修回日期: 2026-05-07
接受日期: 2026-06-18
在线出版日期: 2026-08-28
急性坏死性胰腺炎(acute necrotizing pancreatitis, ANP)是一种病情凶险的疾病, 并发症发生率及死亡率均较高. 近年来, 微创治疗已取代传统开腹手术成为主流治疗方式, 但在最佳干预时机、引流方式选择及胰管中断综合征(disconnected pancreatic duct syndrome, DPDS)的处理策略方面, 临床实践中仍存在诸多争议. 本文结合近年来发表的随机对照试验、多中心队列研究及国际指南共识, 分析经皮引流、内镜引流/清创及外科微创技术在ANP管理中的应用及演变, 重点关注干预时机的优化及DPDS的综合管理策略. 最新证据表明, 对于未包裹坏死组织或无菌性坏死, 应采取保守治疗, 干预时机通常延迟至发病后4 wk, 在引流策略选择上, 内镜引流应作为首选, 双腔固定金属支架在特定情况下优于塑料支架. 对于大型包裹性坏死, 采用一步法内镜清创策略可能缩短病程. 对于合并DPDS的患者, 需制定长期的支架管理策略以降低复发率.
核心提要: 急性坏死性胰腺炎治疗应延迟至发病4周后, 内镜引流优于经皮穿刺. 对大型包裹性坏死, 早期一步法内镜清创可缩短病程. 胰管中断综合征早期拔除双腔固定金属支架后置入双猪尾塑料支架, 以降低胰周积液复发率.
引文著录: 施珍珍, 何文华. 急性坏死性胰腺炎微创治疗策略优化与并发症处理新进展. 世界华人消化杂志 2026; 34(8): 602-608
Revised: May 7, 2026
Accepted: June 18, 2026
Published online: August 28, 2026
Acute necrotizing pancreatitis (ANP) is a severe condition associated with substantial morbidity and mortality. In recent years, minimally invasive interventions have largely replaced traditional open surgery as the mainstream therapeutic approach. Nevertheless, considerable controversy remains in clinical practice regarding the optimal timing of intervention, selection of drainage methods, and management strategy for disconnected pancreatic duct syndrome (DPDS). Drawing on recent randomized controlled trials, multicenter cohort studies, and international guidelines and consensus statements, this review critically examines the application and evolution of percutaneous drainage, endoscopic drainage/debridement, and minimally invasive surgical techniques in the management of ANP, with a focus on the optimization of intervention timing and comprehensive management strategies for DPDS. The latest evidence indicates that conservative treatment should be adopted for nonwalledoff necrosis or sterile necrosis, with intervention generally delayed until 4 weeks after onset. In terms of drainage strategy, endoscopic drainage should be the firstline option, and lumenapposing metal stents (LAMS) are superior to plastic stents in specific situations. For large walledoff necrosis, a onestep endoscopic debridement strategy may shorten the disease course. Furthermore, for DPDS, early removal of LAMS followed by longterm placement of plastic stents is crucial for preventing recurrence.
- Citation: Shi ZZ, He WH. Novel minimally invasive treatment strategies for necrotizing pancreatitis. Shijie Huaren Xiaohua Zazhi 2026; 34(8): 602-608
- URL: https://www.wjgnet.com/1009-3079/full/v34/i8/602.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v34.i8.602
核心提要: 急性坏死性胰腺炎治疗应延迟至发病4周后, 内镜引流优于经皮穿刺. 对大型包裹性坏死, 早期一步法内镜清创可缩短病程. 胰管中断综合征早期拔除双腔固定金属支架后置入双猪尾塑料支架, 以降低胰周积液复发率.
