ERCP术后胰腺炎的预防

内镜逆行胰胆管造影术（ERCP）是广泛用于诊治胆胰疾病的重要手段,而术后胰腺炎（PEP）是其最常见、最严重的并发症,严重者可致死亡。导致PEP发生的机制非常复杂且至今仍未完全明了,一般认为其是由多因素导致的,包括化学性、机械性及与酶有关等。随着ERCP诊治技术的广泛展开,PEP预防的临床研究已成为热点,并取得了一定的进展,本文就此作一综述。     

ERCP与术后胰腺炎的相关分析

目前认为ERCP术后胰腺炎（post-ERCP pancreatitis．PEP）与诸多因素有关 。本文回顾性分析PEP与操作技术因素的相关性，以期重视操作中的高危因素，并降低胰腺炎的发生率。     

乌司他丁预防ERCP术后胰腺炎的Meta分析

目的：评价乌司他丁预防内镜逆行胰胆管造影术后胰腺炎（post-ERCP pancreatitis,PEP）的安全性和有效性。方法：计算机检索Cochrane图书馆（1970—2010年）、PubMed（1966—2010年）、EM-BASE（1966—2010年）及中国生物医学文献数据库（1978—2010年）,查找乌司他丁预防PEP的随机对照试验及其参考文献。由两名研究者独立选择试验、提取资料和评估方法学质量,采用Cochrane协作网RevM4.2软件进行统计。结果：共有6篇随机对照试验,包括1096例患者被纳入分析。乌司他丁组与安慰剂组比较,两组PEP发生率有统计学意义（P=0.04,OR=0.55,95%CI[0.30,0.98]）,两组ERCP术后高淀粉血症发生率有统计学意义（P〈0.0001,OR=0.48,95%CI[0.34,0.66]）;乌司他丁组与加贝酯组比较,两组PEP发生率无统计学意义（P=0.52,OR=1.57,95%CI[0.39,6.24]）,两组ERCP术后高淀粉血症发生率无统计学意义（P=0.13,OR=1.85,95%CI[0.83,4.13]）。结论：乌司他丁可以有效预防PEP的发生,对ERCP术后高淀粉酶血症的预防也有一定的效果,但需剂量充足（≥15万U）;乌司他丁与加贝酯比较,两者预防效果相同。     

生大黄预防ERCP术后胰腺炎的疗效观察

目的:观察生大黄对内镜逆行胰胆管造影(ERCP)术后胰腺炎(PEP)及高淀粉酶血症的预防作用。方法:选择2012年10月—2013年10月共800例术前血清淀粉酶正常行ERCP患者,患者随机分为观察组和对照组,每组各400例,术后均予常规治疗外,观察组于ERCP术后口服生大黄浸泡液(1次/3h)至通便为止。比较两组术后相关临床指标。结果:与对照组比较,观察组PEP(2.0%vs.7.5%)、高淀粉酶血症(5.0%vs.16.3%)、术后腹痛发生率(15.0%vs.51.3%)发生率均明显降低(均P0.05),而且术后排便时间明显缩短(10.61hvs.19.51h)(P0.01)。结论:生大黄可降低PEP及高淀粉酶血症的发生率,减轻术后腹痛的发生率。     

1例ERCP加EST术后并发急性胰腺炎病人的护理

对1例行逆行胰胆管造影加壶腹括约肌切开术(ERCP加EST)术后并发急性胰腺炎病人进行积极有效的治疗和护理，使病情9d内得以控制。提出合理正规的药物治疗、细致周到的心理疏导及优质全面的护理服务是治疗成功的必要条件。     

