2025年美国胃肠内镜学会《消化内镜在慢性胰腺炎管理中的作用指南：方法学及证据回顾》解读

doi:10.16150/j.1671-2870.2025.04.007

摘要/Abstract

摘要：

疼痛是慢性胰腺炎（chronic pancreatitis， CP）患者的主要症状之一，消化内镜在缓解CP患者的疼痛方面具有重要作用，但其临床应用仍存在诸多亟待解决的争议性问题。因此，为提供最佳实践建议，以帮助规范CP患者管理、改善治疗效果并减少实践中的差异性，美国胃肠内镜学会（American Society for Gastrointestinal Endoscopy， ASGE）基于广泛的文献回顾，以高质量的研究证据为基础，制定并发布了《消化内镜在慢性胰腺炎管理中的作用指南》（以下简称指南）。该指南分为“总结和推荐”和“方法学及证据回顾”两部分，分别发表于2024年和2025年。指南阐述了内镜治疗对缓解CP疼痛的有效性，涵盖了腹腔神经丛阻滞（celiac plexus block， CPB）、胰管结石与狭窄的内镜治疗，以及良性胆道狭窄和胰腺假性囊肿等不良事件的处理。指南就疼痛性CP患者采用内镜治疗或外科治疗，CPB治疗疼痛性CP患者时，采用超声内镜引导还是经皮方式，伴有主胰管结石的疼痛性CP患者内镜诊疗方式的选择，伴有主胰管狭窄的疼痛性CP患者内镜治疗时支架放置的种类、大小及数量，合并良性胆道狭窄的CP患者应当放置多个塑料支架还是金属支架，以及合并症状性假性囊肿的CP患者引流方式选择等6个临床核心问题，进行了证据回顾、总结和推荐。本文就2025年ASGE发布的《消化内镜在慢性胰腺炎管理中的作用指南：方法学及证据回顾》进行详细解读，深入了解指南的证据基础，突出有待解决的问题，为临床提供参考及进一步的研究方向。

关键词: 慢性胰腺炎, 疼痛, 内镜, 指南解读

Abstract:

Pain is one of the primary symptoms of patients with chronic pancreatitis (CP). Digestive endoscopy plays a significant role in alleviating pain in CP patients, but its clinical application is still associated with numerous unresolved controversial issues. Therefore, to provide the best practice recommendations to help standardize the management of CP patients, improve treatment outcomes, and reduce variability in clinical practice, the American Society for Gastrointestinal Endoscopy (ASGE) developed and published the Guideline on the role of endoscopy in the management of chronic pancreatitis (hereinafter referred to as the Guideline) based on an extensive literature review and high-quality research evidence. The Guideline is divided into two parts: "summary and recommendations" and "methodology and review of evidence", which were published in 2024 and 2025, respectively. The Guideline outlines the effectiveness of endoscopic therapies for pain relief in CP patients, including celiac plexus block (CPB), endoscopic management of pancreatic duct stones and strictures, and the treatment of adverse events such as benign biliary strictures (BBSs) and pancreatic pseudocysts. It reviews, summarizes, and provides recommendations on six key clinical issues: whether endoscopic or surgical treatment should be used for painful CP patients; whether endoscopic ultrasound-guided or percutaneous approaches should be preferred for CPB in painful CP patients; the choice of endoscopic diagnostic and therapeutic methods for painful CP patients with main pancreatic duct stones; the type, size, and number of stents to be placed during endoscopic therapy for painful CP patients with main pancreatic duct (MPD) strictures; whether multiple plastic stents or metal stents should be placed in CP patients with benign biliary strictures; and the selection of drainage methods for CP patients with symptomatic pseudocysts. This study provides a detailed interpretation of the Guideline on the role of endoscopy in the management of chronic pancrea-titis: methodology and review of evidence, published by ASGE in 2025. It aims to deepen the understanding of the Guideline's evidence base, highlight unresolved issues, and offer clinical guidance and directions for further research.

Key words: Chronic pancreatitis, Pain, Endoscopy, Guideline interpretation

中图分类号:

白娅娅, 周春华, 邹多武. 2025年美国胃肠内镜学会《消化内镜在慢性胰腺炎管理中的作用指南：方法学及证据回顾》解读[J]. 诊断学理论与实践, 2025, 24(04): 407-414.

