内镜括约肌切开术与内镜括约肌切开术联合球囊扩张术治疗胆管结石的比较：基于随机对照试验的系统评价和荟萃分析。
Comparison between endoscopic sphincterotomy endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones: A systematic review and meta-analysis based on randomized controlled trials.
作者信息
de Clemente Junior Cesar Capel, Bernardo Wanderley Marques, Franzini Tomazo Prince, Luz Gustavo Oliveira, Dos Santos Marcos Eduardo Lera, Cohen Jonah Maxwell, de Moura Diogo Turiani Hourneaux, Marinho Fábio Ramalho Tavares, Coronel Martin, Sakai Paulo, de Moura Eduardo Guimarães Hourneaux
机构信息
Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil.
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States.
出版信息
World J Gastrointest Endosc. 2018 Aug 16;10(8):130-144. doi: 10.4253/wjge.v10.i8.130.
AIM
To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials.
METHODS
We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy (ML), perforation and cholangitis.
RESULTS
Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding [FE RD-0.02, CI (-0.03, -0.00), = 33%, = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI (-0.25, -0.06), = 90%, = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI (-0.38, -0.02), = 82%, = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI (-0.03, 0.01), = 0, = 0.36], cholangitis [FE RD-0.00, CI (-0.01, 0.01), =0, = 0.97] and perforation [FE RD-0.01, CI (-0.01, 0.00), = 0, = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI (-0.01, 0.04), = 0, = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI (-0.02, 0.07), = 11%, = 0.31].
CONCLUSION
Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.
目的
通过对随机临床试验的荟萃分析，比较单纯括约肌切开术与乳头球囊扩张联合括约肌切开术在胆总管结石治疗中结石清除率、出血、胰腺炎、机械碎石术的使用、胆管炎及穿孔的发生率。
方法
我们按照PRISMA指南进行了系统评价。文献检索限于2017年7月在MedLine、Cochrane图书馆、LILACS和EMBASE数据库平台上的随机对照试验（RCT）。手工检索包括检索到文章的参考文献。我们提取了关注结果的数据：主要终点是结石清除率；次要终点是胰腺炎、出血、机械碎石术（ML）的使用、穿孔和胆管炎的发生率。
结果
纳入了11项RCT，共1824例患者。单纯括约肌切开术与更多的内镜逆行胰胆管造影（ERCP）术后出血相关[固定效应相对危险度（RRD）-0.02，可信区间（CI）（-0.03，-0.00），I² = 33%，P = 0.05]，总体上更需要机械碎石术[随机效应RRD -0.16，CI（-0.25，-0.06），I² = 90%，P = 0.002]，在结石大于15 mm的亚组分析中也是如此[随机效应RRD -0.20，CI（-0.38，-0.02），I² = 82%，P = 0.003]。两组间胰腺炎[固定效应RRD -0.01，CI（-0.03，0.01），I² = 0，P = 0.36]、胆管炎[固定效应RRD -0.00，CI（-0.01，0.01），I² = 0，P = 0.97]和穿孔[固定效应RRD -0.01，CI（-0.01，0.00），I² = 0，P = 0.23]的发生率相似，总体结石清除率也相似[固定效应RRD -0.01，CI（-0.01，0.04），I² = 0，P = 0.23]，在结石大于15 mm的汇总分析中也是如此[固定效应RRD -0.02，CI（-0.02，0.07），I² = 11%，P = 0.31]。
结论
通过对随机临床试验的荟萃分析，我们发现单纯括约肌切开术与更多的ERCP术后出血及更多的机械碎石术需求相关。然而，在去除胆结石的方法上，单纯括约肌切开术与球囊扩张联合括约肌切开术之间的结石清除率无统计学差异。
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