2006-04-15 00:00 来源:丁香园 - 消化内科讨论版 作者:wuhanp
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Endoscopic Management of Chronic Pancreatitis
Nib Soehendra

Endoscopic management in chronic pancreatitis includes:
1.Pancreatic sphincterotomy
2.Pancreatic stone extraction
3.Stenting of pancreatic main duct
4.Drainage of pseudocyst
5.Treatment of pancreatic abscess
6.Sealing of pancreatic duct fistula
7.Stenting of distal CBD stricture
Chronic pancreatitis is the most common indication for endoscopic intervention in pancreatic diseases.
Chronic pancreatitis is frequently related to acute pancreatitis of different etiologies. The starting point is an attack of acute pancreatitis with autodigestive parenchymal necrosis, which leads to perilobular fibrosis and finally to stricture formation in the main duct. The impaired flow of pancreatic juice increases viscosity and causes plugs of protein in the ducts aggravating the obstruction. This vicious cycle ultimately leads to the development of chronic pancreatitis
With the belief that chronic pancreatitis is an irreversible disease, treatment of the unrelenting pain and deteriorating functions of the gland remain the main goals of all therapeutic modalities. The increase of the intraductal pressure is one of the most important causes of the pain. Pancreatic sphincterotomy, stenting and stone removal in the pancreatic ducts represent therefore the main therapeutic procedures in the endoscopic management of chronic pancreatitis.(fig.1)
Pancreatic sphincterotomy
Endoscopic incision of the pancreatic sphincter is carried out to facilitate ductal stenting and stone extraction. Technically, it is performed in a similar way to biliary sphincterotomy using a double- or triple-lumen sphincterotome over a guide-wire. It is advisable to use a sphincterotome with a monofilament cutting wire of less than 25 mm, and for cannulation a slippery guide-wire (e.g. Terumo guide-wire 0.018 – 0.032”). After selective cannulation of the pancreatic duct, the incision of the sphincter is made stepwise using pure cutting current in the direction of 1-2 o’clock. In case of pancreas divisum, incision of the minor papilla can also be made over a stent using a needle-knife. Biliary sphincterotomy prior to pancreatic sphincter incision is in most of the cases unnecessary. In patients with distal CBD stricture which is frequently present in chronic pancreatitis, biliary sphincterotomy should not be performed, unless biliary stenting is intended.
Ductal stenting
Since stricture of the main pancreatic duct is the most frequently observed pathology in chronic pancreatitis, stenting is the most commonly practiced endoscopic procedure (fig. 2). However, as in any other drainage procedure this treatment is only beneficial if a distinct ductal dilation is present. In our experience, pancreatic duct stenting is successful in around 90% of cases. The common causes of failure are very tight and multiple strictures. Stenting may also be indicated in patients with pancreas divisum suffering from pancreatitis-like pain, as a therapeutic trial to prove that there is inadequate drainage through the minor papilla.

Fig. 2 ERCP findings in chronic pancreatitis (n = 200)
Pancreatic ductal obstruction  90 %
Intraductal calculi       35%
Cysts             25 %
Pancreas divisum       20 %
Distal CBD obstruction     35 %

