急性胰腺炎的内镜下介入治疗

急性胰腺炎内镜治疗的作用仍有争议 ,在 2 0世纪 80年代中期前对于急性胰腺炎的治疗主要为药物、支持、外科手术等治疗 ,内镜下逆行胰胆管造影及十二指肠乳头切开(ERCP EST)被大家认为急性胰腺的是禁忌证。直到近年较多研究证明了内镜介入治疗对于急性胆源性胰腺炎的优点 ,因为急性胆源性胰腺炎 (acutebiliary pancreatitis ,ABP)在胰腺炎占有较大的比例。并且目前逆行胰胆管造影后行十二指肠乳头肌切开治疗严重的胆源性胰腺炎 ,已经在临床上得到了较普遍应用。特别是早期内镜下十二指肠乳头切开引流或取石 (发病 72h内 )对于伴有胆道…     

急性胆源性胰腺炎的内镜下介入治疗

目的 :综合评价早期内镜下介入治疗急性胆源性胰腺炎的方法、疗效及并发症等。方法 :10 3例胆源性胰腺炎患者中 ,5 7例在 72h内行早期内镜下介入治疗 ,4 3例保守治疗 ,保守治疗中的 19例择期内镜检查及治疗 ,3例外科手术治疗。结果 :早期内镜治疗组 80 .70 %患者临床症状得到迅速缓解 ;保守治疗组 6 2 .79%也可迅速缓解。全部内镜治疗后 3例出现胰腺炎加重。结论 :早期内镜介入治疗对于急性胆源性胰腺炎是一种有效而安全的方法 ,对于有明显黄疸、感染、结石嵌顿的病例应急诊内镜下治疗 ;对于病情较轻、黄疸不重的患者可先保守治疗后再行择期内镜治疗     

重症急性胰腺炎的外科治疗

重症急性胰腺炎 (SAP)又称为急性出血坏死性胰腺炎 ,随病因、病期的不同而治疗方法亦不同。胆源性 SAP的治疗原则是 :凡以胆道病为主并伴有梗阻者 ,或 Oddi括约肌狭窄、临床出现梗阻性黄疸时 ,应积极手术治疗 ,以解除胆道梗阻。手术方法可选择经纤维十二指肠镜下 Oddi括约肌切开取石及鼻胆管引流、胆囊切除和胆总管探查 ,T管引流 ,并可加作小网膜胰腺区引流。以胆道病为主但不伴有梗阻者 ,应先非手术治疗 ,待急性胰腺炎缓解后 2～ 3个月再作胆囊切除术。下面重点阐述非胆源性 SAP的外科治疗。1　手术方式1.1　灌洗引流术　适用于胰腺周…     

消化系统疾病

20040353急性胆源性胰腺炎的内镜下介入治疗/蔡逢春…刀内科急危币症杂志一2003,9(2)一68、70 103例胆源性胰腺炎患者,扣,57例在72h内行旱期内镜卜介入治疗,43例保守治疗,保守治疗中的19例择期内镜检查及治疗,3例外科手术治疗。结果:旱期内镜治疗组80.70%患者临床症状得到迅速缓解:保守治疗组62.79%也可迅速缓解。全部内镜治疗后3例出现胰腺炎加重。提示旱期内镜介入治疗对于急性胆源性胰腺炎是·种有效而安全的方法,对于有明显黄疽、感染、结石嵌顿的病例应急诊内镜下治疗;对犷病情较轻、黄疽不屯的患者可先保守治疗后再行择期内镜治疗。表…     

急性胆源性胰腺炎急诊内镜治疗的临床研究

目的 探讨内镜下EST联合ENBD对急性胆源性胰腺炎的治疗作用.方法 对82例急性胆源硅胰腺炎患者在抗炎、抑酶等综合治疗的基础上,行内镜(1～3 d内)ERCP及EST或ENBD等治疗.结果 82例急性胆源性胰腺炎(包括15例重症胰腺炎)均治愈,其中3例发生迟发性十二指肠乳头括约肌切口出血,经内科保守治疗,未发生 严重内镜治疗的并发症,有效地减轻了患者腹痛和降低了血淀粉酶,缩短了病程,疗效满意.结论 早期的内镜治疗急性胆源性胰腺炎安全、疗效好,值得临床推广.     

