多重耐药菌感染的包裹性胰腺坏死的外科治疗策略
| 作者: |
1申鼎成,
1周书毅,
1黄耿文,
1亢浩
1 中南大学湘雅医院 胰胆外科，湖南 长沙 410008 |
| 通讯: |
黄耿文
Email: 1466471168@qq.com |
| DOI: | 10.3978/.10.3978/j.issn.1005-6947.2016.09.016 |
摘要
目的：探讨多重耐药菌（MDRO）感染的包裹性胰腺坏死（WOPN）的外科治疗策略。方法：回顾性分析2010年10月―2016年6月收治的57例有明确病原学依据的WOPN患者临床资料，并重点总结其中35例MDRO感染患者的治疗及结果。结果：全组患者病死率29.8%（17/57），其中MDRO感染患者为40.0%（14/35），而普通细菌感染患者为13.6%（3/22），两者差异有统计学意义（P<0.05）。与普通细菌感染患者比较，MDRO感染患者急性胰腺炎严重程度升高、外科干预次数增多、ICU住院时间延长以及住院费用增加（均P<0.05）。50例（87.7%）采用先行经皮穿刺置管引流（PCD），必要时行微创入路的腹膜后胰腺坏死组织清除术（MARPN）或开腹胰腺坏死组织清除术（OPN）的升阶梯治疗，总治愈率72.0%，其中MDRO感染患者治愈率60.6%；7例（12.3%）采用直接先行OPN，而后联合PCD与MARPN的降阶梯治疗，总治愈率71.4%，其中MDRO感染患者治愈率50.0%。全组共检出MDRO病原菌50株，排名前5位的依次为多重耐药的鲍曼不动杆菌（36.0%，18/50）、多重耐药的肺炎克雷伯菌（20.0%，10/50）、产超广谱β-内酰胺酶的大肠埃希菌（14.0%，7/50）、多重耐药的铜绿假单胞菌（10.0%，5/50）和多重耐药的阴沟肠杆菌（8.0%，4/50）。结论：WOPN治疗上首选升阶梯策略，MDRO感染的WOPN患者预后较差，往往需要更积极的外科治疗策略。
关键词：
胰腺炎，急性坏死性;感染;抗药性，多药
Surgical treatment strategies for wall-off pancreatic necrosis with multi-drug resistant organism infections
CorrespondingAuthor:HUANG Gengwen Email: 1466471168@qq.com
Abstract
Objective: To investigate the surgical treatment strategies for wall-off pancreatic necrosis (WOPN) with multi-drug resistance organisms (MDRO) infections. Methods: The clinical data of 57 WOPN patients with clear pathogenic evidence treated between October 2010 and June 2016 were retrospectively analyzed, and the treatment and outcomes of 35 cases with MDRO infections among them were independently summarized. Results: The mortality in the entire group of patients was 29.8% (17/57), which in patients with MDRO infections was 40.0% (14/35) and in those with common bacterial infections was 13.6% (3/22), and the difference had statistical significance (P<0.05). In patients with MDRO infections compared with patients with common bacterial infections, the severity of acute pancreatitis was aggravated, number of surgical interventions was increased, length of ICU stay was prolonged and hospitalization cost was increased (all P<0.05). Fifty patients (87.7%) received step-up surgical treatment with initial percutaneous catheter drainage (PCD) , followed by minimal access retroperitoneal pancreatic necrosectomy (MARPN) or open pancreatic necrosectomy (OPN) if necessary, and the overall cure rate was 72.0% and the cure rate in cases with MDRO infections was 60.6%; 7 patients (12.3%) underwent step-down surgical treatment with initial OPN directly, or combined with PCD and MARPN later, and the overall cure rate was 71.4% and the cure rate in cases with MDRO infections was 50.0%. A total of 50 MDRO pathogens were detected in the whole group of patients and the top five commonest pathogens were MDR-Acinetobacterbaumanni (36.0%, 18/50), MDR-Klebsiella pneumonia (20.0%,10/50), Escherichia coli with extended-spectrum β-lactamases (14.0%, 7/50), MDR-Pseudomonas aeruginosa (10.0%, 5/50) and MDR-Enterobacter cloacae (8.0%, 4/50), respectively. Conclusion: Step-up strategy is the first choice for WOPN, and those with MDRO infections may have unfavorable outcomes, for whom, more aggressive surgical treatment strategies are always required.
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