72例胰腺损伤诊治分析

高云瀚,王 灿,杨 钱

(重庆市急救医疗中心普外科 400014)

72例胰腺损伤诊治分析

高云瀚,王 灿,杨 钱

(重庆市急救医疗中心普外科 400014)

目的探讨胰腺损伤的诊断和治疗方法｡方法 对近10年间该院手术治疗的胰腺损伤72例作回顾性分析｡主要诊断技术为CT,MRI,内镜逆行胰胆管造影(ERCP)等;手术方法包括修补加引流术､远端胰腺切除术､空肠与远端胰腺Roux-en-Y吻合术､胰十二指肠修补术加广泛引流､胰十二指肠修补术加憩室化术和“损伤控制外科(DCS)”术等术式｡结果52例腹内脏器合并伤中,穿透伤13例(25%),钝性伤39例(75%),二者比较差异无统计学意义(χ2=0.000,P0.05);49例腹以外部位合并伤中,穿透伤6例(12.24%),钝性伤43例(87.76%),二者比较差异有统计学意义(χ2=13.310,P0.01)｡72例患者中死亡9例(12.5%),合并伤､失血总量､伤后至手术时间等因素与患者死亡具有相关性(P0.05)｡术后并发症共18例(25%),Ⅰ～Ⅱ级伤3例,Ⅲ～Ⅴ级伤15例,二者比较差异有统计学意义(χ2=10.667,P0.01)｡术后并发症包括出血､胰瘘､胰腺假性囊肿､胰腺脓肿､创伤性胰腺炎､胰腺内外分泌功能障碍等｡72例患者中存活63例｡34例胰腺损伤级别为Ⅲ～Ⅴ级的患者,伤后随访6个月至22年(中位数随访时间2年),情况良好｡结论避免胰腺损伤早期漏诊,手术时迅速控制合并伤大出血,按胰腺损伤分级采用不同术式,可明显减少并发症和病死率｡

胰腺;创伤和损伤;诊断;外科手术

近年来,胰腺损伤的发病率在中国呈明显增高的趋势,这与车辆逐年增多有关｡而车祸中方向盘损伤是导致胰腺损伤的重要原因｡胰腺损伤容易发生早期漏､误诊,带来严重后果;同时,手术治疗方法的不恰当,也会增加并发症的发生率和致死率[1-4]｡因此,对早期诊断和正确的手术方式需加强认识｡现结合本院2002年1月至2011年12月手术治疗的胰腺损伤患者72例,进行回顾性分析｡

1 资料与方法

1.1 一般资料 本组72例患者中男61例,女11例;年龄17～82岁,平均32.8岁｡穿透伤18例,钝性伤54例;39例交通事故伤中,35例为方向盘损伤｡受伤至入院时间小于1h者36例,≥1～6h者28例,>6h者8例｡42例患者入院时有失血性休克｡除20例患者单一胰腺损伤(穿透伤5例,钝性伤15例)外,其余52例患者均合并腹内其他脏器损伤｡52例合并伤中,49例还合并腹以外部位伤;35例方向盘所致胰损伤中,28例合并心肌挫伤｡

1.2 胰腺损伤诊断 术前诊断24例(33.3%),包括CT确诊22例,内镜逆行胰胆管造影(ERCP)确诊2例;术中诊断48例(66.7%),18例穿透伤患者和30例钝性伤患者系急诊剖腹术中确诊胰腺损伤｡全组均有腹部体征,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｡胰腺损伤部位:胰头17例,胰颈7例,胰体25例,胰尾23例｡美国创伤外科学会器官损伤分级(AAST-OIS)[5]:Ⅰ级8例,Ⅱ级28例,Ⅲ级19例,Ⅳ级11例,Ⅴ级6例｡主胰管损伤共占全组的50.0%｡

