早期内镜治疗急性胆源性胰腺炎46例临床研究

目的探讨急性胆源性胰腺炎患者早期行内镜逆行胰胆管造影(ERCP)和内镜治疗的临床疗效及安全性。方法将我院2005年1月至2010年7月期间住院治疗的91例急性胆源性胰腺炎患者按治疗方式分为ERCP组(46例)和内科保守治疗组(简称对照组,45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、血淀粉酶降至正常时间、平均住院时间及死亡率)进行对比分析。结果 ERCP组ERCP诊断胆总管结石27例,单纯胆囊结石6例,十二指肠乳头旁巨大憩室3例,化脓性胆管炎4例,胆总管下段狭窄3例,ERCP未见异常3例。27例胆总管结石患者中20例行内镜下乳头括约肌切开术(EST),4例行乳头开窗术,3例胆总管微小结石行气囊取石术。27例患者中应用胆道网篮、气囊一次性取石成功20例,7例患者因合并化脓性胆管炎或结石巨大,取石困难,先给予急诊内镜鼻胆管引流术(ENBD),待病情稳定后再行EST取石和(或)碎石治疗。3例十二指肠乳头旁巨大憩室和3例胆总管下段狭窄行EST,4例化脓性胆管炎仅行ENBD。所有患者均行ENBD。ERCP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(P0.05)。血淀粉酶降至正常时间及死亡率两组比较差异无统计学意义(P0.05)。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。     

老年急性胆源性胰腺炎的内镜治疗

目的探讨老年病人急性胆源性胰腺炎患者早期行内镜下逆行胰胆管造影检查和治疗的临床疗效及安全性。方法 87例急性胆源性胰腺炎住院患者,其中老年病人23例(老年组),其余64例为对照组,观察两组的疗效和安全性。结果 23例老年病人均顺利实行了ERCP操作,病情均得到不同程度的改善,同对照组相比没有明显增加并发症率。结论内镜下逆行胰管造影对于治疗老年病人急性胆源性胰腺炎具有微创、安全、有效,是治疗老年病人胆源性胰腺炎的一种有效的方法。     

早期ERCP与保守治疗在不伴有胆管炎的急性胆源性胰腺炎的疗效比较

早期应用ERCP在合并有急性胆管炎的急性胰腺炎的治疗中的作用已得到广泛的认可。但对于不伴有胆管炎的轻型急性胆源性胰腺炎，目前并不主张早期应用ERCP。然而在不伴有胆管炎的重症急性胆源性胰腺炎中是否能够早期应用ERCP目前还没有较为一致的意见。     

急性胆源性胰腺炎内镜治疗作用的探讨

目的:探讨内镜对急性胆源性胰腺炎的诊治作用。方法:收集1997年经内镜诊治的急性胆源性胰腺炎患者20例,并以同时期作保守治疗或手术治疗的15例患者作对照。结果:ERCP操作成功率为85％,对胆源性胰腺炎的诊断准确率为100％,呵同时采用Oddi括约肌切开、取石和/或置鼻胆管引流。治疗成功率为100％。内镜治疗减少了胰腺炎并发症发生率和患者住院天数,降低医疗费用。结论:内镜是胆源性胰腺炎的最佳诊治手段。     

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。     

内镜治疗急性胆源性胰腺炎的临床价值

目的探讨内镜治疗急性胆源性胰腺炎的疗效。方法对我院1998年7月~2004年10月行ERCP、EST、ENBD等方法治疗急性胆源性胰腺炎43例的临床资料进行回顾性分析。结果本组43例经内镜治疗后疗效均满意。术后发生出血1例、形成胰腺假性囊肿2例、死亡1例。无因病情恶化而中转手术治疗者。结论ERCP对急性胆源性胰腺炎的诊断有重要价值;内镜是治疗急性胆源性胰腺炎安全、有效的方法之一。     

