胰腺外伤14例临床分析

笔者回顾性分析 1 4例胰腺外伤患者临床资料 ,提出术中仔细探查是防止漏诊的关键 ,牢固结扎断裂的主胰管是成功的重要因素 ,充分的腹腔引流必不可少 ,特别是治疗并发症往往比治疗胰腺损伤更为重要 ,并就其术前、术中诊断及手术方式作了介绍及讨论     

腹腔内负压封闭引流治疗严重胰腺十二指肠损伤：附16例报告

目的：探讨应用负压封闭引流（VSD）技术治疗严重胰腺十二指肠损伤的价值。 方法：回顾性分析腹腔内应用VSD技术引流治疗的16例严重胰腺十二指肠损伤患者的临床资料;患者AAST损伤分级分别为III级10例,IV级4例,V级2例。 结果：患者的胰腺裂伤仅进行清创和创面止血、十二指肠裂口行单层缝合、合并伤予以相应处理、均在胰腺横断处和十二指肠损伤处行VSD;手术时间65~235 min,平均126 min;术后无1例病死,1例患者因术后腹腔出血转外院治疗,余15例腹部外伤住院时间为16~45 d;III级损伤患者术后发生十二指肠瘘5例,胰瘘3例,均经VSD后自行闭合;IV和V级损伤患者术后VSD持续引流出十二指肠液和胰液,待引流管周围瘘道完整后,再次手术行空肠-瘘道间Roux-en-Y吻合;随访 6个月至15年,无腹腔感染、腹腔积液、胰腺假性囊肿、肠梗阻等并发症发生。 结论：对于病情危重、难以耐受复杂手术的胰腺十二指肠损伤患者,可优先选择简单胰腺十二指肠创面处理加VSD进行治疗。     

严重肝外伤的处理

目的　探讨严重肝外伤的手术治疗效果。方法　对24例严重肝外伤患者的临床资料进行回顾性分析。结果　24例中,肝外伤属Ⅲ级者9例,Ⅳ级10例,Ⅴ级4例,Ⅵ级1例。1例未及手术于抢救中死亡;23例手术治疗;肝缝合修补4例,大网膜填塞修补3例,不规则肝切除16例。同时行肺修补4例,脾切除3例,胰尾切除1例。23例手术者均治愈,未发生严重并发症者。结论　手术是治疗严重肝外伤的有效方法。手术方式的选择应根据患者的局部和全身情况,以及当时、当地医院的条件选择合理术式。加强伴发伤和术后处理对降低严重肝外伤的死亡率有重要意义。     

胰腺外伤的诊断

胰腺外伤的诊断山东医科大学附属医院（２５００１２）寿楠海手术前诊断胰腺损伤的症状隐蔽，早期常缺乏症状，辅助检查不具特异性，术前诊断率低。合并有其它脏器损伤者仅表现为腹内大出血或弥漫性腹膜炎的体征，胰腺损伤易被忽视。凡较强的外力作用于上腹部，特别是老年...     

严重胰腺损伤合并多脏器损伤的外科治疗

目的 探讨严重胰腺损伤合并多脏器损伤的治疗方法.方法 回顾分析2005年1月-2010年12月收治的15例严重胰腺损伤合并多脏器损伤临床资料,包括胰腺损伤Ⅲ级10例,Ⅳ级4例,Ⅴ级l例.行Whipple手术1例,胰尾部切除+脾切除术3例,胰腺周围双套管负压持续冲洗引流10例,胰腺周围穿刺引流术l例,同时进行合并伤的治疗.结果 术后发生胰瘘12例,胰腺周围脓肿5例.治愈14例,1例经胰周穿刺引流治疗后1个月突发出血死亡.结论 严重胰腺损伤手术方式需个体化,术中遵循损伤控制性理念,胰周放置多根双套管,术后持续冲洗和负压引流,早期肠内营养等是提高治疗效果的关键.     

