The Minimally Invasive Surgery Around Pancreat Region Of Severe Acute Pancreatitis

BackgroundThe SAP (severe acute pancreatitis) which accounts for 15-30% of AP(acute pancreatitis). It is featured by dangerous condition,complex symptom,complications and high fatality rate. Recently,as the acknowledge of pathogenesis, natural course and the infection in pancreatitis on the SAP,and the prgress of intensive care and invasive surgery, the therapeutic effect for SAP has been improved greatly.But its death rate is already about 20-30%.Consequently,it already is a difficult peoblem to improve the treatment effect for the medical worker.In the twentieth century,professor Fang had studied the pancreatitis in treat the SAP with durgs.With several years,he invented the Minimally Invasive Surgery Around Pancreat Region which has greatly improved the clinical treatment effect.For the conformation of the treatment scheme and definition of the SAP,we made experimental study. In the meantime,this study will be helpful in supply support therory for the clinical use. Part 1. The establishment of SAP model of ratsObjective:1. Verify the SAP model produced by the method of retrograde pancreatic duct infusion;2. Prepare for the theraputic study on SAP rats.Methods1. Materials:(1) sodium deoxycholate;(2) TNF-α,IL-6 ELISA kits.2. Subject:30 female rats(weighed 0.2kg-0.25kg) were provided by Southern Medical University,Guangzhou3. Grouping:30 rats was divided into two groups(model and control) randomly.15rats per group.4. Method:the model group was built by the method of retrograde pancreatic duct infusion with 5% sodium deoxycholate;the control group was built by the method of retrograde pancreatic duct infusion.5. Specimens collection and test:5 rats were killed in two groups respectively at 6h,12h,24h;the blood AMY,ascites blood AMY,WBC,TNF-α,IL-6 were tested; TNF-α,IL-6 were tested with ELISA kits;the pancreas tissue were made conventional pathology.6. Statistics:SPSS13.0 was used. Factorial design was used in the data of two groups; P<0.05 was considered siginificantly.Results1. General condition:the liabilities of model group and control group are 80% and 100% respectively;2. Indicators:the difference of the indicators between model and control is prominent; the difference of the indicators among the model group is prominent;And with time goes on,the indicators is more serious; the difference of the indicators among the control group isn't prominent.ConclusionsThe SAP model of rats is reliable,repeatable and low-cost.The method of retrograde pancreatic duct infusion is simple and practicable.And the method is a perfect way to build the rats model of SAP for the therapeutic experiment study.Part 2. Study of the minimally invasive surgery around pancreat region for rats with severe acute pancreatitisObjectiveObserve the impact of the minimally invasive surgery around pancreat region to SAP rats.Methods1. Materials:(1) sodium deoxycholate;(2) TNF-α,IL-6,PL-A2 ELISA kits.2. Subject:72 female rats(weighed 0.18kg-0.22kg) were provided by Southern Medical University,Guangzhou3. Group:72 rats were divided into four groups:the natural course group(SAP group),the routine treat group(R group),the DDFA group(DDFA group),the minimally invasive group(W group). There are 18 rats in each group.4. the mthod of build model:Retrograde pancreatic duct infusion.5. Specimens collection and test:6 rats were killed in each group at 6h,12h,24h;the blood AMY, ascites AMY, WBC, TNF-a, IL-6, PL-A2 were tested; TNF-a, IL-6 PL-A2 were tested with ELISA kits;the pancreas tissue were made conventional pathology.6. Statistics: SPSS 13.0 was used. Factorial design was used in the data of groups; P<0.05 was considered siginificantly.Results1. General condition: livabilities of the SAP group,the R group,the DDFA group and the W group are 72.22%,83.33%,94.44%,100% respectively;2. The comparison of the blood AMY, ascites AMY, WBC, TNF-a, IL-6, PL-A2 and pathological scores among groups at different time points have siginificant differences.Conclusionsthe minimally invasive surgery around pancreat region can decreas the WBC, AMY, IL-6, TNF-a, PL-A2, ascites AMY and pathological scores siginificantly. It is a effective way to prevent the SAP course progress.Part 3. Study of the minimally invasive surgery around pancreat region for severe acute pancreatitisObjectiveTo investigate the clinical effect of the minimally invasive surgery around pancreat region in treatingthe SAP.Methods1. Method:Data of 