急性胰腺炎内镜下螺旋型鼻空肠营养管放置方法探讨

目的探讨针对中重度急性胰腺炎患者使用内镜下放置螺旋型营养管不同方法的效果和经济性,判断哪种方法更加有利于中重度急性胰腺炎患者的肠内营养支持治疗,为今后此类患者选择最佳的置管方法提供参考。方法回顾性分析安徽省蚌埠市第三人民院自2011年1月—2015年12月5年期间收治的60例中重度急性胰腺炎患者置入螺旋型鼻空肠营养管的2种放置方法,根据放置方法的不同分成预先放置组(对照组)及直接内镜辅助组(观察组),比较2组的置管成功率、所用置管时间和操作中使用鳄口钳等辅助器械率等情况。结果 2种方法的成功率均为100%,差异无统计学意义。对照组平均用时(13.68±3.65)min,观察组平均用时(8.69±2.92)min,直接内镜辅助组所用时间明显缩短(P<0.05)。对照组89.3%的患者使用了辅助器械鳄口钳,观察组仅有53.1%的患者在操作中使用了鳄口钳,观察组使用辅助器械率显著减少,患者器械耗材方面支出费用下降。结论直接内镜辅助法置入螺旋型鼻空肠营养管的优点是在保证插管成功率的同时缩短了操作时间,患者痛苦减少,使用辅助器械比率低,器械耗材方面支出费用有所下降,患者经济负担减轻。内镜室不需要特殊准备及设备,方法简单易行,值得推广应用。

Relationship between post-ERCP pancreatitis and the change of serum amylase level after the procedure

AIM: To clarify the relationship between the change of serum amylase level and post-ERCP pancreatitis. METHODS: Between January 1999 and December 2002, 1291 ERCP-related procedures were performed. Serum amylase concentrations were measured before the procedure and 3, 6, and 24 h afterward. The frequency and severity of post-ERCP pancreatitis and the relationship between these phenomena and the change in amylase level were estimated. RESULTS: Post-ERCP pancreatitis occurred in 47 patients (3.6%). Pancreatitis occurred in 1% of patients with normal amylase levels 3 h after ERCP, and in 1%, 5%, 20%, 31% and 39% of patients with amylase levels elevated 1-2 times, 2-3 times, 3-5 times, 5-10 times and over 10 times the upper normal limit at 3 h after ERCP, respectively (level < 2 times vs ≥ 2 times, P < 0.001). Of the 143 patients with levels higher than the normal limit at 3 h after ERCP followed by elevation at 6 h, pancreatitis occurred in 26%. In contrast, pancreatitis occurred in 9% of 45 patients with a level higher than two times the normal limit at 3 h after ERCP followed by a decrease at 6 h (26% vs 9%, P < 0.05). CONCLUSION: Post-ERCP pancreatitis is frequently associated with an increase in serum amylase level greater than twice the normal limit at 3 h after ERCP with an elevation at 6 h. A decrease in amylase level at 6 h after ERCP suggests the unlikelihood of development of post-ERCP pancreatitis.

Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.

Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

AIM: To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement (P-GW) in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated. RESULTS: Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% (14 patients: mild, 13; moderate, 1). Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis (4.7%). Of the 49 patients without stent placement, 11 developed pancreatitis (22%: mild, 10; moderate, 1). Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.CONCLUSION: P-GW is useful for achieving selective biliary cannulation. Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials.

Application of endoscopic sphincterotomy in acute pancreatitis with fluid collection:A prospective study

AIM: To elucidate the role of endoscopic sphincterotomy (EST) in the treatment of acute pancreatitis. METHODS: Ninety patients with acute pancreatitis were randomly divided into two groups: EST group and control group. All the patients underwent pancreatitis routine therapy, additionally the EST group was treated with EST and endoscopic naso-bile drainage (ENBD).The time of disappearance of abdominal symptoms and signs,normalization of amylase, hospitalization and absorption of acute fluid was recorded for all patients.RESULTS: The time of disappearance of abdominal pain,normalization of blood and urine amylase and hospitalization was significantly shorter in EST group than in control group. The ratios of disappearance of fluid in mild acute pancreatitis patients was significantly higher in EST group (51.52%, 84.85%, 90.91%,93.94%) than in the control group (0%, 30.30%, 69.70%, 72.73%, P＜0.01 or P＜0.05).When the ratios of reduction of fluid in severe acute pancreatitis patients of the EST group were compared (8.33%, 58.33%, 83.33%, 91.67%) with those in the control group (0%, 8.33%, 25% and 41.67%), there were significant differences. CONCLUSION: The effect of EST+ENBD on acute pancreatitis with fluid is rather good.

NSAIDs for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography:Ready for prime time?

Acute pancreatitis is the most common and the most fearful complication of endoscopic retrograde cholangiopancreatography (ERCP).Prevention of post-ERCP pancreatitis has therefore been of great interest to endoscopists performing ERCP procedures.So far,only pancreatic duct stenting during ERCP and rectal administration of a non-steroidal anti-inflammatory drug (NSAID) prior to or immediately after ERCP have been consistently shown to be effective for prevention of post-ERCP pancreatitis.This commentary focuses on a short discussion about the rates,mechanisms,and risk factors for post-ERCP pancreatitis,and effective means for its prevention with emphasis on the use of NSAIDs including a recent clinical trial published in The New England Journal of Medicine by Elmunzer et al.

Indomethacin for post-endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis:Is it the magic bullet?

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography(ERCP).Pancreatic duct stent insertion after ERCP has been widely accepted as the standard of care for the prevention of this complication in high-risk patients.Unfortunately,the placement of pancreatic stents requires higher level of endoscopic expertise and is not always feasible due to anatomic considerations.Therefore,effective non-invasive pharmacologic prophylaxis remains appealing,particularly if it is inexpensive,easily administered,has a low risk side effect profile and is widely available.There have been multiple studies evaluating potential pharmacologic candidates for post-ERCP pancreatitis(PEP) prophylaxis,most of them yielding disappointing results.A recently published large,multicenter,randomized controlled trial reported that in high risk patients a single dose of rectal indomethacin administered immediately after the ERCP significantly decreased the incidence of PEP compare to placebo.