内镜下覆膜金属支架置入引流治疗胰腺坏死感染和假性囊肿13例及文献分析
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摘要
目的探讨内镜下覆膜金属支架置入引流治疗胰腺坏死感染(infected pancreatic necrosis,IPN)和胰腺假性囊肿(pancreatic pseudocyst,PPC)的有效性、可行性和安全性。方法选取2012-2017年我科收治的IPN、PPC并进行覆膜金属支架置入引流治疗的13例患者。计算机检索同期中国知网、万方数据库、维普网、Cochrane Library、PubMed、Web of Science等数据库收录的公开发表的内镜下覆膜金属支架置入引流治疗IPN和PPC患者文献数据,最终选取12篇文献,纳入IPN 193例,PPC138例,对覆膜金属支架置入引流治疗IPN和PPC的疗效进行分析。结果我科13例患者(IPN 12例,PPC 1例)支架置入成功率100%(13/13),救治成功率92.3%(12/13),1例(7.7%)患者因感染严重及脓腔出血死亡;未发生支架移位、脓(囊)腔破裂穿孔、堵管,术后并发肺部感染者6例(46.2%),平均住院时间为44.8(9～153) d。12篇文献共纳入331例患者(193例IPN、138例PPC),救治成功率98.5%(326/331),死亡率1.5%(5/331)。本研究和文献报道共计344例(206例IPN,138例PPC)患者,手术成功率100%(344/344),救治成功率98.3%(338/344),死亡率1.7%(6/344);发生支架移位13例(3.8%),术后出血11例(3.2%),堵管3例(0.9%),穿孔1例(0.3%),伴肺部感染及泌尿系感染19例(5.5%)。结论内镜下覆膜金属支架置入引流治疗IPN和PPC手术成功率较高,临床疗效较好,并发症少,死亡率低。
Objective To investigate the feasibility,efficacy and safety of endoscopic ultrasound(EUS)-guided drainage of peripancreatic fluid collection(PFC) using lumen-apposing fully covered,selfexpandable metal stent(LAMS) for treatment of infected pancreatic necrosis(IPN) and pancreatic pseudocyst(PPC).Methods We retrospectively analyzed the data of 13 patients(including 11 male and 2 female patients,mean age 42.6±12.1 years) with IPN(12 cases) or PPC(1 case) treated with EUS-guided drainage of PFC using LAMS in our department from January,2012 to December,2017.We also searched China National Knowledge Infrastructure(CNKI),Wanfang Database,VIP Database Network,Cochrane Library,Pubmed,and Web of Science for relevant studies to analyze the efficacy and safety of LAMS in the treatment of IPN and PPC.Results Stent placement was successful in all the 13 patients treated in our department.Twelve(92.3%) of the patients were cured,and 1(7.7%) died for severe infection and intraabscess hemorrhage.None of the patients experienced stent displacement,abscess or cyst cavity rupture(or perforation),or drainage tube occlusion.Six(46.2%) of the patients had pulmonary infections after the operation.The mean length of hospital stay of the patients was 44.8 d(range 9-153 d).We retrieved 12 relevant studies from the databases involving a total of 331 patients(193 with IPN and 138 with PPC),among whom 326(98.5%) were successfully treated and 5(1.5%) died.In the total of 344 cases after combining our cases with the reported cases(including 206 patients with IPN and 138 with PPC),the success rate of LAMS surgery was 100%,the cure rate was 98.3%(338 cases),and the mortality rate was 1.7%(6 cases);stent displacement occurred in 13 cases(3.8%),postoperative bleeding in 11 cases(3.2%),stent occlusion in 3 cases(0.9%),postoperative abscess perforation in 1 case(0.3%),and postoperative with lung and urinary tract infections in 19 cases(5.5%).Conclusion EUS-guided drainage of PFC using LAMS has a high success rate for treatment of IPN and PPC and achieves good clinical outcomes with a low incidence of complications and a low mortality rate of the patients.
