本文選題：鼻膽管引流 + 胰膽管造影��； 參考：《南昌大學(xué)》2015年碩士論文

【摘要】：研究背景:內(nèi)鏡逆行胰膽管造影術(shù)(endoscopic retrograde cholangiopancreatography,ERCP)已成為診治胰膽管疾病不可或缺的手段之一,但其作為一項(xiàng)有創(chuàng)性操作,與其相關(guān)的并發(fā)癥一直居高不下。研究顯示行鼻膽管引流術(shù)(endoscopic nasobiliary drainage,ENBD)置入、取出簡(jiǎn)單,且方便觀察引流液的性狀及量,防治并發(fā)癥具有較好的的效應(yīng),但由于多為單中心研究,樣本量小,結(jié)論不一致。故行預(yù)防性ENBD防治ERCP相關(guān)并發(fā)癥的效應(yīng)尚存爭(zhēng)議、缺乏循證學(xué)依據(jù)。目的:系統(tǒng)評(píng)價(jià)預(yù)防性ENBD防治ERCP相關(guān)并發(fā)癥的效應(yīng)及其安全性。具體包括高淀粉酶血癥、急性胰腺炎(post-ERCP pancreatitis,PEP)、重度胰腺炎(severe post-ERCP pancreatitis,SPEP)、急性膽管炎、重癥膽管炎(acute cholangitis of severe type,ACST)、消化道出血、腸穿孔等ERCP相關(guān)并發(fā)癥發(fā)生率,病死率,術(shù)后并發(fā)癥需外科急診干預(yù)率,ERCP術(shù)后住院時(shí)間,臨床癥狀和體征緩解時(shí)間,住院費(fèi)用等指標(biāo)。方法:計(jì)算機(jī)檢索PubMed、Medline、Web of SCI、Cochrane Library、CBM、CNKI、WanFang Data及CQVIP,并進(jìn)一步追查相關(guān)會(huì)議紀(jì)要、學(xué)位論文,及納入研究的參考文獻(xiàn),檢索時(shí)限從建庫(kù)至2015年3月5日,語(yǔ)種限定為英文或中文,全面收集公開(kāi)報(bào)道的ENBD防治ERCP相關(guān)并發(fā)癥的隨機(jī)對(duì)照試驗(yàn)(random control trial,RCT)和臨床對(duì)照試驗(yàn);依照預(yù)定的文獻(xiàn)納入和排除標(biāo)準(zhǔn)篩選文獻(xiàn);參考NOS評(píng)分標(biāo)準(zhǔn)進(jìn)行質(zhì)量評(píng)價(jià);應(yīng)用系統(tǒng)評(píng)價(jià)的方法對(duì)納入的研究進(jìn)行統(tǒng)計(jì)分析。定量分析應(yīng)用Review Manager 5.3軟件,有統(tǒng)計(jì)學(xué)意義的Meta分析結(jié)果計(jì)算需治療的患者數(shù)(Number needed to be treated,NNT)。結(jié)果:⑴共納入18項(xiàng)研究(RCT 11項(xiàng),臨床對(duì)照試驗(yàn)7項(xiàng)),包含行預(yù)防性ENBD患者1952例(ENBD組)、未行預(yù)防性ENBD患者1577例(no-ENBD組)。⑵ENBD對(duì)高淀粉酶血癥發(fā)生率的影響:Meta分析P0.00001,OR=0.50(95%ci=0.37~0.67),nnt=10;敏感性分析與原meta分析結(jié)果一致,p0.00001,or=0.55(95%ci=0.39~0.76);漏斗圖大致對(duì)稱(chēng),begg’s檢驗(yàn)z=1.07,p=0.283。⑶enbd對(duì)pep發(fā)生率的影響:meta分析p0.00001,or=0.27(95%ci=0.19~0.38),nnt=11;敏感性分析與原meta分析結(jié)果一致,p0.00001,or=0.28(95%ci=0.19~0.39);漏斗圖存在一定的不對(duì)稱(chēng)性,主要為右下角缺失,然而各研究結(jié)果均位于95%可信區(qū)間內(nèi),且begg’s檢驗(yàn)z=1.71,p=0.086。⑷enbd對(duì)spep發(fā)生率的影響:meta分析p=0.03,or=0.19(95%ci=0.04~0.88),敏感性分析結(jié)果失去統(tǒng)計(jì)學(xué)意義,p=0.09,or=0.22(95%ci=0.04~1.30),但納入的研究enbd組spep發(fā)生率為0.3%,明顯低于no-enbd組的3.4%。⑸enbd對(duì)急性膽管炎發(fā)生率的影響:meta分析p0.00001,or=0.50(95%ci=0.37~0.67),nnt=20;敏感性分析與原meta分析結(jié)果一致,p0.00001,or=0.25(95%ci=0.14~0.45);漏斗圖大致對(duì)稱(chēng),begg’s檢驗(yàn)p=1.000。⑹enbd對(duì)acst發(fā)生率的影響:meta分析p=0.009,or=0.10(95%ci=0.02~0.57),nnt=33。⑺enbd對(duì)消化道出血發(fā)生率的影響:meta分析p=0.89,or=0.92(95%ci=0.32~2.68);敏感性分析與原meta分析結(jié)果一致,p=0.89,or=1.09(95%ci=0.33~3.64)。⑻enbd對(duì)病死率的影響:meta分析p=0.08,or=0.20(95%ci=0.03~1.20),enbd組病死率為0.1%,明顯低于no-enbd組的1.1%。⑼enbd對(duì)并發(fā)癥需外科急診干預(yù)率的影響:meta分析p=0.001,or=0.09(95%ci=0.02~0.40);敏感性分析結(jié)果失去統(tǒng)計(jì)學(xué)意義,p=0.08,or=0.15(95%ci=0.02~1.24),但納入的研究enbd組并發(fā)癥需外科急診干預(yù)率為0.1%,明顯低于no-enbd組的2.6%。⑽enbd對(duì)ercp術(shù)后住院時(shí)間的影響:meta分析p=0.21,wmd=-0.81d(95%ci=-2.09d~0.46d)。⑾enbd對(duì)ercp術(shù)后療效的影響:納入的部分研究報(bào)道enbd不能有效縮短血清c反應(yīng)蛋白、丙氨酸轉(zhuǎn)氨酶、膽紅素等實(shí)驗(yàn)室指標(biāo)恢復(fù)正常時(shí)間,但可以有效縮短pep患者臨床癥狀和體征緩解時(shí)間,淀粉酶、中性粒細(xì)胞百分比等實(shí)驗(yàn)室指標(biāo)恢復(fù)正常時(shí)間和平均住院時(shí)間。⑿enbd的安全性:納入的部分研究報(bào)道了enbd的安全性,均未發(fā)生enbd導(dǎo)致的嚴(yán)重后果。結(jié)論:預(yù)防性enbd可有效預(yù)防ercp相關(guān)的高淀粉酶血癥、pep和急性膽管炎的發(fā)生,并且可降低pep和急性膽管炎的重癥化趨勢(shì),從而減少spep和acst的發(fā)生;另外,enbd可縮短pep患者的治愈時(shí)間,尤其是可以提高對(duì)spep和ASCT的內(nèi)科治愈率;除此之外,預(yù)防性ENBD本身并不引起不良后果。故預(yù)防性ENBD防治ERCP相關(guān)并發(fā)癥是一種安全有效的的辦法,值得臨床推廣應(yīng)用。
