慢性胰腺炎内镜治疗的临床研究

目的探讨内镜治疗慢性胰腺炎（CP）的治疗效果。方法研究自1997年1月至2004年12月期间在上海长海医院确诊为CP，并住院行内镜治疗的患者，随访观察其临床疗效。结果符合CP诊断标准并进行内镜下治疗的患者共296例。其中胰管括约肌单纯切开23例，胰头部胰管气囊扩张11例，胰管取石86例。138例放置主胰管支架，26例放置副胰管支架。EUS下经胃壁假性囊肿引流12例，EUS下腹腔神经节阻滞30例。224例患者腹痛症状均有不同程度缓解（P〈0．05），1周后148例患者腹痛症状缓解，其中34例（15．2％）腹痛缓解持续时间达7年。患者内镜治疗成功率100％，无严重并发症发生，体质量均有一定程度增加（P〈0．05）结论内镜治疗能有效缓解CP患者的腹痛症状，增加患者的体质量，是治疗CP的一种安全有效的手段。     

治疗性经内镜逆行胰胆管造影在慢性胰腺炎患者中的应用

目的：探讨治疗性经内镜逆行胰胆管造影（ERCP）在慢性胰腺炎（CP）治疗中的价值。方法对2008年1月－2012年12月间在南京医科大学附属苏州市立医院应用 ERCP 治疗的30例 CP 患者进行回顾性分析。观察术前及术后24h 血淀粉酶变化,动态观察患者治疗前后腹痛缓解情况,随访脂肪泻、焦虑患者病情,定期复查腹部影像学或 ERCP 明确胰腺病变及胰管支架情况。结果所有患者均顺利完成 ERCP 并放置胰管支架,术后72 h 腹痛缓解率83．3％,1例因症状改善不明显至外科手术,术后病死率为0。结论ERCP 是治疗 CP 的有效手段,具有安全、有效、创伤小等优点。     

胰管内支架治疗慢性胰腺炎

目的 探讨胰管内支架引流术治疗慢性胰腺炎的临床疗效。方法 对１４例临床及影像学检查确诊的慢性胰腺炎伴胰管狭窄患者在内镜下进行了胰管内支架引流术，并对术后腹痛缓解率、胃纳、脂肪泻、体重变化及并发症发生率作了近期及远期了随访观察。结果 １４例患者均在内镜下内支架一次性置入成功，支架规格为５～１０Ｆ，术后随访２８～５２０ｄ，平均２１０ｄ，１４例患者术后近期（〈３个月）腹痛缓解率为９２．９％（１３／１４）     

无痛性慢性胰腺炎的治疗及疗效

目的探究成人无腹痛慢性胰腺炎（CP）的治疗方法及其疗效。方法总结近10年CP患者临床资料,分析成人无痛性CP患者治疗措施及疗效。结果成人无痛性CP共56例,成功随访的46例（82．1％）中,男31例,女15例,年龄（51．6±14．5）岁,随访时间（34．5±27．1）个月。（1）CP胰管结石、胰管改变者26例：内镜介入治疗14例,外科手术治疗7例,两者联合治疗3例,保守治疗2例。（2）CP影像学表现为胰腺或腺周占位的18例：均外科手术治疗。以上两组患糖尿病和腹泻症状者均无减少,部分患者一般情况有改善;各1例患者死于胰腺癌。1例胰管结石患者取石术后结石复发。（3）CP胰管改变合并胰腺囊肿者2例：内镜与外科治疗各1例,后者手术后出现胃出血及肝硬化、黄疸,原因不明。结论内镜与外科治疗无痛性CP胰管结石疗效相近,而影像学表现为胰腺或腺周占位的CP则以外科手术为首选,单纯胰管改变患者治疗尚需观察。各种治疗仅可改善部分无痛性CP患者的一般情况;并应加强对无痛性CP患者的随访和定期复查。     