Objective To investigate the feasibility,efficacy and safety of endoscopic ultrasound(EUS)-guided drainage of peripancreatic fluid collection(PFC) using lumen-apposing fully covered,selfexpandable metal stent(LAMS) for treatment of infected pancreatic necrosis(IPN) and pancreatic pseudocyst(PPC).Methods We retrospectively analyzed the data of 13 patients(including 11 male and 2 female patients,mean age 42.6±12.1 years) with IPN(12 cases) or PPC(1 case) treated with EUS-guided drainage of PFC using LAMS in our department from January,2012 to December,2017.We also searched China National Knowledge Infrastructure(CNKI),Wanfang Database,VIP Database Network,Cochrane Library,Pubmed,and Web of Science for relevant studies to analyze the efficacy and safety of LAMS in the treatment of IPN and PPC.Results Stent placement was successful in all the 13 patients treated in our department.Twelve(92.3%) of the patients were cured,and 1(7.7%) died for severe infection and intraabscess hemorrhage.None of the patients experienced stent displacement,abscess or cyst cavity rupture(or perforation),or drainage tube occlusion.Six(46.2%) of the patients had pulmonary infections after the operation.The mean length of hospital stay of the patients was 44.8 d(range 9-153 d).We retrieved 12 relevant studies from the databases involving a total of 331 patients(193 with IPN and 138 with PPC),among whom 326(98.5%) were successfully treated and 5(1.5%) died.In the total of 344 cases after combining our cases with the reported cases(including 206 patients with IPN and 138 with PPC),the success rate of LAMS surgery was 100%,the cure rate was 98.3%(338 cases),and the mortality rate was 1.7%(6 cases);stent displacement occurred in 13 cases(3.8%),postoperative bleeding in 11 cases(3.2%),stent occlusion in 3 cases(0.9%),postoperative abscess perforation in 1 case(0.3%),and postoperative with lung and urinary tract infections in 19 cases(5.5%).Conclusion EUS-guided drainage of PFC using LAMS has a high success rate for treatment of IPN and PPC and achieves good clinical outcomes with a low incidence of complications and a low mortality rate of the patients.
引文
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[8]SIDDIQUI A A,ADLER D G,NIETO J,et al.EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent:a large retrospective,multicenter U.S.experience(with videos)[J].Gastrointest Endosc,2016,83(4):699-707.DOI:10.1016/j.gie.2015.10.020.
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[10]CHANDRAN S,EFTHYMIOU M,KAFFES A,et al.Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent:a national experience(with videos)[J].Gastrointest Endosc,2015,81(1):127-135.DOI:10.1016/j.gie.2014.06.025.
[11]SHAH R J,SHAH J N,WAXMAN I,et al.Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered selfexpanding metal stents[J].Clin Gastroenterol Hepatol,2015,13(4):747-752.DOI:10.1016/j.cgh.2014.09.047.
[12]PENN D E,DRAGANOV P V,WAGH M S,et al.Prospective evaluation of the use of fully covered self-expanding metal stents for EUS-guided transmural drainage of pancreatic pseudocysts[J].Gastrointest Endosc,2012,76(3):679-684.DOI:10.1016/j.gie.2012.04.457.
[13]ITOI T,BINMOELLER K F,SHAH J,et al.Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage(with videos)[J].Gastrointest Endosc,2012,75(4):870-876.DOI:10.1016/j.gie.2011.10.020.
[14]SARKARIA S,SETHI A,RONDON C,et al.Pancreatic necrosectomy using covered esophageal stents:a novel approach[J].J Clin Gastroenterol,2014,48(2):145-152.DOI:10.1097/MCG.0b013e3182972219.
[15]金震东,蒋斐,姚瑶,等.内镜超声引导下经胃穿刺覆膜金属支架引流胰腺假性囊肿的初步临床研究[J].中华消化内镜杂志,2014,31(9):486-488.JIN Z D,JIANG F,YAO Y,et al.Clinical evaluation of fully covered self-expanding metal stent for endosonographguided transgastric pancreatic pseudocyst drainage[J].Chin J Digest Endosc,2014,31(9):486-488.DOI:10.3760/cma.j.issn.1007-5232.2014.09.002.