[Abstract]:Background: endoscopic retrograde cholangiopancreatography (endoscopic retrograde cholangiopancreatography, ERCP) has become one of the indispensable means for the diagnosis and treatment of cholangiopancreatopancreatography, but as a invasive operation, the complications associated with it have remained high. The study showed nasobiliary drainage (endoscopic nasobiliary drainage, EN). BD) it is simple to take out, and it is convenient to observe the characters and quantities of the drainage fluid, and the effect of preventing complications is better. But because of the single center study, the sample size is small and the conclusion is not consistent. Therefore, the effect of preventive ENBD prevention and control of ERCP related complications is still controversial and lack of evidence-based basis. Objective: to systematically evaluate the prevention of the prevention of ERCP related to the prevention of ERCP. The effects and safety of complications included hyperamylacemia, acute pancreatitis (post-ERCP pancreatitis, PEP), severe pancreatitis (severe post-ERCP pancreatitis, SPEP), acute cholangitis, severe cholangitis (acute cholangitis of severe type, acute), gastrointestinal bleeding, intestinal perforation and other related complications, fatality rate, Postoperative complications required emergency surgical intervention rate, hospitalization time after ERCP, clinical symptoms and signs remission time, and hospitalization expenses. Methods: computer retrieval of PubMed, Medline, Web of SCI, Cochrane Library, CBM, CNKI, WanFang Data, and further tracing related conferences, dissertations, and references to the study. The cable time limit was limited to English or Chinese in March 5, 2015. The language was limited to English or Chinese. A comprehensive collection of publicly reported randomized controlled trials (random control trial, RCT) and clinical controlled trials on the prevention and control of complications related to the prevention and treatment of ERCP related to ENBD were collected. Statistical analysis of the integrated study. Quantitative analysis applied Review Manager 5.3 software and statistically significant Meta analysis results to calculate the number of patients needed to be treated (Number needed to be treated, NNT). Results: (1) a total of 18 studies (RCT 11, clinics 7), including 1952 cases of preventive ENBD patients (EN) BD group (group BD), 1577 cases of non prophylactic ENBD patients (group no-ENBD). (2) the effect of ENBD on the