【摘要】 目的探讨胰腺损伤的诊治经验。方法回顾性分析2003年8月至2014年7月在中山大学附属第一医院收治的25例胰腺损伤患者临床资料。其中男17例,女8例;年龄7~54岁,中位年龄26岁。所有患者均签署知情同意书,符合医学伦理学规定。诊断采用1990年美国创伤外科协会(AAST)的胰腺损伤分级标准,Ⅰ级胰腺损伤3例,Ⅱ级9例,Ⅲ级7例,Ⅳ级5例,Ⅴ级1例。观察患者的诊断、治疗及预后情况。结果 2例患者表现为意识障碍,余23例患者均有不同程度的腹痛症状。24例患者中,血清淀粉酶升高患者占63%(15/24)。7例患者术前行腹腔穿刺淀粉酶检测均升高。17例患者术前行超声检查,确诊率41%(7/17)。14例患者术前行CT检查,确诊率71%(10/14)。3例Ⅰ级患者行胰周引流术;9例Ⅱ级患者中,2例保守治疗,6例行胰周引流术,1例行胰腺破裂口修补术;7例Ⅲ级患者中,4例行胰腺近端封闭+远端胰空肠吻合术,2例行胰体尾联合脾脏切除术,1例行单纯胰体尾切除术;5例Ⅳ级患者中,4例行胰腺近端封闭+远端胰空肠吻合术,1例行胰腺近端封闭+远端胰胃吻合术;1例Ⅴ级患者行胰腺坏死组织清除+十二指肠修补+胰周引流术。25例患者中,死亡2例,术后出现胰瘘6例,胰腺假性囊肿5例。1例胰瘘患者行ERCP下胰管支架引流术后治愈,2例胰腺假性囊肿患者行囊肿内引流术后治愈,余胰瘘及假性囊肿患者均行超声引导下穿刺引流治愈。结论术前血清和腹腔穿刺液淀粉酶升高可提示胰腺损伤。术前CT对胰腺外伤的诊断及分级有一定价值。胰腺损伤的手术方式应依据损伤的类型、级别及合并伤等确定。更多还原

【Abstract】 Objective To investigate the diagnosis and treatment experiences for pancreatic trauma. Methods Clinical data of 25 patients with pancreatic trauma admitted to the First Affiliated Hospital of Sun Yat-sen University from August 2003 to July 2014 were retrospectively analyzed. There were 17 males and 8 females, with age ranging from 7 to 54 years and a median age of 26 years. The informed consents of all patients were obtained and the local ethical committee approval had been received. According to the scale of American Association for the Surgery of Trauma(AAST) for pancreatic trauma, 3 cases were classified as grade Ⅰ, 9 as grade Ⅱ, 7 as grade Ⅲ, 5 as grade Ⅳ and 1 as grade Ⅴ. The diagnosis, treatment and prognosis of the patients were observed. Results Two patients were observed with consciousness disorders and the other 23 suffered from acute abdominal pain of varying extent. Elevated serum amylase was observed in 63%(15/24) of the cases. Seven cases were observed with increasing amylase via abdominocentesis before operation. Seventeen cases underwent preoperative ultrasound examination and the rate of confirmed diagnosis was 41%(7/17). Fourteen cases underwent preoperative CT scan and the rate of confirmed diagnosis was 71%(10/14). Three grade I cases underwent peripancreatic drainage alone. Among the 9 cases of grade Ⅱ, 2 received conservative therapy, 6 underwent peripancreatic drainage and 1 received pancreatic rupture repair. Among the 7 cases of grade Ⅲ, 4 underwent proximal pancreatic stump closure + distal pancreaticojejunostomy, 2 underwent distal pancreatectomy with splenectomy and 1 underwent distal pancreatectomy alone. Among the 5 cases of grade Ⅳ, 4 underwent proximal pancreatic stump closure + distal pancreaticojejunostomy and 1 underwent proximal pancreatic stump closure + distal pancreaticogastrostomy. One case of grade Ⅴ underwent pancreatic necrosectomy + duodenorrhaphy + peripancreatic drainage. Of the 25 patients, 2 death case were observed, 6 developed pancreatic fistula and 5 developed pancreatic pseudocyst after operation. One patient with pancreatic fistula was cured after receiving pancreatic duct stent drainage by endoscopic retrograde cholangiopancreatography(ERCP). Two patients with pancreatic pseudocyst were cured after undergoing cyst drainage. The other patients with pancreatic fistula and pseudocyst were cured after undergoing ultrasound-guided puncture drainage. Conclusions Increasing amylase in the serum and fluid by abdominocentesis before operation can be regarded as indicators of pancreatic trauma. Preoperative CT scan is of certain significance in the diagnosis and classifying the pancreatic trauma. Surgical operation for pancreatic trauma should be selected according to the types, grades of trauma and related complications.更多还原