[16]ATTAM R,TRIKUDANATHAN G,ARAIN M,et al.Endoscopic transluminal drainage and necrosectomy by using a novel,through-the-scope,fully covered,large-bore esophageal metal stent:preliminary experience in 10 patients[J].Gastrointest Endosc,2014,80(2):312-318.DOI:10.1016/j.gie.2014.02.013.
[17]GORNALS J B,DE LA SERNA-HIGUERA C,SNCHEZ-YAGUE A,et al.Endosonography-guided drainage of pancreatic fluid collections with a novel lumen-apposing stent[J].Surg Endosc,2013,27(4):1428-1434.DOI:10.1007/s00464-012-2591-y.
[18]YAMAMOTO N,ISAYAMA H,KAWAKAMI H,et al.Preliminary report on a new,fully covered,metal stent designed for the treatment of pancreatic fluid collections[J].Gastrointest Endosc,2013,77(5):809-814.DOI:10.1016/j.gie.2013.01.009.
[19]SAXENA P,SINGH V K,MESSALLAM A,et al.Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure(with video)[J].Gastrointest Endosc,2014,80(2):319-324.DOI:10.1016/j.gie.2014.04.041.
[20]DA COSTA D W,BOERMA D,VAN SANTVOORT H C,et al.Staged multidisciplinary step-up management for necrotizing pancreatitis[J].Br J Surg,2014,101(1):e65-e79.DOI:10.1002/bjs.9346.
[21]IAP/APA.evidence-based guidelines for the management of acute pancreatitis[J].Pancreatology,2013,13(4 Suppl 2):e1-15.DOI:10.1016/j.pan.2013.07.063.
[22]ANTILLON M R,BECHTOLD M L,BARTALOS C R,et al.Transgastric endoscopic necrosectomy with temporary metallic esophageal stent placement for the treatment of infected pancreatic necrosis(with video)[J].Gastrointest Endosc,2009,69(1):178-180.DOI:10.1016/j.gie.2008.03.1066.
[23]PEERY A F,CROCKETT S D,BARRITT A S,et al.Burden of gastrointestinal,liver,and pancreatic diseases in the United States[J].Gastroenterology,2015,149(7):1731-1741.e3.DOI:10.1053/j.gastro.2015.08.045.
[24]FREEMAN M L,WERNER J,VAN SANTVOORT H C,et al.Interventions for necrotizing pancreatitis:summary of a multidisciplinary consensus conference[J].Pancreas,2012,41(8):1176-1194.DOI:10.1097/MPA.0b013e318269c660.
[25]VAN SANTVOORT H C,BESSELINK M G,BAKKER O J,et al.A step-up approach or open necrosectomy for necrotizing pancreatitis[J].N Engl J Med,2010,362(16):1491-1502.DOI:10.1056/NEJMoa0908821.
[26]BANG J Y,HASAN M,NAVANEETHAN U,et al.Lumen-apposing metal stents(LAMS)for pancreatic fluid collection(PFC)drainage:may not be business as usual[J].Gut,2017,66(12):2054-2056.DOI:10.1136/gutjnl-2016-312812.
[27]VARADARAJULU S,RANA S S,BHASIN D K.Endoscopic therapy for pancreatic duct leaks and disruptions[J].Gastrointest Endosc Clin N Am,2013,23(4):863-892.DOI:10.1016/j.giec.2013.06.008.
[28]BAZERBACHI F,SAWAS T,VARGAS E J,et al.Metal stents versus plastic stents for the management of pancreatic walled-off necrosis:a systematic review and meta-analysis[J].Gastrointest Endosc,2018,87(1):30-42.e15.DOI:10.1016/j.gie.2017.08.025.
