经胰管预切开技术和双导丝技术治疗经内镜胰胆管造影术困难插管的Meta分析

Treatment of difficult intubation in ERCP by TPS and DGT:a Meta-analysis

目的系统性评价经胰管预切开技术(transpancreatic sphincterotomy technique,TPS)和双导丝技术(double-guidewire technique,DGT)在治疗经内镜胰胆管造影术(ERCP)困难插管的成功率和安全性。方法检索中国知网(CNKI)、万方数据库(WANFANG)、维普(VIP)、PubMed、Embase、Cochrane图书馆,收集TPS和DGT治疗ERCP困难插管的相关研究,检索时间至2020年7月。两名独立的研究者按纳入和排除标准选择文献、进行资料提取和方法学质量评估,有争议的部分讨论解决,无法达成共识的交给第三位专家进行评估,采用Revman 5.3软件进行Meta分析,各项研究间的异质性分析采用Q检验和I^(2)检验,随机对照试验采用改良版的Jadad评分表进行质量评价,回顾性研究采用纽卡斯-渥太华量表(Newcastle-Ottawa Scale,NOS)进行质量评价,漏斗图进行发表偏倚评估。结果共纳入6组随机对照试验和3组回顾性试验,Meta分析显示在困难插管成功率方面,TPS高于DGT(OR=2.90,95%CI:2.03~4.14,I^(2)=63%);术后总并发症方面,TPS与DGT无明显差异(OR=0.84,95%CI:0.45~1.56,I^(2)=57%);ERCP术后胰腺炎(post ERCP pancreatitis,PEP)方面,TPS与DGT无明显差异(OR=0.80,95%CI:0.50~1.27,I^(2)=27%);出血方面,TPS与DGT无明显差异(RD=0.02,95%CI:0.00~0.50,I^(2)=0%);穿孔方面,TPS与DGT无明显差异(RD=0.00,95%CI:0.01~0.01,I^(2)=0%)。结论与DGT相比,TPS治疗ERCP困难插管成功率更高且安全性相似。

Objective To evaluate the safety and success rate of transpancreatic sphincterotomy technique(TPS)and double-guidewire technique(DGT)in the treatment of difficult intubation in endoscopic retrograde cholangiopancreatography(ERCP).Methods We searched China National Knowledge Infrastructure(CNKI),Wanfang Database,VIP,PubMed,Embase and Cochrane Library to collect relevant studies on the treatment of difficult intubation by means of TPS and DGT.The retrieval time was until July 2020.Two independent investigators selected the literature according to the inclusion and exclusion criteria,extracted data as well as assessed the methodological quality.The disputed parts were discussed among them to reach a consensus.Those issues which could not reach a consensus were handed over to a third expert for evaluation.The software Revman 5.3 was used for Meta-analysis.Heterogeneity among studies was analyzed by Q test and I^(2) test.In the randomized controlled trials,the modified Jadad scale was used to evaluate the quality.In the retrospective studies,Newcastle-Ottawa Scale(NOS)was used to evaluate the quality.Funnel plots were used to assess publication bias.Results A total of 6 randomized controlled trials and 3 retrospective trials were included.Meta-analysis showed that TPS had a higher success rate in difficult intubation than DGT(OR=2.90,95%CI:2.03~4.14,I^(2)=63%).There was no significant difference in total postoperative complications between TPS and DGT(OR=0.84,95%CI:0.45~1.56,I^(2)=57%).Neither was there significant difference in post ERCP pancreatitis(PEP)between TPS and DGT(OR=0.80,95%CI:0.50~1.27,I^(2)=27%).No significant difference was found in bleeding between TPS and DGT(RD=0.02,95%CI:0.00~0.50,I^(2)=0%).TPS and DGT had no significant difference in perforation(RD=0.00,95%CI:0.01~0.01,I^(2)=0%).Conclusion Compared with DGT,TPS achieves a higher success rate,but they have similar safety in treating ERCP difficult intubation.