胰腺损伤23例临床诊治

由于胰腺的解剖位置较深,一旦被损伤,不易及时发现,所以发生率相对较低。但胰腺损伤若未能及时诊治,则后果严重,所以对胰腺损伤的诊治应予以重视。本院1988年10月至2002年8月,收治的23例胰腺损伤,现讨论如下。1临床资料1.1一般资料:本组23例中,男性17例,女6例;年龄23～55岁。损伤原因:腹部闭合性损伤18例,占81.5%,其中以车祸最多;开放性损伤5例。临床表现:均有上腹部疼痛,8例有恶心、呕吐,其中6例呕吐物为咖啡样物质,3例为胆汁,其余为胃内容。均有不同程度的腹膜刺激征。根据1990年美国创伤外科协会制定的“胰腺损伤的器官损伤分级标准”:Ⅰ…     

严重复杂的胰腺创伤临床处理探讨

目的 总结严重复杂性胰腺损伤的诊治经验.方法 回顾性分析21例的临床资料.其中男14例,女7例;年龄9～53岁,平均26岁;损伤分级:Ⅲ级8例,Ⅳ级8例,V级5例.主要诊断方法有淀粉酶测定、B超、CT、ERCP和MRCP等.均采取手术治疗,10例行远侧胰腺空肠Rouxen-Y吻合术;3例行胰头十二指肠切除术;2例行改良十二指肠憩室化手术;3例行胰腺尾部切除术;2例行胰腺断面缝合、主胰管内置管外引流;1例行胰腺两侧断端缝扎,后二期手术行远端胰腺空肠吻合术.结果 术前诊断明确11例,术中确诊10例.18例损伤后12 h内手术治疗,3例延期手术治疗.治愈20例,病死1例(胰头十二指肠切除术后).发生胰瘘并发症3例,经充分引流、药物治疗治愈.结论 胰腺严重创伤的诊断率仍较低,早期应积极剖腹探查弥补术前诊断的不足,手术方式要根据分级采取个体化方案,贯彻损伤控制性外科理念,不宜盲目扩大手术.     

小儿胰腺外伤的诊断与处理

随着社会经济的高速发展 ,人民生活水平的提高 ,现代化交通日益发达 ,各种新兴娱乐项目层出不穷 ,同时亦带来了交通、娱乐事故发生增多。其中 ,小儿胰腺损伤虽不常见 ,但临床过程有其特殊性 ,诊断治疗是否及时恰当 ,将在很大程度上决定患儿预后。本文就此重点做如下总结 ,旨在引起同道重视并供参考。1　小儿胰腺外伤的常见原因1 .1　解剖特点及致伤机制由于小儿体格小于成人 ,同样的创伤作用力下 ,对于小儿往往导致较大范围的损伤 ,因而多系统损伤在小儿更为常见 ;其次 ,小儿腹内脏器较成人缺乏强有力的肌肉以及丰富皮下组织保护 ,更易受伤 …     

严重复杂的胰腺创伤临床处理探讨

Objective To summarize the experience in diagnosis and management for severe and complicated pancreatic trauma. Methods The clinical data of 21 patients with severe pancreatic trauma treated in our hospital were retrospectively analyzed. Of the 21 with a mean age of 26 (9-53), 14were male and 7 female. The causes of trauma were blunt injuries in 13 and patent injuries in 8 of them. The injury grade distribution for these patients was grade Ⅲ in 8 cases, grade Ⅳ in 8, and grade V in 3. The main diagnostic modalities included amylase measurement, ultrasonography, CT,endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography (MRCP) etc. All patients received surgical procedures. Roux-en-Y distal pancreatojejunostomy was performed in 10 patients, pancreatoduodenectomy in 3, modified duodenal diverticulization in 2, distal pancreatectomy in 3, tube installing in major duct and external drainage, and suture of pancreatic section in 2, and suture of two broken side respectively (delayed distal pancreatojejunostomy in the second time) in 1. Results Pancreatic injury was confirmed in 11 cases preoperatively and intraoperatively in the others. The early emergency operation was performed in 18 patients within 12hours, and delayed operation was done in 3 cases. Twenty patients were cured and 1 died after a procedure of pancreatoduodenectomy. The postoperative pancreatic fistula happened in 3 cases and recovered well with conservative line of management. Conclusion The diagnosis of severe and complicated pancreatic trauma is difficultly yet, so the earlier exploratory laparotomy should be suggested. The individual surgical modality based on the grade should be adopted in the operation and the concept of "Damage Control Surgery" should be carried out in the procedure. Extended operation should be avoided.     