1.3 治疗方法

1.3.1 胰腺损伤治疗 胰腺损伤手术方式见表1｡其中4例实施“损伤控制外科(damage control surgery,DCS)”术,具体方法是将治疗分3阶段,(1)初期简化手术:仅暂时止血(结扎､填塞)和阻断污染(钳闭或结扎断裂肠管等),并作腹腔引流;(2)ICU复苏:纠正血流动力学障碍,改善通气,治疗“致死三联征”;(3)48～72h后行确定性手术[2,6-10]｡4例初期手术仅止血､阻断污染和引流,ICU复苏成功的2例在48～72h行保脾远端胰切除术｡采用任何术式均同时作充分的腹腔引流,并在术后给予抑分泌治疗,包括禁食､胃减压､肠外营养和使用分泌抑制药｡术后无胰瘘者,使用奥曲肽0.1mg皮下注射,每日3次,3～5d停药;腹腔引流管在手术1～2周后拔除,并停止胃减压和开始流质饮食｡发生胰瘘者,连续使用奥曲肽;漏量大于300mL/d者,改用生长抑素6mg/d,静脉泵持续输入,并继续胃减压和肠外营养(3例在术后7～10d经鼻肠管做空肠营养)｡所有患者均使用预防性抗生素｡

表1 72例胰腺损伤急诊手术方式(n)

1.3.2 合并伤治疗 腹内脏器合并伤均在急诊剖腹术同时处理;腹以外部位伤,除心肌挫伤行心肌保护､限液和药物等治疗外,需手术者在急诊剖腹术后血流动力学已稳定情况下,施行相应手术,手术方式见表2｡

表2 合并伤手术方式(n)

1.4 统计学处理 使用SPSS17.0统计软件进行统计学处理,计数资料采用χ2检验,以P0.05为差异有统计学意义｡

2 结 果

2.1 合并伤损伤分类结果 52例腹内脏器合并伤中,穿透伤13例(25.0%),钝性伤39例(75.0%),二者比较差异无统计学意义(χ2=0.000,P0.05);49例腹以外部位合并伤中,穿透伤6例(12.2%),钝性伤43例(87.8%),二者比较差异有统计学意义(χ2=13.310,P0.01)｡

2.2 患者死亡相关因素分析结果 72例患者中死亡9例(12.5%)｡其中8例患者死于血管损伤或其他实质脏器大出血;另1例患者合并有单纯肋骨骨折和小量血胸,术中对主胰管损伤只做了修补和引流,术后出现大量胰漏和胰腺脓肿,继发大出血和肠瘘,最后该患者死于全身炎症反应综合征｡72例患者死亡相关因素分析见表3｡

表3 72例患者死亡相关因素分析

2.3 并发症发生情况 术后并发症共18例(25%),Ⅰ～Ⅱ级伤3例,Ⅲ～Ⅴ级伤15例,二者比较差异有统计学意义(χ2=10.667,P0.01)｡术后并发症包括出血､胰瘘､胰腺假性囊肿､胰腺脓肿､创伤性胰腺炎､胰腺内外分泌功能障碍等｡

2.4 随访结果 72例患者中存活63例｡34例胰腺损伤级别为Ⅲ～Ⅴ级的患者,伤后随访6个月至22年(中位数随访时间2年),情况良好｡

3 讨 论

本组钝性伤占75.0%,与 Ahmed和 Vernick[2]及Stawicki和Schwab[9]报道的穿透伤占多数相反｡本组中方向盘所致胰腺损伤占48.6%,其中80.0%还合并钝性心脏损伤｡交通事故中方向盘损伤时,应高度警惕胰腺和心脏损伤的发生｡急诊剖腹术时应剪开胃结肠韧带仔细探查胰腺,尤其注意有无主胰管损伤｡本组2例虽术中发现胰腺挫裂伤,但漏诊主胰管伤,手术方式不到位,术后并发胰瘘,经螺旋CT和ERCP证实主胰管断裂｡因此,即使胰腺小血肿也要剪开包膜探查,仔细显露腺体破裂处主胰管,挤压胰腺观察有无胰液从破口溢出｡未行急诊剖腹探查术者应采用新一代CT､MRI等检查,以明确胰腺损伤情况,ERCP是发现主胰管损伤最可靠的方法[11-18]｡Velmahos等[14]和Phelan等[15]指出,CT诊断胰腺损伤灵敏度不够高,但对主胰管伤的诊断具特异性｡

