超声内镜引导下金属支架引流与经皮肾镜清创治疗胰腺包裹性坏死的疗效比较

doi:10.3877/cma.j.issn.1674-6899.2021.05.009

目的

比较超声内镜引导下金属支架引流与经皮肾镜清创治疗胰腺包裹性坏死(walled off necrosis, WON)的疗效，并探讨不同部位WON的最佳治疗模式。

方法

回顾性分析2018年10月至2020年12月于解放军总医院第一医学中心行超声内镜引导下金属支架引流治疗或行经皮肾镜清创治疗的WON患者临床资料，比较两组的治疗成功率、手术时间、并发症、住院时间、住院费用等。

结果

纳入的38例患者中13例为超声内镜组，WON位置均局限在胰腺或胰周；25例为经皮肾镜组，其中14例局限在胰腺或胰周。两组治疗成功率、并发症均差异无统计学意义。对于位置相同的WON，两组的治疗成功率、并发症差异无统计学意义；但超声内镜组的中位手术时间、住院时间、住院费用均小于经皮肾镜组[37.0 min(22.0~49.5 min)比90.0 min(52.5~135.0 min)，P<0.001；8 d(6~12.5 d)比19 d(9~40 d)，P＝0.002；40 550元(36 734~67 640元)比94 151元(69 813~251 510元)，P<0.001]。

结论

对于WON局限在胰腺或胰周的患者，适合行超声内镜下金属支架引流；当WON累及腹腔或盆腔时适合经皮肾镜清创治疗；若患者同时有多个不同部位的囊腔，可考虑超声内镜联合经皮肾镜清创治疗。

关键词: 胰腺包裹性坏死, 金属支架, 超声内镜, 引流, 经皮肾镜

Objective

To compare the efficacy and safety of endoscopic ultrasound-guided (EUS-guided) drainage with metal stent and percutaneous nephroscopic necrosectomy in the treatment of walled off necrosis (WON), and to discuss the best treatment mode of WON at different sites.

Methods

The clinical datas of patients with WON who underwent EUS-guided drainage with metal stent or percutaneous nephroscopic necrosectomy in our hospital from Oct. 2018 to Dec. 2020 were retrospectively analyzed, and the treatment success rate, procedure duration, complications, hospital stay and cost et al between the two groups were compared.

Results

Thirteen of 38 patients included in the EUS group, and WON were confined to the pancreas or peripancreatic area. Of the 25 patients in the percutaneous nephroscopy group, 14 patients had localized to pancreas or peripancreatic area. There was no statistical difference in treatment success rate and complication rate between the two groups. And there was no statistical difference in treatment success rate and complication rate between the two groups for the WON confined to pancreas or peripancreatic area. However, the median duration of procedure, median hospital stay and median cost in the EUS group was less than that in the percutaneous nephroscopy group [(37.0 min(22.0-49.5 min) vs 90.0 min(52.5-135.0 min), P<0.00; 8 d(6-12.5 d) vs 19 d(9-40 d), P=0.002; 40 550 CNY[36 734-67 640 CNY) vs 94 151 CNY(69 813-251 510 CNY), P< 0.001].

Conclusions

EUS-guided drainage with metal stent is suitable for patients with WON confined to pancreas or peripancreatic area and close to gastric wall. Percutaneous nephroscopic necrosectomy is more suitable for WON involving abdominal cavity and pelvic cavity and far from the gastric wall. If the patient has different sites of cysts at the same time, EUS-guided drainage combined with percutaneous nephroscopic necrosectomy can be considered.

