胆总管结石内镜乳头括约肌切开术后胰腺并发症药物预防策略的特殊性

S. Styazhkina, T. R. Spiridonov, T. O. Eltsov, E. D. Novikova
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摘要

内镜乳头括约肌切开术(EPST)最常见的并发症是急性胰腺炎。这种并发症应该是基于对胰腺导管和实质的机械、化学、静水压、酶和热影响。根据不同的文献数据,EPST 术后胰腺炎(PEP)的发病率在 30% 到 40% 之间,死亡率为 2%-10%。调查的目的是扩大现阶段早期诊断和预防后EST胰腺炎特殊性的信息。为了实现既定目标,我们分析了 559 例确诊胆石症患者的病历,其中 319 例接受了 EPST。研究发现,中性粒细胞/淋巴细胞比率超过 4.96(p=0.001)、LDH 水平超过 250 IU/ml(p=0.01)以及 C 反应与白蛋白指数超过 0.180(p=0.001)是早期诊断的可靠标志。此外,PEEP 的间接诊断指标还包括胆汁淤积和肝细胞细胞溶解的生化指标,以及高血糖合并葡萄糖尿。我们认为,术中在乳头切开术伤口边缘注射肾上腺素,并在随后注射体生长抑素,同时结合直肠双氯芬酸和静脉补液兰贝林,是预防 PEP 的最有效策略。因此,我们可以得出这样的结论:尽管人们一直在研究和寻找预防和早期诊断 PEP 的有效算法,但其数据往往相互矛盾或根本无法证实其有效性。预防和诊断 PEP 的问题依然复杂,需要进一步研究。目前的文献存在差异,有时差异还很大,这为开发和研究新的早期诊断和预防方法提供了依据。
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Peculiarities of pharmacological prevention strategy of pancreatic complications after endoscopic papillosphincterotomy for choledocholithiasis
The most frequent complication of endoscopic papillosphincterotomy (EPST) is acute pancreatitis. This complication is supposed to be based on mechanical, chemical, hydrostatic, enzymatic and thermal impact on pancreatic ducts and parenchyma. According to different literature data, the incidence of post-EPST pancreatitis (PEP) varies from 30 to 40%, and the mortality rate is 2-10%. The aim of the investigation was to expand information about peculiarities of early diagnostics and prevention of post-EST pancreatitis at the present stage. To reach the set goal we analyzed 559 case histories of patients with diagnosed cholelithiasis, 319 of them underwent EPST. During the study it was found out, that elevated neutrophils/lymphocytes ratio over 4,96 (p=0,001), high LDH level over 250 IU/ml (p=0,01), as well as C-reactive to albumin index over 0,180 (p=0,001) are reliable markers of early diagnosis. Also, indirect diagnostic markers of PEEP are biochemical signs of cholestasis and cytolysis of hepatocytes, as well as hyperglycemia combined with glucosuria. We consider the inclusion of intraoperative injections of papillotomy wound margins with Epinephrine in combination with subsequent Somatostatin administration in combination with rectal Diclofenac and intravenous hydration with Reamberin to be the most effective strategy for PEP prevention. Thus, we can conclude that despite the ongoing research and the search for effective algorithms for the prevention and early diagnosis of PEP, their data often contradict each other or simply do not confirm their effectiveness. The problem of prevention and diagnosis of PEP remains complex and requires further study. There are discrepancies, sometimes significant ones, in the current literature, which provides grounds for the development and research of new methods of early diagnosis and prevention.
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