[2]VAN GRINSVEN J,VAN BRUNSCHOT S,BAKKER O J,et al.Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis:an international expert survey and case vignette study[J].HPB(Oxford),2016,18(1):49-56.DOI:10.1016/j.hpb.2015.07.003.
[3]樊超强,刘恩,杨歆,等.内镜清创术与外科清创术治疗胰腺坏死感染的回顾性研究[J].第三军医大学学报,2017,39(8):807-812.FAN C Q,LIU E,YANG X,et al.Efficacy of endoscopic and surgical necrosectomy for infected pancreatic necrosis:a retrospective study of 68 cases[J].J Third Mili Med Univ,2017,39(8):807-812.DOI:10.16016/j.1000-5404.201612051.
[4]BANKS P A,BOLLEN T L,DERVENIS C,et al.Classification of acute pancreatitis-2012:revision of the Atlanta classification and definitions by international consensus[J].Gut,2013,62(1):102-111.DOI:10.1136/gutjnl-2012-302779.
[5]BARON T H,THAGGARD W G,MORGAN D E,et al.Endoscopic therapy for organized pancreatic necrosis[J].Gastroenterology,1996,111(3):755-764.DOI:10.1053/gast.1996.v111.pm8780582.
[6]朱勇,何文华,夏亮,等.内镜下经胃坏死组织清创术治疗重症急性胰腺炎并包裹性坏死的疗效初探[J].中华消化内镜杂志,2015,32(3):187-190.ZHU Y,HE W H,XIA L,et al.Endoscopic debridement of gastric necrotic tissue in the treatment of severe acute pancreatitis with encapsulated necrosis.[J].Chin J Digest Endosc,2015,32(3):187-190.DOI:10.3760/cma.j.issn.1007-5232.2015.03.013.
[7]Greenberg J A,Hsu J,Bawazeer M,et al.Clinical practice guideline:management of acute pancreatitis[J].Can J Surg,2016,59(2):128-140.DOI:10.1503/cjs.015015.
[8]SIDDIQUI A A,ADLER D G,NIETO J,et al.EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent:a large retrospective,multicenter U.S.experience(with videos)[J].Gastrointest Endosc,2016,83(4):699-707.DOI:10.1016/j.gie.2015.10.020.
[9]WALTER D,WILL U,SANCHEZ-YAGUE A,et al.A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections:a prospective cohort study[J].Endoscopy,2015,47(1):63-67.DOI:10.1055/s-0034-1378113.
[10]CHANDRAN S,EFTHYMIOU M,KAFFES A,et al.Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent:a national experience(with videos)[J].Gastrointest Endosc,2015,81(1):127-135.DOI:10.1016/j.gie.2014.06.025.
[11]SHAH R J,SHAH J N,WAXMAN I,et al.Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered selfexpanding metal stents[J].Clin Gastroenterol Hepatol,2015,13(4):747-752.DOI:10.1016/j.cgh.2014.09.047.
[12]PENN D E,DRAGANOV P V,WAGH M S,et al.Prospective evaluation of the use of fully covered self-expanding metal stents for EUS-guided transmural drainage of pancreatic pseudocysts[J].Gastrointest Endosc,2012,76(3):679-684.DOI:10.1016/j.gie.2012.04.457.
[13]ITOI T,BINMOELLER K F,SHAH J,et al.Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage(with videos)[J].Gastrointest Endosc,2012,75(4):870-876.DOI:10.1016/j.gie.2011.10.020.
[14]SARKARIA S,SETHI A,RONDON C,et al.Pancreatic necrosectomy using covered esophageal stents:a novel approach[J].J Clin Gastroenterol,2014,48(2):145-152.DOI:10.1097/MCG.0b013e3182972219.