Key words: Walled-off necrosis, Metal stent, Endoscopic ultrasound, Drainage, Percutaneous nephroscope

图1 超声内镜引导下金属支架引流治疗胰腺包裹性坏死及CT对比

表1 两组胰腺包裹性坏死患者的一般资料比较

项目		超声内镜组(13例)	经皮肾镜组(25例)	统计值	P值
年龄[岁，中位数(P₂₅~P₇₅)]		44.0(36.5~60.5)	36.0(28.0~55.0)		0.124
性别[男，例(%)]		6(46.2)	18(72.0)	χ²＝2.455	0.163
体质量指数(kg/m^2, ±s)		23.05±3.45	23.63±3.79	t＝-0.408	0.687
主要临床症状(例)
	腹痛	10	15	χ²＝1.088	0.473
	腹胀	4	9	χ²＝0.104	>0.999
	恶心、呕吐	1	1	χ²＝0.234	>0.999
	发热	3	13	χ²＝2.935	0.165
	梗阻性症状	0	2	χ²＝1.098	0.538
术前囊肿大小(cm，±s)		10.91±2.52	14.42±4.81	t＝-2.954	0.005
囊肿部位(例)				χ²＝8.050	0.006
	仅胰腺或胰周	13	14
	累及腹腔和(或)盆腔	0	11
CT囊内可见气泡[例(%)]		1(7.7)	11(44.0)	χ²＝5.218	0.030
术前ASA分级(例)
	Ⅰ	1	0	χ²＝1.975	0.342
	Ⅱ	11	14	χ²＝3.112	0.148
	Ⅲ	1	10	χ²＝4.340	0.060
	Ⅳ	0	1	χ²＝0.534	>0.999

表1 两组胰腺包裹性坏死患者的一般资料比较

项目		超声内镜组(13例)	经皮肾镜组(25例)	统计值	P值
年龄[岁，中位数(P₂₅~P₇₅)]		44.0(36.5~60.5)	36.0(28.0~55.0)		0.124
性别[男，例(%)]		6(46.2)	18(72.0)	χ²＝2.455	0.163
体质量指数(kg/m^2, ±s)		23.05±3.45	23.63±3.79	t＝-0.408	0.687
主要临床症状(例)
	腹痛	10	15	χ²＝1.088	0.473
	腹胀	4	9	χ²＝0.104	>0.999
	恶心、呕吐	1	1	χ²＝0.234	>0.999
	发热	3	13	χ²＝2.935	0.165
	梗阻性症状	0	2	χ²＝1.098	0.538
术前囊肿大小(cm，±s)		10.91±2.52	14.42±4.81	t＝-2.954	0.005
囊肿部位(例)				χ²＝8.050	0.006
	仅胰腺或胰周	13	14
	累及腹腔和(或)盆腔	0	11
CT囊内可见气泡[例(%)]		1(7.7)	11(44.0)	χ²＝5.218	0.030
术前ASA分级(例)
	Ⅰ	1	0	χ²＝1.975	0.342
	Ⅱ	11	14	χ²＝3.112	0.148
	Ⅲ	1	10	χ²＝4.340	0.060
	Ⅳ	0	1	χ²＝0.534	>0.999

表2 胰腺包裹性坏死局限在胰腺或胰周的两组患者一般资料比较

项目		超声内镜组(13例)	经皮肾镜组(14例)	统计值	P值
年龄[岁，±s]		40.0±12.1	46.0±17.3	t＝0.409	0.686
性别[男，例(%)]		6(46.2)	12(85.7)	χ²＝4.747	0.046
体质量指数(kg/m²，±s)		23.05±3.45	23.21±3.71	t＝-1.07	0.916
主要临床症状(例)
	腹痛	10	11	χ²＝0.011	>0.999
	腹胀	4	5	χ²＝0.074	>0.999
	恶心、呕吐	1	0	χ²＝1.118	0.481
	发热	3	7	χ²＝2.095	0.236
术前囊肿大小(cm，±s)		10.91±2.52	13.74±4.87	t＝-1.874	0.073
CT囊内可见气泡[例(%)]		1(7.7)	6(42.8)	χ²＝4.340	0.077
术前ASA分级(例)
	Ⅰ	1	0	χ²＝1.118	0.481
	Ⅱ	11	7	χ²＝3.635	0.103
	Ⅲ	1	7	χ²＝5.787	0.033