有关急性胆源性胰腺炎病理生理的目前观点

急性胆源性胰腺炎的发病机理包括因胆石、胆泥或乏特壶腹张力过高致胆胰液返流和胰腺外分泌的分泌液流出受阻。 胆胰返流 胆胰返流是胆源性胰腺炎的主要促发机理。首先,外科括约肌成形术和内镜下括约肌切开术对胆石性胰腺炎的有利作用超过其不利影响。其次,以往有胆石性胰腺炎发作者经保守治疗其复发率高达40％,而作括约肌成形术     

早期急诊内镜鼻胆管引流治疗急性胆源性胰腺炎

目的探讨急性胆源性胰腺炎患者早期急诊行内镜逆行胰胆管造影（ERCP）和鼻胆管引流（ENBD）临床疗效。方法回顾分析自2002年至2011年于我院就诊的83例急性胆源性胰腺炎患者,对其行48h内镜下ERCP及必要的ENBD,观察临床疗效和相关指标（腹痛缓解情况、体温、白细胞、肝功能、血和尿淀粉酶、住院时间及死亡率）。结果除1例患者插管失败后并发DIC死亡,所有患者ENBD均成功施行,成功率98.79%,28例胆总管结石患者同时取石治疗。并发十二指肠穿孔1例（1/82,1.22%）,十二指肠乳头出血7例（7/82,8.54%）。余者均在住院期间行再次取石或二期手术治疗,但最终3例患者死亡,79例患者临床治愈,治愈率95.18%（79/83）。结论根据个体化治疗原则和损伤控制性手术理念,合理地选择适应证后,急性胆源性胰腺炎采用早期急诊ENBD治疗是安全有效的,而且疗效满意。     

逆行胰胆管造影治疗80岁以上老年人胆胰疾病的临床观察

目的 评价治疗性逆行胰胆管造影术(ERCP)对80岁以上老年患者胆胰疾病的疗效及安全性. 方法 回顾分析我院自2004年1月至2008年4月诊治的80岁以上行ERCP治疗的老年患者120例,同时观察其并发症. 结果 120例患者,造影成功117例(成功率97.5%),其中胆管癌22例,十二指肠乳头癌3例,胰腺癌8例,急性胆源性胰腺炎15例,慢性胰腺炎5例,急性化脓性胆管炎9例,胆总管结石58例.在ERCP过程中因血氧饱和度进行性下降和严重的心律失常而中止治疗2例;插镜失败1例,失败原因系肿瘤侵犯导致十二指肠球降部狭窄,镜身不能通过.胆道出血3例,急性胰腺炎2例. 结论 治疗性ERCP对80岁以上老年人胆胰疾病的诊治创伤小,且有效及安全,高龄并非治疗性ERCP的禁忌证.     

内镜下括约肌切开治疗早期急性胆源性胰腺炎

急性胆源性胰腺炎是常见的急腹症之一，临床上以急性上腹部持续性疼痛，恶心、呕吐，发热和血、尿淀粉酶升高以及胆管结石为特点。由于影像学检查、监测手段、抗生素和抑制胰腺分泌药物的不断发展，对治疗急性胆源性胰腺炎有了观点上的更新，如病变早期采用非手术治疗、胰腺坏死组织继发感染者在严密观察下考虑外科手术、以微创技术如内镜治疗取代外科手术治疗，达到引流、减压和抗炎的目的，其操作简单，安全可靠，临床疗效明显，尤其适用于急性胆源性胰腺炎。本临床研究对32例急性胆源性胰腺炎患者行内镜下括约肌切开术（EST）和（或）内镜鼻胆管引流术（ENBD），取得了满意疗效，报道如下。     

十二指肠镜腹腔镜联合治疗急性胆源性胰腺炎

急性胰腺炎(acute pancreatitis,AP)的病因很多,其中由胆道疾病所致是一个重要的病因,称急性胆源性胰腺炎(acute biliary pancreatitis,ABP),在国内占急性胰腺炎年发病人数的15％～50％,病死率达20％～35％[1].随着内镜逆行胰胆管造影(ERCP)、内镜乳头括约肌切开术(EST)、内镜鼻胆管引流(ENBD)和腹腔镜胆囊切除术(LC)的广泛开展,使胆源性胰腺炎外科治疗的传统观念发生了巨大变化.我院2006年1月至2012年3月采用十二指肠镜、腹腔镜联合微创治疗86例ABP患者,取得了满意疗效.     

