如何预防经内镜逆行性胰胆管造影术(ERCP)后胰腺炎?听专家这样说

2020-07-03 MedSci原创 MedSci原创

经内镜逆行性胰胆管造影术(ERCP)是指将十二指肠镜插至十二指肠降部,找到十二指肠乳头,由活检管道内插入造影导管至乳头开口部,注入造影剂后x线摄片,以显示胰胆管的技术。由于ERCP不用开刀,创伤小,手

经内镜逆行性胰胆管造影术(ERCP)是指将十二指肠镜插至十二指肠降部,找到十二指肠乳头,由活检管道内插入造影导管至乳头开口部,注入造影剂后x线摄片,以显示胰胆管的技术。由于ERCP不用开刀,创伤小,手术时间短,并发症较外科手术少,住院时间也大大缩短,深受患者欢迎。在短短几十年中ERCP在临床上取得了巨大的成绩,已经成为当今胰胆疾病重要的治疗手段。 

经内镜逆行性胰胆管造影术(ERCP)诞生于60年代后期,医生将十二指肠镜插至十二指肠降部,找到十二指肠乳头,由活检管道内插入造影导管至乳头开口部,注入造影剂后x线摄片,以显示胰胆管的技术。

1968年首次报道了经内镜逆行胰胆管造影术,可以成功显示胰胆管结构来诊断胆总管结石、胆道良恶性梗阻、胰腺占位等胰胆系统疾病。成为了消化界的“新宠”,在许多胆源性胰腺疾病的诊断和管理中发挥了关键作用。

1974年,Kawai、Classen等相继报道了ERCP下十二指肠乳头括约肌切开术(EST),开辟了治疗性ERCP时代。通过ERCP可以在内镜下放置鼻胆引流管(ENBD)治疗急性化脓性梗阻性胆管炎、行胆管支架引流术、 胆总管结石取石术等微创治疗。

随着影像技术的进步,磁共振胰胆管造影(MRCP)因其无创、无X线照射、不需造影剂等优点己逐步取代诊断性ERCP,成为胰胆疾病首选的诊断方法,ERCP逐渐转向胰胆疾病的治疗,如今,ERCP主要被用于治疗(而非诊断)。由于ERCP不用开刀,创伤小,手术时间短,并发症较外科手术少,住院时间也大大缩短,深受患者欢迎。在短短几十年中ERCP在临床上取得了巨大的成绩,已经成为当今胰胆疾病重要的治疗手段.

ERCP操作与对术者的要求

ERCP是一个充满挑战性的操作,其难度不仅体现在ERCP的学习和操作上,还体现在其可能产生的相关不良反应上。

ERCP后胰腺炎(PEP)是最常见(3.5%)的严重不良事件,且严重PEP占了约10%。

其他与ERCP有关的不良事件包括感染(1.4%),括约肌切开术后出血(1.3%)和穿孔(0.6%)。

是否发生术后胰腺炎与术者的技术熟练程度直接相关,在操作前,术者应接受良好的ERCP培训,此外,患者的个体情况适合进行ERCP操作是降低PEP的关键因素,因此,内镜医生应该明确ERCP的适应征。

Figure thumbnail gr1

减少PEP的五个步骤

预防PEP,按这五步走

一、评估合适ERCP指针

应定期规划程序和检查设备的可用性和正常运行。随后,应考虑以下几个简单的步骤。

识别PEP的危险因素

适当的ERCP适应症后,预防PEP的第一步是确定所有与患者和手术相关的风险因素(表1)。例如,一个年轻肥胖的女性患者,如果有常见的胆管结石和以前发作过急性胆胰腺炎,其发生PEP的风险要比其他患者高得多。

1593684234563867.png

二、药物预防

预防PEP的第二步是使用药物预防(表2)。

1593684283914738.png

自1977年以来,研究人员们陆续评估了至少35种不同的药物在PEP预防中的作用,但很少得出令人满意的结果。最终,Elmunzer等人在2012年发现,经直肠给予非甾体抗炎药(NSAIDs)对PEP的预防有效。

