诊断与治疗性逆行胰胆管造影并发胰腺炎危险因素分析

目的：探讨诊断性胰、胆管显影与胆道支架、乳头括约肌切开取石术等治疗抗逆行胰、胆管造影（ERCP）,对术后并发胰腺炎的影响。方法：412例ERCP操作分为7组,诊断性ERCP为胆胰双管显影（ERCP）组、单纯胆管显影（ERC）组组与单纯管显影（ERP）组,治疗组ERCP分为双管显影加支架术（ERCP＋支架）组、ERC＋支架组、ERCP＋乳头肌切开（EST）取石组及ERC＋EST取石组,比较各组术后4h、24h血清淀粉酶及临床症状改变。结果：术后4h、24h高淀粉酶血症发生率为17．7％及4．4％,并发急性胰腺炎的发生率为3．95,各组中以ERP组发病率为最高。结论：在ERCP操作中,反复胰管造影是并发术后胰腺炎主要危险因素,EST、支架治疗并不增加胰腺炎的发病率。     

联合应用质子泵抑制剂、生长抑素和加贝酯预防ERCP术后胰腺炎和高淀粉酶血症的临床研究

背景：急性胰腺炎和高淀粉酶血症是内镜逆行胰胆管造影术（ERCP）的主要并发症,术前用药对预防和减轻并发症的作用尚存争议。目的：探讨联合应用质子泵抑制剂、生长抑素和加贝酯对ERCP术后胰腺炎（PEP）和高淀粉酶血症的预防作用。方法：共纳入510例行ERCP的患者,随机分为加贝酯组、生长抑素组、联合治疗组（质子泵抑制剂＋生长抑素＋加贝酯）和安慰剂组。观察术后2h、12h和24h血清淀粉酶水平,评估PEP和高淀粉酶血症的发生率．并分析PEP和高淀粉酶血症的危险因素。结果：ERCP术后2h、12h、24h,联合治疗组、生长抑素组和加贝酯组血清淀粉酶水平显著低于安慰剂组（P〈0．05或P〈0．01）,联合治疗组血清淀粉酶水平亦显著低于生长抑素组或加贝酯组（P〈0．05）。ERCP胰管显影者的PEP和高淀粉酶血症发生率显著高于胆管显影者（P〈0．05）。单变量分析显示ERCP操作过程中胰管多次显影、导丝多次插入胰管、导丝辅助、反复插管以及操作中发生上腹疼痛为PEP和高淀粉酶血症的技术相关性高危因素。结论：ERCP术前后联合应用质子泵抑制剂、生长抑素和加贝酯可改善PEP和高淀粉酶血症的发生。     

胰管支架预防困难胆管插管ERCP术后急性胰腺炎的前瞻性研究

目的探讨经内镜逆行胰胆管造影术（ERCP）中置入胰管支架对困难胆管插管患者ERCP术后急性胰腺炎（PEP）的预防效果。方法120例行ERCP诊疗发生困难胆管插管的患者采用随机数字表法随机分成2组,一组术中置入胰管支架（观察组）,另一组未置入（对照组）,对比分析2组ERCP术后高淀粉酶血症、PEP的发生率以及术后患者腹痛评分结果。结果观察组发生ERCP术后高淀粉酶血症15例（27．3％）,PEP5例（8．3％）,无一例重症PEP,术后患者腹痛评分（3．82±1．48）分;对照组发生ERCP术后高淀粉酶血症18例（30．0％）,PEP14例（23．3％）,重症PEP2例（3．3％）,术后患者腹痛评分（4．78±1．93）分。2组ERCP术后高淀粉酶血症发生率比较,差异无统计学意义（P〉0．05）;观察组PEP、重症PEP发生率以及术后患者腹痛评分均明显低于对照组,差异均有统计学意义（P〈0．05）。结论置入胰管支架可以有效降低胆管插管困难所引起的PEP的风险,并能有效缓解患者术后疼痛,具有较好的临床应用价值。     

