头孢呋辛预防ERCP术后胰腺炎的临床应用研究
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摘要
目的将头孢呋辛分别用于经内镜逆行胰胆管造影(Endoscopic retrogradecholangiopancreatograph,ERCP)诊疗术前、术中及术后,加以比较,探讨头孢呋辛在ERCP术后胰腺炎(post-ERCP pancreatitis,PEP)的预防作用及应用最佳时机,以及评价抗生素是否能降低PEP的发病率。
临床资料和方法制定严格的纳入和排除标准。选择2005年12月-2007年12月在我院住院行ERCP检查的胆总管结石病人180例,年龄30-70岁,其中男101例,女79例。排除①近期内有胆管炎、胰腺炎发作,②白细胞总数及中性粒细胞分类、淀粉酶异常者。③近期内(1周)无身体其他部位感染,未曾使用抗生素,④有糖尿病病史及怀孕哺乳。将上述患者随机分为3组,对照组(n=60例)及试验Ⅰ组(n=60例)、试验Ⅱ组(n=60例)。对照组患者ERCP前及术后24小时内均不应用抗生素;试验Ⅰ组行ERCP诊疗后给予头孢呋辛1.5g加入生理盐水100ml静滴1次/12小时(至ERCP后24小时,共使用3次);试验Ⅱ组于ERCP前1小时给予头孢呋辛1.5g加入生理盐水100ml静滴,持续约30-45分钟,ERCP术后继续给予头孢呋辛1.5g静滴1次/12小时(至ERCP后24小时,共使用3次)。以上3组病人均于术前肌注盐酸山莨菪碱10mg,术后给予禁食水,补液、补充电解质等治疗。观察3组患者的体温、症状(发热、腹痛、呕吐)、腹部体征、血清淀粉酶、C反应蛋白(C-reactive protein,CRP)白细胞总数及中性粒细胞分类。将ERCP术后开始出现腹痛、恶心、呕吐等,上腹部或左上腹部压痛,上述症状及体征持续24小时以上,且血清淀粉酶高于正常上限的3倍(420U/L)者定义为ERCP术后胰腺炎。应用统计学SAS9.0软件,对3组患者胰腺炎及高淀粉酶血症的发生率,分别将试验Ⅰ组及试验Ⅱ组与对照组进行比较,进行x~2检验,计数资料的两组比较用确切概率计算,计量资料的两组比较用t检验。P＜0.05认为有统计学意义。
结果对照组有21例患者发生高淀粉酶血症(21/60,35%),其中10例患者发生胰腺炎(10/60,16.7%),试验Ⅰ组有19例患者发生高淀粉酶血症(19/60,31.7%),其中5例患者发生胰腺炎(5/60,8.3%),将两组患者胰腺炎及血清淀粉酶升高者进行比较,计算x~2,两组患者无明显差异。试验Ⅱ组与对照组术前淀粉酶及C反应蛋白无明显差异,术后3小时淀粉酶、术后24小时淀粉酶、C反应蛋白均明显低于对照组;试验Ⅱ组高淀粉酶血症7例(7/60,11.7%),其中2例患者发生胰腺炎(2/60,3.3%),与对照组进行比较,计算x~2分别为5.92(P=0.0295,P＜0.05=,9.13(P=0.0045,P＜0.01),两组患者胰腺炎发生率有差异,高淀粉酶血症发生率有显著性差异。
结论ERCP术前、术后连续静滴头孢呋辛(二代头孢类抗生素)可以降低PEP的发病率,增加了ERCP检查及相关治疗的安全性,具备价格便宜、使用方便、副作用小等特点,在ERCP过程中易于推广使用。
Aim:Using cefuroxime through intravenous during Pre- & intra- or postoperative of endoscopic retrograde cholangiopancreatography,and analyzing,in order to investigate the prevention effect of cefurxime reducing the incidence of ERCP postoperative pancreatitis,and the best utilizing time,evaluate whether antibiotic can reduce the incidence of PEP or not.