表2 胰腺包裹性坏死局限在胰腺或胰周的两组患者一般资料比较

项目		超声内镜组(13例)	经皮肾镜组(14例)	统计值	P值
年龄[岁，±s]		40.0±12.1	46.0±17.3	t＝0.409	0.686
性别[男，例(%)]		6(46.2)	12(85.7)	χ²＝4.747	0.046
体质量指数(kg/m²，±s)		23.05±3.45	23.21±3.71	t＝-1.07	0.916
主要临床症状(例)
	腹痛	10	11	χ²＝0.011	>0.999
	腹胀	4	5	χ²＝0.074	>0.999
	恶心、呕吐	1	0	χ²＝1.118	0.481
	发热	3	7	χ²＝2.095	0.236
术前囊肿大小(cm，±s)		10.91±2.52	13.74±4.87	t＝-1.874	0.073
CT囊内可见气泡[例(%)]		1(7.7)	6(42.8)	χ²＝4.340	0.077
术前ASA分级(例)
	Ⅰ	1	0	χ²＝1.118	0.481
	Ⅱ	11	7	χ²＝3.635	0.103
	Ⅲ	1	7	χ²＝5.787	0.033

表3 两组胰腺包裹性坏死患者的临床结果比较

项目		超声内镜组(13例)	经皮肾镜组(25例)	χ²值	P值
技术成功[例(%)]		12(92.3)	25(100.0)	1.975	0.342
治疗成功[例(%)]		9(69.2)	15(60.0)	0.313	0.728
手术时间[min,中位数(P₂₅~P₇₅)]		37.0(22.0~49.5)	90.0(52.5~135.0)		<0.001
术中出血量[ml，中位数(P₂₅~P₇₅)]		0.0(0.0~0.5)	50.0(35.0~100.0)		<0.001
术后再干预[例(%)]		10(76.9)	10(40.0)	4.677	0.043
	内镜下清创	10	0
	经皮肾镜清创	0	9
	开腹探查	0	1
再干预次数[次，中位数(P₂₅~P₇₅)]		1.0(0.5~2.0)	0.0(0.0~1.0)		0.008
清创时间[min/次，中位数(P₂₅~P₇₅)]		25.0(0.0~33.3)	92.0(55.0~134.3)		<0.001
合并其他引流[例(%)]		2(15.4)	25(100.0)	38.000	<0.001
并发症[例(%)]		5(38.5)	11(44.0)	0.108	>0.999
	感染	3	7
	出血	1	2
	穿孔	0	1
	死亡	0	0
	其他	1	3
住院时间[d，中位数(P₂₅~P₇₅)]		8.0(6.0~12.5)	19.0(9.0~40.0)		0.002
住院费用[元，中位数(P₂₅~P₇₅)]		40 550(36 734~67 640)	118 036(75 162~236 016)		<0.001

表3 两组胰腺包裹性坏死患者的临床结果比较

项目		超声内镜组(13例)	经皮肾镜组(25例)	χ²值	P值
技术成功[例(%)]		12(92.3)	25(100.0)	1.975	0.342
治疗成功[例(%)]		9(69.2)	15(60.0)	0.313	0.728
手术时间[min,中位数(P₂₅~P₇₅)]		37.0(22.0~49.5)	90.0(52.5~135.0)		<0.001
术中出血量[ml，中位数(P₂₅~P₇₅)]		0.0(0.0~0.5)	50.0(35.0~100.0)		<0.001
术后再干预[例(%)]		10(76.9)	10(40.0)	4.677	0.043
	内镜下清创	10	0
	经皮肾镜清创	0	9
	开腹探查	0	1
再干预次数[次，中位数(P₂₅~P₇₅)]		1.0(0.5~2.0)	0.0(0.0~1.0)		0.008
清创时间[min/次，中位数(P₂₅~P₇₅)]		25.0(0.0~33.3)	92.0(55.0~134.3)		<0.001
合并其他引流[例(%)]		2(15.4)	25(100.0)	38.000	<0.001
并发症[例(%)]		5(38.5)	11(44.0)	0.108	>0.999
	感染	3	7
	出血	1	2
	穿孔	0	1
	死亡	0	0
	其他	1	3
住院时间[d，中位数(P₂₅~P₇₅)]		8.0(6.0~12.5)	19.0(9.0~40.0)		0.002
住院费用[元，中位数(P₂₅~P₇₅)]		40 550(36 734~67 640)	118 036(75 162~236 016)		<0.001

