Imaging classification and analysis of the diagnosis and treatment of infected pancreatic necrosis:a report of 126 cases / 中华外科杂志

Objective: To explore the clinical characteristics of various types of infected pancreatic necrosis(IPN) and the prognosis of different treatment methods in the imaging classification of IPN proposed. Methods: The clinical data of 126 patients with IPN admitted to the Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University from December 2018 to December 2021 were analyzed retrospectively. There were 70 males(55.6%) and 56 females(44.4%), with age(M(IQR)) of 44(17)years (range: 12 to 87 years). There were 67 cases(53.2%) of severe acute pancreatitis and 59 cases (46.8%) of moderately severe acute pancreatitis. All cases were based on the diagnostic criteria of IPN. All cases were divided into Type Ⅰ(central IPN)(n=21), Type Ⅱ(peripheral IPN)(n=23), Type Ⅲ(mixed IPN)(n=74) and Type Ⅳ(isolated IPN)(n=8) according to the different sites of infection and necrosis on CT.According to different treatment strategies,they were divided into Step-up group(n=109) and Step-jump group(n=17). The clinical indicators and prognosis of each group were observed and analyzed by ANOVA,t-test,χ2 test or Fisher exact test,respectively. Results: There was no significant difference in mortality, complication rate and complication grade in each type of IPN(all P>0.05). Compared with other types of patients, the length of stay (69(40)days vs. 19(19)days) and hospitalization expenses(323 000(419 000)yuan vs. 60 000(78 000)yuan) were significantly increased in Type Ⅳ IPN(Z=-4.041, -3.972; both P<0.01). The incidence of postoperative residual infection of Type Ⅳ IPN was significantly higher than that of other types (χ2=16.350,P<0.01). There was no significant difference in the mortality of patients with different types of IPN between different treatment groups. The length of stay and hospitalization expenses of patients in the Step-up group were significantly less than those in the Step-jump group(19(20)days vs. 33(35)days, Z=-2.052, P=0.040;59 000(80 000)yuan vs. 122 000(109 000)yuan,Z=-2.317,P=0.020). Among the patients in Type Ⅳ IPN, the hospitalization expenses of Step-up group was significantly higher than that of Step-jump group(330 000(578 000)yuan vs. 141 000 yuan,Z=-2.000,P=0.046). The incidence of postoperative residual infection of Step-up group(17.4%(19/109)) was significantly lower than that of Step-jump group(10/17)(χ2=11.980, P=0.001). Conclusions: Type Ⅳ IPN is more serious than the other three types. It causes longer length of stay and more hospitalization expenses. The step-up approach is safe and effective in the treatment of IPN. However, for infected lesions which are deep in place,difficult to reach by conventional drainage methods, or mainly exhibit "dry necrosis", choosing the step-jump approach is a more positive choice.

Severity grading of grade B pancreatic fistula after pancreaticoduodenectomy: A single-center study / 中国实用外科杂志

OBJECTIVE: To discuss whether grade B pancreatic fistula after pancreaticoduodenectomy(PD)can be graded according to the severity and to provide reference for accurate evaluation and treatment.METHODS: The clinical data of 343 patients underwent PD surgery in the First Affiliated Hospital of Harbin Medical University from December2012 to June 2016 were retrospectively collected,among which 72 cases followed grade B pancreatic fistula. Grade B pancreatic fistula after operation was divided into severe groups of which imaging-assisted interventional therapy was needed and mild group. The total medical cost,length of hospital stay,drainage time,ICU transfer,introperitoneal effusion,introabdominal infection,abdominal hemorrhage,biliary fistula,delayed gastric emptying,number of types and incidence of complications except pancreatic fistula,incidence of pancreatic fistula as the most serious complications,postoperative morbidity index(PMI),fistula average complication burden(ACB)were statistically analyzed between two groups.RESULTS: Univariate analysis revealed that there were significant differences between two groups in the total medical cost(84,000 yuan vs. 132,000 yuan),length of hospital stay(29.0 days vs. 42.0 days),drainage time(20.5 d vs.53.0 d),introperitonal effusion rate(41.1% vs. 87.5%),introabdominal infection rate(10.7% vs. 43.8%),abdominal hemorrhage rate(7.1% vs. 56.3%),the number of other types of complications except pancreatic fistula(1 vs. 4),pancreatic fistula as the most serious complications(53.6% vs. 87.5%),PMI(0.22±0.08 vs. 0.37±0.00),ACB(0.19±0.08 vs. 0.37±0.00),and the P-values were less than 0.05 respectively.CONCLUSION: The severity of grade B pancreatic fistula of ISGPS update classification is heterogeneous,which can be divided into mild and severe groups. It provides a reference for precise and individualized treatment for grade B pancreatic fistula.

The clinical analysis of a step-up approach for severe acute pancreatitis: report of 121 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility and clinical value of the step-up approach for severe acute pancreatitis (SAP).</p><p><b>METHODS</b>Clinical data of 121 SAP patients admitted between January 2002 and December 2011 were retrospectively analyzed. Fifty-eight patients (37 males and 21 females, aged from 20 to 72 years, mean 47.6 years) in the group of direct open necrosectomy from January 2002 to December 2006 were performed laparotomy through removal of all necrotic tissue. Sixty-three patients (42 males and 21 females, aged from 19 to 78 years, mean 46.2 years) of step-up approach from January 2007 to December 2011 underwent percutaneous catheter drainage through retroperitoneum or omental bursa guided by B-type ultrasonography for the first therapy, and then, according to the pathogenetic condition, if necessary, followed by a small incisional necrosectomy along the drainage tube. The two groups were compared for the rates of postoperative complications, death, transfusion and length of stay, medical costs.</p><p><b>RESULTS</b>The rates of total postoperative complications, organ dysfunction, alimentary tract fistula and incisional hernia in step-up approach group were significantly lower than those of direct open necrosectomy group (31.7% vs. 62.1%, 14.3% vs. 37.5%, 6.3% vs. 19.0%, 9.5% vs. 29.3%; χ(2) = 4.43 to 11.17, P = 0.001 to 0.035). The other complications had no significant differences between the two groups (P > 0.05). Patients in step-up approach group had a lower rates of transfusion (44.4% vs. 70.7%, χ(2) = 8.488, P = 0.004), fewer medical costs of transfusion and hospital stay, compared with those in direct open necrosectomy group ((2525 ± 4573) yuan vs. (4770 ± 6867) yuan, t = 2.131, P = 0.035; (171 213 ± 50 917) yuan vs. (237 874 ± 67 832) yuan, t = 2.496, P = 0.014). There were no significant differences of length of stay and mortality between two groups (P > 0.05).</p><p><b>CONCLUSION</b>Step-up approach for SAP which can reduce the rates of postoperative complications, transfusion and medical costs has significant feasibility and great clinical value.</p>