Acute cholangioadenopancreatitis, high prevalence, sometimes heavy disease and rapid changes. In recent years, under the guidance of new thinking of combined treatment of duodenoscopy, laparoscopy and choledochoscopy, the traditional key of surgical treatment of cholangio-genic pancreatitis has changed dramatically. From June 2000 to April 2008, 565 cases of acute cholestatic pancreatitis were treated with a combination of pharmacological treatment, EST and triple-laparoscopic surgery in our hospital, and satisfactory results were achieved. It is reported as follows.
1. Clinical data and methods
1.1 General data
There were 565 cases in this group, 272 males and 293 females, aged 20-90 years old, with an average of 50.5 years old. There were 343 cases with a previous history of gallbladder stones, 98 cases with bile duct stones, 106 cases with a history of one or more episodes of biliary pancreatitis, 30 cases with a previous history of cholecystectomy, 15 cases with bile duct exploration, and 31 cases with other abdominal surgeries.
There were 482 cases of epigastric pain, nausea and vomiting, 195 cases of jaundice with total bilirubin of (20.8-100.5)umol/L (normal value 6-23 umol/L), 478 cases of routine blood (white blood cells 10.0-22.0×109/L), 465 cases of elevated blood amylase 400-1100u/L (normal value 15-115u/L), urinary ALT was elevated in 475 cases, 75-221u/L (normal value 0-40u/L), and AST was elevated in 480 cases, 66-198u/L (normal value 0-40u/L).
Ultrasound showed 501 cases of multiple gallbladder stones (0.5-2.9 cm), 413 cases of multiple bile duct stones (0.3-3.5 cm), and dilated common bile duct 0.9-1.8 cm (average 1.2 cm). 309 cases of pancreatic enlargement and 80 cases of peri-pancreatic oligoclastic exudation were detected by CT.
The diagnostic and case selection criteria for acute biliary pancreatitis were.
(1) Pain in the upper abdomen or left upper abdomen with left low back pain and abdominal distension. Nausea, mostly with vomiting, pressure pain in the left upper abdomen, mild rebound pain, fever or normal body temperature.
(2) Blood amylase more than 2 times the normal value, urinary amylase elevated after 3 days, liver function test total bilirubin and transaminase elevated.
(3) Ultrasound, CT, MRCP suggest enlarged gallbladder, thickened bile duct, diffuse enlargement and exudation of pancreas.
(4) Exclude other causes of pancreatitis.
(5) No history of upper abdominal surgery.
(6) No severe cardiopulmonary insufficiency.
(7) Heavy pancreatitis was not selected to be included in the treatment cases in this paper.
1.2 Grouping and treatment method
After all patients were admitted to the hospital with clear diagnosis by ultrasound CT, laboratory tests of blood and urine amylase, blood and urine routine, electrolytes, liver and kidney function, treatment was.
①Continuous gastrointestinal decompression ;
②broad-spectrum antibiotics combined with vitamins and hormone application;
③ application of drugs to inhibit glandular secretion; ④ nutritional support therapy.
According to the condition ultrasound, CT, ERCP, MRCP and laboratory results to determine the method of conservative, endoscopic and surgical treatment.
(1) Simple LC method: general anesthesia intubation, taking the head high and feet low, tilting 300 on the left side. four-hole method was used: 10 mm subumbilical incision, 10 mm main operating hole under the glabella, 5 mm incision in the midclavicular line under the right rib margin, and 5 mm incision under the rib margin in the right anterior axillary line. The gallbladder, bile ducts, inflammatory exudate and adhesions were routinely explored through the four holes, and the Colot triangle was dissected for routine LC surgery.
(2) Lumpectomy for bile duct exploration and choledochoscopic lithotripsy with four holes as above, main operating hole to access the choledochoscope (5mm Olympus), 1.0-2.0cm incision for common bile duct extraction, choledochoscopic exploration for lithotripsy basket extraction, flushing of bile duct, placement of appropriate T-tube suture, and placement of one drainage tube at Wen’s hole.
(3) According to ultrasound, CT, MRCP, liver function, whether to perform ERCP and EST, ERCP and EST were performed in the endoscopy room, and stones were retrieved by incisional papillary retrieval mesh, and nasal catheters were placed in some patients.
In the first group, MRCP+LC, MRI was first performed to find simple gallbladder stones without combined bile duct obstruction or bile duct stones. Group II: ERCP + EST group for bile duct stones or bile duct dilatation: patients without stones in the gallbladder or after previous gallbladder resection. Group III: ERCP + cholangioscopy + LCBDE, for acute cholangitis, failed EST extraction or due to large stones and papillary anatomical variation.
The fourth group ERCP+EST+LC group: for patients with gallbladder stones, bile duct stones oddi’s sphincter inflammatory stenosis, according to the patient, ultrasound, CT, laboratory tests, ERCP, MRCP comprehensive analysis, group personalized treatment plan.
