内镜逆行胰胆管造影术治疗急性胆源性胰腺炎的临床疗效观察

目的观察内镜逆行胰胆管造影术(ERCP)治疗急性胆源性胰腺炎的效果。方法选取2016-02—2019-02间新蔡县人民医院收治的100例急性胆源性胰腺炎患者,按照随机数字表法分为2组,各50例。对照组采用药物治疗,观察组采用ERCP术治疗。比较2组治疗前后的血清炎症因子(CRP、TNF-α、IL-6、IL-8)水平、肝功能指标(AST、ALT、GGT、TBiL)、生化指标,以及临床症状改善效果。结果治疗后观察组患者的血清炎症因子水平、肝功能指标,以及体温、肝功能、淀粉酶、白细胞计数、胃肠道功能恢复正常时间,和恶心、呕吐消失及腹痛缓解时间等指标比较,均明显优于对照组,差异均有统计学意义(P<0.05)。结论采用ERCP术治疗急性胆源性胰腺炎,能有效抑制炎症因子释放,有利于改善患者的症状和促进肝功能及生化指标的恢复,是处理急性胆源性胰腺炎的重要治疗方式。     

Risk of pancreatitis following endoscopically placed large-bore plastic biliary stents with and without biliary sphincterotomy for management of postoperative bile leaks

BACKGROUND: Endoscopic transpapillary biliary stent placement is effective for closure of postoperative bile leaks. Large-bore stents (10 French) may transiently obstruct the adjacent pancreatic duct orifice causing acute pancreatitis. Endoscopic biliary sphincterotomy may reduce this risk, but it introduces separate risks of bleeding and perforation. The objective of this study was to compare complications after large-bore biliary stent placement (10 Fr) with and without sphincterotomy in patients with bile leaks. METHODS: The institutional endoscopy database was queried to identify patients who had undergone endoscopic retrograde cholangiopancreatogrpahy (ERCP) for bile leak between March 1996 and August 2006. Procedural reports were reviewed for evidence of biliary sphincterotomy, cholangiographic and pancreatographic findings, transpapillary stent placement, and procedural complications. Patients with prior biliary sphincterotomy, choledochoenteric anastomosis, placement of multiple biliary stents and expandable metal biliary stents, biliary stents smaller than 10 Fr, and patients in whom a stent was not placed were excluded. The chi-square test was used for categorical variables. Probability 相似文献   

内镜逆行胰胆管造影在急性胆源性胰腺炎合并胆管微结石治疗中的应用

目的 探讨内镜逆行胰胆管造影（endoscopic retrograde cholangiopancreatography,ERCP）在急性胆源性胰腺炎（acute biliary pancreatitis,ABP）合并胆管微结石治疗中的应用。方法 回顾性分析2016年1 月至2019 年2 月山东省立第三医院肝胆外科收治的21 例ABP患者经内镜超声检查（endoscopic ultrasonography,EUS）发现合并胆管微结石进而行ERCP治疗的临床资料,比较患者术前术后实验室指标变化。结果 ABP患者21 例均顺利进行ERCP治疗,20 例常规插管造影成功,1 例行预切开插管成功。其中十二指肠镜检查发现乳头憩室9 例,乳头过长7 例,乳头狭窄5 例,乳头萎缩3 例,乳头炎4 例。术中放置鼻胆管18例,球囊扩张17例,胰管支架植入15例,胆道支架植入3例。术后谷草转氨酶、谷丙转氨酶、总胆红素、直接胆红素、间接胆红素、血清淀粉酶、血清脂肪酶、胆汁淀粉酶较术前明显降低,差异均具有统计学意义（P＜0.05）。随访1～3 年,21 例患者均无胆源性胰腺炎、胆总管结石的复发。结论 ERCP是治疗ABP合并胆管微结石的有效方法。     

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。     

Outcomes of delayed endoscopic retrograde cholangiopancreatography in patients with acute biliary pancreatitis with cholangitis

ObjectiveThe recommended treatment for acute biliary pancreatitis(ABP) with cholangitis is urgent endoscopic retrograde cholangiopancreatography(ERCP). However, tight schedules in the endoscopy room mean that urgent ERCP may not always be performed. This study aimed to compare the outcomes of early (≤72 h) and delayed(>72 h) ERCP in patients with ABP with cholangitis.MethodsNinety-five patients diagnosed with ABP with cholangitis who underwent ERCP between May 2012 and April 2018 were retrospectively reviewed.ResultsSixty-seven patients(70.5%) were classified in the early ERCP and 28(29.5%) in the delayed ERCP groups. There was no significant difference in pancreatitis severity between the groups. Total bilirubin was higher in the early compared with the late ERCP group (5.7 ± 5.2 versus 3.5 ± 2.3 mg/dL, p = 0.03). Fewer patients in the early group had end-stage renal disease (0 versus 3, p = 0.006) and relatively fewer patients in the early group took aspirin (15(22.4%) versus 12(42.9%), p = 0.04). There were no significant differences between the early and delayed ERCP groups in terms of mortality (2(3.0%) versus 0), disease-related complications(11 (16.4%) versus 5(17.9%), p = 0.86), or ERCP-related complications(5(7.5%) versus 3(10.7%), p = 0.60). The total length of stay(LoS) was shorter in the early group(6.3 ± 4.4 versus 9.8 ± 6.1 days, p = 0.002). The rate of complete stone removal was lower in the early compared with the delayed ERCP group(32/42(76.2%) versus 18/18(100%), p = 0.02).ConclusionDelayed ERCP can be performed in selected patients with ABP with cholangitis, with similar complication rates but longer LoS compared with early ERCP.     