青少年慢性胰腺炎的内镜诊断与治疗

目的：研究诊断性和治疗性经内镜逆行胰胆管造影术(ERCP)在青少年慢性胰腺炎(CP)诊断及治疗中的价值。方法：回顾分析1997年2月～2002年2月间确诊为青少年CP并行ERCP的13例临床资料。结果：13例中12例存在腹痛症状，10例有“胰腺炎”病史。ERCP见胰管扩张12例，胰管结石7例，胰腺假性囊肿2例，胰腺分裂症3例，胆囊结石l例。内镜下治疗：乳头括约肌切开术7例，胰管取石6例，支架置入5例，胰管狭窄扩张术4例，副乳头切开2例。ERCP后高淀粉酶血症4例，胰腺炎急性发作3例，均为水肿型胰腺炎。经6—68个月随访，ll例未复发，2例复发者经再次ER-CP治疗后腹痛未再出现。结论：ERCP对青少年CP的诊断及治疗有较高的价值。但青少年CP患者ERCP术后具有较高的并发症发生率，对此内镜医师应高度重视。     

内镜治疗慢性胰腺炎的探讨

目的 探讨内镜治疗慢性阻塞性胰腺炎疗效及并发症。方法 经内镜治疗２９例慢性胰腺炎中胰管括约肌切开术２７例（１９例为７内镜治疗前处置）,副乳头切开８例,乳头括约肌切开术５例,网篮邓胰石９例,胰管内引流７例,鼻胰管引流３例,辅助探条或球囊扩张共１４例。１３例治疗前、后检测胰腺内分泌功能。结果 ２９例中２６例（８９．７％）治疗后腹痛消失或明显减轻,９例胰腺结石患者中６例取出胰石;７例胰管内引流管未阻塞。     

复发性特发性胰腺炎内镜治疗的临床分析

目的 探讨复发性特发性胰腺炎(RIP)的病因及其内镜治疗的疗效.方法 回顾性分析2005年4月至2011年4月诊断为RIP的58例患者资料.所有患者均行ERCP,术前怀疑Oddi括约肌功能障碍者行Oddi括约肌测压.根据临床表现和ERCP结果判断病因并制订个体化的内镜治疗措施,术后随访观察腹痛及胰腺炎发作情况.结果 58例患者中男性29例,女性29例,胰腺炎发作次数为3 ～ 10余次.病因为胆管微结石29例,Oddi括约肌功能障碍19例(胰腺型16例,混合型3例),胰胆管汇流异常4例,ERCP无明显异常者6例.行单纯胆管括约肌切开33例,胰胆管括约肌共同切开8例,单纯胰管括约肌切开17例,括约肌切开后同时胰管支架置入术24例.58例患者获得随访41例,随访时间3～67个月(平均33个月).随访期间9例(22.0％)患者胰腺炎复发.内镜治疗RIP有效率为78％(32/41).结论 胆管微结石和Oddi括约肌功能障碍是RIP的主要病因,饮酒是其主要诱因.ERCP及其介入治疗疗效确切.     

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。     

青少年慢性胰腺炎的诊断及外科治疗

目的探讨青少年慢性胰腺炎的临床特点、诊断及外科治疗。方法回顾性分析1993年3月～2001年3月手术治疗的7例青少年慢性胰腺炎患者的临床资料。结果青少年患者大多存在先天性胰胆管发育异常(胰腺分裂1例,胰胆管合流异常1例,胆总管囊肿2例)。主要症状为反复上腹痛。B超、CT、ERCP和超声内镜(EUS)等影像学检查有助于早期诊断,其诊断阳性率分别为57．1％(4／7)、71．4％(5／7)、100％(5／5)和100％(4／4)。7例患者均接受了手术治疗,其中行胰头部分切除、胰管空肠侧侧吻合术(Frey's)1例,胰管切开取石、胰管空肠侧侧吻合术3例(其中Partington's术式2例,Puestow's术式1例),Oddi括约肌切开成形术1例,胆总管囊肿切除、肝管空肠Roux-en-Y吻合术 保留十二指肠的胰头切除术(DPPHR)2例。术后近期腹痛均缓解。所有患者均获随访,随访时间2～9年,平均4．7年。1例于术后8个月症状复发,再次手术行胰尾切除,症状缓解。多数患者疗效满意。结论青少年慢性胰腺炎的病因不同于成人慢性胰腺炎,手术时机的掌握和手术方法的选择对患者的生活质量和疾病进程的控制至关重要。     