胰腺损伤手术方式的选择取决于有无主胰管损伤[4,16]｡无主胰管损伤(Ⅰ～Ⅱ级伤)时,只须引流或加修补;虽然Pata等[19]对Ⅲ级胰腺损伤尝试非手术治疗,但多数作者指出主胰管损伤(Ⅲ～Ⅴ级)均应手术,并按部位选择术式;无论何种术式,均应同时行充分的腹腔引流[4,8-9]｡体尾部主胰管损伤应行远端胰切除术,既妥善止血､确切结扎主胰管,又清除了失活组织,避免坏死组织感染后继发性出血､胰瘘､假性囊肿和脓肿等并发症的发生｡无脾伤或脾伤轻者可采用保脾切胰措施[3-4,11,18],本组8例保脾切胰,其中 3例结 扎脾动脉,无并发症｡结扎脾动脉的保脾切胰,注意保留胃短动脉｡胰头颈部的主胰管损伤(Ⅳ～Ⅴ级),行远端胰与空肠的Roux-en-Y吻合,胰头端主胰管结扎并妥善缝闭和大网膜覆盖｡本组4例远端胰空肠端端套入,未置支撑,采用彭淑牖和何小伟[6]推荐的捆绑式吻合,无胰瘘发生｡胰十二指肠联合伤时,实施 Whipple手术病死率高达31%～36%,除非胰头和十二指肠降段失活被迫采用此术式,即使壶腹部破裂仍宜采取多处修补加胰管､胆管和十二指肠腔内外充分引流[7]｡本组6例中,4例分别采用修复胰头和十二指肠加多处引流(壶腹伤置支撑管经十二指肠引流,十二指肠减压引流､胆道“T”管引流和胰床充分引流);仅2例行Whipple手术,6例患者均存活｡濒死患者可采用DCS术,指征主要为患者出现“致死三联征”(凝血障碍､低温､酸中毒)[10],本组中4例初期手术均为填塞和结扎止血,同时充分腹腔引流,ICU复苏成功的2例,48～72h间行保脾远端胰切除术,顺利康复｡Seamon等[8]指出,在严重胰腺损伤实施DCS术时,不加引流的填塞会增加病死率,应避免｡

本组统计显示,无论穿透伤和钝性伤均大多合并腹内其他脏器伤,而钝性伤比穿透伤更易合并腹以外部位多发伤｡单一胰腺损伤甚少引起患者死亡,合并血管和实质脏器伤大出血､多发伤是主要死亡原因,其次为术后并发症[11,13,20]｡本组死于合并伤8例,并发症1例｡因此,首先控制合并伤大出血是提高患者生存率的关键｡另外,肾脏损伤15例中累及左肾12例,说明胰腺损伤时易累及左肾,术中应仔细探查｡本组有28例(38.89%)合并心肌挫伤,方向盘损伤时更须特别警惕,并做相应的检查,如心肌酶谱､肌钙蛋白和超声心动图,经食管超声心动图(TEE)可提高诊断灵敏度｡

本组并发症发生率28.13%,与文献报告相近[14]｡并发症治疗常需联合使用介入､内镜和手术治疗[9]｡与胰腺损伤直接相关的并发症主要为出血､胰瘘､胰腺假性囊肿､胰腺脓肿､创伤性胰腺炎､胰腺内外分泌功能障碍等｡最危急者为出血,可为继续出血和继发性出血,前者多因手术不当､止血不善,术后立即出现;后者原因有化学性和感染性,即胰液腐蚀性出血和胰腺损伤组织坏死感染后出血,多在手术2d后出现｡胰瘘在主胰管损伤时发生率增高,故应妥善结扎或内外引流,引流物至少保留1～2周;术后抑分泌治疗,包括禁食,引出胃液和使用注射用生长抑素,可减少胰瘘发生或促进愈合｡假性囊肿除迅速增大者急诊外引流,一般先行非手术治疗｡超声引导下穿刺置管引流､ERCP下鼻胰管引流､腹腔镜下置管引流等方法,都是近年来日渐用于临床的有效非手术治疗技术｡作者不赞成用胃镜经胃后壁开窗,此法非但引流不畅,反而会增加囊肿感染概率｡通常保守治疗2个月无效再引流,此时囊壁增厚利于吻合｡胰腺脓肿应及时再手术引流,拖延将导致继发性出血､胃肠瘘和全身炎症反应综合征等更严重的并发症｡为避免胰功能障碍,胰切除量不超过80.0%,否则选择远端胰与空肠的Roux-en-Y吻合｡漏诊再手术和术式不当使并发症发生概率大增,甚至导致不应有的死亡[1,2,4,20]｡本组1例手术主胰管损伤却只做了修补和引流,未行远端胰切除,术后出现胰瘘和胰腺脓肿,继发大出血和肠瘘,患者死于全身炎症反应综合征,实为深刻教训｡

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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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