Combined endo‐laparoscopic approach in managing patients with gallstones and common bile duct stones: An early experience

Gallstones with common bile duct stones is a common condition in Hong Kong. Management still remains a challenge nowadays. Laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) is a single‐stage approach which improves patient comfort and is associated with less post‐ERCP pancreatitis. With the new endo‐laparoscopic operating theatre in service, the combined endo‐laparoscopic approach becomes simple and practical. We report here our two early experiences using this approach.     

早期腹腔镜胆囊切除术在急性胆源性胰腺炎中的应用

目的 探讨早期腹腔镜胆囊切除术治疗急性胆源性胰腺炎的疗效。方法 回顾性分析2005年1月至2014年4月我院收治的急性胆源性胰腺炎患者共136例,根据手术选择时间,分为早期手术组（ELC组,入院后5d内行LC）76例和择期手术组（ILC组,出院1个月以上择期行LC）60例,比较两组在手术难度、手术时间、中转开腹率、术后并发症发生率、住院天数和费用的不同。结果 ELC组和ILC组在手术难度、手术时间、中转开腹率、术后并发症发生率上并没有统计学差异（P＞0.05）,而ELC组的住院天数和住院费用明显低于ILC组（P＜0.05）,且ILC组有35.0%的患者在等待手术过程中因胆源性胰腺炎复发入院。结论 对于急性胆源性胰腺炎患者,早期施行LC术并没有增加手术难度、手术时间、中转开腹率和术后并发症发生率,相反大大降低了住院时间和住院费用。     

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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。     

A practical cost-effective management strategy for gallstone pancreatitis

Background

The purpose of this study was to evaluate the outcomes of various surgeon strategies used to evaluate and treat common duct stones (CDSs) in patients presenting with mild to moderate gallstone pancreatitis (GP).

Methods

We performed a retrospective review of patients admitted for mild to moderate GP. Data variables included laboratory values and radiology images, indications for and findings of intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP), length of stay (LOS), and hospital charges. Data were stratified by 2 different management strategies: preoperative ERCP and then laparoscopic cholecystectomy (LC) or LC with IOC followed by selective postoperative ERCP.

Results

During this time period, 80 patients met the study criteria, 56 were treated by LC with IOC, and 24 had a preoperative ERCP performed. The incidence of CDS was 33% (n = 26). The presence of CDSs correlated with an elevated total bilirubin at admission (CDSs 3.5 mg/dL vs 2.1 mg/dL no CDSs, P < .01) and 24 hours after admission (CDS 3.2 mg/dL vs 1.5 mg/dL no CDS, P < .01). Patients who had an IOC compared with those who had preoperative ERCP had a shorter LOS (4.6 vs 5.9 days, P = .04) and lower hospital charges (US $28,510 vs US $38,620; P < .01).

Conclusions

Elevated total bilirubin at admission and 24 hours after admission may predict a patient's risk for CDS. We found that the management of uncomplicated GP with early LC and IOC results in decreased LOS and total hospital charges when compared with preoperative ERCP.     

Outcomes of ERCP: prospective series from a rural centre

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the investigation and management of pancreaticobiliary disease. There is a recognized potential for significant morbidity, and a number of studies have identified patient and operator risk factors for the development of complications, including small case volume. We look at the outcomes of ERCP from a single operator at a rural centre and compare these with published figures. METHOD: Findings from 700 consecutive ERCP were collected prospectively between August 1997 and May 2006. Patients were included on an intention to treat basis, and all predetermined morbidity criteria were recorded. RESULTS: Five hundred and forty-four therapeutic and 156 diagnostic ERCP were included in the study. There were a total of 40 complications (5.71%), with three cases of ERCP-specific mortality (0.4%). The success of therapeutic intervention was 94.3%. CONCLUSIONS: The importance of comparing personal audit to published prospective studies has been emphasized. This has provided quality assurance finding, confirming that comparable success rates, morbidity and mortality are possible in a low-volume rural centre with an operator who has been properly trained and has ongoing ties with a tertiary hepatobiliary unit, a dedicated and skilled local team and suitable patient selection.     