胰管良恶性狭窄的内镜治疗

目的 探讨内镜治疗胰管狭窄的临床疗效。方法 36例影像学检查确诊的胰管狭窄患者,病因包括慢性胰腺炎、胰腺分裂症、胰头癌、胰腺假性囊肿等,分别在内镜逆行胰胆管造影基础上行内镜治疗,包括胰管支架置入、气囊扩张、探条扩张以及经内镜胰管括约肌切开术（EPS）、经内镜乳头括约肌切开术（EST）,同时观察术后症状缓解情况（如腹痛缓解率）、并发症发生率以及近期与远期疗效。结果36例分别进行了胰管支架引流术、气囊扩张、探条扩张、EPS和EST,术后腹痛症状有不同程度的改善,并发症发生率较低。随访1个月～36个月,平均15个月。术后近期（≤3个月）腹痛缓解率为72.2％（26/36）,长期（>3个月）随访显示47.2％（17/36）的患者腹痛缓解无复发,63.9％（23/36）的患者体重增加,生活质量改善。高淀粉酶血症、出血的发生率分别为13.9％（5/36）和5.6％（2/36）,均经一般内科治疗于3日内缓解。支架阻塞、支架脱落的发生率分别为12.5％（3/24）和4.2％（1/24）。结论 经内镜治疗胰管狭窄是安全而有效的方法。     

Extracorporeal Shock Wave Lithotripsy of Pancreatic Duct Stones

Chronic calcifying pancreatitis presents a major clinical problem, often requiring extensive surgery. Extracorporeal shock wave lithotripsy (ESWL) offers a new therapeutic option. We applied ESWL after endoscopic sphincterotomy of the pancreatic orifice in eight patients with impacted pancreatic duct stones. An electromagnetic lithotriptor (Siemens Lithostar, Erlangen, FRG) was used. Patients were treated in prone position under fluoroscopic control. A mean of 6,813 shock waves (range 1,500-10,000) was delivered in one or two sessions. Disintegration of stones was achieved in 6/8 patients, initial relief of pain in 7/8 patients, and total clearance of the pancreatic duct in 3/8 patients. One patient had an exacerbation of her pancreatitis one day after ESWL, which resolved rapidly with medical treatment. No other complications were observed. Four of five patients with fragmented stones had no abdominal complaints at follow-up (mean 17 months, range 3-27). Three patients in whom ESWL was not completely successful (two without and one with partial fragmentation) underwent an operation according to Puestow. Two of them still have abdominal complaints after surgery. From these data, we conclude that ESWL of pancreatic duct stones is a promising new alternative for surgery, when endoscopic stone extraction fails.     

Extracorporeal shock-wave lithotripsy of pancreatic calculi.

Extracorporeal shock-wave lithotripsy (ESWL) has been used to disintegrate pancreatic stones located in the main pancreatic duct for 123 patients with severe chronic pancreatitis. Endoscopic management following ESWL is aimed at restoring the pancreatic flow to the duodenum. Stone disintegration was achieved in 122 patients, whereas a decrease in the main pancreatic duct diameter resulted in 111, and complete clearance of the main pancreatic duct was obtained in 72. Pain relief, complete (40/88) or partial (35/88), correlated significantly with the results of the endoscopic drainage of the main pancreatic duct (e.g., decrease in main pancreatic duct diameter). Relapsing pain was most often related to recurrent pancreatic duct obstruction. Of 76 patients whose body weight had decreased before ESWL, 54 gained weight. Improvement of the exocrine function, evaluated by the [14C]triolein breath test before and 11 months, on the average, after ESWL, was observed in 12 patients among 22 for whom this test was performed before and after treatment. Improvement of the endocrine function after relief of obstruction of the main pancreatic duct was less frequently recorded (4/41). ESWL of pancreatic stones is a new, safe, and highly effective method of facilitating the endoscopic procedures for relief of pancreatic duct obstruction in severe chronic pancreatitis.     

