【作者】 林辉；

【导师】 李兆申； 湛先保； 金震东； 邹多武；

【作者基本信息】 第二军医大学 ， 内科学， 2010， 博士

【摘要】 第一部分胰腺假性囊肿经乳头引流的临床研究目的：胰腺假性囊肿经乳头支架引流已成为一种重要的治疗方式,尤其对PPC与胰管相通或PPC伴胰管异常的病例。本研究目的是分析胰腺假性囊肿经乳头引流的疗效、复发率及影响引流疗效的因素。方法：收集2000年11月至2009年9月长海医院胰腺假性囊肿行经十二指肠乳头胰管支架置管引流或鼻囊管引流的病例临床资料、PPC特征、治疗结果及其并发症。并行前瞻性随访。结果：1、43例患者共实施治疗性ERCP70次,单纯行胰管支架引流36例,单纯鼻囊管引流4例,联合鼻囊管及支架引流3例。技术操作成功率为90.7%(39/43)。急性PPC操作成功率为91.3%(21/23),慢性PPC操作成功率为89.5%(17/19),两者差别无统计意义(P=1.00)。2、囊肿引流成功率为79.5%(31/39)。急性PPC引流成功率为85.7%(18/21),慢性PPC引流成功率为70.6%(12/17),两者差别无统计意义(P=0.426)。胰腺脓肿1例联合鼻囊管与支架引流成功。3、操作相关并发症发生率为16.3%(7/43)。急性PPC并发症发生率为17.4%(4/23),慢性PPC并发症发生率为15.8%(3/19),两者差别无统计意义(P=1.00)。4、平均住院时间为10.2±9.2天,最短2天,最长48天。随访时间(中位数)为774天,最长3256天,最短61天。复发率为6.5%(2/31),2例均为慢性PPC。5、胰体/尾部PPC引流疗效高于胰头部,两者差别有统计意义(P=0.045)。多因素分析发现PPC的部位是引流成功与否的独立危险因素(P=0.018<0.05)。结论：1、十二指肠镜下经乳头支架或鼻囊肿引流是胰腺假性囊肿介入治疗的有效手段,外科手术可用于内镜治疗失败或有严重并发症的病例。2、PPC的部位是经乳头引流成功与否的独立危险因素,胰体/尾部PPC引流成功率高于胰头部。第二部分EUS引导经胃或十二指肠置管引流胰腺假性囊肿的多中心临床研究目的：目前国内外EUS引导经胃或十二指肠置管引流胰腺假性囊肿的多中心、大样本临床研究鲜见报道。本研究目的是对我国EUS引导下经胃或十二指肠置管引流胰腺假性囊肿的疗效,住院天数,并发症率,复发率等进行多中心临床研究。方法：收集2001年05月至2009年12月长海医院,中国医科大学附属盛京医院,长征医院三个中心胰腺假性囊肿EUS引导经胃或十二指肠置管引流的病例临床资料、PPC特征、治疗结果及其并发症。并行前瞻性随访。结果：1、引流前共有14例患者实施ERCP 15次,2例患者ERCP未成功。其中胰管中断2例；胰管与PPC相通1例,予置入胰管支架。93例患者共行置管引流操作106次。技术操作成功率为96.8%(90/93)。急性PPC操作成功率为96.3%(79/82),慢性PPC9例及胰腺脓肿2例均操作成功。2、全部囊肿平均大小为11.5±4.9cm。内镜下胃腔内有隆起的有83例(89.2%),未发现胃内压迫的有10例。囊肿引流成功率为94.4%(85/90)。经胃置管引流84例,成功79例,成功率为94.0%(79/84)；经十二指肠置管引流有6例,均成功引流,无并发症。3、操作相关并发症发生率为14.4%(13/90),PPC并发感染(11/13,84.6%)是主要并发症。引流管不同数量及大小间透壁引流PPC继发感染率的差别无统计学意义。4、平均住院时间为9.9±10.1天,最短1天,最长50天。随访时间(中位数)为712天,最长3057天,最短60天。复发率为5.6%(5/90),5例均为急性PPC。5、PPC的病因、大小、部位,是否并发食管胃底静脉曲张,引流管的类型、数量等因素均不影响引流成功率。EUS引导经胃置管引流成功率高于经乳头支架引流(94.4%&79.5%,P=0.023),差别有统计意义(P<0.05)。结论：1、EUS引导经胃或十二指肠置管引流胰腺假性囊肿有可能替代外科手术,成为PPC微创引流的有效手段；PPC并发感染是其主要并发症,引流管数量与直径不影响透壁引流PPC的继发感染率。2、EUS引导经胃置管引流疗效优于经乳头支架引流。第三部分胰腺假性囊肿的病因及临床特征分析目的：胰腺假性囊肿大部分并发于急、慢性胰腺炎和胰腺损伤。但假性囊肿的病因并不等同于胰腺炎的病因。国内有关胰腺假性囊肿的病因鲜见报道,国外胰腺假性囊肿的病因报道病例数也较少,目前国内外均缺乏大样本的胰腺假性囊肿病因与临床特征分析。本研究目的是通过回顾性分析366例胰腺假性囊肿的临床资料、治疗方式及其并发症,了解假性囊肿的病因、临床特征以及不同治疗方式的优缺点。方法：收集2000年4月-2009年12月间长海医院收治的所有胰腺假性囊肿患者的临床资料。采用统一的软件记录患者的临床流行病学、PPC的原发病、影像学检查及相关的临床治疗经过。结果：1、共收集2000年4月-2009年12月长海医院已确诊胰腺假性囊肿366例,其中男性249例(68.0%)、女性117例(32.0%)。患者的平均发病年龄为48.6±13.5岁,最大87岁,最小9岁。并发于轻症胰腺炎的PPC为59例(59/366,16.1%),并发于重症胰腺炎的PPC为149例(149/366,40.7%),并发于慢性胰腺炎的PPC为98例(98/366,26.8%),无胰腺炎病史有60例(60/366,16.4%)。2、胰腺假性囊肿的病因构成为胆源性158例(43.2%),特发性79例(21.6%),酒精50例(13.7%),外伤17例(4.6%),胰腺肿瘤9例(2.5%),高脂血症8例(2.2%),胰腺术后7例(1.9%),其它38例(10.3%)。3、胰腺假性囊肿按亚特兰大分类为急性PPC204例(64.2%),慢性PPC98例(30.8%),胰腺脓肿16例(5.0%)。平均大小分别为：10.6±5.3cm,6.1±3.5cm及13.4±6.7cm。急性PPC204个中位于胰头部有23个(11.3%,23/204)；而慢性PPC99个中位于胰头部31个(31.3%,31/99)；两者差别有统计学意义χ2=18.275,P=0.000)。4、胰腺假性囊肿的临床表现依次为无不适161例(48.1%),腹痛105例(31.3%),腹胀37例(11.0%),发热28例(8.4%),囊肿增大23例(6.9%)。5、三种治疗方式的并发症率分别为：经皮引流为31.6%(6/19,6例均为感染),内镜引流19.0%(16/84,感染12例、出血2例、ERCP术后胰腺炎2例),外科手术5.0%(7/141,出血4例、肠瘘2例、胰瘘1例)。结论：1、与西方国家明显不同,我国胰腺假性囊肿中胆源性是主要病因,其次分别是特发性、酒精和外伤。2、不同类型胰腺假性囊肿的临床特征差异：急、慢性PPC在胰头部及全胰分布存在差别；急、慢性PPC中腹痛与囊肿增大表现存在差别；腹痛、腹胀、发热是有症状PPC的主要临床表现。胰腺脓肿平均直径最大,其次为急性PPC,慢性PPC平均直径最小。更多还原

