不同时段静脉滴注乌司他丁预防ERCP术后胰腺炎效果分析

目的 探讨不同给药时间静脉滴注不同剂量乌司他丁对预防ERCP术后胰腺炎的效果.方法 选取88例行ERCP术的患者,平均分为4组,分别在术前3d、术前1d及术中给予45万U和15万U乌司他丁静脉滴注,观察4组患者术后阳性率、尿淀粉酶恢复正常天数及术后淀粉酶水平.结果 术前3d组ERCP术后患者血液中TNF-α、IL-6与CRP含量明显低于其他3组（P＜0.05）;其他3组ERCP术后血液中三项指标含量比较差异无统计学意义（P＞0.05）.术前3 d组及术中45万组患者术后阳性率、尿淀粉酶恢复正常天数低于术前1d组及术中15万U组患者（P＜0.05）;术前3d组与术中45万U组相比差异无统计学意义（P＞0.05）.术前3d组及术中45万组患者术后1d尿淀粉酶值明显低于术前1d组及术中15万U组患者（P＜0.05）;术前3d组与术中45万U组尿淀粉酶值差异无统计学意义（P＞0.05）;术后2d及3d4组之间尿淀粉酶值差异无统计学意义（P＞0.05）.结论 术前3d应用15万U乌司他丁乌司他丁预防ERCP术后胰腺炎效果最佳.     

乌司他丁预防ERCP术后急性胰腺炎临床观察

随着内镜逆行胰胆管造影(ERCP)技术的广泛开展,ERCP术后致急性胰腺炎及无症状的高淀粉酶血症越来越受到人们的重视。2000年3月-2004年4月,我们采用乌司他丁预防ERCP术后急性胰腺炎及高淀粉酶血症,效果较好。现总结如下。     

ERCP术后胰腺炎的药物预防进展

ERCP术后胰腺炎（post ERCP pancreatitis，PEP）定义为：ERCP术后持续24h腹痛同时伴有血淀粉酶升高3倍以上，并使患者住院时间延长2d以上。该定义为多数研究所接受，但仍有一些研究将血淀粉酶升高5倍以上或测量血脂肪酶作为划分PEP的依据。由于各研究采用的PEP的定义不尽相同。接受ERCP治疗的人群条件不同以及各研究中心技术条件的差别，近期报道的PEP发生率波动在1％～30％。但大多数非选择性的前瞻性研究认为PEP发生率约为2％～9％。多变量分析研究表明PEP发生的危险因素，详见表1。尽管近年来ERCP技术日益普及和成熟，但PEP的发生率并未明显下降，现着重将药物方面预防PEP的进展综述如下。     

ERCP术后胰腺炎的药物预防研究进展

胰腺炎是ERCP术后主要的并发症之一。近年来 ,许多学者致力于ERCP术后胰腺炎的药物预防研究 ,文章对这方面的进展作一综述。     

含乌司他丁造影剂胰管显影与ERCP术后胰腺炎相关性研究

目的用含乌司他丁造影剂显影胰管,以观察ERCP术后胰腺炎的发生率和预防的临床对照研究。方法将2008年1月至2009年7月上海交通大学医学院附属仁济医院嘉定分院178例患者随机分成对照组85例、实验组93例,实验组用含乌司他丁造影剂显影胰管、而对照组用常规造影剂,操作要求用缓力推注造影剂且仅显示主胰管。结果178例发生ERCP术后胰腺炎共15例,发生率为8.9%,其中对照组11例、占12.9%(11/85),实验组4例、占4.3%(4/93),两组发生率比较差异有统计学意义P0.05,诊断性ERCP术后胰腺炎发生率,对照组和实验组分别为44.4%(4/9)和14.3%(1/7),统计分析差异无统计学意义P0.05。全部患者为轻型胰腺炎,经保守治疗痊愈。结论在ERCP术操作中使用含乌司他丁造影剂显影胰管,能降低ERCP术后胰腺炎的发生率,但不能完全避免术后胰腺炎的发生。     