适时采用十二指肠乳头括约肌开窗术降低ERCP术后胰腺炎的临床价值

目的 评价适时采用十二指肠乳头括约肌开窗术对于ERCP术中插管困难患者术后胰腺炎发生的影响,探讨该手术的有效性和安全性.方法 回顾性分析2006年7月至2009年12月上海交通大学医学院附属新华医院收治的181例ERCP术中插管困难患者的临床资料,其中98例继续采用传统方式插管患者为对照组,83例适时行十二指肠乳头括约肌开窗术患者为研究组,比较两组患者选择性胆管插管的成功率及术后胰腺炎的发生率.计量资料的比较采用t检验,计数资料的比较采用x2检验,等级资料采用Wilcoxon秩和检验.结果 对照组和研究组患者首次插管成功率、术后高淀粉酶血症发生率、术后胰腺炎发生率分别为85.7％ (84/98)、7.1％(7/98)、10.2％( 10/98)和94.0％ (78/83)、18.1％ (15/83)、2.4％( 2/83),两组比较,差异有统计学意义(x2=10.12,5.03,4.41,P＜0.05).对照组和研究组患者中轻、中、重度胰腺炎分别为3、5、2例和1、1、0例,两组比较,差异有统计学意义(Z=-2.11,P＜0.05).结论 对于ERCP术中插管困难的患者适时采用十二指肠乳头括约肌开窗术可减少ERCP术后胰腺炎的发生,是一种安全、有效的方法.     

ERCP术后患者并发胰腺炎的危险因素回归方程构建

目的 构建内镜下逆行胰胆管造影（ERCP）术后患者并发胰腺炎的危险因素回归方程。方法 对2020年1月至2022年12月山西省汾阳医院收治的ERCP术后患者1 026例临床资料进行回顾性分析。根据ERCP术后患者并发胰腺炎情况分为胰腺炎组（n=105）和无胰腺炎组（n=921）。通过单因素及多因素Logistic回归分析法分析ERCP术后患者并发胰腺炎的危险因素,建立危险因素回归方程,并绘制受试者工作特征（ROC）曲线,分析危险因素回归方程对ERCP术后患者并发胰腺炎的预测价值。结果 ERCP术后患者1 026例,并发胰腺炎105例,胰腺炎发生率为10.23%。多因素Logistic回归分析结果显示,胰管插管、造影剂注射频次≥2次、既往存在胰腺炎史、括约肌功能障碍为ERCP术后患者并发胰腺炎的危险因素（OR值分别为3.334、8.560、3.818、2.449,均P<0.05）。构建危险因素回归方程：Logit(P)=-4.588+1.204×胰管插管+2.147×造影剂注射频次+1.340×既往存在胰腺炎史+0.596×括约肌功能障碍,ROC曲线下面积（AUC）为0.842,灵...     

ERCP术后重症急性胰腺炎6例临床分析

目的 探讨ERCP术后急性胰腺炎（PEP）的预防及治疗方法。方法 回顾性总结南京军区南京总医院普通外科2006年4月至2009年8月由外院转入的6例ERCP术后重症急性胰腺炎病例资料,分析临床诊疗经过及预后。结果 6例病人中5例因胆道症状、1例因右上腹痛行ERCP检查,其中1例病人反复插管后置管失败,2例行胰管造影检查,3例行Oddi括约肌预切开术,均未行Oddi括约肌球囊扩张及胰管括约肌切开术,术前、术后均未预防性用药,术后均未放置胰管支架;6例病人在ERCP术后8~48h诊断为SAP,急性期有4例病人并发急性肺损伤,1例并发急性呼吸窘迫综合征（ARDS）,1例并发ARDS、急性肾功能衰竭,后期有5例病人并发胰腺坏死组织感染而行手术引流,1例死亡。结论 严格掌握ERCP适应证、术前充分评估病人危险因素、术中注意避免操作相关危险因素、术后早期诊断,是预防及治疗PEP的关键。     

低分子量肝素预防ERCP术后急性胰腺炎的临床研究

目的：探讨低分子量肝素（LMWH）预防ERCP术后急性胰腺炎发生的作用。方法：将60例患者随机分成ERCP组（E组）和ERCP术前LMWH预处理组（H组），每组30例。观察ERCP术后患者的腹痛程度，血清淀粉酶（ AMS），内毒素（ET），一氧化氮（NO）、白细胞介素6（IL-6）等生化指标以及B超下胰腺形态学变化;观察H组术前术后的凝血功能变化。结果：E组腹痛症状加重者5例（16.7％，5/30），明显高于H组（0，0/30）（P<0.05）。两组患者术前各项生化指标水平均无显著差异（P>0.05），术后4h、24hE组血清ET和AMS水平明显高于H组（P<0.05），24h达高峰;E组血清NO水平明显低于H组（P<0.05）;E组各时点IL-6水平均明显高于H组（均P<0.05）。B超下E组1例胰腺有急性炎性改变，H组无凝血功能变化。结论：LMWH能预防或减轻ERCP术后胰腺急性炎症的发生，是一种简便、经济而安全的方法。其机制可能是通过改善微循环、降低炎症介质水平来实现的。     

