急性胆源性胰腺炎的早期内镜治疗与保守治疗的对比分析

目的 探讨急性胆源性胰腺炎的早期内镜下逆行胰胆管造影检查和治疗与保守治疗的临床疗效及安全性.方法 64例急性胆源性胰腺炎患者,其中36例合并急性胆管炎患者采取急诊实施内镜下十二指肠乳头切开和取石术,28例采取保守治疗者为对照组.结果 36例胆源性胰腺炎合并胆管炎患者顺利实施ERCP;且较保守治疗组病情得到及时有效控制;同对照组相比所有患者均未出现严重并发症.结论 ERCP对于治疗急性胆源性胰腺炎合并急性胆管炎具有微创、安全、有效,是治疗急性胆源性合并急性胆管炎的有效方法之一.     

内镜下双括约肌切开治疗急性胆源性胰腺炎

目的：探讨早期内镜下括约肌切开术（EST）联合内镜下胰管支架置入（ERPD）治疗急性胆源性胰腺炎（ABP）的疗效。方法：前瞻性研究,选取2009年1月至今于我院就诊的44例急性胆源性胰腺炎患者,对其行早期内镜下逆行性胰胆管造影（ERCP）、EST及必要的ERPD,评价疗效,并定期随访观察其长期疗效。结果：早期EST联合ERPD治疗急性胆源性胰腺炎尤其是重症胰腺炎,能有效的缓解腹痛、降低淀粉酶、促进胰腺恢复,降低复发率。结论：急性胆源性胰腺炎采用早期EST联合ERPD治疗是安全有效的,且有较好的长期疗效。     

急性胆源性胰腺炎的EST术相关治疗及护理

目的:总结急性胆源性胰腺炎行内镜下十二指肠乳头括约肌切开术(EST)术的护理措施.方法:回顾性分析29例急性胆源性胰腺炎行EST术的治疗及护理结果.结果:29例病人均顺利进行内镜逆行胆管造影及相关治疗.均治愈或好转出院,近期未有并发症发生,随访半年以上未见胰腺炙复发.结论:加强急性胆源性胰腺炎行内镜逆行胆管造影及相关治疗的护理是手术成功的重要保证.     

Endoscopic therapy for aged patients with biliary acute pancreatitis

目的 探讨高龄胆源性急性胰腺炎(biliary acute pancreatitis,BAP)病人早期内镜治疗的疗效及安全性.方法 将100例BAP病人分为高龄组(80岁及以上)22例,对照组(80岁以下)78例,观察两组内镜治疗的疗效和安全性.结果 高龄组22例均顺利完成了内镜下逆行胰胆管造影(ERCP)操作,与对照组比较,治疗后血淀粉酶、白细胞计数、肝功能恢复正常时间、腹痛缓解时间、腹部体征消失时间及体温恢复正常时间、并发症发生率等差异均无统计学意义.结论 治疗性ERCP对于治疗高龄BAP具有微创、安全、有效等优点.     

早期内镜治疗急性胆源性胰腺炎

探讨急性胆源性胰腺的治疗方法。方法28例急性胆源性胰腺炎患者接受早期内镜逆行胆管造影和乳头切开减压治疗，并于常规治疗的27例进行临床对比观察。结果急性胆源性胰腺炎患者早期内镜减压治疗，可早期缓解症状，减轻病情，提高治愈率，缩短住院时间等。结论早期内镜减压治疗急性胆源性胰腺炎患者，具有创伤小、生理干扰少、恢复快、安全可靠等优点。急性胰腺炎患者一旦明确为胆源性，即应早期内镜减压治疗。     

胆源性胰腺炎早期内镜干预的临床分析

目的探讨早期行内镜逆行胰胆管造影(ERCP)和内镜治疗对于急性胆源性胰腺炎患者的疗效。方法将我院2008年9月～2012年7月期间住院治疗的83例急性胆源性胰腺炎患者按治疗方式分为ERCP组(41例)和保守治疗组(42例)。所有病例均给予积极的常规综合治疗,ERCP组在入院后48 h内行内镜治疗。观察两组的临床疗效并对相关指标(腹痛缓解时间、体温恢复正常时间、白细胞恢复正常时间、肝功能恢复正常时间、平均住院时间)进行对比分析。结果 ER-CP组患者腹痛缓解时间、体温恢复正常时间、白细胞恢复正常时间、肝功能恢复正常时间及平均住院时间均明显短于对照组(P<0.05)。结论急性胆源性胰腺炎患者早期行ERCP能够明确病因,而且内镜治疗微创、安全、有效,能明显缩短住院时间。     

