内镜诊断与治疗慢性胰腺炎的临床研究
摘要
背景:CP是胰腺的一种慢性、进行性、炎症性疾病,其治疗是目前内科、外科均为棘手的难题。随着内镜治疗技术的不断发展,内镜治疗以其操作简便、创伤小、并发症少、疗效好的特点,已被广泛接受为CP的首选方法。
目的:探讨CP的内镜诊断的临床价值,评价内镜治疗CP的临床疗效,评价其安全性。
方法:选取2004年1月1日至2008年5月天津市南开医院收治的32例住院并行内镜治疗的CP患者进行回顾分析,分析B超、CT、MRCP和ERCP等影像学检查的优势与缺点,讨论CP的最佳诊断方法;采取门诊和电话定期随访内镜治疗术后的临床疗效,观察治疗前后患者腹痛症状和BMI的变化。
结果:共纳入符合CP诊断标准并进行内镜下治疗的患者32例。32例患者均行内镜治疗,操作成功率为90.3%(29/32)。其中单纯胰管括约肌切开8例(27.6%),单纯行胰头部胰管气囊括张3例(9.4%);胰管取石7例(24.1%),13例(44.8%)放置主胰管支架,1例(3.4%)放置副胰管支架,经胃壁假性囊肿置管引流2例(17.2%),3例(10.3%)患者内镜治疗未成功。B超、CT、MRCP和ERCP的诊断准确率分别为65.6%(21/32),73.1%(19/26),81.8%(18/22)和93.1%(27/29)。
29例患者随访时间1个月-45个月,其腹痛症状均有不同程度缓解(P＜0.05)。1年后随访23例(82.8%)患者腹痛症状缓解,其中有11例(37.9%)腹痛缓解持续时间长达2年。所有患者体重有一定程度增加(P＜0.05),BMI治疗前为22.09±3.78,治疗后随访1年BMI为25.03±3.42。
14例放置胰管支架的患者中,3例患者因腹痛症状无明显改善在术后18-34天支架提前取出,行外科手术治疗。其余11例患者中6例支架在9个月后取出(9个月内分别行1—2次支架置换),3例支架长期留置超过12个月未进行更换,随访无腹痛症状复发,2例支架置入时问小于3个月。术后6个月内支架脱落1例,支架移位1例。
32例患者共行内镜治疗43例次,术后出现急性胰腺炎2例,一过性高淀粉酶血症7例,恶心呕吐症状5例;无出血、感染、穿孔及急性胆管炎等并发症。
结论:1内镜ERCP诊断CP准确率高,敏感性强,是各项影像学检查中诊断CP的金标准。ERCP与B超及CT联合应用可提高CP诊断的准确率,是我们推荐的最佳方法。
2内镜治疗CP创伤小,安全性高,可重复操作性强,能有效缓解患者的腹痛症状,术后患者体重均有不同程度的增加,可作为治疗CP的首选方法。
Backgroud:Chronic pancreatitis(CP)is a chronic,progressive and inflammatory disease.It is quite difficult for both medicine and surgery to treat it. But with the development of endoscopy technique,most of patients with CP accept endoscopic treatment as their first choice for its convenient operation,lower complications and satisfied outcome.
Objective:To investigate the clinical value of endoscopic diagnosis for CP,to evaluate the clinical effect and security of endoscopic treatment for CP.
Method:Select 32 hospitalized patients of TianJin Nankai hospital between 2004.1 and 2008.5,all of whom received endoscopic treatment.Analyze the results of Ultrasound,Computed Tomography(CT),Magnetic Resonance Cholangiopancreatography(MRCP)and endoscopic retrograde cholangiopancreatography(ERCP)diagnose CP,to establish the best method for diagnosing CP;follow up their clinical therapeutic effect after endoscopic treatment using telephone or clinic service by observe the BMI and abdominal pain changes after endoscopic treatment.
Result:32 patients who consistented with CP diagnostic criteria were selected.All of them received endoscopic treatment,performance achievement ratio 90.3%(29/32).8 patients received endoscopic pancreatic sphincterotomy(EPS), 3(9.4%)dilated pancreatic duct by the balloon;7(24.1%)had the pancreatic stone extracted with endoscopy,13(44.8%)l treated with main pancreatic duct stent,and 1 (3.4%)treated with accessory pancreatic duct stent,5(17.2%)received pseudocyst draining through gastric wall,3(10.3%)endoscopic treatment unsuccessed.The diagnosis accuracy rate of ultrasound,CT,MRCP and ERCP were 65.6%(21/32), 73.1%(19/26),81.8%(18/22)和93.1%(27/29)respectively.