ERCP术后胰腺炎的药物预防研究进展

胰腺炎是ERCP术后主要的并发症之一。近年来，许多学者致力于ERCP术后胰腺炎的药物预防研究，文章对这方面的进展作一综述。     

法莫替丁预防ERCP术后胰腺炎的临床研究

内镜逆行胰胆管造影(ERCP)目前已成为胰胆疾病有效的诊治方法。随着ERCP在临床的广泛应用。其并发的急性胰腺炎及高淀粉酶血症越来越受到临床医师的重视。国内外学者对此进行了广泛的研究，发现生长抑素、奥曲肽及H2受体阻滞剂西咪替丁对ERCP术后胰腺炎及高淀粉酶血症有一定的预防作用。但抑酸作用更为强大的第三代H2受体     

ERCP术后胰腺炎

ERCP(endoscopic retrograde cholangiopancreatogra-phy)作为胆道及胰腺疾病的诊断、治疗手段已越来越多地应用于临床 ,但同时也带来一系列短期的并发症 ,如胰腺炎、出血及穿孔。其中胰腺炎是 ERCP术后最常见也是最严重的并发症。本文对 ERCP术后胰腺炎 (post- ERCP pancreatitis,PEP)的定义、流行病学、发病机制、危险因素、早期诊断及预防和治疗作一综述。一、PEP的定义对于 PEP的定义至今仍有争议。不同中心使用的参数及标准往往不同 ,这也是导致文献报道中 PEP的发生率差异很大的原因之一。很早便有人对 15 0 0 0例接受 ER…     

药物预防ERCP术后急性胰腺炎

内镜逆行胰胆管造影(endoscoplc retrograde cholangiopancreatography，ERCP)开展30年来，由于能在诊断的同时进行一些治疗，是肝胆胰疾病诊治的重要手段之一，国内外已广泛应用于临床。熟练的内镜医师ERCP成功率可达95％，但ERCP引起的术后危重并发症发生率仍可达3％～5％。其主要并发症包括急性胰腺炎、出血和穿孔。尤其是ERCP术后急性胰腺炎往往给患者增加痛苦，     

Comparison between ulinastatin and nafamostat for prevention of post-endoscopic retrograde cholangiopancreatography complications: A prospective,randomized trial

ObjectivesPancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this prospective trial was to compare the effect of ulinastatin and nafamostat on the prophylaxis of post-ERCP complications.MethodsA total of 159 patients who underwent ERCP were divided into ulinastatin (n = 53), nafamostat (n = 53) and control (n = 53) groups. Each patient received ulinastatin (150,000 units), nafamostat (20 mg), or placebo from 2-4 h before ERCP to 6–8 h after ERCP. The primary endpoint was the incidence of PEP, and the secondary endpoints were the incidence of post-ERCP hyperamylasemia, hyperlipasemia and abdominal pain.ResultsThe overall incidence of PEP was 6.3% (10/159) and no significant differences were observed between ulinastatin and nafamostat groups in terms of the incidences of PEP (1.9% and 3.8%, P = 0.560), hyperamylasemia, hyperlipasemia, and abdominal pain, although these were significantly lower than those of the control group (P < 0.001).ConclusionsThere was no significant difference for preventing PEP between ulinastatin and nafamostat and both drugs were efficacious for preventing post-ERCP complications.     

Prophecy about post-endoscopic retrograde cholangiopancreatography pancreatitis:From divination to science

One unresolved issue of endoscopic retrograde cholangiopancreatography(ERCP)is post-ERCP pancreatitis (PEP),which occurs in up to 40%of patients.Identification of risk factors for PEP is especially important in the field of ERCP practice because it may assist physicians in taking protective measures in situations with high risk.A decade ago,Freeman et al meticulously evaluated a large number of potentially relevant risk factors for PEP,which can be divided into patient-relat-ed and procedure-related issues.In this commentary, we summarize this classic article and reevaluate the risk factors for PEP from the current point of view.This is followed by assessment of strategies for prevention of PEP that can be divided into mechanical and pharmacologic methods.     

Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM: To investigate the efficacy and safety profile of pancreatic duct (PD) stent placement for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).METHODS: We performed a search of MEDLINE, EMBASE, and Cochrane Library to identify randomized controlled clinical trials of prophylactic PD stent placement after ERCP. RevMan 5 software provided by Cochrane was used for the heterogeneity and efficacy analyses, and a meta-analysis was performed for the data that showed homogeneity. Categorical data are presented as relative risks and 95% confidence intervals (CIs), and measurement data are presented as weighted mean differences and 95%CIs.RESULTS: The incidence rates of severe pancreatitis, operation failure, complications and patient pain severity were analyzed. Data on pancreatitis incidence were reported in 14 of 15 trials. There was no significant heterogeneity between the trials (I² = 0%, P = 0.93). In the stent group, 49 of the 1233 patients suffered from PEP, compared to 133 of the 1277 patients in the no-stent group. The results of this meta-analysis indicate that it may be possible to prevent PEP by placing a PD stent.CONCLUSION: PD stent placement can reduce postoperative hyperamylasemia and might be an effective and safe option to prevent PEP if the operation indications are well controlled.     

Usefulness of serum lipase for early diagnosis of post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND Post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP)is new onset acute pancreatitis after ERCP. This complication is sometimes fatal.As such, PEP should be diagnosed early so that therapeutic interventions can be carried out. Serum lipase(s-Lip) is useful for diagnosing acute pancreatitis.However, its usefulness for diagnosing PEP has not been sufficiently investigated.AIM This study aimed to retrospectively examine the usefulness of s-Lip for the early diagnosis of PEP.METHODS We retrospectively examined 4192 patients who underwent ERCP at our two hospitals over the last 5 years. The primary outcomes were a comparison of the areas under the receiver operating characteristic(ROC) curves(AUCs) of s-Lip and serum amylase(s-Amy), s-Lip and s-Amy cutoff values based on the presence or absence of PEP in the early stage after ERCP via ROC curves, and the diagnostic properties [sensitivities, specificities, positive predictive values(PPV),and negative predictive value(NPV)] of these cutoff values for PEP diagnosis.RESULTS Based on the eligibility and exclusion criteria, 804 cases were registered. Over the entire course, PEP occurred in 78 patients(9.7%). It occurred in the early stage after ERCP in 40 patients(51.3%) and in the late stage after ERCP in 38 patients(48.7%). The AUCs were 0.908 for s-Lip [95% confidence interval(CI): 0.880-0.940,P 0.001] and 0.880 for s-Amy(95%CI: 0.846-0.915, P 0.001), indicating both are useful for early diagnosis. By comparing the AUCs, s-Lip was found to be significantly more useful for the early diagnosis of PEP than s-Amy(P = 0.023).The optimal cutoff values calculated from the ROC curves were 342 U/L for s-Lip(sensitivity, 0.859; specificity, 0.867; PPV, 0.405; NPV, 0.981) and 171 U/L for sAmy(sensitivity, 0.859; specificity, 0.763; PPV, 0.277; NPV, 0.979).CONCLUSION S-Lip was significantly more useful for the early diagnosis of PEP. Measuring sLip after ERCP could help diagnose PEP earlier; hence, therapeutic interventions can be provided earlier.     

