ERCP相关十二指肠穿孔诊治的经验和教训

目的：ERCP相关的十二指肠穿孔虽然发生率低，但死亡率很高，诊断是否及时、处理是否得当直接关系到这一严重并发症的预后。本文结合文献资料及我院的具体病例，总结与ERCP有关的十二指肠穿孔方面的经验和教训。方法：回顾我院2003年至2006年间所进行的2450例ERCP操作，有9例病人发生了十二指肠穿孔，发生率为0．37％。本文将具体分析相关的基础疾病、ERCP操作情况、穿孔的诊断、治疗手段及治疗效果。结果：7例病人经B超、MRCP或术中造影证实有胆总管结石，2例肝功能异常伴胆管扩张，怀疑胆总管结石；ERCP操作中除2例乳头插管顺利外，其余7例插管困难，运用预切开技术后6例插管成功；除3例穿孔明显的病例外，其余6例取石成功，并留置鼻胆管；穿孔的主要诊断依据为：腹膜炎2例，皮下气肿7例。3例病人进行了急诊手术，切除胆囊，胆总管切开取石后留置T管，并游离十二指肠，在后腹膜间隙放置引流；其中1例因为引流不畅，后腹腔脓肿形成而再次清创引流，平均住院50d。另外6例采用了非手术治疗，禁食，胃肠减压，鼻胆管引流，抗菌抑酶止酸；治疗过程中某些病人有局限性腹痛和发热，但无加重趋势，无病人中转治疗，平均住院13d。无死亡病例。结论：预切开技术应用不当可能导致十二指肠穿孔；皮下气肿是较为敏感的穿孔指标；如果能够早期及时诊断，非手术治疗一般能取得良好结果，建立通畅的胆道和胃肠引流是治疗成功的关键。     

Operative treatment of periampullary retroperitoneal perforation complicating endoscopic sphincterotomy

BACKGROUND: Evidence-based strategies are lacking regarding the appropriate management of periampullary retroperitoneal perforations complicating endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES). We propose a transduodenal operative repair of periampullary retroperitoneal perforation. METHODS: Six patients with duodenal periampullary perforation induced by endoscopic sphincterotomy underwent operation after failure of an attempt of conservative management. After mobilization of the second and the third part of the duodenum, a minimal transversal duodenotomy was carried out, the papilla was exposed, periampullary perforation was readily identified, and was sutured easily as a sphincteroplasty or by 2 or 3 Vicryl 3/0 sutures. Patient outcomes were measured. RESULTS: Periampullary perforation was repaired as sphincteroplasty in 2 cases, and with Vicryl 3/0 sutures in 4 cases. The mean duration of operation was 176 minutes. There were no intraoperative complications. None of the patients required reoperation after transduodenal repair of the perforation. The patients had a normal postoperative course. The median hospital stay was 10.5 days (range, 9 to 20 days) and the mortality rate was nil. There were no delayed complications during a median follow-up of 60 months. CONCLUSIONS: The transduodenal operative approach to periampullary perforation after ERCP/ES at an early stage in the clinical evolution of the perforation is a safe and effective procedure. We consider this approach a useful option for the treatment of periampullary perforation after ERCP/ES when initial endoscopic and conservative management do not yield good results within 24 hours.     