29 patients were followed up for 1-45 months,their abdominal pain significantly relieved(P＜0.05).The abdominal pain of 24(82.8%)patients relieved when they were followed up 2 weeks later,while there were 11 patients whose abdominal pain relieved up to 2 years.The body weight of the patients after treatment was significantly increased(P＜0.05),and their body weight averagely increased 2-10 Kg after treatment.The patients'BMI before treatment was22.09±3.78,and 25.03±3.42 after treatment.
3 of 14 patients who received pancreatic duct stand took out of the stents18-34 days after the operation,because there was no obviously improvement of abdominal pain,and then received the surgical intervention.For another 11patients,6 took out of their stents in 9 months later(exchanged the stents 1-2 times),3 took the stents for more than 12 months without exchanging while there was no abdominal pain recurred,2 took the stems less than 3 months.1 patient's stent amotioed and 1 migrated within 6 months after operation.
32 patients received therapeutic endoscopy 43 times,the post-operation complications are 2 patients had acute pancreatitis,7 had hyperamylasemia and 5 patients suffered nausea and vomiting.There were no haemorrhage,infection, perforation and acute cholangitis.
Conclusion:
1 Endoscopic diagnosis of CP has higher accuracy and sensitivity.It is the golden standard among the examinations.ERCP combined ultrasound and CT can improve the diagnosis accuracy,which is the best approach we suggest.
2 Endoscopic treatment of CP can effectively relieve the abdominal pain and the patients'BMI would increase.The advantage of Endoscoy is minimally invasive, lower complications and satisfied outcome.It indicates that endoscopy is an effective therapeutic method for CP.
目的:探讨CP的内镜诊断的临床价值,评价内镜治疗CP的临床疗效,评价其安全性。
方法:选取2004年1月1日至2008年5月天津市南开医院收治的32例住院并行内镜治疗的CP患者进行回顾分析,分析B超、CT、MRCP和ERCP等影像学检查的优势与缺点,讨论CP的最佳诊断方法;采取门诊和电话定期随访内镜治疗术后的临床疗效,观察治疗前后患者腹痛症状和BMI的变化。
结果:共纳入符合CP诊断标准并进行内镜下治疗的患者32例。32例患者均行内镜治疗,操作成功率为90.3%(29/32)。其中单纯胰管括约肌切开8例(27.6%),单纯行胰头部胰管气囊括张3例(9.4%);胰管取石7例(24.1%),13例(44.8%)放置主胰管支架,1例(3.4%)放置副胰管支架,经胃壁假性囊肿置管引流2例(17.2%),3例(10.3%)患者内镜治疗未成功。B超、CT、MRCP和ERCP的诊断准确率分别为65.6%(21/32),73.1%(19/26),81.8%(18/22)和93.1%(27/29)。
29例患者随访时间1个月-45个月,其腹痛症状均有不同程度缓解(P＜0.05)。1年后随访23例(82.8%)患者腹痛症状缓解,其中有11例(37.9%)腹痛缓解持续时间长达2年。所有患者体重有一定程度增加(P＜0.05),BMI治疗前为22.09±3.78,治疗后随访1年BMI为25.03±3.42。
14例放置胰管支架的患者中,3例患者因腹痛症状无明显改善在术后18-34天支架提前取出,行外科手术治疗。其余11例患者中6例支架在9个月后取出(9个月内分别行1—2次支架置换),3例支架长期留置超过12个月未进行更换,随访无腹痛症状复发,2例支架置入时问小于3个月。术后6个月内支架脱落1例,支架移位1例。
32例患者共行内镜治疗43例次,术后出现急性胰腺炎2例,一过性高淀粉酶血症7例,恶心呕吐症状5例;无出血、感染、穿孔及急性胆管炎等并发症。
结论:1内镜ERCP诊断CP准确率高,敏感性强,是各项影像学检查中诊断CP的金标准。ERCP与B超及CT联合应用可提高CP诊断的准确率,是我们推荐的最佳方法。
2内镜治疗CP创伤小,安全性高,可重复操作性强,能有效缓解患者的腹痛症状,术后患者体重均有不同程度的增加,可作为治疗CP的首选方法。
Backgroud:Chronic pancreatitis(CP)is a chronic,progressive and inflammatory disease.It is quite difficult for both medicine and surgery to treat it. But with the development of endoscopy technique,most of patients with CP accept endoscopic treatment as their first choice for its convenient operation,lower complications and satisfied outcome.