BAI Yaya, ZHOU Chunhua, ZOU Duowu. Interpretation of 2025 American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis： methodology and review of evidence[J]. Journal of Diagnostics Concepts & Practice, 2025, 24(04): 407-414.

图/表 2

表1

核心问题及指南推荐

问题	指南推荐
1.在伴有疼痛及MPD梗阻的CP患者中，内镜治疗与外科手术治疗在疼痛缓解方面相比如何?	A. 对于伴有疼痛、MPD梗阻且无手术禁忌证的CP患者，ASGE建议在开始内镜治疗前先进行外科手术评估； B. 对于有外科手术禁忌证，且患者更倾向于创伤小的情况来说，ASGE推荐内镜治疗作为初始治疗。（有条件推荐/低至中等证据质量）
2.对于接受CPB治疗的疼痛性CP患者，应采用超声内镜（endoscopic ultrasound, EUS）引导还是经皮（percutaneous, PC）穿刺方法?	对于决定进行CPB治疗的疼痛性CP患者，ASGE建议优先选择EUS引导方式，而非PC穿刺途径。（有条件推荐/证据质量低）
3.对于伴有MPD结石的疼痛性CP患者，内镜治疗的最佳方案应如何选择： ① 单纯经内镜逆行性胰胆管造影（endoscopic retrograde cholangiopancreatography, ERCP） ② ERCP联合胰管镜及碎石术 ③ ERCP联合体外冲击波碎石术（extracorporeal shock wave lithotripsy, ESWL）	对于伴有MPD结石的疼痛性CP患者，ASGE建议根据结石的大小、位置及是否透过射线制定诊疗策略： A. 对于位于胰头、胰颈及胰体部，且直径>5 mm的不透射线结石，ASGE建议采用ERCP联合或不联合胰管镜检查，或单独使用ESWL治疗； B. 在ESWL治疗后，若结石充分碎裂（定义为碎片<2~3 mm）但仍未自发排出的情况，ASGE建议联合ERCP（可选择性联合胰管镜检查）以清除结石； C. 对于直径<5 mm的不透射线结石、任何透射线结石，或存在ESWL禁忌证的情况，ASGE推荐ERCP联合或不联合胰管镜检查。（条件性推荐/极低至低证据质量）
4.对于合并MPD狭窄的疼痛性CP患者，在接受ERCP治疗时，胰管支架置入的最佳策略是什么?	对于合并MPD狭窄的疼痛性CP患者，ASGE推荐采取以下治疗策略： A. 支架数量：ASGE建议，对于MPD显著狭窄的初始治疗，推荐置入单根塑料支架（plastic stent, PS）而非多根PS； B. 支架直径：ASGE建议，对于MPD显著狭窄的初始治疗，应在确保安全放置的前提下选择直径尽可能大的PS，同时避免强行或创伤性置入操作，必要时可逐步更换更大直径的支架； C. 金属支架的使用：ASGE不建议对初始支架置入失败的持续性或难治性胰管狭窄患者常规使用全覆膜自膨式金属支架（fully covered self-expandable metal stent, FCSEMS）。（条件性推荐/证据质量极低）
5.对于合并良性胆道狭窄（benign biliary stricture, BBS）的CP患者，若出现黄疸和（或）碱性磷酸酶升高持续超过4周，多根PS与FCSEMS的疗效对比如何?	ASGE建议，对于CP继发的BBS的治疗，推荐优先选择FCSEMS而非多根PS。（条件性推荐/证据质量低至中等）
6.在有CP和症状性假性囊肿的患者中，内镜引流和外科引流相比如何?	在CP患者中，对于症状性假性囊肿，ASGE推荐内镜引流而非外科引流。（有条件性推荐/低证据等级）