急性胰腺炎(acute pancreatitis, AP)是最常见胃肠道疾病之一[1]. 尽管大多数患者表现为轻症且具有自限性, 但约有20%的病例会进展为急性坏死性胰腺炎(acute necrotising pancreatitis, ANP), 此类重症患者常伴有持续性器官衰竭(organ failure, OF), 或感染性胰腺坏死(infected pancreatic necrosis, IPN), 死亡率高达20%-40%[2]. ANP后期并发症中以包裹性坏死(walled-off necrosis, WON)和胰管中断综合征(disconnected pancreatic duct syndrome, DPDS)处理较为棘手. 目前临床共识认为, 对于无菌性坏死, 无论胰周积液(peripancreatic fluid collection, PFC)的体积与范围如何, 均应优先采取保守治疗, 部分坏死组织可随病程进展自行吸收消退[3]. 然而, 当坏死组织或积液引发临床症状-如腹痛、胃流出道梗阻所致的恶心呕吐、胆道梗阻或感染性发热时, 则需考虑进行引流干预[4]. 过去十年间, ANP的治疗模式经历了革命性转变, 已从传统的早期外科手术转向以经皮穿刺引流、内镜引流/清创为核心的微创"升阶梯"治疗策略[5]. 然而, 在微创干预的具体实施层面, 如干预时机的精准把握、引流方式的选择, 以及针对DPDS等特殊并发症的处理策略上, 临床实践中仍存在诸多争议. 本文基于近年来国内外发表的高质量临床研究证据, 系统梳理坏死性胰腺炎及其并发症微创治疗的关键议题, 旨在为优化临床决策提供参考.
坏死性胰腺炎患者的有创干预应推迟至坏死组织形成完整包裹后实施, 通常为发病后≥4 wk. 此阶段坏死组织可发生液化, 且与存活组织间形成清晰界限, 这一病理特征有助于提升干预操作的精准性与安全性[6]. 在干预时机的具体界定上, 有研究提出要从"单纯时间标准"向"基于病理成熟度的个体化判断"转变. 日本多中心队列研究数据显示, 干预时坏死组织包裹程度≥80%的患者, 其临床治疗成功率显著提高、并发症发生率明显降低, 且该效应与发病后时间长短无相关性[7]. 早期有创干预仅适用于特定高危情况, 主要包括存在明确感染证据、进行性OF或休克等[8]. 早期积极引流曾被认为是控制脓毒症、逆转OF的关键手段, 但最新高质量随机对照试验对此提出了新的观点. POINTER试验对比了IPN患者立即引流与延迟引流(>4 wk)的临床效果, 结果显示两组患者主要并发症发生率及死亡率无显著差异, 但延迟引流组可显著减少有创干预的次数及需求[9]. 后续长期随访研究进一步证实, 两组患者在长期死亡率、新发OF发生率、胰腺内/外分泌功能不全发生率及生活质量评分方面均无统计学差异, 且延迟引流组超过1/3的患者可免于引流或手术治疗[10]. 从成本效益角度分析, 立即引流虽增加了医疗费用, 却未带来相应的健康获益[11].
针对伴有早期持续性OF的APN患者, TIMING多中心随机对照试验结果显示, 早期干预组与延迟干预组在主要结局(新发持续性OF或死亡复合终点)上无显著差异, 而早期干预组总体不良事件发生率显著升高[12]. 综上, 现有试验证据表明, 即使对于IPN或伴有早期持续性OF的重症患者, 延迟引流策略仍具有非劣效性, 且安全性更优.
