| Objective: To compare the difference of curative effect between step-up approach and open pancreatic necrosectomy,and to provide a theoretical basis for the choice of treatment for infected pancreatic necrosis(infected pancreatic necrosis,IPN).By analyzing the risk factors of postoperative intestinal fistula,and to provide more references for clinical work.Methods: Collected clinical data of severe acute pancreatitis(severe acute pancreatitis,SAP)complicated with IPN in the Affiliated Hospital of Zunyi Medical University from January 2013 to June 2020 for retrospective analysis.(1)According to the therapy method,the patients were divided into step-up approach(PCD+CNPI/+OPN)group and open pancreatic necrosectomy(open pancreatic necrosectomy,OPN)group,to compare the differences of general data(sex,age,etiology,comorbidities and personal history,APACHEII score,CT severity score,RANSON score,preoperative and postoperative laboratory indexes),operation time,time of carrying drainage tube after operation,postoperative complication incidence,mortality,total hospitalization time and hospitalization costs between PCD+CNPI/+OPN group and OPN group.(2)According to the postoperative intestinal fistula,the patients were divided into intestinal fistula group and non-intestinal fistula group.Relevant clinical data were added,and multivariate regression was used to analyze the possible risk factors for postoperative intestinal fistula.Results:(1)Compared with OPN group,step-up approach group was more significant in improving the clinical symptoms of patients(Excepted blood glucose value(P=0.279)and C-reactive protein(P=0.905),the differences of other clinical indexs(total leukocyte count,blood amylase,urine amylase,blood calcium,procalcitonin)between the two groups were statistically significant(P<0.05)).Step-up approach group could reduce hospitalization time(41(33-50)vs 69.5(62-87))and hospitalization expenses(229869(195866-362139)vs 384943(288694-468987)),and in terms of postoperative complications,step-up approach group could reduce the incidence of postoperative residual abscess(1(2%)vs 9(21.4%)),intestinal fistula(5(10.2%)vs 14(33.3%))and pancreatic fistula(0(0%)vs 4(9.5%)),the differences are statistically significant(P<0.05),however,there was no significant difference in postoperative peripancreatic bleeding(4(8.2%)vs 7(16.7%),P=0.215).Step-up approach group could reduce the mortality of IPN patients and it was more effective for IPN patients,the differences were statistically significant(P<0.05).(2)Multivariate regression analysis showed that the risk factors for postoperative intestinal fistula in IPN patients were preoperative single organ failure(single organ failure,SOF)(OR=22.64,95% CI 1.007-508.745,P<0.05),preoperative hypoproteinemia(OR=19.469,95% CI 2.066-183.436,P<0.05),timing of surgery(OR=1.024,95% CI 1.005-1.044,P<0.05)and the presence of gas on CT imaging(OR=3.481,95% CI 1.367-8.866,P<0.05).Conclusion:(1)The results of this study showed that step-up approach can significantly relieve the symptoms of IPN patients,reduce the incidence of postoperative complications and mortality,and reduce hospitalization time and hospitalization expenses with good clinical application value.As far as the results of this study,step-up approach may be superior to direct OPN in the treatment of IPN to some extent(due to the small sample size of this study,multicentric,large sample size randomized controlled trials will be conducted to further verify the superiority of step-up approach over direct OPN in the future).(2)The risk factors for postoperative intestinal fistula in IPN patients were preoperative single organ failure(single organ failure,SOF),preoperative hypoproteinemia,timing of surgery and the presence of gas on CT imaging.Therefore,preoperative active monitoring of clinical indicators,rational internal medicine management,appropriate operation timing and timely,effective and careful imaging examination could prevent the occurrence of postoperative intestinal fistula in patients with IPN. |
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