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。     

十二指肠镜、腹腔镜联合治疗急性胆源性胰腺炎

目的探讨内镜、腹腔镜联合治疗急性胆源性胰腺炎(acute billiary pancreatitis, ABP)的临床效果,创建ABP微创治疗系统化方案. 方法将696例急性胆源性胰腺炎根据胆道状态、重症度和治疗方法分为单纯LC(腹腔镜胆囊切除术,laparoscopic cholecystectomy)组,ERCP(内镜逆行胰胆管造影,endoscopic retrograde cholangiopancreatography) LC组,ERCP LCBDE(腹腔镜胆总管探查术,laparoscopic coon bile duct exploration)组,ERCP EST(内镜乳头括约肌切开术,endoscopic sphincterotomy)组和重型胰腺炎组,观察疗效. 结果 696例ABP中,实施EST者330例(47.4%),经内镜取石成功267例(38.4%);实施ERCP、LC和LCBDE者分别为411例(59.1%)、513例(73.7%)和85例(12.2%),成功例数分别为409(99.5%)、511(99.6%)和82(96.5%).重型胰腺炎36例,存活34例(94.4%).ABP治愈率99.7%(694/696). 结论内镜、腹腔镜联合微创治疗急性胆源性胰腺炎疗效明显,有助于微创治疗ABP方案的完整和规范.     

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.     

内镜联合腹腔灌洗治疗早期急性重症胆源性胰腺炎

目的探讨内镜联合腹腔穿刺灌洗治疗早期重症胆源性胰腺炎的效果.方法将急性重症胆源性胰腺炎患者62例随机分为2组,即内镜联合腹腔灌洗组(简称内镜组)32例和保守治疗组(对照组)30例.内镜组在入院3     

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.     

The role of clinical and biochemical criteria and endoscopic retrograde cholangiopancreatography in the urgent diagnosis of common bile duct stones in acute pancreatitis

The role of clinical and biochemical criteria in predicting common bile duct (CBD) stones was analyzed in 76 patients with acute pancreatitis undergoing endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Forty patients had ERCP within 72 hours; cholangiography was successful in 92%. Fifty patients had biliary pancreatitis; 25 patients had CBD stones and all were successfully removed by endoscopic sphincterotomy (ES). Twenty-six patients had nonbiliary pancreatitis. Two patients had complications from ERCP and/or ES; two patients died (no CBD stones) but ERCP was noncontributory. Significant differences were found between the biliary and nonbiliary disease groups with respect to age, and bilirubin. gamma-glutamyl transpeptidase, alkaline phosphatase, alanine transaminase, and amylase levels. The first four factors also discriminated between those patients with and without CBD stones. Logistic discriminant functions were estimated providing probabilities for the presence of CBD stones for each patient but were too cumbersome for clinical use. A simple scoring system was devised on the basis of cut-off levels: bilirubin greater than or equal to 40 mumol/L, gamma-glutamyl transpeptidase greater than or equal to 250 IU/L, alkaline phosphatase greater than or equal to 225 IU/L, and age greater than or equal to 70 years, indicating CBD stones. Bilirubin alone had a sensitivity and specificity of 80%; the specificity increased to 93% with all four factors. These results suggest that clinical and biochemical criteria and ERCP and/or ES may have important roles in the management of patients with suspected biliary 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.     

The theory of ''persisting'' common bile duct stones in severe gallstone pancreatitis.

There have been uncertainties as to the role of common bile duct (CBD) stones in severe gallstone pancreatitis. In order to resolve this, ERCP findings in 131 patients with acute pancreatitis were compared with predicted severity, clinical course and final outcome. Significant associations were found between 'persisting' CBD stones, coincidental acute cholangitis, predicted severity and actual outcome. There was evidence for acute obstruction of both the CBD and the pancreatic duct by CBD stones. The theory was therefore proposed that small migrating stones tend to initiate the attack, whereas larger 'persisting' stones tend to convert a mild attack into a severe attack. This hypothesis resolves previously irreconcilable theories and lends support to the use of urgent endoscopic sphincterotomy for treatment, but only in cases predicted to be severe.     