严重十二指肠损伤的治疗

目的探讨严重十二指肠损伤的治疗方法。方法回顾8年间手术治疗的严重十二指肠损伤和胰腺损伤38例患者的临床资料。结果十二指肠憩室化手术8例,5例痊愈,2例肠瘘,死亡1例。胰十二指肠切除9例,3例痊愈,胰瘘6例其中死亡3例。十二指肠直接修补或补片修补16例,13例痊愈,2例发生肠瘘,死亡1例。5例十二指肠修补+胰头切除胰腺空肠吻合(保留十二指肠的胰头切除),4例痊愈,1例胰瘘;其中3例行胰腺空肠捆绑吻合患者,无胰瘘发生,均痊愈出院。结论大部分十二指肠损伤可行十二指肠直接修补或补片修补加可靠的十二指肠和空肠造瘘术;对合并严重胰头部损伤者可在上述手术基础上行保留十二指肠的胰头切除,可获得比较满意的效果。不要轻易使用十二指肠憩室化手术和胰十二指肠切除手术。     

严重胰腺损伤的诊治

目的 探讨严重胰腺损伤的诊断与外科治疗方法。方法 回顾分析我院近20年32例3～5级胰腺损伤的临床资料。结果 术前腹腔穿刺液淀粉酶升高占50％,血淀粉酶升高者占60％(12／20)。B超检查10例,3例提示诊断。CT检查8例,3例提示诊断。术前诊断胰腺损伤仅10例。32例均手术治疗,术中证实胰腺损伤属3级者20例,4级10例,5级2例。治愈25例,死亡7例,死亡率21．9％。并发症有腹腔脓肿、胰瘘、胰腺假性囊肿等。结论 严重胰腺损伤合并伤多,术前诊断困难,术后并发症多和死亡率高。早期确诊、术中仔细探查,合理的手术方式是关键。术中B超和术中造影有助于诊断。生长激素和生长抑素的应用有较好的治疗效果。     

Management of pancreatic trauma

BACKGROUND: Pancreatic injury can pose a formidable challenge to the surgeon, and failure to manage it correctly may have devastating consequences for the patient. Management options for pancreatic trauma are reviewed and technical issues highlighted. METHOD: The English-language literature on pancreatic trauma from 1970 to 2006 was reviewed. RESULTS AND CONCLUSIONS: Most pancreatic injuries are minor and can be treated by external drainage. Injuries involving the body, neck and tail of the pancreas, and with suspicion or direct evidence of pancreatic duct disruption, require distal pancreatectomy. Similar injuries affecting the head of the pancreas are best managed by simple external drainage, even if there is suspected pancreatic duct injury. Pancreaticoduodenectomy should be reserved for extensive injuries to the head of the pancreas, and should be practised as part of damage control. Most complications should initially be treated by a combination of nutrition, percutaneous drainage and endoscopic stenting.     

胰腺结石的病因和诊治

为探讨胰腺结石的病因、形成机理、诊断和治疗方法，作者总结了１９７９年以来诊治的２８例胰腺结石经验。本组２３例进行了手术治疗，其中胰管切开取石、胰肠吻合术１４例，胰体尾切除术３例，胰十二指肠切除术１例，获得满意效果。作者指出胰腺结石的病因与胰管蛔虫、酗酒、慢性胰腺炎、低蛋白饮食有关，其中心为不规则蛋白网架和碳酸钙的沉淀。Ｂ超可作为首选的影像学诊断方法，ＣＴ对确定诊断和设计手术方案有重要意义。     

闭合性胰腺损伤的诊断和治疗：附32例报告

目的：探讨闭合性胰腺损伤的早期诊断和治疗方法。
方法：回顾性分析收治的闭合性胰腺损伤32例的临床资料。
结果：CT诊断符合率为79.3%。非手术治疗4例,其中I级3例,II级1例。 手术治疗28例,I级5例和II级7例行胰周清创外引流术;6例Ⅲ级胰腺损伤中,行远端胰腺切除术和脾切除术4例,行保脾远端胰腺切除术2例;5例Ⅳ级胰腺损伤中,行胰腺空肠Roux-en-Y吻合术4例,行远端胰腺切除术和脾切除术1例;5例Ⅴ级胰腺损伤中,行十二指肠憩室化手术1例,2例胰头严重毁损伤行胰十二指肠切除术,2例由于复合伤情较重,首先应用损伤控制手术,于受伤后48 h再次行彻底性手术。全组死亡3例,死亡原因主要为多器官功能衰竭,余25例中术后发生并发症19例（76.0%）,包括胰瘘、胰腺假性囊肿等,均经治疗而愈。
结论：无明确主胰管损伤、临床情况稳定时,胰腺损伤可先行非手术治疗。手术治疗适于重度闭合性胰腺损伤,根据胰腺损伤的程度选择合理的手术方式可提高治愈率,降低病死率。     

Local complications following pancreatic trauma

Background

Major trauma to the pancreas is uncommon, but associated with significant overall morbidity and mortality. A vast majority of these adverse outcomes can be attributed to the presences of associated injuries. Among those patients who survive the initial injury, however, the subsequent development of pancreas-related complications represents a significant source of adverse outcomes.

