标题：ERCP联合LC治疗急性胆源性胰腺炎疗效及手术时机的选择

      作者：朱禛菁 1，陈裕春 2，徐化 1    1.复旦大学附属华山医院浦东院区手术室，上海 201206；2.复旦大学附属华山医院虹桥院区NICU，上海 201399

      卷次： 2023年34卷6期

      【摘要】 目的 探究内镜逆行胰胆管造影术(ERCP)联合腹腔镜胆囊切除术(LC)对急性胆源性胰腺炎的治疗效果及最佳手术时机的选择。方法 回顾性分析复旦大学附属华山医院 2020年 1月至 2022年 1月期间收治的124例急性胆源性胰腺炎患者的临床资料，根据手术方案的不同分为联合组(接受ERCP联合LC治疗) 72例和开腹组(接受传统开腹治疗) 52例；联合组再根据手术时间分为早期组(发病48 h内手术) 30例和延期组(发病48 h后手术) 42例。比较早期组、延迟组及开腹组患者的围手术期指标[术中出血量、恢复肠内营养天数、结石清除率、腹痛缓解时间、术后住院时间]及术后并发症发生情况；比较三组患者术前及术后7 d肝功能指标[总胆红素(TBIL)、γ-谷氨酰基转移酶(γ-GT)]、白细胞计数(WBC)、血清淀粉酶(SAMY)和血清炎症应激指标[C反应蛋白、白细胞介素-8(IL-8)、血清内皮素(ET)]。结果 早期组、延期组及传统开腹组患者的术中出血量[(51.42±15.68) mL vs (50.66±15.05) mL vs (84.35±25.40) mL]、恢复肠内营养天数[(1.91±0.60) d vs (2.13±0.73) d vs (2.43±0.76) d]、腹痛缓解时间[(3.48±1.14) h vs (3.67±1.17) h vs (4.84±1.61) h]及术后住院时间[(9.34±2.4) d vs (12.05±3.72) d vs (13.19±4.03) d]比较，差异均有统计学意义(P<0.05)，但三组患者的结石清除率和并发症发生率比较差异均无统计学意义(P>0.05)；三组患者术前的血清TBIL、γ-GT、WBC、SAMY、CRP、IL-8、ET水平比较差异均无统计学意义(P>0.05)，但早期组、延期组及传统开腹组患者术后7 d时的血清TBIL [(17.55±4.70) μmol/L vs (17.76±4.81) μmol/L vs (26.13±5.64) μmol/L]、γ-GT [(39.23±6.02) U/L vs (41.26±6.47) U/L vs (58.61±7.73) U/L]、WBC [(6.37±2.12)×109/L vs (6.65±2.21)×109/L vs(8.73±2.78)×109/L]、SAMY [(64.73±10.52) U/L vs (68.46±10.8) U/L vs (102.53±13.72) U/L]、CRP [(21.73±7.43) mg/L vs(22.36±7.50) mg/L vs (48.69±11.26) mg/L]、IL-8 [(82.15.±16.69) pg/mL vs (84.85±18.43) pg/mL vs (112.38±20.58) pg/mL]、ET [(46.56±6.48) ng/L vs (48.07±6.52) ng/L vs (64.17±9.23) ng/L]水平比较，差异均有统计学意义(P<0.05)，且早期组及延期组明显低于传统开腹组，组间比较差异均有统计学意义(P<0.05)。结论 ERCP联合LC治疗急性胆源性胰腺炎效果良好，可有效加快术后恢复，并改善肝功能与炎症反应，患者发病48 h内治疗还可进一步缩短住院时间，促进康复。
      【关键词】 急性胆源性胰腺炎；内镜逆行胆胰管造影；腹腔镜胆囊切除术；手术时机
      【中图分类号】 R657.5+1 【文献标识码】 A 【文章编号】 1003—6350（2023）06—0782—05