40 cases of SAP patients treated between 2001 and 2010 were retrospectively analyzed.2. The implement of the minimally invasive surgery around pancreat region:After admission,the patients were treated with the minimally invasive surgery around pancreat region. The executing process are follows. First, under local anesthesia, two 1 cm-cuts were carried out at the left and right abdomen respectively. Two double-pipes were located at the pancreat surrounding rigion. Close the abdomen and fix the pipes. The normal saline with 5-Fu was imported persistently into abdominal cavity. Then, the flushing liquor was emported with vacuum extractors. At the same time,the DDFA drug project was also carried out.3. Statistical indicators:the WBC, Neutrophils ratio, blood AMY, urine AMY and ascites AMY were recorded at admission and lst,3rd,5th,7th,14th after surgery. The general condition, vital signs changes, complications, therapeutic results were also recorded.4. Statistics:Use SPSS 13.0; repeated measures was used in comparing data, and P<0.05 was considered significantly.Results1. General conditionsThe mean time of hospital stay is 36.65±17.78d. After treated with the minimally invasive surgery around pancreat region, the abdominal symptom improved obviously, the vital signs are more stable than before admission, the colour of fluid drainge changed from dark red to clear.37 patients healed completed,2 patients died after voluntarily discharged and 1 patient improved.2. IndicatorsThe comparission of WBC, Neutrophils ratio, blood AMY, urine AMY and ascites AMY between admission and 1 week,2 week after surgery,leave is significant; The comparission of WBC, Neutrophils ratio, blood AMY, urine AMY and ascites AMY between 1 day after surgery and 1 week,2 week after surgery,leave is also significant.3. ComplicationsIn the treatment process, hydrothorax occurred on 14 patients, respiratory insufficiency happended on 6 patients, pseudocyst happened on 3 patients. Two patients with pseudocyst cured by surgery, and one patient healed through drug treat and persistent peritoneal lavage and drainage with 5-Fu NS.ConclusionsThe minimally invasive surgery around pancreat region is a effective treat method with less complications and be worth to popularize.Part 4. Clinical observation of the continuous rolling flush around infection region in treating severe abdominal infectionObjectiveTo investigate the continuous rolling flush around infection region in treatingthe severe abdominal infection.Methods1. Study method: Data of 8 cases of severe abdominal infection patients treated between 2006 and 2010-4 were retrospectively analyzed.2. Treatment: Place pipes at the infected position by celiotomy or minimally invasive surgery, and continuously swash and drainage using the normal saline or other solutions. Adjust the antibiotics according to the fester nature or the result of germiculture, and use the antiobitics is disused untill the abdominal systoms,signs and the general systoms are eliminated.3. Indicators:Collect the numerical value of temperature, WBC and the neutrophils ratio at admission,the first and the second week after surgery,discharge.4. Statistics: Use SPSS 13.0; repeated measures was used in comparing data, and P<0.05 was considered significantly.Result1. General conditionThe 8 patients were all cured.2. IndicatorsThe comparisions of temperature between admission and the seventh day after surgery, the fourteenth day after surgery, the discharge are all have significant value. The WBC and the neutrophils ratio of the fourteenth day and the discharge all decreased than that of admission, and P<0.05.ConclusionsThe continuous rolling flush around infection region can drain the abdominal infection backlog well, improve the abdominal and general systoms and prevent the bacterimia and the septic shock occcuring and developing. It is valued to spread in clinical work.Part 5. the tentative study of CT and MI-3DVS in the classification of necrotizing pancreatitisObjectiveTo investigate the clinical value of the CT and MI-3DVS in the classification of necrotizing pancreatitis.Methods1. Method: the severe degree of SAP patients admited at 2009-3 to 2011-2 were scored and graded by the scoring standard made with the CT and the MI-3DVS.2. The scoring standard:the content of the standard can be saw at the normal text. 1 to 5 was considered the low level,6 to 10 was considered the middle level,11 to 15 was considered the high level.3. Statistics:the measurement data were