The role of magnetic resonance cholangiography in the management of patients with gallstone pancreatitis

OBJECTIVE: To examine the utility of magnetic resonance cholangiography (MRC) in the preoperative evaluation of patients with gallstone pancreatitis. SUMMARY BACKGROUND DATA: Gallstone pancreatitis is often associated with the presence of common bile duct (CBD) stones that may require endoscopic removal prior to planned laparoscopic cholecystectomy. No reliable clinical criteria exist, however, that can accurately predict CBD stones and the need for preoperative endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Sixty-four patients were identified with gallstone pancreatitis based on clinical presentation and imaging studies over a three-and-a-half-year period. All patients underwent MRC, and the images were evaluated for gallstones, CBD stones, cholecystitis, and pancreatitis RESULTS: Seventeen of the 64 patients (27%) with gallstone pancreatitis were found to have CBD stones confirmed by ERCP. MRC correctly predicted CBD stones in 16 of the 17 patients (sensitivity = 94%). In 1 additional patient, MRC demonstrated CBD stones not seen at ERCP, consistent with probable passage. By comparison, the sensitivities of other criteria for predicting CBD stones were (1) elevated bilirubin >or=2.0 mg/dL = 65%; (2) dilated duct on ultrasound = 55%; and (3) CBD stones on ultrasound = 27%. MRC was able to visualize gallbladder stones in 57 of 62 patients (94%) and correctly predicted acute cholecystitis in 6 of 8 patients. MRC also detected peripancreatic edema and inflammatory changes consistent with acute pancreatitis in 45 of 64 patients (70%). CONCLUSIONS: These results demonstrate that MRC can accurately identify CBD stones preoperatively in patients with gallstone pancreatitis and provide valuable information with respect to other biliary pathology, including cholelithiasis, acute cholecystitis, and pancreatitis. MRC is an effective noninvasive screening tool for CBD stones, appropriately selecting candidates for preoperative ERCP and sparing others the need for an endoscopic procedure with its associated complications.     

Risk factors for cholecystectomy in patients with gallbladder stones after endoscopic clearance of common bile duct stones

Background  Cholecystectomy usually is recommended for patients with gallbladder (GB) stones who previously underwent endoscopic removal of common bile duct (CBD) stones. However, in practice, many patients still have GB stones after improvement of their biliary symptoms. This study aimed to evaluate risk factors for cholecystectomy in patients with GB stones after complete endoscopic clearance of CBD stones. Methods  From August 2003 to April 2006, the medical data of 61 patients with concomitant GB stones who underwent complete endoscopic clearance of CBD stones were reviewed retrospectively. The risk factors for subsequent cholecystectomy were evaluated during a 24-month of follow-up period. Results  Among the 61 patients, 12 (19.7%) subsequently required cholecystectomy for recurrence of biliary symptoms, and 11 of these 12 patients (91.7%) needed cholecystectomy within 12 months. Gallbladder stones 10 mm or larger (p = 0.037) and the acute pancreatitis (p = 0.049) were the independent risk factors for subsequent cholecystectomy. The actuarial probability of remaining free of subsequent cholecystectomy during the follow-up period was higher for the patients with GB stones smaller than 10 mm than for the patients with GB stones 10 mm or larger (86.7% vs. 62.5%; p = 0.037). In addition, the patients with acute pancreatitis had a higher tendency for subsequent cholecystectomy than the patients without acute pancreatitis (50% vs. 16.4%; p = 0.078). Conclusions  Only a small number of patients subsequently needed to undergo cholecystectomy for recurrence of biliary symptoms, and most events developed within 12 months. For the patients with GB stones 10 mm or larger or acute pancreatitis, prophylactic cholecystectomy is strongly recommended after complete clearance of CBD stones.     

