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多腔通道技术应用于超声內镜引导下症状性胰腺透壁性坏死引流

发布日期:2014-1-29 12:40:13 文章来源:GIE(July,2011) 作者次数:1169

    多腔通道技术应用于超声內镜引导下症状性胰腺透壁性坏死引流

    背景
    胰腺透壁性坏死常引起严重的临床恶化,恶化后需要实施开放性清创或內镜下坏死清除术。一项基于EUS的新方法被发明出,它是通过创造多腔通道对坏死液进行有效引流,从而应付发生恶化这种情况。
    目的
    比较內镜下胰腺透壁性坏死MTGT 或CDT治疗效果(MTGT为多腔通道技术,CDT为传统引流技术)。
    设计方案
    回顾性研究
    环境
    Tertiary-care referral center(第三保健转诊中心)
    患者
    此项研究纳入行內镜治疗的胰腺透壁性坏死并发重症急性胰腺炎患者。
    干涉
    在MTGT中有2或3条透壁道,它是在EUS引导下于胰腺坏死腔与胃肠道腔之间被创造的。其中一条是用来经鼻囊肿nasocystic)导管冲洗生理盐水,其他透壁道是用来展开多个支架,以便于对胰腺液进行引流。然而在CDT中是通过1条透壁道展开两个支架,这两个支架各携带一条鼻囊肿(nasocystic)导管。
    主要评价指标
    症状的分辨率,后续CT放射结果,后续手术或內镜下坏死物清除术的必要性。
    结果
    60例症状性胰腺透壁性坏死患者中,采用MTGT治疗的有12例(3例女性,平均年龄55.1岁),CDT 有48例(12例女性,平均年龄55.2岁)。MTGT成功治疗11例,占其总数12的91.7%;而CDT成功治疗25例,占其总数48的52.1%(P = .01)。采用MTGT治疗的患者中,1例需实施內镜下坏死物清除术;而采用CDT治疗的患者中,17例需实施外科手术,3例接受了內镜下坏死物清除术,3例死于多器官衰竭。当我们校正胰腺透壁性坏死和胰管支架植入规模时,采用MTGT治疗要比CDT成功可能性更大(调整后的OR为9.24,置信区间为1.08-79.02;P=0.04)。
    局限性
    结论
    因为內镜引导下MTGT不需外科手和內镜下坏死物清除术辅助,也没有随之而产生的相关毒副作用。因此它是一种治疗症状性胰腺透壁性坏死的有效选择方案。接下来还需要前瞻性研究去证实这些目前极为有限但未来有希望的资料。
    缩写:CDT为传统引流技术,CTD为传统透壁性引流, MTGT为多腔通道技术。
     
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    Multiple transluminal gateway technique for EUS-guided drainage of symptomatic walled-off pancreatic necrosis

    Background
    Walled-off pancreatic necrosis often leads to severe clinical deterioration necessitating open debridement or endoscopic necrosectomy. A new EUS-based approach was devised to manage this condition by creating multiple transluminal gateways to facilitate effective drainage of the necrotic contents.
     
    Objective
    To compare treatment outcomes between patients with walled-off pancreatic necrosis managed endoscopically by a multiple transluminal gateway technique (MTGT) or a conventional drainage technique (CDT).
     
    Design
    Retrospective study.
     
    Setting
    Tertiary-care referral center.
     
    Patients
    This study involved patients with severe acute pancreatitis complicated by walled-off pancreatic necrosis managed endoscopically.
     
    Intervention
    In MTGT, 2 or 3 transmural tracts were created by using EUS guidance between the necrotic cavity and the GI lumen. While one tract was used to flush normal saline solution via a nasocystic catheter, multiple stents were deployed in others to facilitate drainage of necrotic contents. In the CDT, two stents with a nasocystic catheter were deployed via 1 transmural tract.
     
    Main Outcome Measurements
    Resolution of symptoms, radiological findings on follow-up CT, and the need for subsequent surgery or endoscopic necrosectomy.
     
    Results
    Of 60 patients with symptomatic walled-off pancreatic necrosis, 12 (3 women, mean age 55.1 years) were managed by MTGT and 48 (12 women, mean age 55.2 years) by CDT. Treatment was successful in 11 of 12 (91.7%) patients managed by MTGT versus 25 of 48 (52.1%) managed by CDT (P = .01). Although 1 patient in the MTGT cohort required endoscopic necrosectomy, in the CDT cohort, 17 required surgery, 3 underwent endoscopic necrosectomy, and 3 died of multiple-organ failure. Treatment success was more likely for patients treated by MTGT than by CDT (adjusted odds ratio = 9.24; 95% confidence interval, 1.08-79.02; P = .04) when we adjusted for the size of the walled-off pancreatic necrosis and pancreatic duct stent placement.
     
    Limitations
    Selective patient population.
     
    Conclusion
    The EUS-guided MTGT is an effective treatment option for the management of symptomatic walled-off pancreatic necrosis because it obviates the need for surgery and endoscopic necrosectomy and its attendant procedure-related morbidity. Prospective studies are required to confirm these preliminary but promising data.
     
    Abbreviations: CDT, conventional drainage technique, CTD, conventional transmural drainage, MTGT, multiple transluminal gateway technique
     
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