表1

表2

参考文献 28

[1]	BEYER G, HABTEZION A, WERNER J, et al. Chronic pancreatitis[J]. Lancet, 2020, 396(10249):499-512. doi: S0140-6736(20)31318-0 pmid: 32798493
[2]	HINES O J, PANDOL S J. Management of chronic panc-reatitis[J]. BMJ, 2024, 384:e070920.
[3]	DREWES A M, OLESEN A E, FARMER A D, et al. Gastrointestinal pain[J]. Nat Rev Dis Primers, 2020, 6(1):1. doi: 10.1038/s41572-019-0135-7 pmid: 31907359
[4]	LAYER P, YAMAMOTO H, KALTHOFF L, et al. The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis[J]. Gastroenterology, 1994, 107(5):1481-1487. doi: 10.1016/0016-5085(94)90553-3 pmid: 7926511
[5]	SCHNEIDER A, HIRTH M. Pain Management in chronic pancreatitis: Summary of clinical practice, current challenges and potential contribution of the M-ANNHEIM classification[J]. Drugs, 2021, 81(5):533-546. doi: 10.1007/s40265-021-01472-7 pmid: 33587287
[6]	SHETH S G, MACHICADO J D, CHHODA A, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis: methodology and review of evidence[J]. Gastrointest Endosc, 2025, 101(1):e1-e53.
[7]	CAHEN D L, GOUMA D J, NIO Y, et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis[J]. N Engl J Med, 2007, 356(7):676-684.
[8]	CAHEN D L, GOUMA D J, LARAMÉE P, et al. Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis[J]. Gastroenterology, 2011, 141(5):1690-1695. doi: 10.1053/j.gastro.2011.07.049 pmid: 21843494
[9]	ISSA Y, KEMPENEERS M A, BRUNO M J, et al. Effect of early surgery vs endoscopy-first approach on pain in patients with chronic pancreatitis: The ESCAPE randomi-zed clinical trial[J]. JAMA, 2020, 323(3):237-247.
[10]	KEMPENEERS M A, ISSA Y, BRUNO M J, et al. Cost-effectiveness of early surgery versus endoscopy-first approach for painful chronic pancreatitis in the ESCAPE trial[J]. Ann Surg, 2023, 277(4):e878-e884.
[11]	王伟, 廖专, 李兆申, 等. 慢性胰腺炎胰管结石的内镜介入与手术治疗[J]. 中华肝胆外科杂志, 2009, 15(7):502-505.
	WANG W, LIAO Z, LI Z S, et al. Management of pancrea-tic stones: endoscopy or surgery[J]. Chin J Hepatobiliary Surg, 2009, 15(7):502-505.
[12]	张楚悦, 梁光进, 苏莹珍, 等. 内镜介入和外科手术治疗慢性胰腺炎疗效的荟萃分析[J]. 中华肝胆外科杂志, 2023, 29(1):54-59.
	ZHANG C Y, LIANG G J, SU Y Z, et al. Clinical effectiveness of endoscopic versus surgical treatment of chronic pancreatitis: a meta-analysis[J]. Chin J Hepatobiliary Surg, 2023, 29(1):54-59.
[13]	GRESS F, SCHMITT C, SHERMAN S, et al. A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain[J]. Am J Gastroenterol, 1999, 94(4):900-905. pmid: 10201454
[14]	SANTOSH D, LAKHTAKIA S, GUPTA R, et al. Clinical trial: a randomized trial comparing fluoroscopy guided percutaneous technique vs. endoscopic ultrasound guided technique of coeliac plexus block for treatment of pain in chronic pancreatitis[J]. Aliment Pharmacol Ther, 2009, 29(9):979-984.
[15]	刘文静, 翟亚奇, 陈升鑫, 等. 慢性胰腺炎疼痛的非外科治疗[J]. 中华胰腺病杂志, 2024, 24(4):318-320.
	LIU W J, ZHAI Y Q, CHEN S X, et al. Nonsurgical treatment of chronic pancreatitis pain[J]. Chin J Pancreatol, 2024, 24(4):318-320.
[16]	DREWES A M, KEMPENEERS M A, ANDERSEN D K, et al. Controversies on the endoscopic and surgical mana-gement of pain in patients with chronic pancreatitis: pros and cons![J]. Gut, 2019, 68(8):1343-1351.
[17]	BICK B L, PATEL F, EASLER J J, et al. A comparative study between single-operator pancreatoscopy with intraductal lithotripsy and extracorporeal shock wave lithotripsy for the management of large main pancreatic duct stones[J]. Surg Endosc, 2022, 36(5):3217-3226.
[18]	DUMONCEAU J M, COSTAMAGNA G, TRINGALI A, et al. Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial[J]. Gut, 2007, 56(4):545-552.
[19]	VAYSSE T, BOYTCHEV I, ANTONI G, et al. Efficacy and safety of extracorporeal shock wave lithotripsy for chronic pancreatitis[J]. Scand J Gastroenterol, 2016, 51(11):1380-1385.
[20]	SUZUKI Y, SUGIYAMA M, INUI K, et al. Management for pancreatolithiasis: a Japanese multicenter study[J]. Pancreas, 2013, 42(4):584-588.
[21]	PAPALAVRENTIOS L, MUSALA C, GKOLFAKIS P, et al. Multiple stents are not superior to single stent insertion for pain relief in patients with chronic pancreatitis: a retrospective comparative study[J]. Endosc Int Open, 2019, 7(12):E1595-E1604.
[22]	SAUER B G, GURKA M J, ELLEN K, et al. Effect of pancreatic duct stent diameter on hospitalization in chronic pancreatitis: does size matter?[J]. Pancreas, 2009, 38(7):728-731.
[23]	LEE S H, KIM Y S, KIM E J, et al. Long-term outcomes of fully covered self-expandable metal stents versus plastic stents in chronic pancreatitis[J]. Sci Rep, 2021, 11(1):15637. doi: 10.1038/s41598-021-94726-z pmid: 34341385
[24]	COTÉ G A, SLIVKA A, TARNASKY P, et al. Effect of covered metallic stents compared with plastic stents on benign biliary stricture resolution: A randomized clinical trial[J]. JAMA, 2016, 315(12):1250-1257. doi: 10.1001/jama.2016.2619 pmid: 27002446
[25]	RAMCHANDANI M, LAKHTAKIA S, COSTAMAGNA G, et al. Fully covered self-expanding metal stent vs multiple plastic stents to treat benign biliary strictures secon-dary to chronic pancreatitis: A multicenter randomized trial[J]. Gastroenterology, 2021, 161(1):185-195.
[26]	VARADARAJULU S, BANG J Y, SUTTON B S, et al. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial[J]. Gastroenterology, 2013, 145(3):583-90.e1. doi: 10.1053/j.gastro.2013.05.046 pmid: 23732774
[27]	FARIAS G F A, BERNARDO W M, DE MOURA D T H, et al. Endoscopic versus surgical treatment for pancreatic pseudocysts: Systematic review and meta-analysis[J]. Medicine (Baltimore), 2019, 98(8):e14255.
[28]	QUINN P L, BANSAL S, GALLAGHER A, et al. Endoscopic versus laparoscopic drainage of pancreatic pseudocysts: a cost-effectiveness analysis[J]. J Gastrointest Surg, 2022, 26(8):1679-1685. doi: 10.1007/s11605-022-05346-5 pmid: 35562640