早期内镜介入干预对急性胆源性胰腺炎的价值

目的 探讨急性胆源性胰腺炎早期内镜治疗的疗效及安全性.方法 将2001年1月至2012年1月本院收治的420例急性胆源性胰腺炎按治疗方式随机分为早期(48 h内)内镜下逆行胆胰管造影治疗组(ERCP组)218例及同期保守治疗组(对照组)202例.分别观察两组的腹痛缓解时间、血尿淀粉酶恢复时间、肝功能恢复时间、血白细胞计数恢复时间、平均住院天数、平均费用并观察其并发症发生情况.结果 ERCP组全部成功施行内镜下乳头括约肌切开,172例胆总管结石患者行网篮及气囊取石,218例均行内镜鼻胆管引流术,重症20例同时行胰管支架引流.ERCP组平均腹痛缓解时间及血尿淀粉酶恢复时间、肝功能恢复时间、血白细胞恢复时间、平均住院天数、平均费用均明显低于对照组.ERCP组重症病死率为8.0％,对照组重症患者病死率22.2％.结论 急性胆源性胰腺炎早期施行ERCP能够明确病因,疗效确切安全,能缩短住院时间及减少住院费用.     

急性胆源性胰腺炎的微创治疗策略

目的:探讨急性胆源性胰腺炎的微创治疗策略。方法:回顾分析2007年1月至2012年1月51例急性胆源性胰腺炎患者的临床资料。结果:23例急诊行内镜逆行胰胆管造影检查,内镜十二指肠乳头括约肌切开术取石10例(5例结石取净)、取虫1例,17例放置鼻胆管引流。45例行腹腔镜手术,无一例中转开腹。全组死亡1例,死亡率1.96%。结论:急性胆源性胰腺炎在常规基础治疗的同时,应早期内镜解除胆胰开口梗阻,去除胰腺炎的诱发因素;必要时可行腹腔镜冲洗并置管引流,同时处理胆道疾病;条件允许时可待胰腺炎病情稳定后微创处理胆系结石。     

内镜治疗急性胆源性胰腺炎的疗效评价

目的　探讨内镜治疗急性胆源性胰腺炎的临床效果。方法　将 3 6例急性胆源性胰腺炎患者分成两组治疗 ,其中 2 0例于 2 4h内行逆行胰胆管造影术 (ERCP )、内镜下乳头括约肌切开 (EST )后用网篮取石或碎石网篮碎石后气囊取石术及内镜下鼻胆管引流术 (内镜治疗组 ) ;另 16例行保守或急诊外科手术治疗 (对照组 )。结果　内镜组治疗的成功率为 95 .2 4% ,未发生与内镜操作有关的严重并发症 ,与对照组相比 ,内镜组术后腹痛缓解时间、住院时间明显低于对照组 (P <0 .0 1) ,术后第 2天血及尿淀粉酶明显降低 (P <0 .0 5 ) ,第 3天降低更为明显 (P <0 .0 1)。结论　内镜治疗直接针对胆源性胰腺炎的发病原因 ,解除胆胰管开口的梗阻 ,通畅了胆胰液的引流 ,降低胆胰管内压 ,可有效治疗胆源性胰腺炎 ,该方法微创、安全、有效 ,是治疗急性胆源性胰腺炎的理想方法。     

老年人急性胆源性胰腺炎26例诊治体会

急性胰腺炎(AP)是常见的消化系统急症,病情凶险、病死率高.近年胆道系统疾病老年病人AP的发病率有增高趋势,早期诊断及正确的治疗方式对改善预后有重要意义.现将我院2002～2007年老年胆源性胰腺炎病人作一回顾性分析.     