Methods:Made a strict internalizing and elimination standard.Chosen 180 choledocholithiasis patients who were in our hospital and taken the ERCP examination during Dec 2005 to Dec 2007.They were 30-70 years old,including 101 male and 79 female.Those patients who were cholangitis,or pancreatitis,or total white cell count and neutrophilic granulocyte division and amylase were abnormal were discharged.Meanwhile,those subjects must not be infected in some other sites, and not use antibiotic,and without diabetes or pregnancy.Those patients were randomly divided into 3 groups(60 patients per group),control group,test 1 group and test 2 group.Control group patients were taken antibiotic neither preoperative nor postoperative.Test 1 group patients were given 1.5g cefurxime and 100ml physiological saline once per 12 hours postoperative(3 times in 24 hours after ERCP) through intravenous drip.Test 2 group patients were given one more time cefurxime at 1h ahead of taking ERCP comparing to testl group patients.All of those patients were intramuscular 10mg Anisodamine Hydrochloride,and were given to combined modality therapy,such as fasting,fluid replacement,electrolyte replacement,and so on.Observed those three groups patients body temperature,symptom(fever, abdominal pain,vomiting),abdominal signs,serum-amylase,CRP,total white blood cell and neutrophilic granulocyte divide.Those patients who began to be abdominal pain,nauseated,vomiting,upper abdomen or left-upper abdomen tenderness after ERCP,and those symptom lasted over 24,and the volume of serum-amylase were higher 3 times than normal(420U/L) were diagnosed ERCP postoperative pancreatitis. Compared the incidence rate of pancreatitis and hyperamylasemia between test 1 group,test 2 group and control group.Take x~2 test using SAS statistic software. Numeration data were analyzed in precise probability calculation,measurement data were analyzed in t test.It is statistical significance that P＜0.05.
Results:21 patients in control group were hyperamylasemia(21/60,35%),and 10 patients of them were pancreatitis(10/60,16.7%).19 patients in test 1 group were hyperamylasemia(19/60,31.7%),and 5 patients of them were pancreatitis(5/60, 8.3%).Compared the incidence rate of pancreatitis and hyperamylasemia between these two groups,and calculated x~2,there was no significant statistic difference in those data.The volume of preoperative amylase and CRP in test 2 group were just same as the control group,but the volume of 3h postoperative amylase,24h postoperative amylase,and CRP were obviously smaller than the control group.7 patients in test 2 group were hyperamylasemia(7/60,11.7%),and 2 patients of them were pancreatitis(2/60,3.3%).Compared the incidence rate of pancreatitis and hyperamylasemia between test 2 group and control group,and the x~2 was 5.92(0.0295, P＜0.05),9.13(0.0045,P＜0.05),respectively.The incidence rate of pancreatitis between two groups were different,and the incidence rate of hyperamylasemia were significant different.
Conclusion:This research confirmed that continuing being given the second generation cephamycin(Cefuroxime) during both preoperative and postoperative can reduce the incidence rate of PEP,and prevent the complication such as cholangitis and septicemia from happening.These measures can lessen patients' pains and make it be safer to take ERCP examination and related therapy.Now,the second generation cephamycin are widely used in the prevention of postoperative infection.They have many good qualities such as cheap cost,being easy to us and small side effect.It is very convenient generalization that the second generation cephamycin is used in ERCP.
临床资料和方法制定严格的纳入和排除标准。选择2005年12月-2007年12月在我院住院行ERCP检查的胆总管结石病人180例,年龄30-70岁,其中男101例,女79例。排除①近期内有胆管炎、胰腺炎发作,②白细胞总数及中性粒细胞分类、淀粉酶异常者。③近期内(1周)无身体其他部位感染,未曾使用抗生素,④有糖尿病病史及怀孕哺乳。将上述患者随机分为3组,对照组(n=60例)及试验Ⅰ组(n=60例)、试验Ⅱ组(n=60例)。对照组患者ERCP前及术后24小时内均不应用抗生素;试验Ⅰ组行ERCP诊疗后给予头孢呋辛1.5g加入生理盐水100ml静滴1次/12小时(至ERCP后24小时,共使用3次);试验Ⅱ组于ERCP前1小时给予头孢呋辛1.5g加入生理盐水100ml静滴,持续约30-45分钟,ERCP术后继续给予头孢呋辛1.5g静滴1次/12小时(至ERCP后24小时,共使用3次)。以上3组病人均于术前肌注盐酸山莨菪碱10mg,术后给予禁食水,补液、补充电解质等治疗。观察3组患者的体温、症状(发热、腹痛、呕吐)、腹部体征、血清淀粉酶、C反应蛋白(C-reactive protein,CRP)白细胞总数及中性粒细胞分类。将ERCP术后开始出现腹痛、恶心、呕吐等,上腹部或左上腹部压痛,上述症状及体征持续24小时以上,且血清淀粉酶高于正常上限的3倍(420U/L)者定义为ERCP术后胰腺炎。应用统计学SAS9.0软件,对3组患者胰腺炎及高淀粉酶血症的发生率,分别将试验Ⅰ组及试验Ⅱ组与对照组进行比较,进行x~2检验,计数资料的两组比较用确切概率计算,计量资料的两组比较用t检验。P＜0.05认为有统计学意义。
结果对照组有21例患者发生高淀粉酶血症(21/60,35%),其中10例患者发生胰腺炎(10/60,16.7%),试验Ⅰ组有19例患者发生高淀粉酶血症(19/60,31.7%),其中5例患者发生胰腺炎(5/60,8.3%),将两组患者胰腺炎及血清淀粉酶升高者进行比较,计算x~2,两组患者无明显差异。试验Ⅱ组与对照组术前淀粉酶及C反应蛋白无明显差异,术后3小时淀粉酶、术后24小时淀粉酶、C反应蛋白均明显低于对照组;试验Ⅱ组高淀粉酶血症7例(7/60,11.7%),其中2例患者发生胰腺炎(2/60,3.3%),与对照组进行比较,计算x~2分别为5.92(P=0.0295,P＜0.05=,9.13(P=0.0045,P＜0.01),两组患者胰腺炎发生率有差异,高淀粉酶血症发生率有显著性差异。
结论ERCP术前、术后连续静滴头孢呋辛(二代头孢类抗生素)可以降低PEP的发病率,增加了ERCP检查及相关治疗的安全性,具备价格便宜、使用方便、副作用小等特点,在ERCP过程中易于推广使用。
Aim:Using cefuroxime through intravenous during Pre- & intra- or postoperative of endoscopic retrograde cholangiopancreatography,and analyzing,in order to investigate the prevention effect of cefurxime reducing the incidence of ERCP postoperative pancreatitis,and the best utilizing time,evaluate whether antibiotic can reduce the incidence of PEP or not.