在引流策略选择方面, 目前临床常用方式包括超声内镜(endoscopic ultrasound, EUS)引导下经腔引流、经皮置管引流(percutaneous catheter drainage, PCD)及双模态引流, 其中双模态引流即联合经皮与内镜引流. Samanta等[13]纳入218例患者的研究显示, 对于WON患者(无论是否合并感染), 内镜引流的临床成功率显著高于PCD(92.1% vs 64.6%, P<0.0001), 且器官功能衰竭的缓解率更高、缓解速度更快; 该研究同时建议, 对于固体成分>40%的WON, 应避免采用PCD. 一项纳入17项研究[14]的荟萃分析进一步证实, 与PCD相比, 内镜引流可显著缩短包裹性胰腺坏死患者的住院时间、降低重症监护病房入住率, 且减少失血、机械通气及脓毒性休克等并发症的发生. 因此, 在技术可行且具备专业操作能力的前提下, 内镜引流应作为WON的首选治疗方式. EUS引导下引流术可选用多种支架, 包括双猪尾塑料支架(double pigtail plastic stents, DPPS)、自膨式金属支架及双腔固定金属支架(lumen-apposing metal stent, LAMS). 从理论层面而言, LAMS因直径较大, 相较于小口径塑料支架, 可更高效地引流WON内容物, 且可通过支架直接实施内镜下坏死组织清除, 凭借多重优势在临床应用中日益普及[15].
然而, 内镜下引流WON的最佳支架类型目前仍存在争议, 评估DPPS与LAMS安全性及疗效的研究结果存在矛盾. 一项纳入352例WON患者的荟萃分析显示[16], DPPS组与LAMS组在临床成功率、再干预率、死亡率及总不良事件发生率等方面均无统计学差异, 但LAMS组手术时间更短. 与之相反, 另一项纳入1460例WON患者的荟萃分析及系统综述提示[17], LAMS在临床结局及安全性方面优于DPPS. 造成两组结论矛盾的主要原因在于纳入研究的类型不同. 前者仅纳入随机对照试验, 偏倚控制更为充分, 因此结果更为保守和稳定. 后者的研究中包含了大量观察性研究, 这类研究虽然样本量较大但容易受到选择偏倚和混杂因素的影响. 其次, 病灶特征和技术策略差异也可能造成不同研究结论不一致. 有的研究纳入对象中包括感染性与无菌性WON患者, 此外, 固体坏死组织比例和坯死范围不一、清创的时机、联合PCD引流及支架留置时间等不完全相同, 均会影响临床预后. 国际胰腺病学会2025年修订版AP指南推荐, DPPS与LAMS均可用于WON的内镜引流, 而对于感染性WON或坏死范围超过WON体积30%的患者, LAMS可能为更优选择[4]. 对于位于侧腹或盆腔、伴深部腹膜后延伸、内镜无法到达的WON, 或当内镜引流不可行、操作失败时, 需辅助采用PCD[5]. DRACULA多中心回顾性研究首次系统探讨了坏死性胰腺炎患者PCD治疗的实际应用现状及其对预后的影响, 结果表明, 冲洗操作本身、所采用的特定冲洗方案及PCD管尺寸等因素, 与患者住院时长及死亡率无显著相关性; 但与仅接受单一PCD治疗的患者相比, 采用经皮和内引流(双模式)治疗策略的患者死亡率显著更低[18].
尽管多达50%的液体集聚通过引流即可获得临床缓解[19], 但单纯引流无法有效控制感染或清除坏死组织时, 需进一步实施清创治疗. Vanella等[20]开展的前瞻性队列研究, 验证了"象限-坏死-感染"(quadrant necrosis infection, QNI)评分在预测EUS引导下引流后是否需清创的价值. 该研究结果表明, 积液累及多象限、坏死成分比例高及存在明确感染, 是初始引流治疗失败的独立预测因素, 对于QNI高分患者, 应早期制定更积极的清创策略. 关于EUS引导引流后启动内镜下清创(endoscopic transluminal necrosectomy, ETN)的时机, 既往多数内镜医师采取升阶梯策略, 建议在引流后3-21 d内进行[21]. 近年来, 多个高质量随机对照试验对"阶梯策略"提出了挑战. DESTIN临床研究对比了前期内镜清创与内镜升阶梯方案治疗IPN的临床效果, 结果显示, 两种治疗策略在主要并发症发生率及死亡率方面无统计学差异, 但前期清创组可显著缩短治疗周期、减少内镜操作总次数及因症状持续所需的再干预率[22]. ACCELERATE临床试验针对直径>15 cm的大型WON患者开展研究[23], 发现"加速"治疗组(穿刺引流时立即清创)的主要并发症发生率及住院时间均显著降低. 随后, Yuen等[24]的系统回顾与荟萃分析进一步证实, 直接内镜清创与内镜升阶梯方法在主要安全结局(死亡率及严重不良事件)上无显著差异, 但直接清创策略在缩短住院时间方面呈现出优势趋势. 以上新策略可归类为"早期一步法内镜清创", 是比升阶梯策略更积极的治疗模式.