老年人胆源性急性胰腺炎的早期外科治疗体会

目的总结老年人胆源性急性胰腺炎早期外科治疗的经验。方法对1997年1月至2007年1月10年间,收治的39例老年人胆源性急性胰腺炎患者早期外科治疗的临床资料进行回顾性分析。结果39例老年人胆源性急性胰腺炎,术中均见胆总管有不同程度的扩张,其中33例胆总管内有大小不等的结石,12例有脓性胆汁。36例治愈出院。手术后死亡率为7.69%（3/39）,死亡原因为呼吸功能衰竭或多器官功能衰竭5例发生手术后胆漏,发生率为12.8%（5/39）。结论早期积极的胆道取石和/或胆道置管引流、减压等处理,是成功治疗老年人胆源性急性胰腺炎的有效手段。但由于老年人多有重要器官功能不全等,手术风险大,术后并发症多,应遵循“个体化方案”的治疗原则,重视维持水电解质酸碱平衡和血液循环的稳定,加强围手术期处理。     

The role of endoscopic retrograde cholangiopancreatography in the laparoscopic era

BACKGROUND: The optimal approach to patients with suspected common bile duct (CBD) stones remains unsettled. Options include pre- and postoperative endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic exploration of the CBD. This retrospective study evaluates the role of ERCP in the management of suspected CBD stones, with an emphasis on indications, endoscopic findings, and outcome. METHODS: We retrospectively reviewed the consecutive medical records of 99 patients (67 females and 32 males) who underwent ERCP for suspected CBD stones between March 1992 and December 1995. RESULTS: In 86 patients, ERCP was performed preoperatively. Indications for ERCP included jaundice, pancreatitis, elevated liver functions tests (LFT), and ultrasound (US) or computed tomography (CT) scan findings. Forty one (48%) of 86 preoperative ERCP had positive findings; 37 (43%) were negative, and in 8 (9%) we failed to demonstrate the CBD. There were seven (8%) major complications: four cases of acute pancreatitis, one case of acute bleeding, and two cases of acute bleeding with perforation. There was no mortality. When pancreatitis was the only indication for ERCP, 0 of 8 patients had positive findings in comparison with 50% when pancreatitis was associated with jaundice and LFT, and 93% when US or CT scan demonstrated stones or dilation of the CBD. CONCLUSIONS: We conclude that ERCP is a valuable option for management of CBD stones but should be performed selectively. Neither pancreatitis alone nor LFT alone is an indication for ERCP. The presence of CBD stones is more likely when multiple indications are present.     

Single-stage definitive laparoscopic management in mild acute biliary pancreatitis

BACKGROUND: Population-based studies have shown that nearly one third of patients with acute biliary pancreatitis undergo endoscopic retrograde cholangiopancreatography (ERCP) before undergoing laparoscopic cholecystectomy (LC) (two-stage approach). The present study was designed to evaluate the safety of single-stage laparoscopic management to avoid preoperative ERCP. MATERIALS AND METHODS: Between June 1998 and June 2002, 35 female patients and 10 male patients (median age, 59 years) with uncomplicated mild acute biliary pancreatitis were studied prospectively and reviewed retrospectively. LC with fluoroscopic intraoperative cholangiography (IOC) or with fluoroscopic IOC and laparoscopic CBD exploration in cases of concomitant choledocholithiasis was performed as the definitive treatment (single-stage approach). Patients underwent surgery electively when symptoms had subsided and laboratory parameters had improved. RESULTS: LC alone was performed in 39 patients, and an additional laparoscopic CBD exploration was performed in the remaining six. In one patient, IOC yielded a false-positive result. CBD stones were detected in four cases, and debris in the CBD in one case, for an 11% incidence of concomitant choledocholithiasis. The conversion rate was zero, and single-stage laparoscopic treatment was successful in all cases. The overall morbidity rate was 4%. The 30-day postoperative mortality rate was zero. CONCLUSION: Although preoperative ERCP and sphincterotomy still have a role in complicated cases of mild acute biliary pancreatitis, laparoscopic single-stage definitive treatment is feasible and safe in uncomplicated cases of disease when local experience is available.     

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.