expressed by x±s; the ONE way ANOVA was used in interclass comparision and the LSD or Tamhane was used in innergroup comparision; P<0.05 was considered significantly.Result1. General conditionAll the patients were treated with the minimally invasively surgery around pancreat region; All the patients were healing well except for a patient who discharged because of financial straits. The patients who have stones in biliary tract or have the complication of pesudocyst were cured at the second admission.2. Length of staythe ONE way ANOVA was used in comparing the length of stsy of the three groups, and the P=0.006. the difference of the low level and the middle level is not siginificant, and the P=0.467. the length of stay of the low level and the middle level all have siginificant difference in comparing the length of stay of the high level, and the P value are 0.003 and 0.014 respectively.3. ComplicationsThere are not any comlications in the low level group; there are a respiratory insufficiency and a pesudocyst in the middle level group; In the high level group, respiratory insufficiency occurred on three patients, and pseudocyst happened on two patients, one patients of them has the complication of the respiratory insufficiency and the pseudocyst simultaneously. Because of the complication counts are small, the comparision of the three groups is not carried out.ConclusionsThe scoring standard for the necrotizing pancreatitis adequately utilized the superiority of CT in observing the abdominal condition and the index of necrosis volume, and may be a reliable scoring method. Therefore, the dependance of the new standard is still need to be validated by clinical studies with large samples.Part 6. the study of the application of MI-3DVS in pancreatic pseudocystObjectiveTo investigate the application value of MI-3DVS in the pancreatic pseudocyst.Methods1. Materials(1) PHILIPS BRILLIANCE 64-slice helical CT, Image process workstation; (2) binocular tube high pressure injector; (3)computer; (4) DICOM Viewer; (5) ACDSee; (6) Medical Image 3D Visualization System (MI-3DVS); (7) FreeForm Modeling System and PHANTOM. 2. ExaminerYu **, male,52 years, pseudocyst occcured after the SAP; CT: the pesudocyst around pancreace,10*3 cm; the pancreace is pressed by the pseudocyst. The pseudocyst grow not down through 3 months' expectant treatment.3. Collection of CT scan data:Pancreatic CTA during the arterial phase, pancreatic phase and portal venous phase were performed in all of the examiners, then the scan data was upload to dedicated database server and stored.4. Image ReconstructionThe original data was inputted into the personal computer and translated into JPG format through DICOM viewer; then the JPG format was translated into BMP format and the size of the images were adjusted from 512px×512px into 304px×304px by ACDSee. The adjusted images were imported into Medical Image 3D Visualization System (MI-3DVS) and underwent procedure segmentation and three-dimensional reconstruction. The reconstructed models were outputted to STL format; and then STL models were imported into FreeForm Modeling System to be smoothed, denoised and digital painting, etc.5. the comparision between 3D resconstruction and real operationStudy the 3D resconstruction preoperation and observe the space relationship between the pseudocyst and the surrounding organs, and last evaluate the internal drainage surgery. Take photos and photographic recording, and compare the 3D model, simulated surgery and the real operation.Result1. the 3D modelsThose organs, such as pancreas, pseudocyst, liver, spleen, abdominal aorta and its breaches, portal vein and its breaches, all have shown good. It can really displsy the real size, the shape, the space relationship between pseudocyst and adjacent organs. And through different combination way, we can display the two organs relation by hiding other organs. Through zoom out, zoom in, rotateing and see through, we can understand the space relationship between pseudocyst and adjacent organs further.2. the simulated surgeryThe simulated operation process is vivid, precise, and have the feel of "force" which likes the feel of real operation.Conclusions1. The 3D reconstruction technology is helpful in the choose of thrapeutic method of pseudocyst and the formulation of reasonable operative method;2. The simulated operation has great application value in preoperative practice, decreasing operative complications, doctor-patient communication, teaching, and so on.