Long-term clinical outcome after endoscopic pancreatic ductal drainage for patients with painful chronic pancreatitis.

BACKGROUND & AIMS: Endotherapy for patients with painful chronic pancreatitis (CP) gives early and midterm clinical results comparable with those of conventional surgery. The authors evaluated long-term clinical outcome after endoscopic pancreatic ductal drainage, focusing on pain and pancreatic endocrine/exocrine functions. METHODS: Of 110 patients with painful CP endoscopically treated between October 1987 and December 1989, 56 long-surviving patients were followed-up for 14.4 years (SD, .6 y); 40 patients died and 14 patients were lost to follow-up evaluation. Technical results included decreased ductal dilation and stone clearance. Clinical results included the rate of hospitalizations for pain before and after endotherapy, the need for surgery, the course of endocrine/exocrine insufficiencies, and late mortality. RESULTS: Complete or partial technical success initially was obtained in 48 of 56 long-surviving patients. Long-term clinical success (< or =5 hospitalizations for pain during follow-up evaluation, without surgery) was obtained for 37 of 56 patients. At a mean follow-up time of 14.4 years, 44 patients had avoided surgery and the annual rate of hospitalizations for pain decreased significantly (before endotherapy: 0.98 [+/-1.36] vs 0.40 [+/-0.51] for the 3 years thereafter vs 0.14 [+/-0.22] for the last 11 years of follow-up evaluation; P < .001). Short duration of disease before initial therapy and absence of smoking at the last follow-up evaluation were associated with long-term clinical success. CONCLUSIONS: Endotherapy provides long-term benefits for about two thirds of patients with painful CP. Good clinical outcome was associated with cessation or absence of smoking, whereas alcohol abuse increased the risks for diabetes mellitus, steatorrhea, and mortality.     

Painless chronic pancreatitis

BackgroundPainless chronic pancreatitis (CP) is a rare form of the disease.AimTo evaluate the prevalence and the characteristics of this overlooked form of pancreatitis.MethodsPatients with a diagnosis of CP and absence of pain were selected, excluding patients suffering from autoimmune pancreatitis. Clinical data, imaging features, and exocrine and endocrine function were therefore analyzed.ResultsAmong 781 patients observed between 2010 and 2016, 74 patients with painless CP (9.5%) were selected. Mean age at diagnosis was 60.8 (SD 10.8) years. 38(51%) individuals did not report any symptom, 36(49%) were affected by symptoms other than pain. Pancreatic calcifications were diagnosed in 70 patients (95%), main pancreatic duct dilation in 55(74%), and pancreatic atrophy in 39(53%).Thirty-six patients (55%) had severe exocrine pancreatic insufficiency(EPI). Diabetes was observed in 34 out of 72 patients (47%). During a mean follow-up of 2.9 (SD 2.8) years, only a mild pancreatitis was diagnosed in a 71-year old female. No patient underwent endoscopic treatment or surgery, developed pancreatic cancer or died.ConclusionsIn a tertiary center painless CP is observed in 10% of cases, and it is frequently associated with EPI. The probability of onset of pain is very low in a short-term follow-up.     

Infected pancreatic pseudocysts with colonic fistula formation successfully managed by endoscopic drainage alone: report of two cases

Fistulization of pancreatic pseudocysts into surrounding viscera is a well-known phenomenon and usually requires surgical management. We report two cases of pancreatic pseudocysts that developed spontaneous fistulas to the colon with resulting fever and abdominal pain. The patients were managed nonoperatively with a combination of endoscopic drainage and antibiotics, and their pseudocysts and fistulas resolved. The patients have remained symptom-free for a mean of 14 months of follow-up.     