关于坏死组织的清创方式, 传统方式是外科开腹坏死组织清除术, 但该术式伴随较高的并发症发生率和病死率[25], 且患者术后发生长期胰腺功能不全的风险较高[26]. 2010年荷兰一项随机对照试验[27]直接对比了阶梯式微创治疗与开腹清创术的疗效, 证实与开腹坏死组织清除术相比, 微创升阶式治疗方案可显著降低主要并发症或死亡的复合终点发生率. 一项纳入6项随机对照试验[28]、共1045例患者的系统综述, 对比了内镜升阶式策略与外科微创升阶式方法的临床效果, 结果显示, 两种策略的病死率相当(8%-18% vs 6%-15%), 但内镜升阶式策略可显著降低胰瘘发生率(8% vs 34%, P<0.01)及新发OF发生率, 且在多项研究中可缩短患者住院时间. 对于坏死灶距胃或十二指肠腔1.5厘米内的患者, ETN可作为有效的首选治疗方案[29]. 但该方法存在一定局限性, 主要表现为需多次重复操作、难以量化坏死负荷、无法有效处理大量坏死组织、深部腹膜后延伸病灶及远端左侧积液[30]. 在微创外科清创中, VARD通过在引流管处做小切口, 借助腹腔镜视频引导完成清创操作, 通常单次手术即可达到治疗目的[31]. 经皮窦道内镜清创(peroral endoscopic necrosectomy, PEN)则需扩张PCD的窦道, 随后使用内镜或肾镜进行清创操作. 与VARD相比, PEN的主要优势在于可利用经腹腔、肋间及极细小的引流窗口进行操作, 可有效减少伤口并发症的发生; 其主要缺点为操作器械相对细小, 往往需要多次手术才能完成彻底清创[29].
ANP的长期管理不仅需行有效引流与清创, 还需注意是否合并DPDS. DPDS是指因主胰管节段性坏死, 导致有功能的近端胰腺组织与消化道连续性完全中断, 上游胰腺分泌液无法正常排出, 进而引发PFC反复出现、腹痛及胰腺炎复发等症状的临床综合征[32]. DPDS的报道发生率存在较大差异, 在坏死性胰腺炎患者中可达10%-30%, 但受限于临床认识延迟及诊断标准不统一, 其实际发生率很可能被低估[33].
准确诊断DPDS是制定科学治疗方案的前提. 临床上, 若内镜下移除支架后PFC迅速复发, 应高度怀疑DPDS的可能[32]. 影像学诊断方面, 增强计算机断层扫描虽常用于初步评估, 但难以可靠区分真正的胰管中断与积液压迫、胰腺水肿所致的胰管狭窄[33]; 磁共振胰胆管成像目前已成为DPDS的标准诊断手段[34]. 内镜逆行胰胆管造影仍是确认胰管完全中断的金标准, 但该操作存在一定的创伤性及感染风险, 临床通常仅用于具有明确治疗意图的病例[35]. DPDS治疗难度较高且严重影响患者远期生活质量[36].