Efficacy of endoscopic retrograde cholangiopancreatography combined with laparoscopic cholecystectomy in thetreatment of acute biliary pancreatitis and selection of surgical timing.
ZHU Zhen-jing 1, CHEN Yu-chun 2, XU Hua 1.1.Operating Room, Pudong Branch of Huashan Hospital Affiliated to Fudan University, Shanghai 201206, CHINA; 2.NICU,Hongqiao Branch of Huashan Hospital Affiliated to Fudan University, Shanghai 201399, CHINA
【Abstract】 Objective To explore the therapeutic effect of endoscopic retrograde cholangiopancreatography(ERCP) combined with laparoscopic cholecystectomy (LC) on acute biliary pancreatitis and the selection of the best sur-gical timing.Methods The clinical data of 124 patients with acute biliary pancreatitis treated in Huashan Hospital Affil-iated to Fudan University were retrospectively analyzed between January 2020 and January 2022. According to differentsurgical regimens, the patients were divided into combined group (receiving ERCP combined with LC, n=72) and tradi-tional laparotomy group (receiving traditional laparotomy, n=52). According to the operation time, the patients in com-bined group were further classified into early group (surgery within 48 hours of onset, n=30) and delayed group (surgeryafter 48 hours of onset, n=42). The perioperative indexes [intraoperative blood loss, the number of days of enteral nutri-tion recovery, stone clearance rate, abdominal pain relief time, postoperative length of hospital stay] and occurrence ofpostoperative complications were compared among early group, delayed group, and laparotomy group. The liver func-tion indexes [total bilirubin (TBIL), γ-glutamyltransferase (γ-GT)], white blood cell count (WBC), serum amylase (SA-MY) and serum inflammatory stress indexes [C-reactive protein, interleukin-8 (IL-8), serum endothelin (ET)] of thethree groups were compared before surgery and at 7 days after surgery. Results There were statistically significant dif-ferences among early group, delayed group and traditional laparotomy group in terms of intraoperative blood loss[(51.42±15.68) mL vs (50.66±15.05) mL vs (84.35±25.40) mL], the number of days of enteral nutrition recovery [(1.91±0.60) d vs (2.13±0.73) d vs (2.43±0.76) d], relief time of abdominal pain [(3.48±1.14) h vs (3.67±1.17) h vs (4.84±1.61) h]and postoperative length of hospital stay [(9.34±2.4) d vs (12.05±3.72) d vs (13.19±4.03) d] (P<0.05); there were no sta-tistically significant differences in stone clearance rate and incidence rates of complications among the three groups (P>0.05). There were no statistically significant differences in the levels of serum TBIL, γ-GT, WBC, SAMY, CRP, IL-8 andET before surgery among the three groups (P>0.05). There were statistical differences in levels of serum TBIL [(17.55±4.70) μmol/L vs (17.76±4.81) μmol/L vs (26.13±5.64) μmol/L], γ-GT [(39.23±6.02) U/L vs (41.26±6.47) U/L vs (58.61±7.73) U/L], WBC [(6.37±2.12)×109/L vs (6.65±2.21)×109/L vs (8.73±2.78)×109/L], SAMY [(64.73±10.52) U/L vs (68.46±10.8) U/L vs (102.53±13.72) U/L], CRP [(21.73±7.43) mg/L vs (22.36±7.50) mg/L vs (48.69±11.26) mg/L], IL-8 [(82.15±16.69) pg/mL vs (84.85±18.43) pg/mL vs (112.38±20.58) pg/mL] and ET [(46.56±6.48) ng/L vs (48.07±6.52) ng/L vs(64.17±9.23) ng/L] among early group, delayed group, traditional laparotomy group at 7 days after surgery (P<0.05),and the above levels in early group and delayed group were significantly lower than those in traditional laparotomygroup (P<0.05). Conclusion ERCP combined with LC has a good effect in the treatment of acute biliary pancreatitis. Itcan effectively speed up postoperative recovery, improve the liver function and inflammatory response. Treatment within48 hours of onset can further shorten the length of hospital stay and promote the rehabilitation.
      【Key words】 Acute biliary pancreatitis; Endoscopic retrograde cholangiopancreatography; Laparoscopic chole-cystectomy; Surgical timing