此后,全球各地的研究人员纷纷开启了随机对照试验,进一步验证了经直肠给予NSAIDs药物对PEP的有效性。

为了使预防效果最优化,应在ERCP操作开始前很短的时间内(经直肠)给予NSAIDs,一般来说,临床上在术前20min给予单剂量吲哚美辛100mg。

三、评估乳头的特征

第三步是仔细评估乳头,因为每个乳头都是不同的。首先,应该清楚地看到乳头,并认识到它的特点(即,存在外翻,长管),然后选择最佳的插管方法。这一步对降低PEP很重要。最近,2项前瞻性多中心试验表明,乳头的大体外观确实影响胆管插管。根据这些研究,乳头被分为4种类型:第1种,最常见的或 "常规乳头";第2种,"小乳头"(小,通常是平的,直径不超过3毫米);第3种,"突出的或下垂的乳头"(管口朝向尾部);第4种,"褶皱的或脊状的乳头"(导管粘膜似乎从管口远端延伸出来,或者在脊上,或者在褶皱中)。作者认为每一种类型的乳头都对应着一定程度的插管困难。从实践的角度来看,如果最初的受训者面对的是3型或4型乳头,那么停止任何插管的尝试,让培训师继续进行是符合逻辑的。专家插管后,学员可以继续进行支架置入、取石等操作。这种实用的方法也可以减少PEP和其他ERCP相关的不良事件。

四、插管前的思考:导丝引导技术 vs 造影剂辅助方法

当前研究认为,与注射造影剂相比,导丝插管更安全。然而,这些研究的主要偏差与造影剂的体积、浓度、类型以及注射力有关,这些因素极难标准化。比如,通过注射少量造影剂来观察导管的方向能极大程度促进医生对导管解剖结构的了解,还有助于对导丝选择的判断。因此,注射少量造影剂是十分合理的。在透视引导下,由训练有素的助手进行轻柔的导丝操作也是一个关键的要求。

五、胰管支架置入术

最后一步是胰管支架置入术,该步鄹是预防PEP的另一个关键环节。

主胰管有多个胰腺导丝通过,使用了双导丝法插管,进行了内镜乳头切除术,此外,在所有高危患者中也应使用胰管支架置入术(MPD)。

抢救性主胰管支架植入术可用于预防胰腺炎的发展,但该操作应在PEP发生后的8-20小时内完成。用于主胰管支架植入术支架植入术的支架应是短(小于5厘米,直径小(5法式)和远端无法兰的塑料支架)

特殊情况

对于有直肠非甾体抗炎药禁忌症的患者,如果没有液体超负荷的风险,并且没有放置胰腺支架,建议采用乳酸林格氏溶液积极补液(ERCP期间3 mL/kg/h,ERCP后20 mL/kg栓剂,ERCP后8小时3 mL/kg/h)。 21对于PEP的高危患者,建议在手术前服用100mg直肠非甾体抗炎药,再加上MPD多处入路的情况下使用胰腺塑料支架,当然,还要用乳酸林格氏溶液积极补液。这种高风险的ERCP应该由有经验的内镜专家进行。

术后护理

ERCP术后患者情况如何?大多数ERCP手术不会出现不良事件,但在怀疑有PEP的情况下,第一步是建立诊断。这是通过临床、实验室和影像学检查在预先确定的时间范围内完成的。应尽快开始适当的治疗。最后,与患者及家属进行公开、即时、全面的讨论是非常重要的。

结论

PEP的预防是一个过程,由几个步骤组成,应始终采用(图1)。ERCP团队中拥有训练有素的内镜医生和护士是极其重要的,是这个过程的基础。一个可靠的ERCP适应症是避免不良事件的根本。该手术最好在有多学科团队的三级转诊中心进行。PEP的预防应在手术前20分钟使用NSAIDs。在尝试插管前,应充分评估乳头,并据此选择插管附件和插管类型。对于所有高危患者和情况,只要认为有必要,都应放置胰腺支架。最后,考虑到深度学习和人工智能的快速发展,我们拥有能够识别高危患者和高危乳头的软件只是时间问题。

原始出处:

Ivo Boskoski and Guido Costamagna. How to Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterology.2020 , 158 ( 8 ) :2037-2040.

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    2020-07-05 sodoo
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    2020-07-03 mswert122

    #ERCP#专业

    0

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