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与注射造影剂技术相比,导丝胆管插管不会降低高低危病人内镜逆行胆胰管造影后胰腺炎风险

发布日期:2014-1-29 12:40:28 文章来源:GIE 作者次数:1374
    与注射造影剂技术相比,导丝胆管插管不会降低高低危病人内镜逆行胆胰管造影后胰腺炎风险

    背景

    导丝(GW)插管通过避免主胰管出现浑浊可以降低内镜逆行胆胰管造影后胰腺炎PEP)风险。

    目的

    比较胆总管内常规对比内镜逆行胆胰管造影术ERCP)和导丝插管对高低危病人PEP的影响。

    设计

    前瞻性的比较干预单中心研究

    环境

    三级转诊中心。

    患者

    通过ERCP对有一个完整乳头的胆道疾病患者行前瞻性检查。

    干预

    使用一个造影剂(对照组)的括约肌切开器或一条无造影剂的亲水导丝行胆道插管。

    主要测量指标

    导丝组与注射造影剂(对照组)的胰腺炎发生率。

    结果

    1249例患者中有60例发生PEP4.8%),35来自导丝组(678例),即所占比例为5.2%,25例来自对照组(571例),所占比例为4.4%,两组相比无显著差异。高危患者PEP总发生率显著高于低危患者,分别为12.2%和3.5%,P <0.001,但是采用两种技术的组内PEP总发生率是相似的。导丝和对照两组之间,意外主胰管(MPD)插管或出现浑浊的患者PEP发生率无显著差异,两组发生率分别为15.2%,8.4,但是PEP发生率与胰腺炎发生率有关,这些患者胰腺炎发生率(11.9%)显著高于造影剂或导丝未进入主胰管患者的发生率(3.5%)(P <0.001。多元分析表明,10次以上乳头插管,MPD插管或出现浑浊,疑似奥狄括约肌功能失常预切手段等都是与PEP独立相关的重大风险因素。

    局限性

    缺乏随机化。

    结论

    对选择的胆总管插管来说,采用对照和导丝技术诱导高低危患者PEP发生风险是相似的。MPD任何操作都可视为一种PEP高风险因素。如对乳头的多次插管尝试或者采用预切手段。

    缩写词:ARP,急性复发性胰腺炎;CBD,胆总管;Cl,置信区间;Conl,对比剂;GW,导丝;MPD,主胰管;PEP,内镜逆行胆胰管造影后胰腺炎;SOD,奥狄括约肌功能失常。

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    Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

    Background

    Guidewire (GW) cannulation can reduce the risk of post-ERCP pancreatitis (PEP) by avoiding the opacification of the main pancreatic duct.

    Objective

    To compare the effects of conventional contrast ERCP and GW cannulation of the common bile duct on the rate of PEP in low- and high-risk patients.

    Design

    Prospective, comparative-intervention single-center study.

    Setting

    Tertiary referral center.

    Patients

    Patients with biliary disease with an intact papilla were prospectively examined by ERCP.

    Interventions

    Biliary cannulation using a sphincterotome with contrast injection (ConI) or a hydrophilic GW without contrast injection.

    Main Outcome Measurements

    Pancreatitis rate in the GW group and the contrast injection (ConI) group.

    Results

    PEP occurred in 60 of 1249 patients (4.8%), 35 of 678 (5.2%) in the GW group and 25 of 571 (4.4%) in the ConI group (not significant). The overall rate of PEP was significantly higher in high-risk patients (12.2%) than in low-risk patients (3.5%) (P < .001), but was similar for the 2 techniques within each of these 2 groups. In patients with unintended main pancreatic duct (MPD) cannulation or opacification, the rate of PEP was not significantly different with the GW (15.2%) and ConI (8.4%) techniques but was associated with a significantly higher rate of pancreatitis (11.9%) than in patients in whom the contrast medium or GW did not enter the MPD (3.5%) (P < .001). Multivariate analysis indicated that more than 10 papillary cannulation attempts, MPD cannulation or opacification, suspected sphincter of Oddi dysfunction, and precut methods were significant risk factors independently associated with PEP.

    Limitations

    Lack of randomization.

    Conclusions

    For selective cannulation of the CBD, the risk of inducing PEP is similar with the ConI and GW techniques in high-risk and low-risk patients. Any manipulation of the MPD must be considered a high-risk factor for PEP, such as multiple attempts on the papilla or use of the precut method.

    Abbreviations:  ARP, acute recurrent pancreatitis, CBD, common bile duct, CI, confidence interval, ConI, contrast injection, GW, guidewire, MPD, main pancreatic duct, PEP, post-ERCP pancreatitis, SOD, sphincter of Oddi dysfunction

     

     

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