Objective:To investigate the clinical value of endoscopic diagnosis for CP,to evaluate the clinical effect and security of endoscopic treatment for CP.
Method:Select 32 hospitalized patients of TianJin Nankai hospital between 2004.1 and 2008.5,all of whom received endoscopic treatment.Analyze the results of Ultrasound,Computed Tomography(CT),Magnetic Resonance Cholangiopancreatography(MRCP)and endoscopic retrograde cholangiopancreatography(ERCP)diagnose CP,to establish the best method for diagnosing CP;follow up their clinical therapeutic effect after endoscopic treatment using telephone or clinic service by observe the BMI and abdominal pain changes after endoscopic treatment.
Result:32 patients who consistented with CP diagnostic criteria were selected.All of them received endoscopic treatment,performance achievement ratio 90.3%(29/32).8 patients received endoscopic pancreatic sphincterotomy(EPS), 3(9.4%)dilated pancreatic duct by the balloon;7(24.1%)had the pancreatic stone extracted with endoscopy,13(44.8%)l treated with main pancreatic duct stent,and 1 (3.4%)treated with accessory pancreatic duct stent,5(17.2%)received pseudocyst draining through gastric wall,3(10.3%)endoscopic treatment unsuccessed.The diagnosis accuracy rate of ultrasound,CT,MRCP and ERCP were 65.6%(21/32), 73.1%(19/26),81.8%(18/22)和93.1%(27/29)respectively.
29 patients were followed up for 1-45 months,their abdominal pain significantly relieved(P＜0.05).The abdominal pain of 24(82.8%)patients relieved when they were followed up 2 weeks later,while there were 11 patients whose abdominal pain relieved up to 2 years.The body weight of the patients after treatment was significantly increased(P＜0.05),and their body weight averagely increased 2-10 Kg after treatment.The patients'BMI before treatment was22.09±3.78,and 25.03±3.42 after treatment.
3 of 14 patients who received pancreatic duct stand took out of the stents18-34 days after the operation,because there was no obviously improvement of abdominal pain,and then received the surgical intervention.For another 11patients,6 took out of their stents in 9 months later(exchanged the stents 1-2 times),3 took the stents for more than 12 months without exchanging while there was no abdominal pain recurred,2 took the stems less than 3 months.1 patient's stent amotioed and 1 migrated within 6 months after operation.
32 patients received therapeutic endoscopy 43 times,the post-operation complications are 2 patients had acute pancreatitis,7 had hyperamylasemia and 5 patients suffered nausea and vomiting.There were no haemorrhage,infection, perforation and acute cholangitis.
Conclusion:
1 Endoscopic diagnosis of CP has higher accuracy and sensitivity.It is the golden standard among the examinations.ERCP combined ultrasound and CT can improve the diagnosis accuracy,which is the best approach we suggest.
2 Endoscopic treatment of CP can effectively relieve the abdominal pain and the patients'BMI would increase.The advantage of Endoscoy is minimally invasive, lower complications and satisfied outcome.It indicates that endoscopy is an effective therapeutic method for CP.
引文
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[1]王洛伟、李兆申等,慢性胰腺炎全国多中心流行病学调查[J].胰腺病学,2007,7:1-5.
[2]Bolan PJ,Fink AS,Endoscopic retrograde cholangiopancreatography in chronic pancreatitis[J].World J Surg,2003,27:1183-1191.
[3]Terumi Kamisawal,Masakatsu Matsukawa.Possibility of diagnosing early-stage chronic pancreatitis by endoscopic retrograde pancreatography[J].J Gastroenterol,2007,42[Suppl ⅩⅦ]:103-107.
[4]Kensei Maeshirol,Seiyo Ikedal,et al.Balloon-catheter endoscopic retrograde pancreatography-compression study for diagnosis of early-stage pancreatitis[J].J Gastroenterol 2007,42[Suppl ⅩⅦ]:95-102.
