Gargiulo A, Barbaro F, Caserta G, Gargiulo A, Manzi F, Milizia U, Occhigrossi G
Prima Divisione Chirurgia, Ospedale Pertini, Roma.
Ann Ital Chir. 1998 Jul-Aug;69(4):473-7.
The authors report on a multicentric trial performed on early endoscopic sphincterotomy in severe pancreatitis. A large figure (7.764) of biliary pancreatitis was collected and 4.285 sphincterotomies were carried out. The results have been highly satisfactory: removal of hypertension and infection in biliary tree, stopped the trend toward necrosis and infection in almost all cases precociously treated. However, answering to the many doubts raised by some colleagues about the danger of this method, the authors examined all the complications that were reported. Hemorrhages and perforations of the biliary tree were the most common one. There were 120 (2.8%) hemorrhages, most frequently treated by medical means; in 20 cases a surgical hemostasis (1 death) had to be performed. Perforations, 24 (0.56%) were treated by medical therapy in 18 cases; 6 patients underwent surgical approach, with no deaths. Other complications (cholangitis, stent ruptures), less frequent, were treated successfully without surgical operations. The authors believe the main cause of this complications to be lack of experience and delay of endoscopic procedure (papillary oedema, fragility). What they suggest, is that endoscopic sphincterotomy has to be performed by an expert endoscopist, and within 48-72 hours from disease onset. Observing also that contrast introduced in the biliary tree could be harmful, they suggest to practice cholangiography at low pressure, and always leaving a nose-biliary drain. Endoscopic sphincterotomy, therefore, if correctly performed, reduces the necessity of surgery in severe pancreatitis. In this way, operations have to be carried out only in those patients with septic complications, with encouraging results and a sharp reduction of mortality.
作者报告了一项关于重症胰腺炎早期内镜括约肌切开术的多中心试验。收集了大量（7764例）胆源性胰腺炎病例，并进行了4285例括约肌切开术。结果非常令人满意：消除了胆管高压和感染，几乎所有早期接受治疗的病例都过早地停止了坏死和感染的趋势。然而，为了回应一些同事对该方法危险性提出的诸多疑问，作者检查了所有报告的并发症。胆管出血和穿孔是最常见的并发症。有120例（2.8%）出血，大多数通过药物治疗；20例需要进行手术止血（1例死亡）。穿孔24例（0.56%），18例通过药物治疗；6例患者接受了手术治疗，无死亡病例。其他并发症（胆管炎、支架破裂）较少见，无需手术即可成功治疗。作者认为这些并发症的主要原因是缺乏经验和内镜操作延迟（乳头水肿、组织脆弱）。他们建议，内镜括约肌切开术必须由专业内镜医师在疾病发作后48 - 72小时内进行。他们还指出，胆管内注入造影剂可能有害，建议进行低压胆管造影，并始终留置鼻胆管引流管。因此，内镜括约肌切开术如果操作正确，可减少重症胰腺炎的手术必要性。这样，手术仅需在那些有感染性并发症的患者中进行，结果令人鼓舞，死亡率大幅降低。