NSAIDs预防ERCP术后急性胰腺炎的研究进展

目的 内镜逆行胰胆管造影术（ERCP）是肝脏、胆道、胰腺疾病诊断与治疗的重要手段之一.在将ERCP用于临床工作中,也会带来一些并发症,其中ERCP术后并发的急性胰腺炎以其较高的发生率及危险性引起了广大临床医师的重视.为了降低ERCP术后急性胰腺炎的发生率,临床医师在行ERCP术时运用各种手段及药物来减少其发生.非甾体抗炎药（NSAIDs）作为一类廉价、给药方便、不良反应小的药物在预防ERCP术后急性胰腺炎中有着较好的应用前景.     

ERCP在腹腔镜胆囊切除围手术期的应用

目的 探讨内交易ＥＲＣＰ在腹腔镜胆囊切除围手术期的应用价值。方法 从１９９８年１月至１９９９年４月在１５００例ＬＣ病人中,有选择地进行术前３３例和术后２０例的ＥＲＣＰ及内镜治疗,包括ＥＳＴ,ＥＮＢＤ和网篮取石术。其指征为：近期有为发生或黄我,肝功能异常,碱性磷酸酶升高,Ｂ超或ＣＴ示胆总管扩张或有结石,术中造影有胆管结石,术后有临床症状。结果 在术前３３例ＥＲＣＰ中,除１例失败外,胆囊病变外的阳性发     

Pediatric ERCP in a multidisciplinary community setting

Endoscopic retrograde cholangiopancreatography (ERCP) has been used to evaluate and treat pancreaticobiliary disorders and trauma in the pediatric population. Still representing a small percentage of total pediatric endoscopies, this procedure has been performed most commonly by a small subset of adult and pediatric gastroenterologists at quaternary referral centers. Methods: In this study, we present a review of one fellowship-trained general surgeon’s experience with pediatric ERCP in a teaching community pediatric hospital for the purpose of comparison with national series. Results: All ERCPs performed by one general surgeon as part of a multidisciplinary team over a 5-year period in patients aged 16 years or less were reviewed. Success and complication rates were compared between our series and published pediatric and adult series using Fisher’s exact test. Comparisons were made of indications, type of anesthesia, final diagnosis, and therapeutic interventions to ensure similar study populations. A total of 26 ERCPs were performed in 19 patients ranging from 7 to 16 years old. Therapeutic procedures included sphincterotomy (11), stent placement (7), stone removal (3), and dilation (2). In one case, stone removal and stent placement were performed in conjunction with pancreatic lithotripsy. In two cases the involved duct was not visualized. There were no instances of pancreatitis, bleeding, or perforation related to ERCP. Conclusions: When compared with published series, our data demonstrated no significant difference in success or complication rates. Our study demonstrates that pediatric ERCP can be performed by fellowship-trained general surgeons with success and complication rates comparable to accepted standards. Integration of the ERCP-trained general surgeon into the pediatric team is a potential asset in the care of pediatric patients with pancreaticobiliary disorders.     

ERCP及EST术后早期并发症及其处理的57例临床分析

探讨和分析ERCP及EST术后早期并发症及其处理方法。结果:我院近4年(1994年1月～1997年11月)行2225例次ERCP及EST术后共发生并发症者57例(2.56％),其中急性胰腺炎35例(1.57％),胆管感染5例(0.22％),出血12例(0.54％),结石及网篮嵌顿1例(0.04％),药物反应2例(0.09％),后腹膜腔积气2例(0.09％),经保守治疗痊愈54例(94.74％),手术治疗3例(5.26％),死亡1例(0.04％)。结论:诊断性ERCP并发症中以急性胰腺炎发生率为高,与插管困难、反复显影、注造影剂压力过大及量过多有关。EST并发症中以出血最为常见,与操作、黄疸、糖尿病有关。绝大多数发生并发症患者可经内镜治疗及内科保守治疗而得以痊愈(94.74％),仅极少数病人需要外科手术治疗。     

