经内镜乳头切开术对急性胆源性胰腺炎的早期治疗。

Early treatment of acute biliary pancreatitis by endoscopic papillotomy.

作者信息

Fan S T, Lai E C, Mok F P, Lo C M, Zheng S S, Wong J

机构信息

Department of Surgery, University of Hong Kong, Queen Mary Hospital.

出版信息

N Engl J Med. 1993 Jan 28;328(4):228-32. doi: 10.1056/NEJM199301283280402.

DOI:10.1056/NEJM199301283280402

PMID:8418402

Abstract

BACKGROUND

Most patients with acute biliary pancreatitis have stones in the biliary tract or ampulla of Vater. Because these stones may be passed spontaneously soon after a patient is admitted to the hospital, the importance of early operative removal is not known. We tested the hypothesis that endoscopic papillotomy within 24 hours of admission decreased the incidence of complications in patients with acute biliary pancreatitis.

METHODS

We studied 195 patients with acute pancreatitis who were randomly assigned to one of two groups: 97 patients underwent within 24 hours after admission emergency endoscopic retrograde cholangiopancreatography (ERCP) followed by endoscopic papillotomy for ampullary and common-bile-duct stones, and 98 patients received initial conservative treatment and selective ERCP with or without endoscopic papillotomy only if their condition deteriorated.

RESULTS

One hundred twenty-seven patients ultimately proved to have biliary stones. Emergency ERCP with or without endoscopic papillotomy resulted in a reduction in biliary sepsis as compared with conservative treatment (0 of 97 patients vs. 12 of 98 patients, P = 0.001). The decrease in biliary sepsis occurred both in patients predicted to have mild pancreatitis (0 of 56 patients in the group that received emergency ERCP vs. 4 of 58 patients in the conservative-treatment group, P = 0.14) and in patients predicted to have severe pancreatitis (0 of 41 patients vs. 8 of 40 patients, P = 0.008). In all patients who had unrelenting biliary sepsis, persistent ampullary or common-bile-duct stones were identified. There were no major differences in the incidence of local complications (10 patients in the group that received emergency ERCP vs. 12 patients in the conservative-treatment group) or systemic complications (10 patients vs. 14 patients) of acute pancreatitis between the two groups, but the hospital mortality rate was slightly lower in the group undergoing emergency ERCP with or without endoscopic papillotomy (5 patients vs. 9 patients, P = 0.4).

CONCLUSIONS

Emergency ERCP with or without endoscopic papillotomy is indicated in the treatment of patients with acute pancreatitis.

摘要

背景

大多数急性胆源性胰腺炎患者的胆道或 Vater 壶腹部有结石。由于这些结石可能在患者入院后不久自行排出，早期手术取出结石的重要性尚不清楚。我们检验了这样一个假设，即入院 24 小时内进行内镜乳头切开术可降低急性胆源性胰腺炎患者并发症的发生率。

方法

我们研究了 195 例急性胰腺炎患者，将他们随机分为两组：97 例患者在入院后 24 小时内接受了急诊内镜逆行胰胆管造影（ERCP），随后针对壶腹和胆总管结石进行了内镜乳头切开术；98 例患者接受了初始保守治疗，仅在病情恶化时才选择性地进行 ERCP 及内镜乳头切开术。

结果

最终证实 127 例患者有胆石症。与保守治疗相比，无论是否进行内镜乳头切开术，急诊 ERCP 均使胆源性败血症的发生率降低（97 例患者中 0 例 vs. 98 例患者中 12 例，P = 0.001）。胆源性败血症的减少在预计为轻度胰腺炎的患者中（接受急诊 ERCP 的组中 56 例患者中的 0 例 vs. 保守治疗组中 58 例患者中的 4 例，P = 0.14）以及预计为重度胰腺炎的患者中（41 例患者中的 0 例 vs. 40 例患者中的 8 例，P = 0.008）均有发生。在所有持续性胆源性败血症患者中，均发现有持续性壶腹或胆总管结石。两组急性胰腺炎的局部并发症发生率（接受急诊 ERCP 的组中有 10 例患者 vs. 保守治疗组中有 12 例患者）或全身并发症发生率（10 例患者 vs. 14 例患者）无显著差异，但无论是否进行内镜乳头切开术，接受急诊 ERCP 的组的医院死亡率略低（5 例患者 vs. 9 例患者，P = 0.4）。