2.Results
In the first group MRCP+LC group, 81 cases were successfully cured by LC surgery.
The second group ERCP + EST group, this group 73 cases, 28 cases after routine cholecystectomy, combined with pancreatitis, all patients underwent ERCP at the same time to remove bile duct stones by EST.
The third group, ERCP + choledochoscopy + LCBDE group, 243 cases, failed EST surgery, large stones, inflammatory stenosis of the lower bile duct, placed nasobiliary duct for one week and then LCBDE and T-tube drainage, cured and discharged.
The fourth group: ERCP+EST+LC group. 166 cases had ERCP and EST firstly, papillary myotomy was performed to remove the stone after imaging, and LC was performed one week later, and the operation was successfully cured. At the follow-up of 6 months-2 years, 12 cases had recurrence of bile duct stones and 2 ESTs were performed to remove the stones.
Two of the patients had longer inflammatory stenosis ducts in the lower bile duct, so papillotomy could not be performed to remove the stone, and they were referred to open abdomen to perform choledochal jejunostomy. In all, four groups of patients were successfully cured by surgery. 500 cases were followed up for 6 months-2 years, and 12 cases of bile duct stones recurred after two years, and the stones were removed by EST twice.
3. Discussion
Acute biliary pancreatitis, due to multiple stones in the common bile duct, multiple stones in the gallbladder, mud-like stones, combined infection, stones moving in the distal bile duct, inflammatory waves, stone impaction, causing obstruction, resulting in transient or transient duodenal papillary edema or spasm of Oddi’s sphincter, followed by bile reflux to the pancreatic duct, inflammatory stimulation, inflammatory pressure increase in the pancreatic duct, inducing pancreatitis, pathological changes in the acute pancreas In the case of acute pancreatic pathological changes, the early edematous pancreatitis should be treated clinically early to relieve the cause of the disease and unblock the drainage.
For patients with jaundice, transient jaundice, biliary colic, elevated blood and urine amylase, and elevated leukocytes, ultrasound, CT or MRCP should be performed for dynamic observation in case of emergency, and ERCP, ENBD (nasal bile duct drainage), LCBDE, and LC should be selected as early as possible once the diagnosis is clear.
At present, the management of non-obstructive acute pancreatitis tends to be a combination of Chinese and Western medicine and non-surgical treatment. Because its pathological changes are characterized by pancreatic edema and interstitial inflammation, which are often mild and self-limiting, obstructive acute pancreatitis is an absolute indication for emergency ERCP.
In 1997, the United States and Britain included ERCP and EST in the treatment plan of acute pancreatitis as Class A recommendations. In China, Li Zhaoxing declared that the effect of emergency endoscopic treatment is significantly better than conventional treatment, and the success rate can reach more than 90%.
Our data show that the combined endoscopic or triscopic treatment of biliary pancreatic cases is more successful, and the combined endoscopic or triscopic treatment has the following advantages.
(1) The cause of the disease can be observed directly under the microscope to make a clear diagnosis, and at the same time, the cause can be treated to relieve obstruction and stricture, and unblock the drainage.
②It can rapidly relieve biliary colic and prevent heavy pancreatitis, avoiding open surgery to strike again for patients who are already in the state of systemic inflammatory response syndrome to multi-organ dysfunction syndrome, and buying time and creating conditions for the final cure of the disease.
③The endoscopic or triple-scope combined operation is simple, less traumatic, less painful, less abdominal interference, completely reliable, and with low complication rate operated by endoscopists with rich clinical experience. There were no serious morbidities, no perforation and bleeding in this group.
④Pancreatitis caused by combined benign papillary stenosis after cholecystectomy, bile duct residual or regenerative stones resulting from EST is feasible.
During the endoscopic treatment of acute biliary pancreatitis, the different pathological states of the biliary tract should be analyzed comprehensively, and performing EST to retrieve stones is the most ideal method, but it cannot be fully applied to all patients. It creates conditions for subsequent LCBDE. Endoscopic treatment is only to solve the problem of biliary obstruction, which leads to the initiating factor of pancreatitis, and gallbladder stones are not endoscopically treated but LC is performed.
Regarding the timing of LC it is recognized that mild pancreatitis is completely possible within 7 days after the onset of the disease, and it is better to perform LC after 3 months for slightly severe pancreatitis, with no intermediate open abdomen in the whole group of LC. For patients with pancreatitis combined with endoscopic lumpectomy cholecystectomy, we take the advantages of the three mirrors to maximize the period of less trauma, less pain and shorter hospital stay.
In conclusion, with the development of modern technology, the treatment of cholangio-pancreatitis: the combination of drugs and tri-scope, comprehensive analysis of treatment, dynamic observation of the selection of indications, tri-scope combination, so that the treatment of cholangio-pancreatitis standardized, minimally invasive, efficacy significantly improved, to be promoted.