“Diagnostic Value of MRCP in Biliary Pancreatitis: Result of Long-Term Follow-up”

Aim : Magnetic resonance cholangiopancreatography (MRCP) has increasingly been used to evaluate the common bile duct. This study was to determine the role of MRCP instead of endoscopic retrograde cholangiopancreatography (ERCP) in the management of patients with acute biliary pancreatitis.

Methods : A total of 81 patients with mild or moderate biliary pancreatitis who underwent MRCP and were treated in our department with selective ERCP between May 2001 and July 2007 were entered into a prospective database. Results : MRCP was considered abnormal in 13 patients. Ten patients underwent ERCP. Three patients did not undergo ERCP due to protocol violations. In nine patients, stone extraction was performed. The remaining patient who had dilatation of the CBD underwent ES. The false positive rate of MRCP was 10%. The median follow-up of overall patients was 36 months (range 23–99 months).

The patients with normal MRCP had a median follow-up of 39.5 months (range 23–99 months). During the follow-up period in the normal MRCP group, five patients were diagnosed with recurrent biliary pancreatitis, of which three underwent ERCP (7.4%). There was no disease-related mortality during this period.

Conclusion : In conclusion, the use of MRCP in acute biliary pancreatitis is safe and may be recommended as a tool to aid in the selective use of ERCP.     

急诊ERCP在急性胆源性胰腺炎治疗中的应用

目的探讨急诊ERCP在急性胆源性胰腺炎(ABP)急性反应期中的作用与地位。方法回顾分析92例ABP患者,根据是否早期接受急诊ERCP分为ERCP组(ERCP组,52例)和非ERCP组(N-ERCP组,40例)。观察ERCP组中胆总管微小结石或胆泥发生率;比较两组重症胰腺炎发生率、腹痛缓解时间、血清淀粉酶及肝功能变化。结果 ERCP组中49例急诊ERCP治疗成功,成功率达94.2%。ERCP组中,胆总管微小结石及胆泥共6例,占胰腺炎病因11.5%(6/52);ERCP组重症胰腺炎发生率[5.8%(3/52)]明显低于N-ERCP组[20%(8/40)](P<0.05)。ERCP组腹痛缓解时间(3.5±1.1 d vs 5.0±1.5 d)、血清淀粉酶下降速度(50±135 U/L vs 201±120 U/L)、肝功能(TBIL:125±114μmol/L vs 250±140μmol/L;ALT:210±183 U/L vs 452±215 U/L;GGT:241±198 U/L vs 450±285 U/L)改善情况均优于N-ERCP组(P<0.05)。结论急诊治疗性ERCP可显著缓解临床症状和降低重症胰腺炎发生率。     

Preoperative endoscopic retrograde cholangiopancreatography (ERCP) in patients with pancreatic pseudocyst associated with resolving acute and chronic pancreatitis.

Experience with patients with pancreatic pseudocysts has led the authors to the hypothesis that preoperative evaluation of the pancreatic and bile ducts by ERCP will define those patients who may be inadequately treated by pseudocyst drainage alone without attention to associated pancreatic and biliary ductal abnormalities. In patients with certain ductal abnormalities, the pseudocyst operation was combined with a definitive operative drainage of the pancreatic duct and/or of the biliary tree where appropriate. A prospective evaluation of routine preoperative ERCP was undertaken over a 36-month period in all patients scheduled for operative treatment of pseudocyst of the pancreas. From an initial group of 44 patients with pseudocysts, three patients who had spontaneous regression of the pseudocyst were excluded. ERCP was successful in 39 of the remaining 41 patients. Among 41 operated patients, 24 were admitted with a diagnosis of pseudocyst that arose after an episode of acute pancreatitis, and 17 had chronic pancreatitis with pseudocyst. Nine patients, initially assumed to have acute pancreatitis, were recognized to have chronic pancreatitis on the basis of ERCP findings. Communication with the main pancreatic duct (MPD) was demonstrated in 18 of 41 pseudocysts, and the rate of communication was similar in patients with acute and chronic pancreatitis. Dilatation of the MPD was seen in 23 of 41 patients and was associated with chronic pancreatitis in 21. Dilatation of the common bile duct was found in 12 patients with chronic pancreatitis. The operative plan was altered by ERCP findings in 24 of 41 patients; 22 of the 24 patients had chronic pancreatitis. There were no complications of ERCP. These data suggest that ERCP should be performed in all patients with pseudocysts to establish correct diagnosis and to allow optimal choice of operation.     