内镜下逆行胰胆管造影并发十二指肠穿孔15例诊治分析

目的总结内镜下逆行胰胆管造影术（ERCP）并发十二指肠穿孔的临床诊治策略。方法2005年1月至2011年12月间杭州市第一人民医院共对11250例患者进行ERCP．其中15例（0．13％）出现十二指肠穿孔．对该15例患者的临床资料进行回顾性分析。结果15例患者中男性6例．女性9例．年龄45-87岁。7例为十二指肠乳头括约肌切开（EST）穿孔,5例为内镜致十二指肠壁穿孔．3例为导丝和网篮致穿透性穿孔。所有患者均有程度不一的腹痛和腹胀症状：上腹部CT提示胰周和后腹膜不同程度的积气或积液。7例穿孔在ERCP中经X线透视即获诊断：8例于术后3h至5d出现腹痛、腹胀、皮下积气和发热等症状,经腹部平片或上腹部CT明确诊断。9例患者采取内科保守治疗．其中4例在穿孔后3h内发现．采用内镜下金属钛夹封闭穿孔口加鼻胆管引流术．无腹腔脓肿发生,住院时间10-15d;5例于穿孔后10h至5d诊断,并发肠瘘2例,腹腔脓肿4例。死亡1例,住院时间15-105d。6例患者采取手术治疗,其中4例在穿孔后4-8h手术者术后无脓肿形成．住院时间18．21d：另2例分别于穿孔后24h和30h手术,术后反复腹腔出血1例．腹腔脓肿致多器官功能衰竭死亡1例。结论对于ERCP并发十二指肠穿孔。首要的是依靠术中及时发现及术后CT等检查尽早明确诊断：治疗上除传统的外科手术外．应积极采用内镜下金属钛夹、鼻胆管引流术等内镜微创治疗。     

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??Diagnosis and therapy of ERCP-related duodenal perforation: an analysis of 6 cases TANG Jian, ZHANG Xi-wen, LI Fu. Department of Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200001,China
Corresponding author: ZHANG Xi-wen, E-mail:zhangxw@sh163.net
Abstract Objective To study the prevention, diagnosis and treatment of periduodenal perforation related to endoscopic retrograde cholangiopancreatography (ERCP) by retrospective research. Methods The clinical data of 6 cases of periduodenal perforation admitted from January 2006 to December 2010 in Renji Hospital, Shanghai Jiaotong University School of Medicine were analyzed retrospectively. Results Of all the 6 cases, 5 cases were confirmed with bile duct stone, the other case had a mass on the head of the pancreas. Three cases received EST and nasol-biliary drainage after the procedure, in whom 2 cases were failed to cannulate and 1 case was failed for pre-spincterotomy was also failed. Another case developed periduodenal perforation directly by the duodenal scope. Two cases were treated conservatively. Four cases received open surgery, in whom 3 cases were fully-recovered and one died. Conclusion Postoperative careful observation, diagnosis on time and individual choice of reasonable treatment according to the different etiologies of perforation are the key factors to improve the results of periduodenal perforation related to ERCP.     

Posterior laparostomy for retroperitoneal infections caused by periampullar endoscopic procedures: an old technique for an emerging disease

Duodenal perforations occur in 0.4-1% of endoscopic manoeuvres. In cases of periampullary injury, the best therapeutic approach is still controversial. Generally, the first treatment will be conservative, but in some patients large retroperitoneal infections requiring surgical treatment develop. Six patients, referred to our unit for extensive retroperitoneal collections and unstable septic conditions as a consequence of periampullary duodenal perforation during ERCP, were treated by right posterior laparostomy with twelfth rib resection. The septic process was treated efficaciously by the open posterior approach that favoured the spontaneous closure of the duodenal leak after a mean period of 14.5 +/- 5.2 days. No hospital deaths or major complications were recorded. Late incisional hernia developed in one case. The technique of posterior laparostomy with twelfth rib resection permits adequate debridement and drainage of both the upper and lower parts of the retroperitoneal space involved in infection after periampullary duodenal perforations. The good control of both the retroperitoneal septic process and the duodenal secretions facilitates the spontaneous closure of the duodenal leak, thus avoiding the risk of more complex and dangerous procedures.     

Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy

OBJECTIVE: To evaluate the authors' experience with periduodenal perforations to define a systematic management approach. SUMMARY BACKGROUND DATA: Traditionally, traumatic and atraumatic duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical management, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a selective approach have not elaborated distinct management guidelines. METHODS: A retrospective chart review at the authors' medical center from June 1993 to June 1998 identified 14 instances of periduodenal perforation related to endoscopic retrograde cholangiopancreatography (ERCP), a rate of 1.0%. Charts were reviewed for the following parameters: ERCP findings, clinical presentation of perforation, diagnostic methods, time to diagnosis, radiographic extent and location of duodenal leak, methods of management, surgical procedures, complications, length of stay, and outcome. RESULTS: Fourteen patients had a periduodenal perforation. Eight patients were initially managed conservatively. Five of the eight patients recovered without incident. Three patients failed nonsurgical management and required extensive procedures with long hospital stays and one death. Six patients were managed initially by surgery, with one death. Each injury was evaluated for location and radiographic extent of leak and classified into types I through IV. CONCLUSIONS: Clinical and radiographic features of ERCP-related periduodenal perforations can be used to stratify patients into surgical or nonsurgical cohorts. A selective management scheme is proposed based on the features of each type.     