incidence of hyperamylase: Meta analysis of P0.00001, OR=0.50 (95%ci=0.37~0.67), nnt=10; sensitivity analysis was consistent with the results of original meta analysis, p0.00001, or=0.55. The impact of rate: Meta analysis p0.00001, or=0.27 (95%ci=0.19~0.38), nnt=11; sensitivity analysis and the original meta analysis results, p0.00001, or=0.28 (95%ci=0.19~0.39); the funnel graph has a certain asymmetry, mainly in the right lower corner, but the results are in the 95% confidence interval, and Begg 's test z=1.71. The impact of the incidence: Meta analysis p=0.03, or=0.19 (95%ci=0.04~0.88), and the results of sensitivity analysis lost statistical significance, p=0.09, or=0.22 (95%ci=0.04~1.30), but the incidence of SPEP in ENBD group was 0.3%, which was significantly lower than that of 3.4%. ENBD in the no-enbd group. Nnt=20; the sensitivity analysis is consistent with the results of the original meta analysis, p0.00001, or=0.25 (95%ci=0.14~0.45); the funnel plot is roughly symmetrical, and the Begg 's tests the effect of p=1.000. ENBD on the incidence of ACST: Meta analysis p=0.009. The sensitivity analysis was consistent with the results of the original meta analysis, p=0.89, or=1.09 (95%ci=0.33~3.64). The effect of ENBD on the mortality was p=0.08, or=0.20 (95%ci=0.03~1.20), and the fatality rate of the ENBD group was 0.1%, which was significantly lower than that of no-enbd group. The results of sensitivity analysis lost statistical significance, p=0.08, or=0.15 (95%ci=0.02~1.24), but the incidence of complications in the group ENBD was 0.1%, which was significantly lower than the effect of 2.6%. ENBD on the time of hospitalization after ERCP: Meta analysis p=0.21, wmd= -0.81d. The part of the study reported that ENBD could not effectively shorten the serum C reactive protein, alanine aminotransferase, bilirubin and other laboratory indexes to restore normal time, but could effectively shorten the time of clinical symptoms and signs remission of PEP patients and the normal time and average time of hospitalization of the laboratory indexes such as amylase and neutrophils percentage. ENBD Safety: part of the study reported that ENBD was safe and had no serious consequences caused by ENBD. Conclusion: prophylactic ENBD can effectively prevent ERCP related hyperamylasemia, PEP and acute cholangitis, and reduce the severe trend of PEP and acute cholangitis, thus reducing the occurrence of SPEP and ACST; moreover, ENBD can Shorten the cure time of PEP patients, especially to improve the cure rate of SPEP and ASCT; in addition, preventive ENBD itself does not cause adverse consequences. Therefore, preventive ENBD prevention and control of ERCP related complications is a safe and effective method, which is worthy of clinical application.

【學(xué)位授予單位】：南昌大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R657.4

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