[15]金震东,蒋斐,姚瑶,等.内镜超声引导下经胃穿刺覆膜金属支架引流胰腺假性囊肿的初步临床研究[J].中华消化内镜杂志,2014,31(9):486-488.JIN Z D,JIANG F,YAO Y,et al.Clinical evaluation of fully covered self-expanding metal stent for endosonographguided transgastric pancreatic pseudocyst drainage[J].Chin J Digest Endosc,2014,31(9):486-488.DOI:10.3760/cma.j.issn.1007-5232.2014.09.002.
[16]ATTAM R,TRIKUDANATHAN G,ARAIN M,et al.Endoscopic transluminal drainage and necrosectomy by using a novel,through-the-scope,fully covered,large-bore esophageal metal stent:preliminary experience in 10 patients[J].Gastrointest Endosc,2014,80(2):312-318.DOI:10.1016/j.gie.2014.02.013.
[17]GORNALS J B,DE LA SERNA-HIGUERA C,SNCHEZ-YAGUE A,et al.Endosonography-guided drainage of pancreatic fluid collections with a novel lumen-apposing stent[J].Surg Endosc,2013,27(4):1428-1434.DOI:10.1007/s00464-012-2591-y.
[18]YAMAMOTO N,ISAYAMA H,KAWAKAMI H,et al.Preliminary report on a new,fully covered,metal stent designed for the treatment of pancreatic fluid collections[J].Gastrointest Endosc,2013,77(5):809-814.DOI:10.1016/j.gie.2013.01.009.
[19]SAXENA P,SINGH V K,MESSALLAM A,et al.Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure(with video)[J].Gastrointest Endosc,2014,80(2):319-324.DOI:10.1016/j.gie.2014.04.041.
[20]DA COSTA D W,BOERMA D,VAN SANTVOORT H C,et al.Staged multidisciplinary step-up management for necrotizing pancreatitis[J].Br J Surg,2014,101(1):e65-e79.DOI:10.1002/bjs.9346.
[21]IAP/APA.evidence-based guidelines for the management of acute pancreatitis[J].Pancreatology,2013,13(4 Suppl 2):e1-15.DOI:10.1016/j.pan.2013.07.063.
[22]ANTILLON M R,BECHTOLD M L,BARTALOS C R,et al.Transgastric endoscopic necrosectomy with temporary metallic esophageal stent placement for the treatment of infected pancreatic necrosis(with video)[J].Gastrointest Endosc,2009,69(1):178-180.DOI:10.1016/j.gie.2008.03.1066.
[23]PEERY A F,CROCKETT S D,BARRITT A S,et al.Burden of gastrointestinal,liver,and pancreatic diseases in the United States[J].Gastroenterology,2015,149(7):1731-1741.e3.DOI:10.1053/j.gastro.2015.08.045.
[24]FREEMAN M L,WERNER J,VAN SANTVOORT H C,et al.Interventions for necrotizing pancreatitis:summary of a multidisciplinary consensus conference[J].Pancreas,2012,41(8):1176-1194.DOI:10.1097/MPA.0b013e318269c660.
[25]VAN SANTVOORT H C,BESSELINK M G,BAKKER O J,et al.A step-up approach or open necrosectomy for necrotizing pancreatitis[J].N Engl J Med,2010,362(16):1491-1502.DOI:10.1056/NEJMoa0908821.
[26]BANG J Y,HASAN M,NAVANEETHAN U,et al.Lumen-apposing metal stents(LAMS)for pancreatic fluid collection(PFC)drainage:may not be business as usual[J].Gut,2017,66(12):2054-2056.DOI:10.1136/gutjnl-2016-312812.
[27]VARADARAJULU S,RANA S S,BHASIN D K.Endoscopic therapy for pancreatic duct leaks and disruptions[J].Gastrointest Endosc Clin N Am,2013,23(4):863-892.DOI:10.1016/j.giec.2013.06.008.
[28]BAZERBACHI F,SAWAS T,VARGAS E J,et al.Metal stents versus plastic stents for the management of pancreatic walled-off necrosis:a systematic review and meta-analysis[J].Gastrointest Endosc,2018,87(1):30-42.e15.DOI:10.1016/j.gie.2017.08.025.