Pneumoretroperitoneum,Bilateral Pneumothorax and Subcutaneous Emphysema Following Endoscopic Biliary Sphincterotomy

We report a case of pneumothorax, subcutaneous emphysema and pneumoretroperitoneum after an endoscopic sphincterotomy. A 40-yr-old woman presented with dyspnea immediately after she had undergone an endoscopic retrograde cholangiopancreatogram for a residual stone in common bile duct. On arrival to our hospital, she complained about severe dyspnea and on examination subcutaneous emphysema was discovered. A CT scan was conducted and showed a right-sided pneumothorax, a pneumoretroperitoneum in the peritoneal cavity. We recommended to the patient an immediate laparotomic exploration. We discovered a duodenal perforation in which we sutured it with accompanying pyloric exclusion, double truncular vagotomy and gastroenteroanastomosis. Endoscopic retrograde cholangiopancreatogram (ERCP) is a popular procedure for biliary and pancreatic diseases, but it can cause severe complications such as intestinal perforation. Besides perforations, air can spread through the abdominal cavity, retroperi-toneum, mediastinum, and the soft tissues of the neck, eventually causing pneumothorax. Early recognition and appropriate management is crucial for optimal results.     

Endoscopic sphincterotomy for stenosis of the sphincter of Oddi

BACKGROUND: Sphincter of Oddi dysfunction (SOD) is one of the causes of postcholecytectomy syndrome and biliary pain. Endoscopic sphincterotomy (EST) is recommended in some cases for patients refractory to conservative treatment. By the Milwaukee classification, patients with biliary pain can be divided into three groups. Group I patients show all the objective signs suggestive of a disturbed bile outflow-i.e., elevated liver function tests, dilated common bile duct (CBD), and delayed contrast drainage during endoscopic retrograde cholangio pancreatography (ERCP). Group II patients have biliary-type pain along with one or two of the criteria from group I. Group III patients have only biliary pain, with no other abnormalities. This study confirms the effectiveness of EST for the relief of symptoms in group I patients (papillary stenosis). METHODS: Between 1989 and 1999, we treated eight patients clinically diagnosed as having group I papillary stenosis by EST. Their ages ranged from 52 to 73 years. In addition to biliary pain, all patients were found to have dilated CBD, elevated enzyme levels, and delayed contrast drainage at ERCP. None of the patients had CBD stones or other causes of obstruction. Sphincter of Oddi manometry was not performed. RESULTS: EST was successfully performed in eight patients. Each patient had a very large papilla. A false orifice was found in one patient. In five patients, endoscopic cannulation of the bile duct was very difficult. The use of a long, tapered catheter and guidewire papillotomy was necessary in four patients. A precut papillotomy was performed in one patient. All patients achieved resolution of their symptoms after EST. There were no complications. The average length of the follow-up period was 26 months. CONCLUSIONS: SOD is a real entity that continues to pose a diagnostic dilemma. EST is an effective and safe modality for the treatment of papillary stenosis (group I patients). SOD manometry is not necessary before EST in group I patients.     

Management of ERCP-related small bowel perforations: the pivotal role of physical investigation

Background

Management of endoscopic retrograde cholangiopancreatography (ERCP)–associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment.

Methods

A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival.

Results

Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days.

Conclusion

Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.     

