本文選題：重癥急性胰腺炎　切入點：CT多平面重建　出處：《南方醫(yī)科大學》2017年碩士論文

【摘要】：背景:重癥急性胰腺炎(SAP)是一種起病急驟,病情兇險多變,并發(fā)癥及死亡率較高的急腹癥。腹腔鏡下置管腹腔灌洗引流(LPLD)通過清除胰周壞死組織及積液,減少胰酶吸收,降低炎癥反應,顯著降低多器官功能衰竭的發(fā)生率和病死率。但SAP患者早期胰周組織水腫粘連,解剖結構不清,術中易出血及引起嚴重并發(fā)癥。因此,目前國內外專家對SAP患者早期行LPLD仍存在爭議,如何提高早期腹腔鏡手術治療SAP的安全性和有效性仍需不斷探索。CT檢查SAP敏感性高,是SAP檢查的首選。SAP的CT表現(xiàn)與臨床嚴重程度相關,是LPLD術前評估的重要依據(jù)。術前通過CT對胰周情況的評估,有利于術中胰腺壞死組織清除及胰周精準置管。普通CT的平面圖像,對準確判斷胰腺壞死區(qū)域、胰周積液分布及周圍血管的關系存在困難,使手術時間延長,風險增加。CT多平面重建通過對平面圖像的識別、重組,重建與胰腺及周圍相近的立體圖像,對胰腺壞死區(qū)域、胰周積液分布及周圍血管的關系評估更精確,對選擇最佳手術入路、縮短手術時間、減小手術損傷、提高胰腺壞死病灶清除率及保證術后引流效果有重要的臨床意義,國內外未見相關的研究報道。目的1、探討重癥急性胰腺炎早期腹腔鏡置管引流手術的臨床治療效果。2、探討重癥急性胰腺炎CT多平面重建指導腹腔鏡置管引流手術的臨床應用。方法第一部重癥急性胰腺炎早期腹腔鏡置管引流手術的臨床療效分析�；仡櫺苑治鑫以�2007年1月至2014年12月54例行腹腔鏡手術置管引流的重癥急性胰腺炎患者的臨床資料,觀察臨床療效;對手術前后的CT改變進行分析,觀察CT改變與臨床療效的關系。第二部分重癥急性胰腺炎CT多平面重建指導腹腔鏡置管引流的臨床應用。前瞻性對2015年1月至2016年12月14例SAP患者行CT多平面重建,指導行腹腔鏡置管引流手術,與2013年1月至2014年12月16例常規(guī)CT檢查組的SAP患者進行比較,探討CT多平面重建指導腹腔鏡置管引流的臨床價值。結果1、治愈50例,4例死亡,死亡率7.4%,1例死于合并胰腺癌,1例死于多器官功能衰竭,2例死于遲發(fā)腹腔大出血,平均住院時間(38.7+24.6)d。術后CT提示胰腺壞死殘留及胰周感染12例,1例再次手術,2例遲發(fā)腹腔出血死亡。通過術前與術后CT改變比較顯示,術后胰腺壞死殘留及胰周感染的患者住院時間延長,差異有統(tǒng)計學意義(P0.05)。2、CT多平面重建與CT常規(guī)掃描組比較,手術時間短、出血量少、術后住院天數(shù)少,差異有統(tǒng)計學意義(P0.05)。結論1、早期腹腔鏡置管引流手術治療SAP是一種安全、有效的治療手段。2、早期腹腔鏡置管引流手術后胰腺壞死殘留及胰周感染是SAP患者住院時間延長并產生嚴重并發(fā)癥的主要原因。3、重癥急性胰腺炎CT多平面重建指導腹腔鏡置管引流可提高手術的安全性和有效性。
[Abstract]:Background: severe acute pancreatitis (SAP) is a kind of acute abdomen with acute onset, severe and changeable condition, high complications and high mortality. LPLD can reduce trypsin absorption by removing peripancreatic necrotic tissue and effusion. The incidence and mortality of multiple organ failure were significantly reduced in patients with SAP. However, the early peripancreatic tissue edema and adhesion, unclear anatomical structure, bleeding and serious complications occurred in the early stage of SAP. At present, experts at home and abroad still have controversy about early LPLD in patients with SAP. How to improve the safety and effectiveness of early laparoscopic surgery for SAP still needs to explore continuously the sensitivity of CT examination for SAP. The CT findings of SAP are related to the clinical severity and are the important basis for preoperative evaluation of LPLD. It is helpful to clear the necrotic tissue of the pancreas during the operation and to place the accurate tube around the pancreas. The plane image of common CT is difficult to accurately judge the relationship between the necrotic area of the pancreas, the distribution of peripancreatic effusion and the surrounding blood vessels, and the operation time is prolonged. Risk increase. Ct multiplanar reconstruction is more accurate in evaluating the relationship between pancreatic necrosis areas, peripancreatic effusion distribution and surrounding blood vessels by identifying, reconstructing, and reconstructing stereoscopic images of the pancreas and its surroundings. It has important clinical significance to select the best operative approach, shorten the operation time, reduce the operation injury, improve the clearance rate of pancreatic necrosis focus and ensure the postoperative drainage effect. There are no related research reports at home and abroad. Objective 1. To investigate the clinical effect of laparoscopic catheter drainage in the early stage of severe acute pancreatitis (SAP). 2. To discuss CT multiplanar reconstruction of severe acute pancreatitis to guide laparoscopic catheter drainage surgery. Methods the clinical curative effect of the first stage of severe acute pancreatitis with laparoscopic catheter drainage was analyzed retrospectively. From January 2007 to December 2014, 54 cases of severe acute pancreatitis were treated by laparoscopic catheterization and drainage in our hospital from January 2007 to December 2014. Clinical data of patients with pancreatitis, To observe the clinical effect, to analyze the changes of CT before and after operation, To observe the relationship between CT changes and clinical efficacy. Part two: clinical application of CT multiplanar reconstruction to guide laparoscopic catheter drainage in severe acute pancreatitis. Ct multiplanar reconstruction was performed in 14 patients with SAP from January 2015 to December 2016. The clinical value of laparoscopic catheterization and drainage guided by CT multiplanar reconstruction in 16 SAP patients with conventional CT inspection group from January 2013 to December 2014 was discussed. Results 1. 50 cases were cured and 4 cases died. The mortality rate was 7.4%. 1 case died of pancreatic cancer and 1 case died of multiple organ failure. 2 cases died of delayed abdominal hemorrhage. The mean hospitalization time was 38.7 24. 6 days. Ct showed that pancreatic necrosis remained and peripancreatic infection occurred in 12 cases. 2 patients died of delayed abdominal hemorrhage after reoperation. The CT changes before and after operation were compared. The hospitalization time of the patients with residual pancreatic necrosis and peripancreatic infection was prolonged, and the difference was statistically significant. Compared with the conventional CT scan group, the time of operation was shorter, the amount of bleeding was less, and the days of postoperative hospitalization were less. Conclusion 1. Early laparoscopic catheterization and drainage is safe in the treatment of SAP. Effective treatment. 2. The residual pancreatic necrosis and peripancreatic infection after early laparoscopic drainage were the main causes of prolonged hospitalization and severe complications in patients with SAP. Ct multiplanar reconstruction guidance for severe acute pancreatitis. Laparoscopic catheterization and drainage can improve the safety and effectiveness of the operation.
【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R576;R816.5

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