Pattern of management of common bile duct stones in the laparoscopic era: a NSW survey

Background : The management of common bile duct (CBD) stones in the laparoscopic era remains controversial with various management strategies employed by surgeons. The aim of this study was to ascertain the common practice across a single Australian state, and to see if a ‘best practice’ for CBD stone management could be established. Methods : A questionnaire was sent to 390 general surgeons in New South Wales in April 1999. Data collected included the type of practice, number of cholecystectomies performed, preoperative markers of CBD stones, indications for preoperative endoscopic retrograde cholangiopancreatography (ERCP), use of operative cholangiography (OC) and the management of CBD stones found on OC. Results : The questionnaire was returned by 223 (57%) surgeons. Fifty‐four (14%) of these respondents were excluded as they did not perform laparoscopic cholecystectomy, leaving 169 (43%) respondents for analysis. The preoperative indicators for CBD stones were ranked as: jaundice > dilated CBD on ultrasound > serum bilirubin > serum alkaline phosphatase/alanine aminotransferase > previous biliary pancreatitis. Preoperative ERCP would be performed by 88% for persistent jaundice or cholangitis, 33% for elevated liver function test, 25% for dilated CBD and 24% for biliary pancreatitis. Operative cholangiography is routinely performed by 67%, selectively by 29% and never by 4%. If CBD stones are encountered 47% would attempt laparoscopic clearance via the cystic duct or choledochotomy; however, 72% replied that they would use postoperative ERCP as part of their usual strategy for the management of CBD stones. Conclusions : There was no clear common pattern for the management of suspected or proven CBD stones. There were three management issues in which there was a ‘common practice’. These were: (i) the use of preoperative ERCP for patients with persistent jaundice or cholangitis; and the routine use of (ii) OC and (iii) postoperative ERCP to clear the CBD, assuming other methods had failed.     

Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically

Background: Two recent meta‐analyses suggest that operative common bile duct (CBD) exploration (laparoscopic or open) may be superior to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis when the gall bladder is in situ. Much of the published work regarding laparoscopic exploration comes from enthusiasts of the technique and may not be transferable to other institutions. In our institution, both hepatobiliary and general surgeons carry out cholecystectomy, with differing levels of expertise in laparoscopic bile duct exploration. ERCP and laparoscopic antegrade transampullary endobiliary stents are available. We reviewed the management of choledocholithiasis in this setting. Methods: A retrospective review of all patients undergoing cholecystectomy during 2004 and 2005 at John Hunter and Belmont Hospitals (Newcastle, Australia) was conducted. Results: The overall incidence of choledocholithiasis was 10.3% (70 of 681). Fifty patients underwent preoperative ERCP, with choledocholithiasis confirmed in only 24 patients (therapeutic rate 30%). Thirty‐one patients underwent CBD exploration with 100% clearance through an open approach (12 patients) and 58% clearance through a laparoscopic approach (11 of 19 patients). Hepatobiliary surgeons carried out 22 of 31 CBD explorations (clearance rate 82%) and placed 13 transampullary antegrade endobiliary stents. In comparison, general surgeons carried out nine CBD explorations (clearance rate 56%) and placed only four antegrade stents. Conclusion: This series suggests that preoperative ERCP is significantly overutilized, laparoscopic CBD exploration is less successful than open CBD exploration and that antegrade transampullary intraoperative endobiliary stenting is underutilized by non‐hepatobiliary surgeons.     

腹腔镜胆囊切除结合内镜Oddi's括约肌切开取石二期治疗胆道结石

目的:探讨联合应用腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)和内镜Oddi's括约肌切开术(endoscopic sphincterotomy,EST)+内镜下胆总管取石二期治疗胆囊和胆管结石病的方法和价值.方法:对12例胆囊和胆总管结石病病人(术前经MRCP或B超证实),在全麻下一期行LC术后1 w,二期行ERCP+EST+内镜下胆总管取石以清除残余胆管结石.结果:12例病人LC和EST均在2 w内顺利完成,术中和术后无严重并发症发生,术后10~15 d出院.结论:联合应用LC和EST+内镜下胆总管取石分期治疗胆囊和胆管结石病切实可行,该法具有手术成功率高、病人痛苦少和住院时间短的优点.     