Surgical management of endoscopic retrograde cholangiopancreatography-related perforations

Background: A retrospective review was carried out of consecutive cases of endoscopic retrograde cholangiopancreatography (ERCP)‐related perforation to identify risk factors and technique affecting surgical outcome. Methods: Eighteen patients (0.45%) out of 4030 ERCP performed were operated on for ERCP‐related perforation at Singapore General Hospital. Results: The group's median age was 72.5 years and 14 patients had ductal stone disease. Five perforations were discovered at ERCP while 10 required computed tomography for diagnosis. Eight patients were operated on within 24 h whereas 10 patients had surgery after 24 h. Five of six with type I (lateral duodenal) perforations had early surgery versus one of seven with type II (peri‐Vaterian; P = 0.03). There were four type III (bile duct) perforations and one type IV (retroperitoneal air). Five of six patients with type I perforation had simple repair compared with five of seven type II requiring the complex duodenal diversion procedure (P = 0.10). Three patients (16.7%) succumbed after surgery due to sepsis and myocardial infarction. Advanced age>70 years resulted in higher mortality of 30% versus none in patients <70 years (P = 0.22). Conclusions: Early diagnosis is important but difficult especially for the type II perforations. Duodenal diversion is used more frequently in patients with type II perforations and those operated on late. Advanced age contributes to poorer outcome in surgical treatment of ERCP perforations.     

Surgical management of complications of endoscopic sphincterotomy with precut papillotomy

We reviewed 574 endoscopic sphincterotomy procedures. Fifty-six precut papillotomies were performed. Presenting conditions included choledocholithiasis, cholangitis, benign and malignant papillary strictures, and stenosing papillitis. Complications were identified in 16 percent: perforation in 9 percent, pancreatitis in 5 percent, bleeding in 2 percent, and pancreatic abscess in 2 percent. One patient died. Six patients required operation for complications. Perforation of the duodenum or common bile duct seen within 8 hours was managed with drainage and closure of the perforation with minimal complications. Duodenal perforations operated on later than 8 hours required more extensive procedures. All these patients had significant post-operative complications. Three patients were managed nonoperatively. Precut papillotomy carries a significantly higher complication rate than conventional sphincterotomy. Our experience suggests that there is no place for conservative management of duodenal perforation.     

Operative and non-operative management of endoscopic retrograde cholangiopancreatography-associated duodenal injuries

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is indispensable in everyday surgical practice. Despite this, as an invasive procedure, it has its own mortality and morbidity, the most feared of which is periduodenal perforations. Our experience with ERCP related periduodenal perforations and its treatment strategies are presented. Additionally, a rarely encountered subtype is highlighted.

Methods

Patients who underwent ERCP and sustained a periduodenal perforation between August 2008 and October 2011 were reviewed.

Results

During the period from August 2008 to October 2011, 597 ERCP procedures were performed in our hospital. Ten of these patients (3 male, 7 female) had a perforation. The mean patient age was 56.6 years. During the procedure, injury was suspected in four patients; it passed unnoticed in the remaining six. The decision to operate or follow a conservative policy was based on a combination of clinical and radiological findings. Operative intervention was required in three patients, with one mortality, while conservative treatment was followed in the remaining seven. A laparotomy was performed early in two patients whereas it was performed after an initial period of conservative treatment in one. The presence of periduodenal fluid collection, contrast extravasation or free intraperitoneal air were decisive factors for performing laparotomy.

Conclusions

ERCP-related periduodenal perforations include different categories. Certain types require operative repair while others should be treated conservatively. The choice of the management approach should be individualised, depending on the clinical picture and radiological findings. Although rare, these are potentially serious complications that may end fatally. Early recognition and appropriate intervention is the only way to avert a fatal outcome.     

重视医源性胆胰肠结合部损伤的预防和治疗

随着肝胆管结石病发病率的增高、胆道手术的普遍开展以及LC、ERCP等新技术的推广,医源性胆管损伤时有发生.胆管损伤后漏诊或处理不当往往会导致严重后果,如胆汁漏、腹膜炎、反复胆道感染、胆管狭窄、胆汁性肝硬化等.胆管损伤构成了当前腹部外科中的难题之一[1].中华医学会外科学分会胆道外科学组制订的<胆管损伤的预防与治疗指南(2008版)>将胆管损伤分为6级、4类、3度[2].对于胆管损伤,临床医生往往首先想到的是肝门至十二指肠上缘这一区域内的第Ⅲ、Ⅳ级损伤,殊不知Ⅱ级损伤的修复更难;Ⅴ、Ⅵ级损伤术中更易漏诊,后果更严重,病死率更高[3-5].因此,本文就胆管损伤中最具特殊性的、尚未引起足够重视的胆胰肠结合部损伤的预防与治疗进行探讨.     