分组/临床结局指标	内镜治疗组与手术治疗组比较
死亡率^[7-9] 操作相关死亡率总体死亡率	2组均未报告操作相关的死亡病例 2组无统计学差异
技术成功率	内镜治疗组显著低于手术治疗组（OR=0.07; 95%CI为0.02~0.24; I² = 0%, P < 0.001）
不良事件发生率	2组无统计学差异（OR=2.31; 95%CI为0.31~17.30; I² = 81.78%, P = 0.41）
住院时长	2组无统计学差异
疼痛缓解总体疼痛缓解完全疼痛缓解部分疼痛缓解	内镜治疗组缓解率更低（OR=0.38; 95%CI为0.21~0.70); I² = 0, P < 0.001）内镜治疗组缓解率更低（OR=0.44; 95%CI为0.23~0.87; I² = 0, P = 0.02） 2组无统计学差异（OR=0.70; 95%CI为0.37~1.33; I² = 0, P = 0.27）
生活质量躯体生活质量精神生活质量	内镜治疗组评分更低（平均差-3.66; 95%CI为-7.29~0.04; I² = 0; P = 0.05） 2组无统计学差异（平均差-2.63; 95%CI为-6.27~1.02; I² = 0; P = 0.16)
胰腺功能胰腺外分泌功能不全胰腺内分泌功能不全	2组胰腺外分泌功能均无明显恶化或改善 2组无统计学差异（OR=1.41; 95%CI为0.35~5.64; I² = 58.33%, P = 0.62）