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急性胆石性胰腺炎复发的预防方法

论文编号:lw200802231246083615 所属栏目:呼吸论文 发布日期:2018年01月15日 论文作者:无忧论文网
【摘要】 目的 探讨急性胆石性胰腺炎复发的预防方法。方法 对1999年1月~2001年7月连续入院并治愈的112例急性胆石性胰腺炎患者的临床资料进行分析、随访。所有患者入院前均无胆石性胰腺炎病史且未行胆囊切除术。根据患者住院期间是否行内镜下Oddi括约肌切开术(endoscopic phincterotomy,简称EST),将所有患者分为EST组和非EST组,并根据是否行胆囊切除术进一步分组,比较各组胆石性胰腺炎复发率。结果 平均随访18.5个月(6~30个月)。EST组38例,其中16例行胆囊切除术,均无胆石性胰腺炎复发(0/38);非EST组74例,14例胆石性胰腺炎复发(14/74),复发率为189%,两组差异有显著性(P<0.01)。在非EST组中,胆囊切除29例,2例胆石性胰腺炎复发(2/29),复发率为6.9%;未作胆囊切除45例,12例胆石性胰腺炎复发(12/45),复发率为26.7%,胆囊切除后胆石性胰腺炎复发率显著降低(P<005)。复发距患者出院时间为2周~2年不等。对2例胆囊切除术后复发的胆石性胰腺炎患者行ERCP,均发现有胆总管结石,行EST后,无胰腺炎发作。结论 EST能有效预防胆石性胰腺炎复发,并具有创伤小、恢复快等优点,适合于高龄、一般情况差、不能耐受手术的患者;胆囊切除能降低胆石性胰腺炎复发率,胆总管结石是胆囊切除术后胆石性胰腺炎复发的主要原因。 【关键词】 内镜下Oddi括约肌切开 胆石性胰腺炎 复发 Clinical methods of preventing the recurrence of acute gallstone pancreatitis 【Abstract】 Objective To explore the clinical methods of preventing the recurrence of acute gallstone pancreatitis.Methods From January 1999 to July 2001,the clinical data of 112 consecutive cases of cured acute gallstone pancreatitis were analyzed and followed.Before admission all patients had no gallstone pancreatitis and cholecystectomy.All cases were divided into EST group or non-EST group according to whether EST (endoscopic sphincterotomy) was performed or not.The incidence of recurrent pancreatitis in each group was compared.Results Median follow-up after discharge was 18.5 (range,6 to 30) months.None had recurrent pancreatitis in all 38 cases of EST group (0/38),including 16 cases underwent cholecystectomy,14 had recurrent pancreatitis in all 74 cases of non-EST group (14/74),the recurrence rate was 18.9% (P<0.01).In non-EST group,45 cases didnt undergo cholecystectomy (intact gallbladder),12 had recurrent gallstone pancreatitis (12/45),the recurrence rate was 26.7%,29 cases underwent cholecystectomy,2 had recurrent gallstone pancreatitis (2/29),the recurrence rate was 6.9%.The recurrence rate was significantly reduced after cholecystectomy (P<0.05).The duration from patients discharge to recurrence was 2 weeks to 2 years.2 recurrent gallstone pancreatitis cases who had undergone cholecystectomy were performed ERCP and EST,common bile duct calculi were found in all 2 cases,after EST,no symptoms of pancreatitis appeared.Conclusion EST is an effective and alternative method for preventing the recurrence of gallstone pancreatitis,and it is suitable for aged high-risk patients because of its minimally invasiveness.Cholecystectomy can reduce the recurrence rate of gallstone pancreatitis,common bile duct calculi are the major cause of recurrent gallstone pancreatitis. 【Key words】 endoscopic sphincterotomy gallstone pancreatitis recurrence 急性胆石性胰腺炎是胆道结石的一个严重并发症,具有较高的病死率,并且常常反复发作。为防止胆石性胰腺炎复发,通常采取胆囊切除术。近年来,国外有文献报道可应用内镜下Oddi括约肌切开术(EST)来防止胆石性胰腺炎复发[1,2],本文分析比较EST、胆囊切除术对预防胆石性胰腺炎复发的临床效果,旨在探讨防止胆石性胰腺炎复发的方法。 1 资料与方法 1.1 一般资料 1999年1月~2001年7月连续入院并治愈的112例急性胆石性胰腺炎患者,男48例,女64例,平均年龄68.8岁(29~82岁)。所有患者入院前均无胆石性胰腺炎病史且未行胆囊切除术,居住在上海市能够随访。胆石性胰腺炎的诊断标准除了有上腹部疼痛、血尿淀粉酶增高、CT证实有胰腺炎外,还必须有B超、CT证实有胆囊和(或)胆总管结石,实验室肝功能检查显示血清胆红素、ALT等升高,并能排除酒精性、高脂血症等其他原因。全组胆囊结石109例,同时合并胆总管结石35例,胆总管有结石、胆囊无结石3例。胆囊结石直径3~30mm不等,其中以4~10mm居多,胆囊结石数量1~80枚不等,以1~10枚居多。胆总管结石直径3~12mm,数量1~5枚。全组急性胆囊炎34例,慢性胆囊炎78例。CT增强显示胰腺坏死16例,其中胰腺坏死程度≤30% 9例,30%~50% 4例,>50% 3例,胰腺肿大96例,其中56例有胰周积液。根据Balthazar CT评分及APACHE Ⅱ评分,重症胰腺炎31例,轻症胰腺炎81例。患者有黄疸或血清胆红素超过正常值3倍,有明显胆道梗阻者,建议行EST。根据是否行EST,将患者分为EST组和非EST组。两组在年龄、性别、病情严重度APACHE Ⅱ评分方面差异均无显著性。 1.2 治疗方法 入院后常规予禁食、补液、抗炎、胰酶抑制剂等非手术治疗,原则上待症状缓解后行EST或(和)胆囊切除术,手术指征为慢性结石性胆囊炎和(或)胆总管结石。在行胆囊切除术时,术中常规经胆囊管行胆道造影,若发现有胆总管结石,则同时行胆总管切开、取石。如果患者病情加剧或不能缓解,则急诊行EST,或急诊剖腹胆囊切除、胆总管探查、胰腺包膜切开减压或胰腺坏死组织清除、灌洗引流术。EST方法:先行十二指肠镜(Olympus公司生产,型号JF-230)下逆行性胆胰管造影(ERCP),若发现有胆总管结石,则行EST,并用取石网篮和(或)取石气囊将结石取出;若造影未发现胆总管结石,则行预防性EST。EST时将十二指肠乳头隆起的轴线全部切开,以使胆胰管由共同开口于十二指肠,变为分别开口于十二指肠(见图1、图2)。患者出院后,随访比较两组胆石性胰腺炎复发率。 1.3 统计学方法 采用χ2检验。其中P<0.05为差异有显著性,P<0.01为差异有非常显著性。 图1 切开前胆胰管共同开口