Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
Clin Gastroenterol Hepatol. 2012 Oct;10(10):1101-9. doi: 10.1016/j.cgh.2012.05.017. Epub 2012 May 27.
BACKGROUND & AIMS: Endoscopic sphincterotomy (EST) is the standard treatment for choledocholithiasis. Endoscopic papillary balloon dilation (EPBD) has a lower risk for bleeding than EST, but EPBD is reserved for patients with bleeding diathesis because some studies reported that it increases the risk for pancreatitis. A short dilation time (≤1 minute) is therefore recommended to reduce pancreatitis. However, there is evidence for an inverse relationship between EPBD duration and pancreatitis, prompting reevaluation of the optimal duration and relative safety of EPBD vs EST.
We systematically reviewed randomized controlled trials to compare long EPBD (>1 minute), short EPBD (≤1 minute), and EST regarding pancreatitis and overall complications. In addition to pairwise meta-analyses, Bayesian network meta-analysis was undertaken to compare the 3 procedures together. Relation between duration and outcome was also analyzed by meta-regression.
Compared with EST, short EPBD had a higher risk for pancreatitis (odds ratio [OR] by traditional analysis, 3.87; 95% confidence interval, 1.08-13.84 and OR by network meta-analysis, 4.14; 95% credible interval, 1.58-12.56), but long EPBD did not pose a higher risk than EST (1.14, 0.56-2.35 and 1.07, 0.38-2.76). Long EPBD had a lower overall rate of complications than EST (0.61, 0.36-1.04 and 0.54, 0.20-1.36). In network meta-analysis, probabilities of being the safest treatment for long EPBD/short EPBD/EST regarding pancreatitis and overall complications were 43.9%/0.2%/55.9% and 90.3%/1.3%/8.4%, respectively.
Duration of EPBD is inversely associated with pancreatitis risk. Currently recommended ≤1-minute dilation actually increases pancreatitis. EPBD with adequate duration may be preferred over EST because of comparable pancreatitis but lower overall complication rates.
内镜下括约肌切开术（EST）是治疗胆总管结石的标准治疗方法。内镜乳头气囊扩张术（EPBD）的出血风险低于 EST，但 EPBD 仅适用于有出血倾向的患者，因为一些研究报告称其会增加胰腺炎的风险。因此，推荐短时间扩张（≤1 分钟）以降低胰腺炎的风险。然而，有证据表明 EPBD 持续时间与胰腺炎呈反比关系，这促使我们重新评估 EPBD 与 EST 之间的最佳持续时间和相对安全性。
我们系统地回顾了随机对照试验，比较了长 EPBD（>1 分钟）、短 EPBD（≤1 分钟）和 EST 治疗胰腺炎和总体并发症的情况。除了两两荟萃分析外，还进行了贝叶斯网络荟萃分析来比较这 3 种手术。还通过荟萃回归分析了时间与结果之间的关系。
与 EST 相比，短 EPBD 发生胰腺炎的风险更高（传统分析的比值比 [OR]，3.87；95%置信区间，1.08-13.84；网络荟萃分析的 OR，4.14；95%可信区间，1.58-12.56），但长 EPBD 并不比 EST 更危险（1.14，0.56-2.35；1.07，0.38-2.76）。长 EPBD 的总体并发症发生率低于 EST（0.61，0.36-1.04；0.54，0.20-1.36）。在网络荟萃分析中，长 EPBD/短 EPBD/EST 治疗胰腺炎和总体并发症的安全性最高的概率分别为 43.9%/0.2%/55.9%和 90.3%/1.3%/8.4%。
EPBD 的持续时间与胰腺炎风险呈反比关系。目前推荐的≤1 分钟扩张实际上增加了胰腺炎的风险。由于胰腺炎发生率相当，但总体并发症发生率较低，因此适当延长 EPBD 的持续时间可能优于 EST。
