梗阻型胆源性胰腺炎内镜治疗时机的选择

The timing of endoscopic therapy of obstructive acute biliary pancreatitis

目的探讨梗阻型胆源性胰腺炎内镜治疗的时机与疗效。方法回顾性分析360例梗阻型胆源性胰腺炎内镜治疗的资料。根据发病后内镜治疗时间分为两组：急诊内镜（EE）组168例，即在发病48h内急诊行内镜逆行性胰胆管造影术（ERCP）、内镜下乳头括约肌切开（ES）／或取石术、鼻胆管引流术（ENBD）；延期内镜（DE）组192例，在早期非手术治疗基础上于发病48h后延期行上述内镜治疗。结果两组内镜治疗总成功率为96．9％。EE组在发病后腹痛缓解时间、血淀粉酶、血胆红素、白细胞计数恢复正常的时间以及平均住院时间显著低于DE组（P〈0．05～0．001）。重症胆源性胰腺炎急诊内镜治疗并发症总发生率显著低于DE组（9．6％vs28．9％，P〈0．05），两组间病死率差异无显著性（P〉0．05）；轻症患者两组间并发症发生率、病死率差异亦无显著性（P〉0．05）。结论重症梗阻型胆源性胰腺炎应在发病48h内行急诊内镜治疗；轻症患者如早期非手术治疗无效或出现急性胆道感染症状，亦应争取及时行急诊内镜治疗。

Objective To investigate the timing of endoscopic therapy of obstructive acute biliary pancreatitis. Methods Three hundrend and sixty cases of obstructive acute biliary pancreatitis treated by endoscopy were analyzed. The patients were divided into two groups ： One bundred and sixty-eight cases received emergency endoscopic therapy （ EE group ） within 48 hours from the onset of symptoms, including endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy （ ERCP ＋ ES ） , with or without stone extraction and endoscopic naso-biliary drainage （ENBD）;192 cases received delay endoscopic therapy （DE group ）after initial 48 hours of conservative management. Results The total success rate of therapeutic endoscopy was 96.9 % . The time for disappearance of abdominal pain, the time for serum amylase level, serum bilirubin level and WBC count to return to normal, and the length of hospitalization were significantly shorter in EE group than those in DE group（ all P 〈 0.05 - 0. 001 ）. In cases with severe acute biliary pancreatitis, the morbidity in the EE group was significantly lower than DE group（ 9.6 % vs28.9 % ,P 〈 0.05 ） , but the difference in mortality rate between the two groups was not significant （ P 〉 0.05 ） . In cases of mild acute biliary pancreatitis, morbidity and mortality rate between the EE and DE groups were not significantly different （ P 〉 0. 05 ）. Conclusions This study shows that in severe acute biliary pancreatitis patiens with biliary tract obstruction, emergency endoscopic therapy should be performed within 48 hours from the onset of symptoms ; patients with mild acute biliary pancreatitis shoud also undergo prompt endoscopic therapy after ineffective conservative management or appearance of symptoms of acute biliary tract infection.