胰管塑料支架在ERCP选择性胆管插管困难时的应用研究

[目的]探讨胰管塑料支架在内镜逆行性胰胆管造影术(ERCP)选择性胆管插管困难时的应用。[方法]将在ERCP中选择性胆管插管困难的104例患者分为无胰管塑料支架组、胰管塑料支架组,观察并比较2组选择性胆管插管成功率,术后胰腺炎、高淀粉酶血症和腹痛等并发症的发生率。[结果]胰管塑料支架组与无胰管塑料支架组选择性胆管插管成功率比较差异无统计学意义(P0.05),胰管塑料支架组术后胰腺炎、高淀粉酶血症和腹痛等并发症的发生率较无胰管塑料支架组显著性降低(P0.05~0.01)。[结论]对ERCP选择性胆管插管困难的患者预防性放置胰管塑料支架,虽然未能提高胆管插管的成功率;但是可明显降低术后胰腺炎、高淀粉酶血症和腹痛并发症的发生率。     

经内镜逆行胰胆管造影术后并发胰腺炎的危险因素分析

目的探讨发生经内镜逆行胰胆管造影术（ERCP）术后胰腺炎（PEP）的危险因素。方法回顾性分析4234例接受ERCP诊疗患者的临床资料,提取患者年龄、性别、手术史、重大疾病史等基本信息以及术前实验室检查、腹部彩超、CT、磁共振胰胆管成像等检查结果,详细录入ERCP术中操作、术中诊断、并发症以及术后处理等情况,运用单因素分析和多因素分析手段分别寻找PEP发生的危险因素和独立危险因素,并采用矩阵相关分析方法探寻各危险因素之间是否存在共线性关系。结果共发生226例PEP,发生率为5．3％。单因素分析显示女性（X^2=9．715,P=0．002）、年龄〈60岁（X^2=6．108,P=0．013）、慢性胰腺炎（X^2=14．703,P=0．001）、初次ERCP（X^2=14．899,P=0．000）、高血压（X^2=4．489,P=0．034）、术前黄疸阴性（X^2=19．159,P=0．000）、困难插管（X^2=45．824,P=0．000）、留置胰管导丝（X^2=30．223,P=0．000）、乳头预切开（X^2=45．928,P=0．000）、胰管造影（X^2=20．170,P=0．000）为PEP发生的危险因素。多因素非条件Logistic回归分析显示女性（OR=1．449,P=0．011）、初次ERCP（OR=1．745,P=0．003）、术前黄疸阴性（OR=1．917,P=0．000）、困难插管（OR=3．317,P=0．ooo）以及胰管造影（OR=1．823,P=0．004）为PEP发生的独立危险因素。矩阵相关分析提示困难插管与乳头预切开、留置胰管导丝之间存在一定的共线性,相关系数分别为-0．788和-0．699。结论女性、年龄〈60岁、慢性胰腺炎、初次ERCP、高血压、术前黄疸阴性、困难插管、留置胰管导丝、乳头预切开、胰管造影均可能引发PEP。其中术前黄疸阴性、初次ERCP、女性患者、困难插管和胰管造影是PEP的独立危险因素,而留置胰管导丝和乳头预切开因与困难插管密切相关,故不应当视为独立的危险因素。     

不同方式十二指肠乳头括约肌切开术在经内镜逆行胰胆管造影术中的应用

目的 观察经胰管和针状刀十二指肠乳头括约肌切开术(EST)在行内镜逆行胰胆管造影术(ERCP)解决胆管插管困难中的应用效果.方法 对在ERCP过程中出现胆管插管困难而行EST术的患者64例,32例采用经胰管EST,另32例采用针状刀EST,比较两种术式在ERCP中插管成功率和并发症的发生情况.结果 本组32例患者经针状刀EST成功实施ERCP30例(93.8％);另32例患者经胰管EST成功实施ERCP 24例(75.0％,c2=4.267,P=0.042).经胰管EST失败的8例患者,有5例改为针状刀EST后,成功插管并完成了ERCP检查;两组患者术后胰腺炎、穿孔、术中出血发生率差异均无统计学意义(P＞0.05).结论 在行ERCP过程中插管困难时可通过EST手术扩大切口,以提高插管成功率.     