The technique of pancreatic duct stenting is similar to that of biliary stenting and is based on the Seldinger principle. Strictures of the pancreatic main duct however may be more difficult to stent due to their fibrotic, tight and tortuous nature.
Stenting has proved to be safe and effective method of draining the duct in chronic pancreatitis. Complete or partial pain relief can be achieved initially in around 85% of patients. Unfortunately, the figure for pain relief drops to around 60-70% during follow-up, mainly due to stent clogging. As long as the problem of stent occlusion remains, surveillance of patients is mandatory. Stent exchange should be scheduled at 3 months interval. To effectively dilate the stricture, dilating catheter (5 to 11.5 French), dilating balloon (5 to 10 mm according to the diameter of the distal duct) and stent retriever (10 French) are used. Placement of multiple stents for about one year (increase the number of 7-10 French stents every 3 months) has been shown to have encouraging long-term results (fig. 3).
Treatment of pancreatic stones
Pancreatic duct stones are the next most frequent cause of ductal obstruction in patients with chronic pancreatitis. They can be removed following endoscopic sphincterotomy by using a Dormia basket or a balloon catheter if they are mobile and not too large. Unfortunately, most of the obstructing stones are impacted in the duct and located behind a stricture. In these cases, extracorporeal shock wave lithotripsy (ESWL) has first to be applied. After successful disintegration, stone fragments can be extracted endoscopically.
Using the new generation of machine, ESWL is well tolerated by the patients and is not associated with any significant complications. Fragmentation of pancreatic stones can be achieved in 80-100% of cases with pain relief in 50-90% of patients.
Drainage of pseudocysts
Pancreatic pseudocysts which occur with an incidence of around 10-30% in chronic pancreatitis need treatment because they cause symptoms like pain, nausea and vomiting or because they cause complications such as gastric outlet obstruction, jaundice and abscess formation. Pseudocysts occurring in chronic pancreatitis spontaneously resolve less frequently than those found in acute pancreatitis and have a tendency to develop complications especially if treatment if delayed.
Symptomatic pseudocysts, which are usually larger than 6 cm in diameter, can be treated effectively and safely by endoscopic drainage. This can be performed either transpapillary if the cyst communicates with the main pancreatic duct, or by a transmural approach if the cyst has direct contact with the gastric or duodenal wall and produces a recognizable bulge in the lumen.
The size and the proximity of the cyst to the gut wall can be assessed precisely by CT and endoscopic ultrasound (EUS). EUS plays an important role in the endoscopic management of pancreatic pseudocysts. It provides informations concerning interposed vessels and collateral veins which are common in patients with portal hypertension. EUS-guided puncture and drainage is therefore strongly recommended in these patients, and also if there is no endoscopically visible bulging of the stomach or duodenal wall (fig. 4).
Transgastric drainage is the most commonly practiced endoscopic modality. Following EUS-guided puncture of the cyst through the gastric wall using a FNA-needle, a guide-wire is inserted through the needle. Over the guide-wire, a stent or a naso-biliary catheter can be placed. Owing to the relatively high risk of secondary infection due to stent clogging, placement of an additional naso-cystic catheter for continuous rinsing is advisable. Creation of a cyst-gastrostomy using a dilating balloon (10-20 mm diameter) is recommended in infected pseudocysts and pancreatic abscesses. To maintain the opening of cyst-gastrostomy a 10 French double-pigtail stent is placed. Repeated balloon dilatation may be required to remove debris of necrotic tissue from the cyst cavity by using a Dormia basket or Roth retrieval net.
The success rate of endoscopic cyst drainage amounts to 80-90% with a complication rate between 10-15% (bleeding, infection).
Concomitant pancreatic fistulae can be sealed by using the tissue glue n-butyl-2-cyanoacrylate (Histoacryl). Prior to occlusion, sufficient drainage of the cyst and healing of the infection must be ensured. Endoscopic sealing is indicated if leakage persists despite sufficient ductal drainage.


内镜下行胰管括约肌切开,主要是为了便于置入支架及取石。其操作技术类似于胆管括约肌切开。在导丝引导下使用双腔或三腔切开刀进行切开。建议使用超滑导丝(如Terumo 0.018-0.032”导丝)。选择性胰管插管后沿1-2点钟方向用单纯切割电流切开。对胰腺分裂症患者,行副乳头切开可先置入导管再沿导管用针状刀切开。对大多数病例不必预先做胆管括约肌切开。对慢性胰腺炎常并发的远端胆总管狭窄也不需要进行胆道括约肌切开,除非需要置入胆道支架。



表1 胰腺炎的ERCP表现
胰管梗阻       90%
胰管结石      35%
囊肿        25%
胰腺分裂      20%
胆总管远端狭窄   35%

  在慢性胰腺炎,支架置入已被证实是一种安全有效引流胰管的方法。在85%左右的病人可完全或部分缓解疼痛。不幸的是,在随访期,疼痛缓解率下降到60-70%,原因主要是支架阻塞。只要支架阻塞的问题仍存在,就必须对患者进行随访监测。一般间隔3个月需要更换支架。为了有效扩张狭窄,需要使用扩张导管(5-11.5Fr)、扩张球囊(按近端导管直径选择5-10mm)及支架回收器(10 Fr)。在一年内使用多支架置入(每3个月从7-10 Fr逐步增加支架)获得长期疗效的结果令人鼓舞。












编辑: Zhu