梗阻型急性胆源性胰腺炎的治疗方式及手术时机的选择

目的 探讨梗阻型急性胆源性胰腺炎的治疗方式及手术时机的选择.方法 回顾分析广州医学院第三附属医院2000年至2010年76例梗阻型急性胆源性胰腺炎的临床资料.结果 全组手术治疗36例,两周内手术20例,延期手术16例,死亡1例,术后随访无复发.内镜治疗15例,其中ERCP/EST 11例,ERCP/ENBD 1例,ERCP 3例,均获痊愈,随访1例复发.非手术治疗25例,死亡1例,随访6例复发.结论 外科手术在胆源性胰腺炎治疗中具有重要地位.对梗阻型急性胆源性胰腺炎患者应在经短期积极的非手术治疗后早期手术或内镜治疗解除胆道梗阻.

Abstract：

Objective To investigate the management and timing of operation in obstructive acute biliary pancreatifis.Methods A etrospective review was performed of seventy-six consecutive patients who presented to a single tertiary care institution from 2000 to 2010 with obstructive acute biliary pancreatitis.Results Of the seventy-six patients,thirty-six patients underwent operations,with early(after onset within 2 weeks)operations in twenty cases,delayed operationsin sixteen cases and one case dead,no one experienced recurrent pancreatitis during follow-up.Fifteen patients were treated by endoscopy,ERCP/EST in eleven cases,ERCP/ENBD in one case and ERCP only in three case.All patients were cured,only one patient experienced recurrent pancreatitis.Twenty-five patients received conservative treatment,one patient died,six patients experienced recurrent panereatitis.Conclusions Surgery is essential in the management of acute biliary pancreatitis.In cases of obstructive acute biliary pancreatitis,early operation or endoscopic therapy should be performed to remove biliopancreatic obstruction after aggressive conservative treatment.     

Acute biliary pancreatitis. Therapeutic trends

BACKGROUND: Treatment of biliary pancreatitis includes suppression of the biliary cause by cholecystectomy and common bile duct clearance. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy for eradication of biliary stones and laparoscopic cholecystectomy (L.C.) for residual gallbladder stones would be ideal but were once considered to be contraindicated by most surgeons. The timing of definitive biliary tract surgery and the role of ERCP have been the focus of discussion in recent years. METHODS: During a two-year study period 51 patients with acute biliary pancreatitis were studied. Seven patients (14%) underwent emergency laparotomy, necrosectomy, cholecystectomy, exploration of the common bile duct and T-tube insertion, because unstable clinical conditions, with evidence of pancreatic and peripancreatic necrosis on CT-scan. Elective open cholecystectomy and CBD exploration were performed in 7 patients after the resolution of acute pancreatitis during the same hospital admission. RESULTS: Early ERCP and L.C. were associated with favourable outcomes. 33 patients underwent ERCP preoperatively: 17 within 72 hours of admission and 16 after signs of clinical improvement. Laparoscopic cholecystectomy performed 3-25 days after admission was successful in 27 of 29 patients. Postsphincterectomy bleeding occurred in one patient and was treated successfully by endoscopic epinephrine injection. For median hospital stay and recurrence there were statistical differences between early and delayed ERCP. CONCLUSIONS: ERCP and sphincterectomy have a certain role in conjunction with laparoscopic cholecystectomy in the management of patients with acute biliary pancreatitis, particularly in institutions where there is easy access to expert interventional endoscopic techniques. This policy should reduce the risk of cholangitis and recurrent pancreatitis.     