经胰管乳头括约肌预切开术在困难胆道插管中的临床应用

目的评价经胰管乳头括约肌预切开术在困难胆道插管中的安全性和疗效。方法回顾性分析2005年7月至2006年7月在我院行ERCP的患者。对常规胆管插管失败且导丝反复进入胰管（〉4次）者行经胰管乳头括约肌预切开，胆管插管成功后，导丝留置胆管内，继续完成胆管括约肌切开及相应的治疗。统计插管的成功率及并发症的发生率。结果在整个研究期间内共行ER—CP1576例次，需胆管深插管879例次，经胰管乳头括约肌预切开者30例。经胰管乳头括约肌预切开后，首次ERCP胆管深插管成功率为93．3％（28／30），2次ERCP插管成功率为96．7％（29／30）。2例（占6．7％）发生并发症，为轻型胰腺炎。无出血、穿孔或操作相关的死亡发生。结论在困难胆道插管中采用经胰管乳头括约肌预切开术是一种安全有效的方法。     

胰管支架预防高危ERCP术后胰腺炎的临床分析

目的 观察胰管支架置人预防高危患者内镜逆行胰胆管造影（ERCP）术后胰腺炎及高淀粉酶血症的效果.方法 将确定有ERCP指征并符合纳入标准的72例高危患者按照随机数字表法分为胰管支架组和对照组,每组36例.比较两组术后3h、24 h血清淀粉酶水平及高淀粉酶血症、急性胰腺炎、重症胰腺炎的发生率.结果 胰管支架组术后3h和术后24 h血淀粉酶值分别为（128.68±173.35） U/L和（92.41±88.44） U/L,均低于对照组（432.37 ±515.20） U/L和（465.89±736.54） U/L,差异有统计学意义（P＜0.05）;胰管支架组术后高淀粉酶血症、急性胰腺炎、重症胰腺炎的发生率分别为5.6％、2.8％、0,对照组为22.2％、16.7％、11.1％,两组比较差异有统计学意义（P＜0.05）.结论 胰管支架置入能明显降低高危患者ERCP术后高淀粉酶血症、急性胰腺炎及重症胰腺炎的发生率.     

胰管导丝占据法在困难内镜逆行胰胆管造影中的应用价值

目的评价胰管导丝占据法在内镜逆行胰胆管造影（ERCP）中胆管选择性插管困难时的应用价值。方法2008年6月至2012年6月间共3505例患者符合入选条件。开始均尝试对患者用导丝辅助的括约肌切开刀行选择性胆管插管（标准法）,若导丝反复进入胰管5次仍未插管成功则导丝留置于胰管,退出切开刀另用一根导丝尝试插管（占据法）,尝试失败则行经胰预切开或针状刀乳头开窗术（占据法失败行预切开）,若尝试插管达5次胰管亦未能进入则行针状刀乳头开窗术（胆胰管插管失败行预切开）。比较各组间胆管插管成功率及并发症的发生率。结果标准法插管成功率（93．4％）明显高于占据法（54．8％,P〈0．001）、占据法失败行预切开（81．3％,P〈0．001）及胆胰管插管失败行预切开（84．6％,P=0．011）;占据法失败行预切开及胆胰管插管失败行预切开插管成功率均明显高于占据法（P值均〈0．001）;各组间术后胰腺炎发生率差异无统计学意义。标准法插管成功后行括约肌切开有2例出血,行预切开插管患者中有5例出血、1例穿孔,无死亡病例。结论胰管导丝占据法胆管插管成功率虽不高,但当标准插管法困难时应首先尝试,以尽量避免预切开的风．呤．     

内镜下十二指肠乳头预切术在恶性胆道梗阻诊治中的应用

目的 探讨内镜下十二指肠乳头预切术在恶性胆道梗阻诊治中的应用价值.方法 对46例插管困难的恶性胆道梗阻患者,根据十二指肠乳头及其周围结构、插管情况等采用不同预切方法对乳头括约肌施行内镜下预切术,观察ERCP诊治的完成情况,以及并发症发生情况.结果 应用弓形刀切开法4例、针状刀切开法24例、经胰管胆管切开法12例、联合方法6例,其中35例预切术后胆管插管成功,成功率达76.1%（35/46）.发生术后黏膜渗血3例、胰腺炎1例、高淀粉酶血症2例、胆管炎1例,未见穿孔发生.结论 内镜下乳头预切术可提高恶性胆道梗阻患者ERCP诊治的成功率,且适时、正确地应用可以降低并发症的发生率.     

Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study

BACKGROUND: Pancreatitis is the most frequent complication of ERCP. Injury to the papilla during ERCP could obstruct pancreatic duct outflow and initiate pancreatitis. A randomized prospective study was performed to evaluate the effect of pancreatic duct stent placement on the frequency and severity of post-ERCP pancreatitis in a selected group of patients. METHODS: The study group consisted of patients over 18 years of age at high risk for post-ERCP pancreatitis because of a difficult cannulation, sphincter of Oddi manometry, and/or the performance of endoscopic sphincterotomy. Patients were prospectively randomized to have a pancreatic duct stent placed or no stent upon completion of the ERCP. The endoprosthesis used was either a 5F nasopancreatic catheter or 5F, 2-cm long pancreatic stent. Study endpoints were the frequency and severity of post-ERCP pancreatitis. RESULTS: Patients undergoing pancreatic duct stent placement had a lower frequency of post-ERCP pancreatitis as compared with those in the control group (28% vs. 5%; p < 0.05). Pancreatitis tended to be less severe in patients who had pancreatic duct drainage. CONCLUSIONS: Pancreatic duct stent insertion after ERCP reduces the frequency of post-ERCP pancreatitis in patients at high risk for this complication.     

Frequency and severity of post-ERCP pancreatitis correlated with extent of pancreatic ductal opacification

BACKGROUND: Pancreatitis is the most common complication of diagnostic and therapeutic ERCP. Almost certainly, the etiology of this pancreatitis is multifactorial. OBJECTIVE: The primary objective of this study was to evaluate the relationship between the extent of pancreatic ductal opacification and the frequency of pancreatitis. DESIGN: Retrospective study. SETTING: The ERCP database at our institution was searched for prospectively collected data from 1994 to 2005. PATIENTS AND INTERVENTIONS: A total of 14,331 ERCPs were included in the analysis. Patients were divided into 4 groups according to the extent of pancreatic duct opacification: group 1, no attempted opacification or failed cannulation of the pancreatic duct (n = 6739); group 2, opacification of head only (n = 845); group 3, opacification of head and body (n = 2061); and group 4, opacification to the tail (n = 4685). The incidence and severity of pancreatitis was compared between and within each group. RESULTS: The overall pancreatitis rate was 4.0%. There was a progressively higher frequency of pancreatitis with increased extent of opacification to the pancreatic ductal system (P < .001). The overall pancreatitis severity was mild in 2.9%, moderate in 0.8%, and severe in 0.3% of cases. There was a significant difference in pancreatitis severity between patients with pancreatogram (regardless of grade of filling) and patients without pancreatogram. (P < .001). However, there was no difference in the pancreatitis severity between groups 2 to 4 (patients with pancreatogram). Age (65 years vs >65 years), sex, and type of procedure performed (diagnostic and therapeutic) were not significantly different beyond the extent of pancreatic ductal opacification. Multivariate analysis showed that suspected sphincter of Oddi dysfunction with manometry and the extent of pancreatic duct opacification were independent predictors of post-ERCP pancreatitis. CONCLUSIONS: Less filling of the pancreatic ductal system was associated with less post-ERCP pancreatitis. Before performing endoscopic retrograde pancreatography, endoscopists should carefully evaluate whether any pancreatogram or what extent of pancreatogram is needed clinically. Greater use of noninvasive pancreatography and less use of endoscopic retrograde pancreatography should decrease post-ERCP pancreatitis.     

