Neuhaus H
Dept. of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany.
Endoscopy. 2004 Jan;36(1):8-16. doi: 10.1055/s-2004-814119.
In view of increasingly accurate noninvasive diagnostic imaging modalities for pancreatic diseases, endoscopic retrograde cholangiopancreatography (ERCP) should be mainly restricted to therapeutic indications. Acute pancreatitis is still the most common complication of ERCP. Prevention measures should focus in particular on well-defined risk groups. Temporary pancreatic duct drainage, preferably using small-diameter endoprostheses, can reduce the incidence of post-ERCP pancreatitis in at-risk individuals. By contrast, pharmacological prevention does not appear to be effective. ERCP in conjunction with sphincter of Oddi manometry frequently reveals the diagnosis of undetermined causes of acute recurrent pancreatitis. Endoscopic sphincterotomy (EST) is the treatment of choice in patients with sphincter of Oddi dysfunction or papillary stenosis. For these indications, dual pancreaticobiliary sphincterotomy promises a lower early morbidity and a better long-term outcome than biliary EST alone. In patients with pancreatic divisum, the cannulation rate of the dorsal duct can be improved by methylene blue staining and/or stimulation of the pancreatic secretion. Papillotomy of the minor papilla with short-term stenting appears to be an effective and safe approach for associated acute recurrent pancreatitis. Large-scale trials indicate that the majority of symptomatic patients with chronic pancreatitis can be well managed in the long term by endoscopic interventions. There is still a lack of prospective randomized controlled trials on endotherapy for chronic pancreatitis; however, they are also lacking for the surgical approach. Endoscopic and/or endosonographically guided drainage has become the treatment of choice for the majority of symptomatic pancreatic pseudocysts. Transmural debridement of pancreatic abscesses and infected necroses is still investigational, but appears to offer a minimally invasive alternative to surgery in selected cases. Pancreatic endotherapy is technically demanding and potentially hazardous; these interventions should be restricted to high-volume centers with options for an interdisciplinary team approach. Methods that have not yet been established should be evaluated in carefully designed prospective trials.
鉴于用于胰腺疾病的非侵入性诊断成像方式越来越精确，内镜逆行胰胆管造影术（ERCP）应主要限于治疗适应证。急性胰腺炎仍然是ERCP最常见的并发症。预防措施应特别关注明确的风险群体。临时胰管引流，最好使用小直径内支架，可降低高危个体ERCP后胰腺炎的发生率。相比之下，药物预防似乎无效。ERCP联合Oddi括约肌测压术常可明确急性复发性胰腺炎的不明病因。内镜括约肌切开术（EST）是Oddi括约肌功能障碍或乳头狭窄患者的首选治疗方法。对于这些适应证，双胰胆管括约肌切开术与单独的胆管EST相比，早期发病率更低，长期预后更好。在胰腺分裂症患者中，通过亚甲蓝染色和/或刺激胰腺分泌可提高背侧胰管的插管率。小乳头乳头切开术并短期置入支架似乎是治疗相关急性复发性胰腺炎的有效且安全的方法。大规模试验表明，大多数有症状的慢性胰腺炎患者可通过内镜干预得到长期良好管理。目前仍缺乏关于慢性胰腺炎内镜治疗的前瞻性随机对照试验；然而，手术治疗方法也缺乏此类试验。内镜和/或内镜超声引导下引流已成为大多数有症状胰腺假性囊肿的首选治疗方法。胰腺脓肿和感染性坏死的经壁清创术仍在研究中，但在某些选定病例中似乎提供了一种微创的手术替代方法。胰腺内镜治疗技术要求高且有潜在风险；这些干预措施应限于具备跨学科团队协作条件的大容量中心。尚未确立的方法应在精心设计的前瞻性试验中进行评估。
