内镜联合腹腔灌洗治疗重症急性胆源性胰腺炎的疗效

Therapeutic effect of endoscopic intervention combined with peritoneal lavage for the treatment of severe acute biliary pancreatitis

目的 探讨内镜治疗联合腹腔灌洗治疗重症急性胆源性胰腺炎的临床疗效。方法 2009年1月至2014年1月收治的重症急性胆源性胰腺炎患者90例,按数字随机分组法分为观察组及对照组,每组45例。对照组采用常规保守治疗;观察组在此基础上采用内镜逆行胰胆管造影（ERCP）及十二指肠乳头括约肌切开术（EST）联合腹腔灌洗治疗。腹腔灌洗治疗均于入院1~3 d进行,在B超引导下使用经皮肝穿刺胆道引流（PTCD）穿刺导管进行腹腔穿刺,在积液或积脓处留置引流管持续引流,2 d后用甲硝唑以及生理盐水进行腹腔灌洗。如有胰腺坏死感染、合并有脓肿予以手术治疗。动态观察血尿淀粉酶及血白细胞计数,比较两组的治疗效果。结果 观察组45例患者行ERCP均成功,胆管显影率100%,所有患者均进行了EST,胆总管结石的清除率88.9%;腹腔引流放置PTCD管2~4根/例,放置时间为3~23 d。与对照组比较,观察组1个月内手术率、病死率均明显降低（P〈0.05或P〈0.01）,治愈率略有提高（P〉0.05）,并发症发生率略有降低（P〉0.05）,腹痛缓解时间、血尿淀粉酶及白细胞恢复正常时间以及住院时间均明显缩短（P均〈0.01）。结论 内镜治疗联合腹腔灌洗对重症急性胆源性胰腺炎可以起到很好的治疗效果,恢复快,并发症少,病死率低,可以在一定程度上替代外科手术治疗。

Objective To investigate the efficacy of endoscopic intervention combined with peritoneal lavage in the treat- ment of severe acute biliary panereatitis. Methods Ninety patients with severe acute biliary pancreatitis admitted in our hospital between January 2009 and January 2014 were enrolled in this study, and the patients were divided into observation group and control group （n = 45 each） according to digital random grouping method. The conventional conservative treat- ments were taken in control group. On top of the conservative treatments, endoscopic retrograde cholangiopancreatography （ERCP） plus endoscopic sphincterotomy （EST） combined with peritoneal lavage were taken in observation group. The peri- toneal lavage treatments were all performed within one to three days. Under the guidance of B ultrasound, the puncture cath- eter of percutaneous biliary drainage（PTCD） was used for the abdominocentesis, and the drainage tubes were indwelled in the places of effusion or empyema for continued drainage. The peritoneal lavage using metronidazole and normal saline was performed two days later. If pancreatic necrosis, infection and abscess existed the operation was actively performed in two groups. Blood and urine amylase, white blood cell count were dynamically observed. The therapeutic effects in two groups were compared. Results In the observation group, the ERCP were all successful; the bile duct visualization rate was 100% ;EST were all performed;the clearance rate of choledocholithiasis was 88.9% ;the number of indwelled PTCD tubes was 2 to 4 per patient;the time of indwelling PTCD tubes was 3 to 23 days. Compared with control group, the operation rate within one month, mortality decreased significantly in observation group（P 〈 0. 05 or P 〈 0.01 ） ;the cure rate increased inobservation group （ P 〉 0.05 ） ; the incidence of complication decreased in observation group （ P 〉 0. 05 ） ; the time of abdom- inal pain remission,the time back to normal levels for blood/urine amylase and white blood ceils count and the time of hos- pitalization stay were all shortened in observation group （ all P 〈 0.01 ）. Conclusion The endoscopic intervention therapy combined with abdominal cavity lavage have the advantages of better efficacy, rapid recovery, fewer complications and lower mortality for the treatment of severe acute biliary pancreatitis and could replace the surgical treatment to some extent.