【作者】 周文策；

【导师】 李玉民；

【作者基本信息】 兰州大学 ， 外科学， 2011， 博士

【摘要】 第一部分内镜联合早期肠内营养治疗急性重症胆源性胰腺炎目的急性重症胆源性胰腺炎是外科急危重症,并发症多,死亡率高,治疗费用高,效果尚不满意。本研究通过评价内镜联合早期肠内营养治疗的临床效果,以期改善急性重症胆源性胰腺炎的治疗效果,降低并发症及治疗费用。方法对我院2004年1月至2009年7月间收治的105例急性重症胆源性胰腺炎患者,随机分为两组,50例行内镜ERCP+EST+ERBD,同时放置肠内营养管行早期肠内营养；与55例常规治疗联合肠内外营养的患者进行比较。分别对患者术后主观症状、体征、血常规、生化指标、血清内毒素含量、TNF-α、IL-10、CD4+/CD8+、CT分级、患者总住院费用及住院时间等指标进行比较。结果入选患者均可顺利完成两种治疗方案。与传统治疗方案相比,内镜联合早期肠内营养方案对患者主观症状、体征、血常规、生化指标、内毒素血症、TNF-α、IL-10、CD4+/CD8+、CT分级改善明显,患者住院费用、住院时间均明显减少。结论内镜联合早期肠内营养治疗急性重症胆源性胰腺炎是安全、有效、经济的治疗方案。第二部分ERCP术后胰腺炎技术层面危险因素分析(附7168例报告)目的：ERCP术后胰腺炎(PEP)是ERCP术后最常见和严重的并发症之一。本研究通过回顾性分析四个发展时期中PEP的发病率和相关危险因素的差异,试图证实ERCP术后胰腺炎发生率逐渐下降可能是归于严格的患者选择标准、内镜设备的完善和技术的改进。方法：回顾性分析了1989年12月至2010年3月于兰州大学第一医院行诊断与治疗性ERCP的7168例次患者的临床资料,根据ERCP设备和技术的不同发展阶段,病例被分成4组。对各组间PEP的发病率和主要危险因素进行比较。结果：7168例ERCP术后胰腺炎的总发生率为3.70%(265/7,168)。比较四个时期PEP的发生率,第一阶段为4.09%(77/1,884)；第二阶段为5.79%(86/1,489)；第三阶段为3.95%(62/1,568)；第四阶段为1.80%(40/2,227)。通过单变量分析,发现胰管内支架置入(OR 0.300)和应用异丙酚复合麻醉(OR 0.632)对于PEP似乎是保护性因素。通过多变量分析,发现重复插管(OR 3.462)、胰管造影(OR 3.218)、胆管括约肌球囊扩张(OR 2.847)、乳头预切开(OR 2.493)、高压非选择性注射(OR 1.428)、过度电凝切开(OR 1.263)、既往胰腺炎病史(OR 3.843)和Oddi括约肌功能紊乱(OR 1.782)是明确引起PEP相关危险因素。结论：PEP发生率的明显降低与不断改善的ERCP操作技术相关。通过持续地改进ERCP技术,例如常规使用导丝、高选择性插管、胰管内支架置入和谨慎的乳头切开,PEP发病风险可以尽可能被降低。第三部分胆胰管双支架置入术预防高危患者ERCP术后胰腺炎的临床价值目的：ERCP术后胰腺炎(post-ERCP pancreatitis, PEP)是最常见的和最严重的ERCP术后并发症之一,本研究的目的是评估内镜下胆胰管双支架植置入术对PEP的临床预防效果。方法：收集我院普外二科2005年1月至2011年8月期间经ERCP诊疗中心对行内镜治疗的具有PEP高危因素的患者409例,根据术中是否留置胆管支架及胰管支架分为三组,分布比较各组之间PEP发生率和严重程度的差异。结果：PEP发生率：无支架组23.2%(13/56),ENBD/ERBD组11.9%(32/270), ERBD+ERPD组3.6%(3/83),三组之间均存在显著差异(P<0.05)。三组患者轻度PEP发生率无显著差异；但ERBD+ERPD组中度PEP的发生率较无支架组(1.2% vs.0.10.7%；P=0.017)和ENBD/ERBD组(1.2% vs.7.4%；P=0.035)均显著降低；ENBD/ERBD重度PEP的发生率较无支架组显著降低(1.1%vs.7.1%；P=0.018)。结论：内镜下胆胰管双支架置入术可以降低ERCP术后胰腺炎的发生率和严重程度,对PEP是一项安全、有效的预防措施,值得临床进一步推广应用。更多还原

