内镜超声引导下内镜逆行胰胆管造影术对远端恶性胆管梗阻性狭窄进行胆道引流：一项系统评价和荟萃分析

Endoscopic ultrasound-guided endoscopic retrograde cholangiopancreatography biliary drainage for obstructed distal malignant biliary strictures: A systematic review and meta-analysis.

作者信息

Logiudice Fernanda P, Bernardo Wanderlei M, Galetti Facundo, Sagae Vitor M, Matsubayashi Carolina O, Madruga Neto Antonio C, Brunaldi Vitor O, de Moura Diogo T H, Franzini Tomazo, Cheng Spencer, Matuguma Sergio E, de Moura Eduardo G H

机构信息

Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States.

出版信息

World J Gastrointest Endosc. 2019 Apr 16;11(4):281-291. doi: 10.4253/wjge.v11.i4.281.

BACKGROUND

For palliation of malignant biliary obstruction (MBO), the gold-standard method of biliary drainage is endoscopic retrograde cholangiopancreatography (ERCP) with the placement of metallic stents. Endoscopic ultrasound (EUS)-guided drainage is an alternative that is typically reserved for cases of ERCP failure. Recently, however, there have been robust randomized clinical trials (RCTs) comparing EUS-guided drainage and ERCP as primary approaches to MBO.

AIM

To compare EUS guidance and ERCP in terms of their effectiveness and safety in palliative biliary drainage for MBO.

METHODS

This was a systematic review and meta-analysis, in which we searched the MEDLINE, , and Cochrane Central Register of Controlled Trials databases. Only RCTs comparing EUS and ERCP for primary drainage of MBO were eligible. All of the studies selected provided data regarding the rates of technical and clinical success, as well as the duration of the procedure, adverse events, and stent patency. We assessed the risk of biases using the Jadad score and the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation criteria.

RESULTS

The database searches yielded 5920 records, from which we selected 3 RCTs involving a total of 222 patients (112 submitted to EUS and 110 submitted to ERCP). In the EUS and ERCP groups, the rate of technical success was 91.96% and 91.81%, respectively, with a risk difference (RD) of 0.00% (95%CI: -0.07, 0.07; = 0.97; = 0%). The clinical success was 84.81% and 85.53% in the EUS and ERCP groups, respectively, with an RD of -0.01% (95%CI: -0.12, 0.10; = 0.90; = 0%). The mean difference (MD) for the duration of the procedure was -0.12% (95%CI: -8.20, 7.97; = 0.98; = 84%). In the EUS and ERCP groups, there were 14 and 25 adverse events, respectively, with an RD of -0.06% (95%CI: -0.23, 0.12; = 0.54; = 77%). The MD for stent patency was 9.32% (95%CI: -4.53, 23.18; = 0.19; = 44%). The stent dysfunction rate was significantly lower in the EUS group (MD = -0.22%; 95CI:-0.35, -0.08; = 0.001; = 0%).

CONCLUSION

EUS represents an interesting alternative to ERCP for MBO drainage, demonstrating lower stent dysfunction rates compared with ERCP. Technical and clinical success, duration, adverse events and patency rates were similar.

背景

对于恶性胆道梗阻（MBO）的姑息治疗，胆道引流的金标准方法是内镜逆行胰胆管造影术（ERCP）并置入金属支架。内镜超声（EUS）引导下引流是一种替代方法，通常用于ERCP失败的病例。然而，最近有一些强有力的随机临床试验（RCT）比较了EUS引导下引流和ERCP作为MBO的主要治疗方法。

目的

比较EUS引导和ERCP在MBO姑息性胆道引流中的有效性和安全性。

方法

这是一项系统评价和荟萃分析，我们检索了MEDLINE、和Cochrane对照试验中央注册库数据库。只有比较EUS和ERCP用于MBO初次引流的RCT符合条件。所有入选的研究都提供了有关技术成功率和临床成功率、手术持续时间、不良事件和支架通畅率的数据。我们使用Jadad评分评估偏倚风险，并使用推荐分级评估、制定和评价标准评估证据质量。

结果

数据库检索产生了5920条记录，从中我们选择了3项RCT，共涉及222例患者（112例接受EUS治疗，110例接受ERCP治疗）。在EUS组和ERCP组中，技术成功率分别为91.96%和91.81%，风险差异（RD）为0.00%（95%CI：-0.07，0.07；P = 0.97；I² = 0%）。EUS组和ERCP组的临床成功率分别为84.81%和85.53%，RD为-0.01%（95%CI：-0.12，0.10；P = 0.90；I² = 0%）。手术持续时间的平均差异（MD）为-0.12%（95%CI：-8.20，7.97；P = 0.98；I² = 84%）。在EUS组和ERCP组中，分别有14例和25例不良事件，RD为-0.06%（95%CI：-0.23，0.12；P = 0.54；I² = 77%）。支架通畅的MD为9.32%（95%CI：-4.53，23.18；P = 0.19；I² = 44%）。EUS组的支架功能障碍率显著较低（MD = -0.22%；95CI：-0.35，-0.08；P = 0.001；I² = 0%）。