【Abstract】 Objective:Transpapillary approach can be used for pseudocyst drainage when PPC communicated with the main pancreatic duct, espccially for pseudocyst with pancreatic-duct abnormality. Our purpose is to analyze the efficacy, recurrence rate and prognostic factors for clinical success of endoscopic pseudocyst transpapillary drainage.Methods:Data on all patients who were undergoing transpapillary drainage between November 2000 and September 2009 were entered into a computerized database. Patient data, pseudocyst characteristics, drainage technique, and outcomes were obtained through restrospective review. Prospective follow-up to determine long-term outcome was carried out.Results:1. Total procedures of interventional ERCP were 70 in 43 patients.36 of the 43 patients underwent pancreatic-duct stent drainge, nasocystic catheters in 3 patients and a combination of stent plus nasocystic catheter in 3 cases. The technical success rate for acute pseudocyst drainage was 90.7%(39 of 43 patients), for chronic pseudocyst drainage 89.5%(17/19, P=1.00 VS. acute pseudocyst).2. The overall clinical success rate was 79.5%(31 of 39 patients). The clinical success rate for acute pseudocyst drainage was 85.7%(18/21), for chronic pseudocyst drainage 70.6%(12/17, P=0.426 VS. acute pseudocyst).3. Complications occurred in 7 of 43 patients (16.3%). Complications related to acute pseudocyst drainage occurred in 4 of 23 patients (17.4%), to chronic pseudocyst drainage in 3/19 (15.8%, P=1.00 VS. acute pseudocyst).4. The mean hospital stay for all patients undergoing transpapillary drainage was 10.2±9.2 days (range 2-48 days). Median follow-up was 774 days (range 61-3256 days) for 39 patients. Pseudocyst recurred in 2 of 31 patients (6.5%) with PPC successfully drained endoscopically.5. There was significant difference in the clinical success rate of pancreatic head pseudocyst versus body/tail pseudocyst (62.5% vs 91.3%, P=0.045). None of the other factors tested were significant predictors of clinical success.Conclusion:Endoscopically transpapillary drainage is effective approach for the drainage of pancreatic pseudocyst. The clinical success rate of pancreatic body/tail pseudocyst drainage is higher than pancreatic head. Surgery can be reserved for those patients in whom transpapillary drainage fails.KEY WORDS:pancreatic pseudocyst, Duodenoscopy, transpapillary drainage, stentPart two EUS-guided endoscopic drainage of pancreatic pseudocysts: immediate and long-term results of a multicenter study in ChinaObjective:There is seldom multicenter, large sample reports of EUS-guided endoscopic Drainage of Pancreatic Pseudocysts now. Our purpose is to analyze the efficacy, recurrence rate and prognostic factors for clinical success of EUS-guided transmural drainage.Methods:Data on all patients who were undergoing EUS-guided transmural drainage between May 2001 and December 2009 were entered into a computerized database. Patient data, pseudocyst characteristics, drainage technique, outcomes and complications were obtained through restrospective review. Prospective follow-up to determine immediate and long-term outcome was carried out.Results:1. Pancreatography was obtained in 14 of the 93 patients before transmural drainage, communication of the pseudocyst with the main pancreatic duct was demonstrated in 1 case. Total procedures of transmural drainage were 106 in 93 patients. The overall technical success rate for transmural drainage was 96.8%(90 of 93 patients), the technical success rate for acute pseudocyst drainage was 96.3%(79/82), for chronic pseudocyst drainage 100%(9/9), for abscess drainage 100% (2/2).2. The mean size of the pseudocysts was 11.5±4.9cm. A total of 89 pseudocysts bulged into the digestive wall (95.7%). The overall