【Abstract】 Objective:Acute severe biliary pancreatitis (ASBP) is a severe and fatal disease, and the expenditure is huge and therapeutic effects are still not satisfactory. This study aimed to improve the therapeutic effects and reduce the expenditure of ASBP treatment. Methods:105 patients diagnosed with ASBP were recruited in our department from January 2004 to July 2009. Patients were divided into two groups; the E group:50 patients who underwent endoscopic retrograde choledochopancreatography (ERCP)+endoscopic sphincterotomy (EST)+ endoscopic lithotripsy basket (ESR)+endoscopic retrograde biliary drainage (ERBD) and enteral nutrition (EN), and the R group:55 patients who underwent conventional treatment without ERCP. Subsequently, subjective symptoms, signs, biochemical analysis, serum endotoxin, TNF-α, grades by computed tomography (CT), cost of hospitalization and length of stay were compared between the two groups. Results: All enrolled patients complied well with all therapeutic regimens. Endoscopic therapy that combined EN could significantly improve symptoms, clinical signs, laboratory values, tumor necrosis factor a and endotoxin while significantly reducing hospital expenditure and length of hospital stay. The experimental findings revealed that there were obvious advantages in the E group compared with the R group. Conclusions: Endoscopic therapy combined with EN is an effective, safe and economic therapeutic regimen of acute severe biliary pancreatitis. Objective:Post-ERCP pancreatitis (PEP) is one of the most common and serious complications after ERCP. This study aims to test this hypothesis that the incidence of post-ERCP declined over time due to improved patient selection and/or endoscope equipments and endoscopic techniques. Methods:A total 7,168 cases of ERCP procedures were retrospectively analyzed. According to different development stages of ERCP equipments and techniques, cases were divided into four groups. Incidence rate and major risk factors for acute PEP were compared between groups. Results:Of the 7,168 cases, the overall incidence of PEP was 3.70%(265/7,168). The incidence of PEP was 4.09%(77/1,884) in the StageⅠ,5.79%(86/1,489) in the StageⅡ,3.95% (62/1,568) in the StageⅢ, and 1.80%(40/2,227) in the StageⅣ. The identifiable risk factors for PEP from multivariate analysis include repeated cannulation (OR 3.462), pancreatic duct injection (OR 3.218), balloon dilation of biliary sphincter (OR 2.847), papillae pre-cut (OR 2.493), non-selective high-pressure injection (OR 1.428), excessive electrocoagulation incision (OR 1.263), history of pancreatitis (OR 3.843), and suspected sphincter of Oddi dysfunction (OR 1.782). Conclusions:Improved technical procedures were associated with a significant reduction in the incidence of PEP. Risks for developing PEP may be minimized by constant improvement in the ERCP techniques, such as a routine use of guidewire, highly selective cannulation, pancreatic stent placement, and cautious incision. Objective:Post-ERCP pancreatitis (PEP) is one of the most common and serious complications after ERCP. This study aims to assess prophylactic value of pancreatic and biliary stent placement for PEP. Methods:A total 409 high risk cases were divided into three groups according to different therapeutic strategy. Incidence rate and degree of PEP were compared between groups. Results:The incidence of PEP was 23.2%(13/56) in non drainage group,11.9%(32/270) in the group of ENBD/ERBD,3.6%(3/83) in the group of ERBD+ERPD, there were significant difference of incidence of PEP among each group (P<0.05). The incidence of mild PEP was not significantly different among each group (P>0.05). The incidence of moderate PEP in group of ERBD+ERPD was lower than it in group of ENBD/ERBD (1.2% vs.7.4%; P=0.035) and group of non drainage (1.2% vs.0.10.7%; P=0.017). The incidence of severe PEP in group of ENBD/ERBD was lower than it in non drainage group (1.1% vs.7.1%; P=0.018). Conclusions:Pancreatic and biliary stent placement could reduce the incidence and degree of PEP for high risk patients, which is safe and effective approach for prophylaxis of PEP, deserving further clinical application and extension in future.更多还原