Methods and results

A total of 257 patients admitted from January 1996 to April 2007 were identified from the trauma registry database at our institution. One hundred and eighty-three patients surviving more than 48 h after admission were selected for analysis. These patients were grouped according to the surgical management utilised to address their pancreatic injuries: either resection or operative drainage. After exclusion of patients with associated vascular injuries, those undergoing drainage had lower rate of associated hollow viscus injuries (51.9% vs. 69.9%; p = 0.016) and lower rates of associated solid organ injuries (44.2% vs. 70.9%; p ≤ 0.001). Patients undergoing drainage were noted to have a higher incidence of pseudocyst formation (19.5% vs. 9.0%; OR: 2.47, 95% CI, 0.92-6.67; p = 0.068), but lower hospital lengths of stay (18.7 ± 18.5 vs. 33.8 ± 63.5; p = 0.001). No difference in mortality was noted between the two populations (5.7% vs. 3.0%; p = 0.700). After multivariate analysis pseudocyst formation was the only complication that proved different between the two management groups, with patients undergoing operative drainage more commonly developing this adverse sequela (OR: 2.93, 95% CI, 1.02-8.36; p = 0.041).

Conclusions

In the absence of vascular injury, the choice of surgical management did not affect adjusted mortality or the overall occurrence of pancreas-related complications. Individuals treated with operative drainage alone, however, were significantly more likely to develop a post-operative pseudocyst than their resectional counterparts.     

儿童外伤性胰腺炎13 例报告

目的：探讨儿童外伤性胰腺炎的临床特点及诊治方法。 方法：回顾性分析2003年1月—2011年12月收治的13例外伤性胰腺炎患儿的临床资料。 结果：13例患儿中,男8例,女5例;年龄5~12（7.22±3.54）岁。病因包括腹部钝挫伤7例,车祸伤4例,坠落伤2例,均为腹部闭合性损伤。9例胰腺I级损伤（2例合并肝挫伤）和3例II级损伤均采用抗感染、禁食、胃肠减压、全静脉营养,抑酶等保守治疗,其中4例出院1~2个月后并发胰腺假性囊肿,1例经对症治疗自行吸收,3例行囊肿空肠Roux-en-Y吻合术（其中1例腹腔镜下探查拟镜下吻合未成功中转开腹）;1例胰腺III级损伤（合并脾挫伤）行腹腔镜下腹腔引流术,术后1个月并发胰腺假性囊肿,行腹腔镜探查,囊肿空肠Roux-en-Y吻合术。所有患儿均治愈。 结论：儿童外伤性胰腺炎应根据胰腺损伤程度不同采取不同治疗方法。腹腔镜下腹腔引流术是治疗儿童III级外伤性胰腺炎的有效方法之一,但与腹腔镜下胰腺假性囊肿空肠吻合术一样仍需要进一步探索与总结。     

胰腺手术后影响引流管留置时间的相关因素

目的 探讨胰腺术后影响引流管留置时间的相关因素.方法 对217例胰腺术后病人临床资料进行回顾性分析,其中胰十二指肠切除术58例,胰体尾切除术77例,单纯胰腺肿物摘除术32例,慢性胰腺炎胰管扩张行胰管空肠吻合术21例,保留十二指肠的胰头切除术18例,胰腺节段切除术11例.回顾分析胰腺疾病术后引流时间与病人性别、年龄、病变性质、手术方式、术后第1天腹腔引流液淀粉酶水平、术后10 d内是否发热等因素之间的关系.结果 病人的手术方式、术后第1天腹腔引流液淀粉酶浓度以及术后10 d内是否发热与病人术后引流管留置时间相关.结论 手术方式、术后第1日腹腔引流液淀粉酶水平以及术后体温状况可以为确定术后拔除腹腔引流管的时机提供依据.     

Diagnosis and treatment of pancreatic trauma

Pdasenisvcterinereactt iiacvbe dt rsoaymumminpaatol mis isn a.ju Brryeult as tioitvm heealytsim caeo hmsig pwhlii ctihantoceuiddte aannncdeyof morbidity and complications.The mortality rate canbe as high as12%-20%.1Essential points inmanagement of pancrea…