表4 胰腺包裹性坏死局限在胰腺或胰周的两组患者的临床结果比较

临床结果		超声内镜组(13例)	经皮肾镜组(14例)	统计值	P值
技术成功[例(%)]		12(92.3)	14(100.0)		0.481
治疗成功[例(%)]		9(69.2)	8(57.1)	χ²＝0.422	0.695
手术时间(min，±s)		35.7±15.35	77.7±40.48	t＝-3.614	0.002
术中出血量[ml，中位数(P₂₅~P₇₅)]		0.0(0.0~0.5)	50.0(20.0~62.5)		<0.001
术后再干预[例(%)]		10(76.9)	3(21.4)	χ²＝8.315	0.007
	内镜下清创	10	0
	经皮肾镜清创	0	2
	开腹探查	0	1
再干预次数[次，中位数(P₂₅~P₇₅)]		1(0.5~2.0)	0(0.0~0.3)		0.002
清创时间[min/次，中位数(P₂₅~P₇₅)]		25.0(0.0~33.3)	70.0(45.6~101.9)		<0.001
合并其他引流[例(%)]		2(15.4)	14(100.0)	χ²＝27.000	<0.001
并发症[例(%)]		5(38.5)	6(42.8)	χ²＝0.054	0.816
	感染	3	5
	出血	1	1
	穿孔	0	0
	死亡	0	0
	其他	1	0
住院时间[d，中位数(P₂₅~P₇₅)]		8(6.0~12.5)	11(8.8，32.0)		0.036
住院费用[元，中位数(P₂₅~P₇₅)]		40 550(36 734~67 640)	94 151(69 813~251 510)		<0.001

表4 胰腺包裹性坏死局限在胰腺或胰周的两组患者的临床结果比较

临床结果		超声内镜组(13例)	经皮肾镜组(14例)	统计值	P值
技术成功[例(%)]		12(92.3)	14(100.0)		0.481
治疗成功[例(%)]		9(69.2)	8(57.1)	χ²＝0.422	0.695
手术时间(min，±s)		35.7±15.35	77.7±40.48	t＝-3.614	0.002
术中出血量[ml，中位数(P₂₅~P₇₅)]		0.0(0.0~0.5)	50.0(20.0~62.5)		<0.001
术后再干预[例(%)]		10(76.9)	3(21.4)	χ²＝8.315	0.007
	内镜下清创	10	0
	经皮肾镜清创	0	2
	开腹探查	0	1
再干预次数[次，中位数(P₂₅~P₇₅)]		1(0.5~2.0)	0(0.0~0.3)		0.002
清创时间[min/次，中位数(P₂₅~P₇₅)]		25.0(0.0~33.3)	70.0(45.6~101.9)		<0.001
合并其他引流[例(%)]		2(15.4)	14(100.0)	χ²＝27.000	<0.001
并发症[例(%)]		5(38.5)	6(42.8)	χ²＝0.054	0.816
	感染	3	5
	出血	1	1
	穿孔	0	0
	死亡	0	0
	其他	1	0
住院时间[d，中位数(P₂₅~P₇₅)]		8(6.0~12.5)	11(8.8，32.0)		0.036
住院费用[元，中位数(P₂₅~P₇₅)]		40 550(36 734~67 640)	94 151(69 813~251 510)		<0.001

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Comparison of endoscopic ultrasound-guided drainage with metal stent and percutaneous nephroscopic necrosectomy for walled off necrosis

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Comparison of endoscopic ultrasound-guided drainage with metal stent and percutaneous nephroscopic necrosectomy for walled off necrosis