重视医源性胆胰肠结合部损伤的预防和治疗

随着肝胆管结石病发病率的增高、胆道手术的普遍开展以及LC、ERCP等新技术的推广,医源性胆管损伤时有发生.胆管损伤后漏诊或处理不当往往会导致严重后果,如胆汁漏、腹膜炎、反复胆道感染、胆管狭窄、胆汁性肝硬化等.胆管损伤构成了当前腹部外科中的难题之一[1].中华医学会外科学分会胆道外科学组制订的<胆管损伤的预防与治疗指南(2008版)>将胆管损伤分为6级、4类、3度[2].对于胆管损伤,临床医生往往首先想到的是肝门至十二指肠上缘这一区域内的第Ⅲ、Ⅳ级损伤,殊不知Ⅱ级损伤的修复更难;Ⅴ、Ⅵ级损伤术中更易漏诊,后果更严重,病死率更高[3-5].因此,本文就胆管损伤中最具特殊性的、尚未引起足够重视的胆胰肠结合部损伤的预防与治疗进行探讨.     

重视医源性胆胰肠结合部损伤的预防和治疗

随着肝胆管结石病发病率的增高、胆道手术的普遍开展以及LC、ERCP等新技术的推广,医源性胆管损伤时有发生.胆管损伤后漏诊或处理不当往往会导致严重后果,如胆汁漏、腹膜炎、反复胆道感染、胆管狭窄、胆汁性肝硬化等.胆管损伤构成了当前腹部外科中的难题之一[1].中华医学会外科学分会胆道外科学组制订的<胆管损伤的预防与治疗指南(2008版)>将胆管损伤分为6级、4类、3度[2].对于胆管损伤,临床医生往往首先想到的是肝门至十二指肠上缘这一区域内的第Ⅲ、Ⅳ级损伤,殊不知Ⅱ级损伤的修复更难;Ⅴ、Ⅵ级损伤术中更易漏诊,后果更严重,病死率更高[3-5].因此,本文就胆管损伤中最具特殊性的、尚未引起足够重视的胆胰肠结合部损伤的预防与治疗进行探讨.     

重视医源性胆胰肠结合部损伤的预防和治疗

随着肝胆管结石病发病率的增高、胆道手术的普遍开展以及LC、ERCP等新技术的推广,医源性胆管损伤时有发生.胆管损伤后漏诊或处理不当往往会导致严重后果,如胆汁漏、腹膜炎、反复胆道感染、胆管狭窄、胆汁性肝硬化等.胆管损伤构成了当前腹部外科中的难题之一[1].中华医学会外科学分会胆道外科学组制订的<胆管损伤的预防与治疗指南(2008版)>将胆管损伤分为6级、4类、3度[2].对于胆管损伤,临床医生往往首先想到的是肝门至十二指肠上缘这一区域内的第Ⅲ、Ⅳ级损伤,殊不知Ⅱ级损伤的修复更难;Ⅴ、Ⅵ级损伤术中更易漏诊,后果更严重,病死率更高[3-5].因此,本文就胆管损伤中最具特殊性的、尚未引起足够重视的胆胰肠结合部损伤的预防与治疗进行探讨.     