Combination of two-hour post-endoscopic retrograde cholangiopancreatography amylase levels and cannulation times is useful for predicting post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography(ERCP) serum amylase levels and other factors for predicting postERCP pancreatitis.METHODS This was a retrospective,single-center cohort study of consecutive patients who underwent ERCP from January 2010 to December 2013.Serum amylase levels were measured 2 h post-procedure,and patient- and procedure-related pancreatitis(PEP) risk factors wereanalyzed using a logistic model.RESULTS A total of 1520 cases(average age 72 ± 12 years,60% male) were initially enrolled in this study,and 1403 cases(725 patients) were ultimately analyzed after the exclusion of 117 cases.Fifty-five of these cases developed PEP.We established a 2 h serum amylase cutoff level of two times the upper limit of normal for predicting PEP.Multivariate analysis revealed that a cannulation time of more than 13 min [odds ratio(OR) 2.28,95%CI:1.132-4.651,P=0.0210] and 2 h amylase levels greater than the cutoff level(OR=24.1,95%CI:11.56-57.13,P0.0001) were significant predictive factors for PEP.Forty-seven of the 55 patients who developed PEP exhibited 2 h amylase levels greater than the cutoff level(85%),and six of the remaining eight patients who developed PEP(75%) required longer cannulation times.Only 2 of the 1403 patients(0.14%) who developed PEP did not exhibit concerning 2 h amylase levels or require longer cannulation times.CONCLUSION These findings indicate that the combination of 2 h post-ERCP serum amylase levels and cannulation times represents a valuable marker for identifying patients at high risk for PEP.     

Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.     

The use of gabexate mesylate and ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Background/Aims

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP.

Methods

From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia.

Results

PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05).

Conclusions

Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.     

Pancreatic stents for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis should be inserted up to the pancreatic body or tail

AIM To investigate the location to which a pancreatic stent should be inserted to prevent post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP).METHODS Over a ten-year period at our hospital, 296 patients underwent their first ERCP procedure and had a pancreatic stent inserted; this study included 147 patients who had ERCP performed primarily for biliary investigation and had a pancreatic stent inserted to prevent PEP. We dividedthese patients into two groups: 131 patients with a stent inserted into the pancreatic head(head group) and 16 patients with a stent inserted up to the pancreatic body or tail(body/tail group). Patient characteristics and ERCP factors were compared between the groups.RESULTS Pancreatic amylase isoenzyme(p-AMY) levels in the head group were significantly higher than those in the body/tail group [138.5(7.0-2086) vs 78.5(5.0-1266.5), P = 0.03] [median(range)]. No cases of PEP were detected in the body/tail group [head group, 12(9.2%)]. Of the risk factors for post-ERCP hyperamylasemia(≥ p-AMY median, 131 IU/L), procedure time ≥ 60 min [odds ratio(OR) 2.65, 95%CI: 1.17-6.02, P = 0.02) and stent insertion into the pancreatic head(OR 3.80, 95%CI: 1.12-12.9, P = 0.03) were identified as independent risk factors by multivariate analysis.CONCLUSION Stent insertion up to the pancreatic body or tail reduces the risk of post-ERCP hyperamylasemia and may reduce the risk of PEP.     

Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis

Background and Aims:  Acute pancreatitis following endoscopic retrograde cholangiography presents a unique opportunity for prophylaxis and early modification of the disease process because the initial triggering event is temporally well defined and takes place in the hospital. We report a prospective, single-center, randomized, double-blind controlled trial to determine if rectal diclofenac reduces the incidence of pancreatitis following cholangiopancreatography.
Methods:  Entry to the trial was restricted to patients who underwent endoscopic retrograde pancreatography. Immediately after endoscopy, patients were given a suppository containing either 100 mg diclofenac or placebo. Estimation of serum amylase level and clinical evaluation were performed in all patients.
Results:  One hundred patients entered the trial, and 50 received rectal diclofenac. Fifteen patients developed pancreatitis (15%), of whom two received rectal diclofenac and 13 received placebo ( P  < 0.01).
Conclusions:  This trial shows that rectal diclofenac given immediately after endoscopic retrograde cholangiopancreatography can reduce the incidence of acute pancreatitis.