ERCP、EST、ENBD治疗胆总管结石391例临床分析

目的 总结应用逆行胰胆管造影术（ERCP）、内镜括约肌切开术（EST）和鼻胆管引流术（ENBD）治疗胆总管结石的疗效.方法 胆总管结石患者391例,常规行ERCP检查,证实胆管内有结石后行EST.然后根据结石情况采取不同方法处理.（1）结石直径小于1.0 cm的315例用取石网篮取石;（2）结石直径大于1.0 cm的61例用碎石篮碎石;（3）6例巨大结石而于胆管内置入支架3个月.术后所有病人常规置入鼻胆引流管.结果 EST成功382例（97.70%）,胆总管结石完全取出367例（96.07%）.发生各种并发症35例（8.95%）,主要为急性胰腺炎、急性胆管炎和Oddi扩约肌切口渗血,未成功病例和一例重症胰腺炎转开腹手术治疗治愈.结论 ERCP、EST和ENBD诊治胆管结石特别是胆总管结石,安全、有效,病人痛苦小.     

经内镜逆行胰胆管造影在治疗妊娠合并急性胆源性胰腺炎中的作用

目的 探讨ERCP在妊娠合并急性胆源性胰腺炎(ABP)中的治疗作用.方法 选择2002年1月至2007年1月共收治的24例妊娠合并ABP患者,其中轻症14例,重症10例.在内科治疗的基础上,在无x线透视下急诊行ERCP.先行内镜鼻胆管引流术(ENBD)以减压、减黄,待患者病情稳定后,对明确有胆总管结石的患者,若早、中期妊娠则行内镜胆道塑料内支架引流术(ERBD),若晚期妊娠则在终止妊娠后再次行ERCP取石.结果 24例患者均顺利完成急诊ERCP+ENBD,有4例见壶腹部结石嵌顿,用针型刀剖开十二指肠乳头,取出结石;15例明确有胆总管结石,其中5例行ERBD,10例终止妊娠后再次行ERCP取石成功.无孕妇死亡,无转外科手术治疗,均治愈出院.重症患者中有2例胎儿死亡.结论　对妊娠合并ABP患者急诊行ERCP+ENBD,病情稳定后行ERBD或再次行ERCP取石是安全、有效的.     

Evaluation of Endoscopic Naso-biliary Drainage Established without Endoscopic Sphincterotomy for Malignant Obstructive Jaundice

Abstract: Endoscopic naso-biliary drainage (ENBD) without endoscopic sphincterotoyny (ES) was carried out using 7.2 Fr naso-biliary tubes in 36 patients with malignant obstructive jaundice. The success rate of this method was SO .4% (37/16 cases). The effectiveness of ENBD without ES in terms of lowering total bilirubin values was good or excellent in 24 out of 29 cases (82.8%). Complications were observed in 1 out of 37 cases (10.8%);fortunately, none were as severe as perforation or bleeding. After ENBD established without ES serum amylase levels increased makcdly in 7 cases (17.9%), but these increases were transient and decveased vapidly. Endoscopic internal bilio-duodenal drainage established without ES was also successfully performed, using 10 or 12 Fr endoprosthetic tirbes, in 6 cases of malignant obstructive jaundice. Amylase levels after this procedure did not show any significant elevation. This fact suggests that compression of the pancreatic orifice by the naso-biliary tube dose not cause hyperamylaseynia. Endoscopic biliary drainage established without ES is an effective, safe, and simple method which can be applied to patients with malignant obstructive jaundice.     