Risk for post-ERCP pancreatitis after needle knife precut sphincterotomy following repeated cannulation attempts

GOALS: The aim of this study was to determine the risk and identify the factors associated with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients who undergo needle knife precut sphincterotomy (NKS). In addition, we evaluated the effect of gabexate for the prevention of post-ERCP pancreatitis. BACKGROUND: NKS, after repeated cannulation attempts during ERCP, is known to increase the risk of post-ERCP pancreatitis. However, the specific risk factors for post-ERCP pancreatitis have not been identified, and the preventive role of protease inhibitors, such as gabexate, has not yet been established. STUDY: The medical records of 200 patients who underwent NKS, after repeated cannulation attempts during ERCP, were reviewed retrospectively. The potential risk factors for post-ERCP pancreatitis were investigated. The effect of gabexate infused after the ERCP procedure was also evaluated. RESULTS: Thirteen (6.5%) patients out of 200 developed post-ERCP pancreatitis. Sex, age, the presence of pancreatitis at procedure, underlying disease, direction of the sphincterotomy, success or failure of cannulation after NKS, diameter of common bile duct, pancreatic duct status, and the presence of acinar filling were not associated with the risk of pancreatitis. Gabexate infusion after ERCP increased the incidence of ERCP-associated pancreatitis. CONCLUSIONS: We could not identify any risk factors associated with the development of post-ERCP pancreatitis in patients who underwent NKS after repeated cannulation attempts during ERCP. However, gabexate administered after the ERCP procedure was found to increase the incidence of pancreatitis.     

ENBD预防胆总管结石ERCP术后急性胰腺炎及高淀粉酶血症的临床价值

目的观察内镜鼻胆管引流术(ENBD)预防内镜逆行胰胆管造影术(ERCP)术后急性胰腺炎及高淀粉酶血症的效果。方法收集我院胆总管结石行ERCP取石术的患者367例,其中ENBD组309例,对照组58例,比较两组术后2 h及24 h血清淀粉酶值、高淀粉酶血症及急性胰腺炎的发生率。结果 ENBD组术后2 h、24 h的血清淀粉酶值分别为(396.6±240.3)U/L和(620.8±345.5)U/L,明显低于对照组的(593.9±470.5)U/L和(1 074.0±609.1)U/L(P<0.05);ENBD组有42例发生高淀粉酶血症(13.6%)、15例发生急性胰腺炎(4.9%),对照组则分别为13例(22.4%)和8例(13.8%),两组比较差异均有统计学意义(P<0.05)。结论 ENBD能有效预防胆总管结石患者ERCP术后急性胰腺炎及高淀粉酶血症的发生。     

Nasobiliary drainage can reduce the incidence of post-ERCP pancreatitis after papillary large balloon dilation plus endoscopic biliary sphincterotomy: a randomized controlled trial

Background and aims: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis can be reduced following endoscopic papillary balloon dilation with the placement of an endoscopic nasobiliary drainage (ENBD) catheter. The aim of this study was to determine whether the placement of an ENBD reduces the risk of post-ERCP pancreatitis following endoscopic papillary large balloon dilation together with endoscopic biliary sphincterotomy.

Methods: A total of 160 patients with bile duct stones were randomly assigned (1:1) to an ENBD group or no-ENBD group. The primary outcome of this study was the incidence of post-ERCP pancreatitis. The secondary outcome was the incidence of post-ERCP hyperamylasemia.

Results: In total, 160 patients were randomized, and 155 were found to be eligible for the analysis. The two groups were similar regarding clinical and demographic factors as well as patient- and procedure-related risk factors for post-ERCP pancreatitis. Post-ERCP pancreatitis developed in 9 patients, that is, 8/77 (10.4%) of the control group and 1/78 (1.28%) of the ENBD group (p?=?.018; per protocol analysis). Intention to treat analysis also revealed that ENBD reduced the rate of post-ERCP pancreatitis (8/80 (10%) in the control group vs. 1/80 (1.25%) the ENBD group (p?=?.034)). Multivariate regression analysis identified not undergoing ENBD as an independent risk factor for post-ERCP pancreatitis (ENBD compared with no-ENBD: OR 0.087, 95% CI 0.011–0.734; p?=?.025).

Conclusion: This study demonstrated that placement of an ENBD was effective and safe for the prevention of post-ERCP pancreatitis in patients undergoing endoscopic papillary large balloon dilation together with endoscopic biliary sphincterotomy.     