Management of gallstone pancreatitis in Auckland: progress and compliance

Background: Recent advances in the management of acute gallstonepancreatitis include the introduction of laparoscopic cholecystectomy,defining the role of endoscopic retrograde cholangiopancreatography(ERCP) and early cholecystectomy to prevent recurrent pancreatitis.The aim of the present study was to review the current managementof gallstone pancreatitis in Auckland Hospital, compare findingswith a similar study published a decade ago and to determine theextent to which the management is compliant with recently publishedconsensus guidelines. Methods: A retrospective review of consecutive patients admittedwith acute pancreatitis during a 39‐month study period was undertaken.Data were recorded regarding demographics, diagnosis, predictedand actual severity of gallstone pancreatitis (index and recurrentattacks), the role of ERCP and computed tomography scanning, thetiming of cholecystectomy (open and laparoscopic), intraoperativecholangiography, duration of hospital stay, complications and mortality. Results : There were 216 patients admitted with acute pancreatitis,106 of whom had proven gallstones. An ERCP was performed in 62(59%) patients with gallstone pancreatitis but not morecommonly in patients with severe pancreatitis, and common bile duct stoneswere identified in 26% of these patients. Of the 70 (66%)patients who had a cholecystectomy, 56 (80%) had it within3 weeks of admission. Although the proportion of patientswith gallstone pancreatitis who had a cholecystectomy is similarto the earlier study, there has been a significant increase in theproportion of patients having a cholecystectomy during the indexadmission (χ² = 3.83; P = 0.05).This has resulted in a reduction in recurrent pancreatitis (P < 0.001).Although the overall mortality from gallstone pancreatitis has notsignificantly decreased, it has for patients with predicted severegallstone pancreatitis (P = 0.02). Conclusion : There has been reasonable compliance with publishedguidelines and some progress in the management of gallstone pancreatitis,particularly in relation to performing timely laparoscopic cholecystectomywith a reduction in the incidence of recurrent pancreatitis. Concernsremain regarding the overuse of diagnostic ERCP in patients withmild pancreatitis.     

腹腔镜内镜联合治疗胆囊结石合并胆总管结石疗效分析

目的 比较性分析腹腔镜胆囊切除术联合内镜逆行胰胆管造影取石术治疗胆囊结石合并胆总管结石的效果.方法 选择2012年1月～2013年1月安徽医科大学第一附属医院急诊外科采用腹腔镜联合内镜治疗的21例患者作为观察组,同时选择同期开腹治疗的患者30例作为对照组.观察两组治疗效果、切口愈合情况及平均住院时间.结果 肛门排气时间、平均住院时间、术后切口感染发生率、术后镇痛药物使用率均少于对照组,两组比较差异有统计学意义（P＜0.05）.结论 腹腔镜胆囊切除术联合内镜逆行胰胆管造影治疗胆囊结石合并胆总管结石是一种安全有效的微创治疗方法.     

中重症急性胰腺炎1271例分析

目的分析重症急性胰腺炎的病因、诊断、治疗及预后。方法回顾分析中国医科大学附属第一医院胰腺外科2010年8月至2016年7月收治1 271例成人重症急性胰腺炎的临床资料。结果中重症急性胰腺炎1 144例(90.0%),重症急性胰腺炎127例(10.0%)。保守治疗939例(73.9%),有创干预332例(26.1%)。有创干预包括超声或CT引导经皮穿刺置管引流(PCD)72例111人次(21.7%),行ERCP治疗42例(12.7%),开腹手术37例41人次(11.1%),经皮肾镜坏死组织清除引流3例,经后腹腔镜入路行感染坏死组织清除引流1例,腹腔镜或开腹胆囊切除术182例(54.8%)。共死亡64例(5.0%),治愈率为95.0%。中重症急性胰腺炎病死率为0.3%,重症急性胰腺炎病死率为48.0%。老年病人死亡28例(占该组病死率7.9%),非老年病人死亡36例(占该组病死率3.9%)。PCD病人死亡14例(19.4%),坏死组织清除术后死亡12例(32.4%)。结论重症急性胰腺炎治疗需要根据病因、局部及全身并发症采取个体化、创伤递增式(Step-up)治疗,及时清除感染的坏死物,有利于降低重症急性胰腺炎的病死率。     

MRCP与ERCP对胆道梗阻诊断价值的比较

目的：探讨磁共振胰胆管成像(MRCP)对胰胆管梗阻性疾病的诊断价值及局限性.方法:采用快速自旋回波水成像技术,对35例临床拟诊胆道梗阻并均行内窥镜逆行胰胆管造影(ERCP)的患者进行MRCP检查,并将MRCP影像资料与ERCP进行对照分析,21例经手术病理证实,14例为ERCP检查证实.结果:MRCP成功率为100%,MRCP图像与ERCP极其相似,依据MRCP图像可以作出与ERCP基本一致的诊断.对胆道梗阻的部位诊断正确率达91.4%,定性诊断正确率达80.6%.MRCP图像的空间分辨率略逊于ERCP,有时不能显示胰管及其分支.对ERCP失败或显示不全的病例,MRCP可获得有价值的诊断信息.结论:MR-CP在诊断胆道梗阻性疾病方面具有简便、安全,无创伤性,无需造影剂等优点,而且具有与ERCP相同的诊断价值,在许多方面可取代ERCP.