重视医源性胆胰肠结合部损伤的预防和治疗

Because of the particularity in causes, mecha-nisms and clinical performances, injury in choledocho-pancreatico-duodenal junction is usually doomed with a delayed diagnosis, often leading to a poor prognosis. The early manifestations of bile duct perforation include peritoneal swelling caused by detained water after trans-T-tube injection, blue staining of the field of operation and contrast medium leaking outside the bile duct system, peritoneal or abdominal gas accumulation, pneu-mothorax or subcutaneous emphysema after endoscopic sphincte-rotomy (EST) or endoscopic retrograde cholangiopancreatogra-phy (ERCP). Postoperative high fever, abdomical pain radia-ting to right side back and waist, fluid accumulation in the right iliac fossa or around the right kidney are the associated evidences. If the perforation is discovered during the operation, it should be sutured and choledocal T-tube drainage should be performed. If the perforation is not discovered during the opera-tion, biliointestinal bypass should be constructed. The injuries resulted from ERCP or EST procedures should be treated accord-ing to the detailed situation. Conservative treatment can be given to those who are in relatively stable status. If the condition of the patients deteriorated, timely conversion to laparotomy is needed. For patients with delayed diagnosis, thorough drainage of the region, separation of bile and pancreatic juice, duodenal diver-ticularization and jejunostomy should be considered. The key point in preventing the injury in choledocho-pancreatico-duode-hal junction lies on full knowledge of the anatomy of the region, delicate practice without forceful exploration and detailed exami-nation after the operation to avoid missing diagnosis.     

重视医源性胆胰肠结合部损伤的预防和治疗

随着肝胆管结石病发病率的增高、胆道手术的普遍开展以及LC、ERCP等新技术的推广,医源性胆管损伤时有发生.胆管损伤后漏诊或处理不当往往会导致严重后果,如胆汁漏、腹膜炎、反复胆道感染、胆管狭窄、胆汁性肝硬化等.胆管损伤构成了当前腹部外科中的难题之一[1].中华医学会外科学分会胆道外科学组制订的<胆管损伤的预防与治疗指南(2008版)>将胆管损伤分为6级、4类、3度[2].对于胆管损伤,临床医生往往首先想到的是肝门至十二指肠上缘这一区域内的第Ⅲ、Ⅳ级损伤,殊不知Ⅱ级损伤的修复更难;Ⅴ、Ⅵ级损伤术中更易漏诊,后果更严重,病死率更高[3-5].因此,本文就胆管损伤中最具特殊性的、尚未引起足够重视的胆胰肠结合部损伤的预防与治疗进行探讨.     

重视医源性胆胰肠结合部损伤的预防和治疗

随着肝胆管结石病发病率的增高、胆道手术的普遍开展以及LC、ERCP等新技术的推广,医源性胆管损伤时有发生.胆管损伤后漏诊或处理不当往往会导致严重后果,如胆汁漏、腹膜炎、反复胆道感染、胆管狭窄、胆汁性肝硬化等.胆管损伤构成了当前腹部外科中的难题之一[1].中华医学会外科学分会胆道外科学组制订的<胆管损伤的预防与治疗指南(2008版)>将胆管损伤分为6级、4类、3度[2].对于胆管损伤,临床医生往往首先想到的是肝门至十二指肠上缘这一区域内的第Ⅲ、Ⅳ级损伤,殊不知Ⅱ级损伤的修复更难;Ⅴ、Ⅵ级损伤术中更易漏诊,后果更严重,病死率更高[3-5].因此,本文就胆管损伤中最具特殊性的、尚未引起足够重视的胆胰肠结合部损伤的预防与治疗进行探讨.     

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对于急性胆源性胰腺炎,内镜治疗具有重要的地位。行内镜逆行胰胆管造影术(ERCP)及内镜超声检查可明确诊断,指导进一步治疗。早期行经内镜鼻胆管引流(ENBD)、经内镜乳头括约肌切开术(EST)、胰管支架置入可及时解除梗阻,降低胆管、胰管压力,引流胆汁及胰液,缓解胰腺炎,降低并发症的发生率。内镜治疗可能导致出血、穿孔、胰腺炎加重、腹膜后感染等严重并发症,因此应严格掌握适应证,对于伴有急性胆管炎的急性胆源性胰腺炎,早期内镜治疗是绝对适应证;对于不伴有急性胆管炎的重症急性胰腺炎,应严密观察,除留置空肠营养管之外的早期内镜治疗并没有明显益处。