clinical success rate was 94.4%(85 of 90 patients). EUS-guided transmural drainage was performed on 87 patients, EUS-guided transduodenal drainage on 6 patients.3. Complications occurred in 13 of 90 patients (14.4%). This included secondary infection (11/13), bleeding (1/13), ineffective drainage (1/13). Secondary infection is major complications.4. The mean hospital stay for all patients undergoing transmural drainage was 9.9±10.1 days (range 1-50 days). Median follow-up was 712 days (range 60-3057 days) for 90 patients. Pseudocyst recurred in 5 of 90 patients (5.6%) with pseudocyst successfully drained endoscopically.5. The clinical success rate of EUS-guided transmural drainage is significantly higher than transpapillary drainage (P＜0.05). No significant differences were observed regarding success when the number of double-pigtail stent, pseudocyst etiology, size, location, and so on were considered.Conclusion:EUS-guided transmural drainage is effective approach for microinvasive drainage of pancreatic pseudocyst and has gained acceptance as an alternative to surgical drainage. Secondary infection is major complications. The clinical success rate of EUS-guided transmural drainage is significantly higher than transpapillary drainage.Part three Etiology and characteristics in pancreatic pseudocyst: Clinical analysis of 366 casesObjective:Pancreatic pseudocysts (PPCs) arise as complication of acute and chronic pancreatitis or pancreatic trauma. But the etiologies of PPC are not the same as pancreatitis. There is seldom large sample reports of etiology in pancreatic pseudocyst now. Our purpose is to analyze the etiology, characteristics and treatment approach in pancreatic pseudocyst by retrospective review of clinic records.Methods:Medical records were reviewed and analyzed of 366 PPC patients who were admitted in changhai hospitals in China from April 2000 to December 2009 in terms of etiology and hospital course.Results:1. Of the 366 patients (249 men,117 women; mean age 48.6±13.5 years,range 9-87 years),59 patients had mild pancreatitis (59/366,16.1%),149 patients had severe acute pancreatitis (149/366,40.7%),98 patients had chronic pancreatitis (98/366,26.8%), 60 patients had no history of pancreatitis (60/366,16.4%).2. The causes of the ppc varied widely:gallstones,158patients(43.2%); idiopathic, 79(21.6%); alcohol ingestion,50(13.7%); trauma,17(4.6%); pancreatic tumor,9(2.5%); hyperlipidemia,8(2.2%); medications,7(1.9%), other,38(10.3%).3. The PPCs were classified as acute PPC in 204 patients, chronic PPC in 98 patients and abscess in 16 patients. Mean diameter of this three kinds PPC was 10.6±5.3cm, 6.1±3.5cm and 13.4±6.7cm, respectively. There is significant difference between acute and chronic PPCs located in the pancreatic head(χ2=18.275, P=0.000).4. The symptoms of the PPCs included abdominal pain (31.3%), early satiety (11.0%), fever (8.4%), enlarging cyst (6.9%). Asymptomatic PPCs were present in 48.1% of cases. 5. The complication rates of percutaneous, endoscopic, surgical drainage were 31.6%, 19.0% and 5.0%, respectively.Conclusions:1.The results of the present investigation show that gallstones is the main etiologic cause of the PPCs in China; 2. There is significant difference between acute and chronic PPCs located in the pancreatic head; 3. The main symptoms of the PPCs include abdominal pain, early satiety and fever.更多还原