胰管结石的诊断与治疗

目的 探讨胰管结石的诊断方法及如何选择合理的治疗方式.方法 对2005年3月至2009年8月收治的16例胰管结石患者的临床资料进行回顾性分析.结果 15例患者以不同程度的上腹痛就诊,1例以不规则腹泻就诊.血、尿淀粉酶高于正常值上限3例,血糖升高4例.B超、CT、MRI、ERCP和腹部平片的诊断率分别为93.8%(15/16)、68.8%(11/16)、57.1%(4/7)、100%(2/2)和50%(3/6).治疗方式包括内镜下胰管括约肌切开取石+胰管支架引流术2例,胰管切开取石、胰管空肠Roux-en-Y吻合术12例,胰十二指肠切除术1例,胰体尾切除+胰管空肠Roux-en-Y吻合术1例.全组无手术死亡病例.治疗后腹痛症状均有明显改善.随访14例,无结石复发,失访2例,随访率为87.5%,随访时间为1～53个月.结论 胰管结石首选B超检查,多种影像技术的联合应用可明显提高诊断率.全面的影像学检查是判断选择内镜治疗抑或是手术治疗的重要依据.随着内镜治疗技术的逐步成熟,ERCP将与外科手术一样成为胰管结石重要的治疗手段.     

胰腺分裂内镜治疗价值

目的探讨内镜下治疗胰腺分裂的疗效和安全性。方法收集2006年6月至2013年6月在南京大学医学院附属鼓楼医院消化科就诊的8例胰腺分裂患者的临床资料,对术中及术后情况进行回顾性分析。结果8例胰腺分裂患者共行经内镜逆行胰胆管造影术28例次,均置入胰管支架,其中7例同时行副乳头括约肌切开术,6例行内镜下扩张术,1例行胰管取石术。术后出现1例次轻度胰腺炎。随访2～47个月,1例死于胰腺癌,3例已拔出支架,3例定期复查,1例失访。患者术后慢性胰腺炎急性发作频率及腹痛程度均较术前明显降低。结论内镜下治疗胰腺分裂安全有效,可减少胰腺炎发作频率,减轻术后腹痛程度,术后并发症发生率低。     

Diagnostics and therapy of chronic pancreatitis

Chronic pancreatitis (CP) is characterized by progressive, chronic inflammation of the pancreas, resulting in loss of exocrine and endocrine function and chronic abdominal pain. In most cases, CP is induced by long-term alcoholism. The second most frequent diagnosis is idiopathic CP, in the absence of known causes of CP. However, the identification of genetic and immunological causes continuously reduces the number of cases classified as idiopathic pancreatitis. Common symptoms of CP comprise abdominal pain radiating to the back, diarrhea, steatorrhea and the development of diabetes. The diagnosis is mainly based on clinical features, typical morphological findings such as pancreatic calcifications, duct stenoses and dilatations, as well as pathologic pancreatic function tests. Treatment of CP includes watch and wait strategies in asymptomatic patients, symptomatic treatment of the clinical features such as pain, exocrine and endocrine insufficiency, as well as interventional or surgical therapy of complications such as pseudocysts, pancreatic duct stenosis, stones or biliary obstruction.     

Diagnostik und Therapie der chronischen Pankreatitis

Chronic pancreatitis (CP) is characterized by progressive, chronic inflammation of the pancreas, resulting in loss of exocrine and endocrine function and chronic abdominal pain. In most cases, CP is induced by long-term alcoholism. The second most frequent diagnosis is idiopathic CP, in the absence of known causes of CP. However, the identification of genetic and immunological causes continuously reduces the number of cases classified as idiopathic pancreatitis. Common symptoms of CP comprise abdominal pain radiating to the back, diarrhea, steatorrhea and the development of diabetes. The diagnosis is mainly based on clinical features, typical morphological findings such as pancreatic calcifications, duct stenoses and dilatations, as well as pathologic pancreatic function tests. Treatment of CP includes watch and wait strategies in asymptomatic patients, symptomatic treatment of the clinical features such as pain, exocrine and endocrine insufficiency, as well as interventional or surgical therapy of complications such as pseudocysts, pancreatic duct stenosis, stones or biliary obstruction.