[5]Jakobs R,BENZ C,et,al.Pancreatic endoscopic sphincterotomy in patients with chronic pancreatitis:a single-center experience in 171 consecutive pantients[J].Endoscopy,2002,34(7):551-554.
[6]Nils Ewald,Axel Michael Marzeion,et al.Endoscopic sphincterotomy in patients with stenosis of ampulla of Vater:Three-year follow-up of exocrine pancreatic function and clinical symptoms[J],World J Gastroenterol,2007,13(6):1-5.
[7]TopazianM,Aslnaian H,AndersenD.Outcome following endoscopic stenting of pancreatic duct strictures in chronic pnacreatitis[J].J Clin Gastroenteml,2005,39(10):908.
[8]G.C.Vitale,K.Cothron,et al,Role of pancreatic duct stenting in the treatment of chronic pancreatitis[J].Surg Endosc(2004)18:1431-1434.
[9]Farnbacher M.J,MiLhldorfer S,Intervenlional endoscopic therapy in chronic pancreatitis including temporary stenting:A definitive treatment?[J],SCAND.J.GASTROENTEROL2006,41(1):111-117.
[10]Morgan DE,Smith JK,Hawkins K,Wilcox CM.Endoscopic stenttherapy in advanced chronic pancreatitis:relationships between ductal changes,clinical response,and stent patency[J].Am J Gastroenterol,2003,98(82):1-6.
[11]Bartoli E,Ddcemerie K,et al,Endoscopic treatment Of chronic pnacreatitis[J].Gastroenterol Clln Biol,2005,29(5):515.
[12]Ishihara T,Yamaguchi T,et al,Efficacy of s-type stents for the treatm- ent of the main pancreatic duct stricture in patients with chronic pancreatitis[J].SCAND J GASTROENTEROL.2006, 41(6):744-750.
[13]Kwi-Sook Choi and Myung-Hwan Kim, Extracorporeal shock wave lithotripsy for the treatment of pancreatic duct stones[J].J Hepatobiliary Pancreat Surg,2006,13:86-93.
[14] Guda NM, Partington S, Freeman ML. Extracorporeal shock wave lithotripsy in the management of chronic calcific pancreatitis:a meta-analysis[J]. JOP, 2005,6:6-12.
[15] Yasuyuki Karasawal, Shigeyuki Kawal, et al, Extracorporeal shock wave lithotripsy of pancreatic duct stones and patient factors related to stone disintegration[J] J Gastroenterol,2002,37:3 69-375.
[16] Nakazawa T, Ohara K, Sano J, Anto H, Ito M. Endoscopic pancreatic stenting in combination with extracorporeal shock wave lithotripsy for pancreatic duct stones (in Japanese) [J]. Tan to Sui (J Bil Pancr),2001,22:139-43.
[17] Naoki Sasahira, Minoru Tada,et al, Outcomes after clearance of pancreatic stones with or without pancreatic stenting[J].J Gastroenterol,2007,42:63-69
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[1]王洛伟、李兆申等,慢性胰腺炎全国多中心流行病学调查[J].胰腺病学,2007,7:1-5.
[2]Bolan PJ,Fink AS,Endoscopic retrograde cholangiopancreatography in chronic pancreatitis[J].World J Surg,2003,27:1183-1191.
[3]Terumi Kamisawal,Masakatsu Matsukawa.Possibility of diagnosing early-stage chronic pancreatitis by endoscopic retrograde pancreatography[J].J Gastroenterol,2007,42[Suppl ⅩⅦ]:103-107.
[4]Kensei Maeshirol,Seiyo Ikedal,et al.Balloon-catheter endoscopic retrograde pancreatography-compression study for diagnosis of early-stage pancreatitis[J].J Gastroenterol 2007,42[Suppl ⅩⅦ]:95-102.
[5]Jakobs R,BENZ C,et,al.Pancreatic endoscopic sphincterotomy in patients with chronic pancreatitis:a single-center experience in 171 consecutive pantients[J].Endoscopy,2002,34(7):551-554.
[6]Nils Ewald,Axel Michael Marzeion,et al.Endoscopic sphincterotomy in patients with stenosis of ampulla of Vater:Three-year follow-up of exocrine pancreatic function and clinical symptoms[J],World J Gastroenterol,2007,13(6):1-5.
