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感染性坏死性胰腺炎立即干预与延迟干预的比较
Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis


Lotte Boxhoorn ... 其他 • 2021.10.07
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感染性坏死性胰腺炎早期干预不优于延迟干预

 

曹峰,李非*

首都医科大学宣武医院普通外科;首都医科大学急性胰腺炎临床诊疗与研究中心*通讯作者


胰腺坏死发生于约15%的急性胰腺炎患者,其中1/3会继发感染而成为感染性坏死性胰腺炎(INP)。INP死亡率达30%,是造成急性胰腺炎患者死亡的重要原因之一1。2010年荷兰胰腺炎工作组报道的PANTER研究结果确立了“进阶手术”(Step-up)在INP治疗策略中的地位。置管引流作为“进阶手术”策略的初始干预步骤,在INP的治疗中具有重要作用2

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摘要


背景

感染性坏死性胰腺炎是一种可能引起患者死亡的疾病,采用升阶梯疗法,其中导管引流常延迟至感染性坏死被包裹。早期导管引流可否改善患者结局尚不清楚。

 

方法

我们对感染性坏死性胰腺炎患者开展了一项多中心、随机优效性试验。该试验比较了诊断为感染性坏死并随机分组后24小时内的立即引流与达到包裹性坏死(walled-off necrosis)阶段之后的延迟引流。主要终点是综合并发症指数(Comprehensive Complication Index)评分,该指数纳入了6个月随访期间的所有并发症。

 

结果

共计104例患者被随机分配接受立即引流(55例患者)或延迟引流(49例患者)。立即引流组和延迟引流组的综合并发症指数(评分范围为0~100,评分较高表示并发症较严重)平均评分分别为57分和58分(平均差,-1;95%置信区间[CI],-12~10;P=0.90)。立即引流组和延迟引流组的死亡率分别为13%和10%(相对危险度,1.25;95% CI,0.42~3.68)。立即引流组和延迟引流组的平均干预次数(导管引流和坏死组织清除术)分别为4.4次和2.6次(平均差,1.8;95% CI,0.6~3.0)。在延迟引流组中,19例患者(39%)接受了抗生素保守治疗,无需引流;其中17例患者存活。两组的不良事件发生率相似。

 

结论

对感染性坏死性胰腺炎患者开展的此项试验未能证明在并发症方面,立即引流优于延迟引流。被随机分配到延迟引流组的患者接受的有创干预较少(由Fonds NutsOhra和Amsterdam UMC资助,POINTER在ISRCTN注册号为ISRCTN33682933)。





作者信息

Lotte Boxhoorn, M.D., Sven M. van Dijk, M.D., Ph.D., Janneke van Grinsven, M.D., Ph.D., Robert C. Verdonk, M.D., Ph.D., Marja A. Boermeester, M.D., Ph.D., Thomas L. Bollen, M.D., Ph.D., Stefan A.W. Bouwense, M.D., Ph.D., Marco J. Bruno, M.D., Ph.D., Vincent C. Cappendijk, M.D., Ph.D., Cornelis H.C. Dejong, M.D., Ph.D., Peter van Duijvendijk, M.D., Ph.D., Casper H.J. van Eijck, M.D., Ph.D., Paul Fockens, M.D., Ph.D., Michiel F.G. Francken, B.Sc., Harry van Goor, M.D., Ph.D., Muhammed Hadithi, M.D., Ph.D., Nora D.L. Hallensleben, M.D., Jan Willem Haveman, M.D., Ph.D., Maarten A.J.M. Jacobs, M.D., Ph.D., Jeroen M. Jansen, M.D., Ph.D., Marnix P.M. Kop, M.D., Krijn P. van Lienden, M.D., Ph.D., Eric R. Manusama, M.D., Ph.D., J. Sven D. Mieog, M.D., Ph.D., I. Quintus Molenaar, M.D., Ph.D., Vincent B. Nieuwenhuijs, M.D., Ph.D., Alexander C. Poen, M.D., Ph.D., Jan-Werner Poley, M.D., Ph.D., Marcel van de Poll, M.D., Ph.D., Rutger Quispel, M.D., Tessa E.H. Römkens, M.D., Ph.D., Matthijs P. Schwartz, M.D., Ph.D., Tom C. Seerden, M.D., Ph.D., Martijn W.J. Stommel, M.D., Ph.D., Jan Willem A. Straathof, M.D., Ph.D., Hester C. Timmerhuis, M.D., Niels G. Venneman, M.D., Ph.D., Rogier P. Voermans, M.D., Ph.D., Wim van de Vrie, M.D., Ph.D., Ben J. Witteman, M.D., Ph.D., Marcel G.W. Dijkgraaf, Ph.D., Hjalmar C. van Santvoort, M.D., Ph.D., and Marc G. Besselink, M.D., Ph.D. for the Dutch Pancreatitis Study Group*
From the Departments of Gastroenterology and Hepatology (L.B., P.F., R.P.V.), Surgery (S.M.D., J.G., M.A.B., M.F.G.F., M.G.B.), Radiology (M.P.M.K., K.P.L.), and Epidemiology and Data Science (M.G.W.D.), Amsterdam UMC, University of Amsterdam, and the Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam (M.A.J.M.J.), Amsterdam Gastroenterology Endocrinology Metabolism, and the Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis (J.M.J.), Amsterdam, the Departments of Research and Development (L.B., S.M.D., N.D.L.H., H.C.T.), Gastroenterology and Hepatology (R.C.V.), Radiology (T.L.B., K.P.L.), and Surgery (H.C.T., H.C.S.), St. Antonius Hospital, Nieuwegein, the Department of Surgery, Maastricht University Medical Center, Maastricht (S.A.W.B., C.H.C.D., M.P.), the Departments of Gastroenterology and Hepatology (M.J.B., J.-W.P.), and Surgery (C.H.J.E.), Erasmus MC University Medical Center, and the Department of Gastroenterology and Hepatology, Maasstad Hospital (M.H.), Rotterdam, the Departments of Radiology (V.C.C.), and Gastroenterology and Hepatology (T.E.H.R.), Jeroen Bosch Hospital, Den Bosch, the Department of Surgery, Gelre Hospitals, Apeldoorn (P.D.), the Department of Surgery, Radboud University Medical Center, Nijmegen (H.G., M.W.J.S.), the Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen (J.W.H.), the Department of Surgery, Medical Center Leeuwarden, Leeuwarden (E.R.M.), the Department of Surgery, Leiden University Medical Center, Leiden (J.S.D.M.), the Department of Surgery, University Medical Center Utrecht, Utrecht (I.Q.M., H.C.S.), the Departments of Surgery (V.B.N.), and Gastroenterology and Hepatology (A.C.P.), Isala Clinics, Zwolle, the Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft (R.Q.), the Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort (M.P.S.), the Department of Gastroenterology and Hepatology, Amphia Hospital, Breda (T.C.S.), the Department of Gastroenterology and Hepatology, Maxima Medical Center, Veldhoven (J.W.A.S.), the Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede (N.G.V.), the Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht (W.V.), and the Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede (B.J.W.) — all in the Netherlands. Address reprint requests to Dr. Besselink at the Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, De Boelelaan 1117, 1081 HV The Netherlands, or at m.g.besselink@amsterdamumc.nl. *A complete list of the Dutch Pancreatitis Study Group members is provided in the Supplementary Appendix, available at NEJM.org.

 

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