Methods:Made a strict internalizing and elimination standard.Chosen 180 choledocholithiasis patients who were in our hospital and taken the ERCP examination during Dec 2005 to Dec 2007.They were 30-70 years old,including 101 male and 79 female.Those patients who were cholangitis,or pancreatitis,or total white cell count and neutrophilic granulocyte division and amylase were abnormal were discharged.Meanwhile,those subjects must not be infected in some other sites, and not use antibiotic,and without diabetes or pregnancy.Those patients were randomly divided into 3 groups(60 patients per group),control group,test 1 group and test 2 group.Control group patients were taken antibiotic neither preoperative nor postoperative.Test 1 group patients were given 1.5g cefurxime and 100ml physiological saline once per 12 hours postoperative(3 times in 24 hours after ERCP) through intravenous drip.Test 2 group patients were given one more time cefurxime at 1h ahead of taking ERCP comparing to testl group patients.All of those patients were intramuscular 10mg Anisodamine Hydrochloride,and were given to combined modality therapy,such as fasting,fluid replacement,electrolyte replacement,and so on.Observed those three groups patients body temperature,symptom(fever, abdominal pain,vomiting),abdominal signs,serum-amylase,CRP,total white blood cell and neutrophilic granulocyte divide.Those patients who began to be abdominal pain,nauseated,vomiting,upper abdomen or left-upper abdomen tenderness after ERCP,and those symptom lasted over 24,and the volume of serum-amylase were higher 3 times than normal(420U/L) were diagnosed ERCP postoperative pancreatitis. Compared the incidence rate of pancreatitis and hyperamylasemia between test 1 group,test 2 group and control group.Take x~2 test using SAS statistic software. Numeration data were analyzed in precise probability calculation,measurement data were analyzed in t test.It is statistical significance that P＜0.05.
Results:21 patients in control group were hyperamylasemia(21/60,35%),and 10 patients of them were pancreatitis(10/60,16.7%).19 patients in test 1 group were hyperamylasemia(19/60,31.7%),and 5 patients of them were pancreatitis(5/60, 8.3%).Compared the incidence rate of pancreatitis and hyperamylasemia between these two groups,and calculated x~2,there was no significant statistic difference in those data.The volume of preoperative amylase and CRP in test 2 group were just same as the control group,but the volume of 3h postoperative amylase,24h postoperative amylase,and CRP were obviously smaller than the control group.7 patients in test 2 group were hyperamylasemia(7/60,11.7%),and 2 patients of them were pancreatitis(2/60,3.3%).Compared the incidence rate of pancreatitis and hyperamylasemia between test 2 group and control group,and the x~2 was 5.92(0.0295, P＜0.05),9.13(0.0045,P＜0.05),respectively.The incidence rate of pancreatitis between two groups were different,and the incidence rate of hyperamylasemia were significant different.
Conclusion:This research confirmed that continuing being given the second generation cephamycin(Cefuroxime) during both preoperative and postoperative can reduce the incidence rate of PEP,and prevent the complication such as cholangitis and septicemia from happening.These measures can lessen patients' pains and make it be safer to take ERCP examination and related therapy.Now,the second generation cephamycin are widely used in the prevention of postoperative infection.They have many good qualities such as cheap cost,being easy to us and small side effect.It is very convenient generalization that the second generation cephamycin is used in ERCP.
引文
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