[7]TopazianM,Aslnaian H,AndersenD.Outcome following endoscopic stenting of pancreatic duct strictures in chronic pnacreatitis[J].J Clin Gastroenteml,2005,39(10):908.
[8]G.C.Vitale,K.Cothron,et al,Role of pancreatic duct stenting in the treatment of chronic pancreatitis[J].Surg Endosc(2004)18:1431-1434.
[9]Farnbacher M.J,MiLhldorfer S,Intervenlional endoscopic therapy in chronic pancreatitis including temporary stenting:A definitive treatment?[J],SCAND.J.GASTROENTEROL2006,41(1):111-117.
[10]Morgan DE,Smith JK,Hawkins K,Wilcox CM.Endoscopic stenttherapy in advanced chronic pancreatitis:relationships between ductal changes,clinical response,and stent patency[J].Am J Gastroenterol,2003,98(82):1-6.
[11]Bartoli E,Ddcemerie K,et al,Endoscopic treatment Of chronic pnacreatitis[J].Gastroenterol Clln Biol,2005,29(5):515.
[12]Ishihara T,Yamaguchi T,et al,Efficacy of s-type stents for the treatm- ent of the main pancreatic duct stricture in patients with chronic pancreatitis[J].SCAND J GASTROENTEROL.2006, 41(6):744-750.
[13]Kwi-Sook Choi and Myung-Hwan Kim, Extracorporeal shock wave lithotripsy for the treatment of pancreatic duct stones[J].J Hepatobiliary Pancreat Surg,2006,13:86-93.
[14] Guda NM, Partington S, Freeman ML. Extracorporeal shock wave lithotripsy in the management of chronic calcific pancreatitis:a meta-analysis[J]. JOP, 2005,6:6-12.
[15] Yasuyuki Karasawal, Shigeyuki Kawal, et al, Extracorporeal shock wave lithotripsy of pancreatic duct stones and patient factors related to stone disintegration[J] J Gastroenterol,2002,37:3 69-375.
[16] Nakazawa T, Ohara K, Sano J, Anto H, Ito M. Endoscopic pancreatic stenting in combination with extracorporeal shock wave lithotripsy for pancreatic duct stones (in Japanese) [J]. Tan to Sui (J Bil Pancr),2001,22:139-43.
[17] Naoki Sasahira, Minoru Tada,et al, Outcomes after clearance of pancreatic stones with or without pancreatic stenting[J].J Gastroenterol,2007,42:63-69
[18] Dite P, Ruzicka M, Zboril V, Novotny I. A prospective, randomized trial comparing endoscopic and surgical therapy for chronic pancreatitis[J]. Endoscopy,2003,35:553-8.
[19]Zhang AB,Zheng SS.Treatment of pancreatic pseudocysts in line with D'Egidio's classification[J]. World J Gastroenterol,2005,11(5):729232.
[20]Cooperman AM.Surgical treatment of pancreatic pseudocysts[J].Surg Clin North Am,2001,81:4112419.
[21]Soliani P,Ziegler S,Franzini C.The size of pancreatic pseudocyst does not influence the outcome of invasive treatments[J].Dig Liver Dis,2004,36(2):135 - 140.
[22] L.Weckman,M.-L.Kylanpaa, Endoscopic treatment of pancreatic pseudocysts [J]. Surg Endosc,2006,20:603-607.
[23] Brugge WR. Approaches to the drainage of pancreatic pseudocysts[J].Curr Opin Gastroenterol ,2004 ,20(5): 488-492.
[24]Dohmotom,Akiyamak,Liokay.Endoscopic and endosonographic management of pancreatic pseudocysta long- term follow- up[J]. Rev Gastroenterol Peru,2003, 23(4):269- 275.
[25]Cahen D,Rauws E,Fockens P,et al.Endoscopic drainage of pancreatic pseudocysts:long-term outcome and procedural factors associated with safe and successful treatment [J].Endoscopy,2005,37(10):977-983.
[26]Rosso E,Alexakis N,Ghaneh P,et al. Pancreatic pseudocyst in chronic pancreatitis:endoscopic and surgical treatment [J]. Dig Surg,2003,20(5):397-406.
[27]Nalon WH,Walser E.Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas[J].Ann Surg,2005 ,241(6): 948-960.
[28] Rosch T.Daniel S.Scbolz M, et al.Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with Long-Term Follow-Up [J].Endoscopy,2002,(34) : 765-771.