Acute cholangitis in association with acute pancreatitis: incidence, clinical features and outcome in relation to ERCP and endoscopic sphincterotomy

Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) have been shown to be valuable in managing patients with acute cholangitis, their role in patients who have simultaneous acute cholangitis and acute pancreatitis is not known. We have reviewed 32 consecutive patients presenting with both conditions over ten years which represents 23.0 per cent of all cases of gallstone-related acute cholangitis and 14.4 per cent of all cases of biliary acute pancreatitis admitted during the same period. The majority of patients were elderly (median 76 years) and female (75 per cent). Five patients had previously undergone cholecystectomy. Eleven patients were clinically shocked (34 per cent) and blood cultures were positive in 9/14 cases (64 per cent). Twenty patients (63 per cent) had a predicted severe attack of acute pancreatitis (modified Glasgow criteria). Common bile duct (CBD) stones were identified in 15 of 23 patients with successful ERCP. Of these 23 patients, 9 were treated by endoscopic sphincterotomy (ES) alone, 5 by ES and surgery, 4 by surgery alone and 5 were treated conservatively. There was one death (4.3 per cent). Nine patients were managed without cholangiography; four had surgery and five were treated conservatively. There were three deaths (33 per cent; P = 0.10). Evidence of recent CBD stone passage was apparent in eight patients (25 per cent) compared with five out of eighty-seven patients (5.7 per cent) with acute cholangitis alone (P less than 0.005). The results indicate that ERCP and ES may have an important role in the management of these patients.     

A prospective study of ERCP and endoscopic sphincterotomy in the diagnosis and treatment of gallstone acute pancreatitis. A rational and safe approach to management

From a consecutive series of 112 patients with acute pancreatitis, 70 patients with suspected gallstones were randomized to urgent endoscopic retrograde cholangiopancreatography (ERCP) (less than 72 hours) and endoscopic sphincterotomy (ES) if choledochal stones were present (n = 35), or to conventional treatment (n = 35). Endoscopic retrograde cholangiopancreatography, successful in 89% of cases, indicated choledochal stones in 11 patients, all of whom underwent successful stone retrieval by ES. Later during hospital admission, ERCP was performed in 13 more patients and choledochal calculi were extracted from two patients by ES. No complications were attributable to ERCP or ES. Two patients died of biliary pancreatitis; both had been conventionally treated and may have benefited from urgent ERCP/ES. Our experience, which extends to another 24 patients with ERCP and ten with ES during acute pancreatitis, indicates that these are safe techniques and deserve wider consideration in the management of acute pancreatitis.     

Acute biliary pancreatitis: Diagnosis and management

Acute biliary pancreatitis is a serious complication of biliary calculous disease and is associated with significant morbidity and mortality. The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute biliary pancreatitis has been the focus of discussion in recent years. In addition, the exact role of laparoscopic cholecystectomy (LC) in the management of acute biliary pancreatitis has not yet been fully defined. In this report, we evaluated a protocol of emergency ERCP (within 24 hours) for predicted severe attacks, early ERCP (within 72 hours) for predicted mild attacks, and interval LC for management of acute biliary pancreatitis. Between January 1992 and June 1995 a total of 75 patients with acute biliary pancreatitis were managed according to the protocol. Bedside ultrasonography at admission diagnosed 94% of all 64 patients with gallbladder stones, but the sensitivity of visualizing choledocholithiasis was low (19%). Forty-five (60%) of them were predicted to have a severe attack by either Ranson or glucose/urea criteria. Emergency ERCP and endoscopic sphincterotomy (ES) for identifiable common bile duct (CBD) or ampullary stones were performed on all patients predicted to have a severe attack within 24 hours from presentation. An early endoscopic procedure was performed on all patients predicted to have a mild attack within 72 hours from presentation. ERCP was successful in 95% of all patients, and CBD stones were detected in 52 (69%) of them. ES and stone clearance were successful in all of these 52 patients. The morbidity associated with the endoscopic procedure was 3%, and there were no deaths. All except one patient survived the attack of acute pancreatitis, resulting in an overall mortality of 1%. Interval LC was performed on 46 patients with a conversion rate of 4%. The median postoperative hospital stay after LC was 2 days, and there was no major intraoperative or postoperative morbidity or mortality. Our experience suggests that the policy of emergency ERCP for patients with predicted severe disease, early ERCP for patients with predicted mild disease, and interval LC are associated with favorable outcomes in patients with acute biliary pancreatitis. Acute biliary pancreatitis can be managed safely and effectively by a combined endoscopic and laparoscopic approach.     

Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.