Placement of endoscopic naso-biliary drainage does not preclude subsequent percutaneous transhepatic biliary drainage

We prospectively investigated whether the placement of endoscopic naso-biliary drainage (ENBD) precluded percutaneous transhepatic biliary drainage (PTBD). In 40 patients, the caliber of the intrahepatic bile duct was measured prior to ENBD by ultrasonography. When PTBD was required after ENBD, the ENBD catheter was clamped for 1 to 2 h before PTBD, and its caliber was again measured at the time of PTBD. When PTBD was performed within 7 days (mean, 1.8 days) after ENBD (n = 27), the size of the intrahepatic bile duct was 5.0 ± 2.3 mm before and 4.6 ± 2.3 mm after ENBD. There was no significant difference between these values (P > 0.5). When PTBD was performed 8 to 40 days (mean, 17.8 days) after ENBD (n = 13), the bile duct diameter was significantly reduced, from 4.2 ± 1.5 mm (pre-ENBD) to 1.8 ± 1.7 mm (post-ENBD) (P < 0.05). When PTBD was conducted within 7 days (mean, 1.8 days) after ENBD, previous ENBD did not induce collapse of the bile duct, if the ENBD catheter was clamped for 1 to 2 h before the puncture of the bile duct. Received: July 30, 1999 / Accepted: November 26, 1999     

90岁及以上胆总管结石患者内镜疗效分析

目的 探讨经内镜十二指肠乳头括约肌切开术(EST)及胆道塑料支架置入(ERBD)治疗90岁及以上患者胆总管结石的疗效及安全性.方法 对37例行EST及ERBD治疗胆总管结石的90岁及以上患者的临床资料进行回顾性分析.结果 EST 1次取石成功30例;1次取出部分结石4例,经行内镜下鼻胆引流,5 d后再次取石成功;成功率为91.9%.2例因结石大,碎石失败后行ERBD,6个月后结石变小,取出胆管结石;1例因乳头旁巨大憩室插胆管未成功而致取石失败.37例患者中并发出血1例(2.7%),无肠穿孔、胰腺炎等并发症发生.结论 内镜行EST及ERBD治疗90岁及以上老年人胆总管结石安全、有效,具有创伤小、并发症少、操作灵活简便等优点.     

经内镜胆道引流治疗胆道梗阻

目的：进一步提高经内镜胆道引流术的成功率。方法：总结1998年1月至2001年9月对320例胆道梗阻患者行十二指肠镜下各种胆道引流术的经验，其中鼻胆管引流术（ENBD）242例，胆道内置管引流术（ERBD）43例，胆道金属支架术（EMBE）35例。结果：305例得到成功引流，胆道梗阻症状缓解；失败15例。其中ENBD失败10例，经调整鼻胆管位置或重新置管获得成功；ERBD失败3例，2例选用合适长度的支架后引流成功，1例经努力仍未成功改用经皮肝穿刺胆道引流；EM-BE失败2例，其中1例金属支架未超出肿瘤狭窄段，经原金属支架再套入另一金属支架而成功，另1例支架放置1月又出现胆道阻塞，经原金属支架通道再放入塑料支架而恢复通畅引流。结论：经内镜引流治疗胆道梗阻疗效确切，及早分析内镜引流失败原因并采取相应的对策，绝大多数引流失败是可以避免或补救的。     

Transnasal endoscopic retrograde chalangiopancreatography using an ultrathin endoscope： A prospective comparison with a routine oral procedure

AIM： To investigate if transnasal endoscopic retrograde cholangiopancreatography （n-ERCP） using an ultrathin forward-viewing scope may overcome the disadvantages of conventional oral ERCP （o-ERCP） related to the largecaliber side-viewing duodenoscope. METHODS： The study involved 50 patients in whom 25 cases each were assigned to the o-ERCP and n-ERCP groups. We compared the requirements of esophagogastroduodenoscopy （EGD） prior to ERCP, rates and times required for successful cannulation into the pancreatobiliary ducts, incidence of post-procedure hyperamylasemia, cardiovascular parameters during the procedure, the dose of a sedative drug, and successful rates of endoscopic naso-biliary drainage （ENBD）. RESULTS： Screening gastrointestinal observations were easily performed by the forward-viewing scope and thus no prior EGD was required in the n-ERCP group. There was no significant difference in the rates or times for cannulation, or incidence of hyperamylasemia between the groups. However, the cannulation was relatively difficult in n-ERCP when the scope appeared U-shape under fluoroscopy. Increments of blood pressure and the amount of a sedative drug were significantly lower in the n-ERCP group. ENBD was successfully performed succeeding to the n-ERCP in which mouth-to-nose transfer of the drainage tube was not required. CONCLUSION： n-ERCP is likely a well-tolerable methodwith less cardiovascular stress and no need of prior EGD or mouth-to-nose transfer of the ENBD tube. However, a deliberate application is needed since its performance is difficult in some cases and is not feasible for some endoscopic treatments such as stenting.     