DPDS的管理策略需结合患者具体情况制定个体化多学科治疗方案. 保守治疗(包括鼻空肠管喂养及奥曲肽应用)的临床效果通常有限[37]. 历史上, 手术治疗是DPDS的主要干预方式, 主要包括胰管空肠吻合术(对有活力的上游胰腺组织进行引流)及离断胰腺残余部分切除术[38]. 随着EUS技术的不断发展, 内镜干预或联合PCD已成为DPDS的标准治疗方法, 尤其是LAMS的应用显著改善了DPDS合并PFC患者的预后[39]. DPDS患者尽量避免单独使用PCD, 其治疗DPDS的疗效差, 且不可避免会导致胰外瘘形成[37]. 针对DPDS的内镜干预方式主要包括: EUS引导下PFC引流术(endoscopic ultrasound-guided drainage of pancreatic fluid collections, EUS-PFD)、EUS引导下胰管引流术(endoscopic ultrasound-guided pancreatic duct drainage, EUS-PDD)和经乳头胰管支架置入术. 其中, 经乳头胰管支架置入术治疗DPDS的疗效较差, 成功率仅为20%[40]; EUS-PDD技术要求较高, 其技术成功率约为80%, 不良事件发生率约为20%[41]. 因此, 对于伴有症状的PFC合并DPDS患者, 优先考虑实施EUS-PFD.
LAMS在PFC的初始处理中发挥着关键作用, 但迟发性出血风险限制了其长期留置[42]. 目前临床处理DPDS的标准模式为: 在早期拔除LAMS后, 长期置入DPPS. 长期留置DPPS可显著降低PFC的复发率及再干预率[32]. 一项前瞻性研究表明, 在使用金属支架进行引流清创后, 拔除金属支架的同时更换为DPPS并长期留置可显著降低PFC的复发率[43]. 一项研究观察了长期留置DPPS的安全性和有效性[44], 结果显示伴有PFC的DPDS的患者长期留置DPPS是安全有效的. 然而, 一项有关在拨除金属支架的同时替换为DPPS并且长期留置预防PFC复发的随机对照研究中表明, 在金属支架被替换为塑料支架后并不能减少PFC的复发[45]. Zhou等[46]的研究发现, 更换并长期留置DPPS患者的PFC复发率显著低于未更换支架者(23.3% vs 70.83%). 上述研究结论存在差异的主要原因包括: 首先, PFC复发的核心驱动因素为胰管中断部位胰液持续积聚, 不同研究纳入的DPDS部位及坏死范围存在异质性; 其次, LAMS留置与拔除时机不同, Chavan等[45]在引流后4 wk即取出LAMS, 此时坏死组织多未完全液化吸收, 易造成后续DPPS堵塞并直接升高PFC复发风险, 而本研究及Bang等[43]、Gkolfakis等[44]均在LAMS引流期间联合多次内镜下清创, 待坏死组织大部分清除、坏死腔缩小后再置换DPDS, 可显著降低支架闭塞概率; 最后, 支架规格与管理策略不同, Zhou等[46]的研究提示, 与10Fr规格DPPS相比, 7Fr规格DPPS在复发率控制及安全性方面可能具有更优的临床结局.
综上所述, 以内镜引流和清创为代表的微创技术已成为ANP及DPDS的治疗首选策略. 在干预时机方面, ANP的引流治疗应尽量推迟至WON形成后实施; 对于特定患者亚群, 尤其是大型WON患者, 早期一步法内镜清创策略可促进患者更快康复、降低医疗资源消耗, 且不增加安全风险. 在干预策略方面, 内镜路径是ANP的首选干预方式, 对于内镜无法触及的坏死积液、因各种原因无法实施内镜手术或内镜操作失败的患者, VARD和PEN是重要治疗手段. 对于DPDS合并有症状PFC的患者, 优先考虑实施EUS-PFD, 推荐在早期拔除LAMS后置入DPPS, 以有效预防PFC复发.
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学科分类: 胃肠病学和肝病学
手稿来源地: 江西省
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科学编辑: 刘继红 制作编辑:张砚梁