ERCP术后胰腺炎的诊断与治疗

目的探讨ERCP术后并发胰腺炎的诊断与治疗。方法回顾性分析2824例行ERCP患者的有关临床资料。统计高淀粉酶血症与PEP的发生率,观察ERCP后血淀粉酶变化的规律。结果高淀粉酶血症与PEP是ERCP后最常见的并发症,本组总发生率达87．3％。结论ERCP术后并发胰腺炎一般较轻,经保守治疗后均能恢复。重症胰腺炎的发生率较低,但愈后较差。     

EST+胆胰管引流治疗急性胆源性胰腺炎

目的 探讨内镜下乳头奥迪氏扩约肌切开(endoscopic sphincterotomy,EST) 胆胰管引流技术在急性胆源性胰腺炎(acute biliary pancreatitis,ABP)诊治中的应用价值.方法 将入选的315例ABP患者随机分为EST治疗组(n=132)和非EST对照组(n=183),并根据APACHEⅡ评分,将每组再进一步分为重症组和轻症组.两组患者均给予中西医结合治疗.EST治疗组在入院后24 h内行ERCP(endoscopic retrograde cholangiopancreatography) EST,如发现胆管或胆胰共同通道有结石,则行网篮气囊取石或碎石器碎石取石,如结石多、结石直径大,结石难以一次取尽则急诊不强行取石术.如ERCP证实胰管狭窄或胰管有结石,则行胰管支架植入或鼻胰管引流.所有患者EST术后均行鼻胆管引流术(endoscopic naso-billiary drainage ENBD).结果 对重症ABP,EST治疗组的并发症发生率、转开腹手术率、住院天数及住院费用均明显低于非EST对照组(X12=7.12,X22=5.64,t1=2.57,t2=2.28,P＜0.05);而两组轻症之间无显著差异.结论 早期应用EST技术治疗ABP是可行的、有效的和安全的.     

Identification of significant difficulty of selective deep cannulation by a simple predictive model: an endoscopic scale for teaching ERCP

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure associated with a risk of serious complications. This cohort study was designed to assess the accuracy of an endoscopic method aimed at discriminating procedures eligible to teach ERCP: patients with and without significant difficulty of selective deep cannulation (DSDC). METHODS: Clinically relevant variables were analyzed in a cohort of 400 consecutive patients (estimation group = 250 patients; validation group = 150 patients) who underwent an ERCP procedure. RESULTS: Multivariate analysis identified fixated duodenum, inflamed duodenum, soft major papilla, previous biliary surgery, and papilla with ectopion as independent predictors of DSDC. We constructed a model and a score system combining these five variables. The area under the ROC curve was 0.81 for the estimation group and 0.80 for the validation group. Using the best cutoff score (> 1.63), absence of significant DSDC could be excluded with high accuracy (negative predictive value = 89.2%) in 111 (44.4%) of 250 patients. Similarly, it could be excluded with the same certainty in 77 (51.3%) of the 150 patients in the validation group. CONCLUSIONS: A combination of easily accessible variables accurately predicts the absence of significant DSDC in half the patients who underwent the ERCP procedure. This score system discriminates procedures eligible to teach ERCP.     

ERCP in association with laparoscopic cholecystectomy

Background With the evolution of laparoscopic cholecystectomy (LC) as the standard operation for benign gallbladder disease, the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones has to be defined. Methods From November 1990 to April 1994 we attempted LC in 1,788 patients. Eighty-nine patients underwent ERCP preoperatively under the following indications: jaundice or a history of jaundice, cholangitis, gallstone pancreatitis, abnormal liver function tests, and a sonogram showing either CBD stones or a dilated CBD. With intent to minimize the number of unnecessary ERCPs only patients with jaundice, cholangitis, and high abnormalities on the liver function tests (LFTs) were directly referred for ERCP. All other patients with suspected choledocholithiasis were initially investigated with intravenous cholangiography (IVC) and tomography; only patients with positive findings on IVC subsequently underwent ERCP. Eighteen patients underwent ERCP postoperatively and the indications included jaundice, bile leak, and abnormal intraoperative cholangiogram. Results Of the 89 patients having ERCP preoperatively 54 patients (60.7%) were found to have CBD stones which were removed endoscopically in all cases except in one patient where a large CBD stone was removed during laparoscopic exploration of the CBD. Eight patients of the 18 patients having ERCP postoperatively were found to have CBD stones and all of them had their CBD cleared endoscopically. There were no mortalities, while four patients developed a mild pancreatitis. Conclusions Although there is an increasing tendency to clear the bile duct with a laparoscopic approach, ERCP and sphincterotomy has a certain role in conjunction with LC in the management of patients with a high suspicion of CBD stones, particularly in institutions where there is easy access to expert interventional endoscopic techniques.     