Percutaneous recanalization of the bile duct along an endoscopic naso-biliary catheter

Percutaneous recanalization of the bile duct is essential for placing biliary stents and carrying out other interventions. This prospective study was performed to establish safe approaches for percutaneous recanalization of the bile duct when it had previously resulted in failure. Between July 1995 and July 1999, percutaneous recanalization of the bile duct was attempted in 58 patients with a malignant biliary stenosis. When recanalization failed, an endoscopic naso-biliary drainage (ENBD) catheter was placed across the stenosis. The procedure was again attempted along the ENBD catheter. In the period of the study, four patients underwent successful recanalization after ENBD, although attempts prior to ENBD had been unsuccessful. As a result, the success rate of recanalization in the period was 100% (58/58). When recanalization fails, the use of an ENBD catheter may provide access to the biliary tree, and the biliary stenosis can be recanalized safely. Received: November 11, 1999 / Accepted: February 25, 2000     

Endoscopic nasobiliary drainage for treating bile leak after laparoscopic cholecystectomy.

BACKGROUND/AIMS: Bile leaks are common complications of laparoscopic cholecystectomy. We evaluated the diagnosis and endoscopic treatment of bile leaks. METHODOLOGY: A total of 436 patients underwent laparoscopic cholecystectomy with infrahepatic drainage. We performed immediate endoscopic retrograde cholangiopancreatography (ERCP) on all patients with bile discharge from an infrahepatic drain, and treated bile leaks which were not due to a major ductal injury by endoscopic nasobiliary drainage (ENBD) without endoscopic sphincterotomy (ES). RESULTS: Ten patients developed bile leaks which were recognized within 18 hours of operation. ERCP, on post-operative day 1 or 2, showed a bile leak from the cystic duct (9 patients) or the liver bed (1 patient). All patients underwent ENBD. Only 1 patient, who had a retained stone, had ES. In all patients, the bile leak resolved promptly and both the infrahepatic and nasobiliary drains were removed within 6 days of cholecystectomy. All patients were asymptomatic at a mean follow-up of 30 months. CONCLUSIONS: Routine placement of an infrahepatic drain is recommended for the early detection of bile leaks. Bile leaks can be successfully treated by prompt ENBD without ES.     

伴发多器官功能不全综合征的重症急性胆管炎的内镜治疗

目的 探讨伴发多器官功能不全综合征(MODS)的重症急性胆管炎(ACST)患者的内镜治疗价值.方法 对2000年1月-2008年10月期间122例伴发多器官功能不全综合征的ACST病例,分两个阶段进行内镜治疗.危重期以挽救患者生命为目的,治疗性ERCP+ENBD为首选方法.病情平稳后,针对病因择期进行EST+胆道取石术、EST+胆道内支架置入术和(或)腹腔镜联合治疗.结果 122例ACST患者危重期急诊内镜治疗均获成功,术后第3天,患者黄疸指数、白细胞总数、体温以及有休克、精神症状、脓性胆汁的患者例数,均比治疗前有明显下降;术后1周功能不全器官恢复率60.2%,术后2周功能不全器官恢复率82.6%.择期治疗结果:36例行择期胆道取石术,一次取石成功率为91.7%;85例行腹腔镜胆囊切除术,手术成功率95.3%;16例行胆道内支架置入术,术后3个月支架有效率81.3%.急诊及择期内镜治疗全程无严莺并发症及死亡病例.10例肿瘤患者,随访6个月生存率70%.结论 治疗性ERCP+ENBD是救治伴发多器官功能不全综合征的ACST患者的首选方法,而EST十胆道取石术或EST+胆道内支架置入术以及联合腹腔镜手术,是后续治疗ACST的理想方法.