充性PN的对象是EN不能满足60%以上能量需求的病人,低营养风险筛查2002（NRS2002）评分≤３分或危重症病人营养风险（NUTRIC）评分≤５分病人建议术后7 d启动;对于术前高营养风险（NRS2002评分≥5分或NUTRIC评分≥6分）,术后48~72 h开始。补充性PN处方中添加谷氨酰胺和ω-3脂肪酸可优化外科病人临床结局,多腔袋的应用可减少血流感染,适合外科术后短期补充性PN病人。     

重症急性胰腺炎完全胃肠外营养与肠外联合肠内营养治疗对比研究

目的 观察重症急性胰腺炎(SAP)完全胃肠外营养(TPN)与肠外营养(PN)联合肠内营养(EN)治疗中各项指标的变化,分析二者疗效.方法 29例SAP随机分为TPN组(14例)和PN+EN组(15例),并均行非手术治疗14 d,观察疗效及化验指标的变化.结果 营养支持治疗14 d后,各组血清白蛋白(ALB)、总蛋白(TSP)、血钙(Ca2+)、谷丙转氨酶(ALT)、谷草转氨酶(AST) 较营养支持前均显著升高(P<0.05);各组血糖、血清淀粉酶、血WBC均较营养支持前显著下降(P<0.05);各组血总胆红素(TB)治疗前后差异无统计学意义(P>0.05);PN+EN组血WBC显著低于TPN组(P<0.05),其余化验指标组间比较差异无统计学意义(P>0.05);各组APACHEⅡ评分较治疗前显著降低(P<0.05),PN+EN组评分显著低于TPN组(P<0.05).PN+EN组住院天数、住院总费用、感染发生率及死亡率均显著低于TPN组(P<0.05).结论 PN联合EN治疗SAP优于TPN.     

Management of Severe Acute Pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.