Endoscopic retrograde cholangiopancreatography in conjunction with laparoscopic cholecystectomy

Summary Laparoscopic cholecystectomy (LC) has become the primary surgical treatment for symptomatic cholelithiasis. In conjunction with the dramatic rise in LC there has been an increase in the number of endoscopic retrograde cholangiopancreatographies (ERCPs) performed. For this study, the records of patients referred to the surgical endoscopy department between January 1991 and February 1992 were reviewed. Seventy-seven ERCPs were performed in conjunction with LC. The indications for ERCP included jaundice or a history of jaundice, gallstone pancreatitis, a suspicious filling defect on either ultrasound or intraoperative cholangiogram, abnormal liver function tests, cholangitis, or postoperative bile leak. Sixty-two procedures were performed prior to LC and 15 procedures after LC. Forty-two patients were female (54.5%) and the patients ages ranged from 14 to 92 years (mean 54.1 years). Of the 62 patients having ERCP preoperatively 35 patients (56.5%) had no evidence of common bile duct (CBD) stones and underwent LC as planned. Twenty-three patients were found to have CBD stones, of which six were referred for an open cholecystectomy and CBD exploration, because of large multiple CBD stones or the presence of a large duodenal diverticulum. Seventeen patients had their CBD cleared endoscopically, and four patients were not successfully cannulated.Fifteen patients had ERCP after LC. There were two patients with CBD injuries who were referred for surgical correction. Two patients had leakage from the cystic duct stump, and four patients had CBD stones, all of whom were successfully treated with endoscopic sphincterotomy. There were four patients who had a normal postoperative ERCP and two patients who could not have their CBD cannulated.There were no mortalities, but there were four cases of complications. Two patients had bleeding after stone extractions, and they required blood transfusions. One patient developed cholangitis from stenosis of the papilla after an endoscopic sphincterotomy, and one patient developed pancreatitis which resolved with conservative treatment. There is an increasing role for ERCP and sphincterotomy in patients undergoing LC. ERCP carries an inherent morbidity and therefore routine ERCP is not justified. However, with the proper suspicion of CBD stones a preoperative ERCP is indicated prior to a planned laparoscopic cholecystectomy.     

内镜诊治十二指肠乳头旁憩室合并胆胰疾病523例报告

目的探讨经内镜逆行胰胆管造影术(endoscopic retrograde choangiopancreatography,ERCP)及内镜下乳头括约肌切开术(endoscopic sphincterotomy,EST)对十二指肠乳头旁憩室合并胆胰疾病的诊治方法及价值。方法回顾性分析我院2007年7月~2009年6月1842例首次ERCP检查出523例十二指肠乳头旁憩室合并胆胰疾病的十二指肠乳头旁憩室与十二指肠乳头内镜下关系及其对ERCP成功率、EST及其并发症的影响。结果十二指肠乳头旁憩室合并胆胰疾病患者占ERCP总数的28.4%(523/1842),经ERCP明确十二指肠乳头旁憩室合并胆总管结石395例,占75.5%(395/523)。ERCP造影成功率97.5%(510/523)。实施EST482例全部成功,内镜取石成功率95.2%(376/395)。术后并发症16例(3.1%),包括出血5例,轻型急性胰腺炎5例,高淀粉酶血症4例,穿孔1例,诱发憩室炎1例,均经中西医结合非手术综合治疗痊愈,无死亡病例。术后315例随访1~24个月,平均10.5月,无胆道症状复发。结论只要严格执行内镜下治疗原则,熟练掌握操作技巧,内镜治疗是十二指肠乳头旁憩室合并部分胆胰疾病的微创、安全、有效的首选治疗手段。