内镜综合治疗在胰瘘治疗中的临床价值

Clinical value of integrated endoscopic management of pancreatic fistula

摘要:

目的 评估内镜综合治疗用于胰瘘治疗的疗效及安全性。方法 2006年8月至2019年12月间在南京大学医学院附属鼓楼医院接受内镜治疗的胰瘘病例，依据纳排标准，最终45例纳入回顾性分析，主要观察内镜治疗方式、介入次数、技术成功率、桥接成功率、胰瘘愈合率、胰瘘愈合时间以及并发症发生情况。结果 45例中，33例（73.3%）仅接受内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography，ERCP）治疗，其中胰管完全断裂7例（21.2%），治疗方式包括鼻胰管置入24例、胰管支架置入22例、胰管狭窄球囊或探条扩张12例、乳头括约肌切开8例、胰管结石清理3例；12例（26.7%）接受内镜联合治疗，其中胰管完全断裂5例（41.7%），治疗方式包括ERCP引流联合内镜超声引导下穿刺引流9例、内镜超声引导下胰管穿刺引流联合ERCP会师术1例、ERCP引流联合经皮引流2例。内镜下中位介入3.0（2.0，5.0）次，41例（91.1%）内镜治疗技术成功，28例（62.2%）桥接成功，中位随访59.7（43.7，111.4）个月，33例（73.3%）胰瘘愈合、6例（13.3%）胰瘘未愈合、6例（13.3%）失访。有13例（28.9%）出现术后短期（1周内）并发症，包括急性胰腺炎5例、支架或引流管脱落或移位或堵塞5例、囊腔感染4例、囊肿增大2例、出血1例（部分病例存在2种或2种以上并发症），均经保守治疗或内镜下治疗后好转，无原发病或手术相关的死亡。结论 内镜综合治疗用于胰瘘治疗安全、有效，ERCP是胰瘘内镜下治疗的基础，在胰管完全离断综合征等情况下，ERCP、内镜超声引导下穿刺引流及内镜下清创等综合技术联合应用对胰瘘的治疗具有临床价值。

Abstract:

Objective To evaluate the efficacy and safety of integrated endoscopic management of pancreatic fistula. Methods Clinical data of 45 patients who were diagnosed as having pancreatic fistula and underwent endoscopic treatment from August 2006 to December 2019 at Nanjing Drum Tower Hospital were retrospectively analyzed. The endoscopic approaches, number of interventions, technical success rate, bridging success rate, pancreatic fistula healing rate, healing time, and postoperative complications were summarized. Results Among the 45 patients, 33 (73.3%) patients received retrograde cholangiopancreatography (ERCP) alone, of which 7 (21.2%) had complete pancreatic duct dissections. The treatment methods included nasopancreatic drainage in 24 patients, pancreatic duct stenting in 22, pancreatic ductal stricture balloon or probe dilatation in 12, endoscopic sphincterotomy in 8, and pancreatic duct stone removal in 3. Twelve (26.7%) patients received endoscopic combination treatment, of which 5 (41.7%) had complete pancreatic duct dissections, and the treatment methods included ERCP drainage combined with endoscopic ultrasound (EUS)-guided drainage in 9 patients, EUS-guided drainage combined with ERCP rendezvous technique in 1, and ERCP drainage combined with percutaneous drainage in 2. The median number of endoscopic interventions was 3.0 (2.0, 5.0), and 41 (91.1%) patients had successful endoscopic treatment, 28 (62.2%) patients had successful bridging. With the median follow-up time of 59.7 (43.7, 111.4) months, 33 (73.3%) patients achieved healed pancreatic fistulas, 6 (13.3%) had non-healed pancreatic fistulas, and 6 (13.3%) lost follow-up. There were 13 (28.9%) patients with short-term (within 1 week) postoperative complications, including acute pancreatitis in 5 patients, stent or drain displacement or blockage in 5, cyst infection in 4, cyst enlargement in 2, and hemorrhage in 1 (some cases had 2 or more complications), all of which were improved by conservative or endoscopic treatment. There were no primary morbidities or surgery-related deaths. Conclusion ERCP is the basis for endoscopic treatment of pancreatic fistula. It is safe and reliable for the management of pancreatic fistula in various types. Disconnected ductal syndrome often needs the combined application of ERCP and/or EUS-guided drainage and other techniques.