ERCP在不明原因复发性急性胰腺炎诊治中的作用

目的探讨ERCP在不明原因复发性急性胰腺炎(RAP)诊治中的作用。方法收集15例不明原因RAP患者。其中男5例,女10例,年龄25～65岁,中位年龄38岁,病程1～2年,发病次数2～5次。10例在急性发作期,5例在发作间期行ERCP诊治。结果15例患者经ERCP明确病因者6例(3例胆管微结石,1例胆总管末端小囊肿,1例胰管小结石,1例胰管蛋白栓子),可疑病因者6例(乳头旁憩室2例,十二指肠乳头炎4例),未明确病因者3例。根据ERCP检查结果,9例行乳头括约肌切开术(EST),6例行胰管括约肌切开术。术后随访2年,15例患者均未复发胰腺炎。ERCP和EST术后2例出现一过性高淀粉酶血症,无其他并发症。结论ERCP对不明原因RAP有明确病因和指导治疗的作用。     

Intravenous bolus somatostatin after diagnostic cholangiopancreatography reduces the incidence of pancreatitis associated with therapeutic endoscopic retrograde cholangiopancreatography procedures: a randomised controlled trial

BACKGROUND: Previous studies suggested that somatostatin given before endoscopic retrograde cholangiopancreatography (ERCP) may reduce the incidence of post-ERCP pancreatitis. However, the routine use of somatostatin in all patients undergoing ERCP is not likely to be cost effective. This study evaluated whether intravenous bolus somatostatin given after diagnostic cholangiopancreatography could reduce the incidence of pancreatitis in a group of patients undergoing therapeutic ERCP procedures. METHODS: In a randomised, double blind, controlled trial, the effect of intravenous bolus somatostatin 250 microg given immediately after diagnostic cholangiopancreatography was compared with that of placebo in patients who required endoscopic sphincterotomy or other therapeutic procedures. The primary end point was the incidence of post-ERCP clinical pancreatitis, and a secondary end point was the incidence of hyperamylasemia. RESULTS: A total of 270 patients were randomised. The somatostatin group (n=135) and the placebo group (n=135) were comparable in age, sex, indications for treatment, and types of procedure. The frequencies of clinical pancreatitis (4.4% v 13.3%; p=0.010) and hyperamylasemia (26.0% v 38.5%; p=0.036) were both significantly lower in the somatostatin group compared with the placebo group. CONCLUSIONS: A single dose of intravenous bolus somatostatin, given immediately after diagnostic cholangiopancreatography, is effective in reducing the incidence of pancreatitis after therapeutic ERCP. This novel approach of administering prophylactic somatostatin may offer a cost effective prophylaxis for post-ERCP pancreatitis.     

RISK FACTORS FOR POST‐ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS: PROSPECTIVE SINGLE‐INSTITUTION STUDY

Pancreatitis is the most common and serious complication of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and hyperamylasemia after ERCP is common. The aim of the present study was to examine the potential patient‐ and procedure‐related risk factors for post‐ERCP pancreatitis including hyperenzymenia in a prospective study. Data were collected prospectively on patient characteristics and endoscopic techniques from 184 ERCP performed at a single referral center and entered into a database. Data were collected prior to the procedure, at the time of procedure, and 24–72 h after procedure. The primary end‐point was the incidence of post‐ERCP pancreatitis and the secondary objective was the incidence of hyperamylasemia. Of the 184 patients enrolled, diagnostic ERCP was performed in 37 (20.1%) and therapeutic ERCP in 147 (79.9%). Pancreatitis developed in two patients (1.1%) and was graded mild in one (0.5%) and severe in the other (0.5%). Hyperamylasemia occurred in 14 patients (7.6%). Six investigated variables, female gender, therapeutic ERCP, major papilla sphincterotomy, stenting, difficult cannulation, and bile duct diameter were not significant risk factors for post‐ERCP pancreatitis. Although there was no significant factors in pancreatitis, the number of cannulations and precut sphincterotomies were significantly related to hyperamylasemia. The present study emphasizes a technical factor (difficult cannulation) as the determining high‐risk predictors for post‐ERCP pancreatitis.