外科理论与实践 ›› 2023, Vol. 28 ›› Issue (06): 540-550.doi: 10.16139/j.1007-9610.2023.06.010

• 论著 • 上一篇    下一篇

不同插管方法在ERCP困难胆管插管的效果:系统评价和网状荟萃分析

祁洋, 姚文飞, 李谦益, 姚伟, 孔雷, 徐瑞云, 吴宇权, 李能平()   

  1. 上海交通大学医学院附属瑞金医院普外科,上海 200025
  • 收稿日期:2022-10-31 出版日期:2023-11-25 发布日期:2024-03-04
  • 通讯作者: 李能平,E-mail:linengp@163.com
  • 基金资助:
    上海市卫生和健康委员会科研课题基金(201740203)

Efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis

QI Yang, YAO Wenfei, LI Qianyi, YAO Wei, KONG Lei, XU Ruiyun, WU Yuquan, LI Nengping()   

  1. Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
  • Received:2022-10-31 Online:2023-11-25 Published:2024-03-04

摘要:

目的: 应用网状荟萃分析,比较不同插管方法在内镜逆行胰胆管造影术(endoscopic retrograde cholangio-pancreatography, ERCP)困难胆管插管时的效果。方法: 选取英文发表的随机对照研究文献,对ERCP困难胆管插管时所采用的不同插管方法(早期或晚期针刀切开法、胰腺导丝辅助法、胰腺支架辅助法、经胰腺括约肌切开法、持续常规插管法)的效果,进行比较分析。主要观察指标为胆管插管成功率以及ERCP术后胰腺炎(post-ERCP pancreatitis,PEP)发生率。对不同插管方法的效果进行成对和网状荟萃分析,并根据累积排名曲线下面积(surface under the cumulative ranking curve, SUCRA)进行排名。结果: 18项研究符合要求,共2 033例病人。经胰腺括约肌切开法的胆管插管成功率显著高于持续常规插管法(RR=1.34, 95% CI:1.02~1.77)、胰腺导丝辅助法(RR=1.26, 95% CI:1.00~1.60)。根据SUCRA评分排名,经胰腺括约肌切开法胆道插管成功率最高,其次为早期针刀切开法。与持续常规插管法相比,只有早期针刀切开法可显著降低PEP发生率(RR=0.53, 95%CI:0.30~0.94)。与胰腺导丝辅助法相比,早期针刀切开法(RR=0.41, 95%CI:0.17~0.99)、经胰腺括约肌切开法(RR=0.49, 95%CI:0.25~0.96)的PEP发生率均显著降低。根据SUCRA评分排名,早期针刀切开法对降低PEP发生率效果最显著,其次为经胰腺括约肌切开法。结论: 经胰腺括约肌切开法可提高ERCP困难胆管插管时的胆管插管成功率;早期针刀切开法、经胰腺括约肌切开法可降低PEP发生率,可作为ERCP困难胆道插管时的选择方法。

关键词: 内镜逆行胰胆管造影, 困难胆管插管, 网状荟萃分析

Abstract:

Objective To assess the comparative efficacy of different methods for difficult biliary cannulation in endoscopic retrograde cholangio-pancreatography (ERCP) through a network meta-analysis. Methods Randomized controlled trials (RCTs) that compared the efficacy of different adjunctive methods (early or late needle-knife technique, pancreatic guidewire-assisted technique, pancreatic stent-assisted technique, transpancreatic sphincterotomy, persistent standard cannulation technique) for difficult biliary cannulation with each other were identified. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. Pairwise and network meta-analysis and ranking according to surface under the cumulative ranking curve(SUCRA) for all methods were performed. Results Eighteen RCTs were identified according to selection criteria, and 2 033 patients were enrolled. The use of transpancreatic sphincterotomy over persistent standard cannulation technique (RR=1.34, 95% CI: 1.02-1.77) and over pancreatic guidewire-assisted technique(RR=1.26, 95% CI: 1.00-1.60)significantly increased the success rate of biliary cannulation. Based on SUCRA ranking, transpancreatic sphincterotomy followed by early needle-knife techniques were ranked highest in terms of increasing the success rate of biliary cannulation. Only early needle-knife technique significantly decreased PEP rate when compared with persistent standard cannulation technique (RR=0.53, 95%CI: 0.30-0.94), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR=0.41, 95%CI: 0.17-0.99; RR=0.49, 95%CI: 0.25-0.96; respectively). Based on SUCRA ranking, early needle-knife technique followed by transpancreatic sphincterotomy were ranked highest for decreasing the PEP rate of biliary cannulation. Conclusions Transpancreatic sphincterotomy increases the success rate of difficult biliary cannulation in ERCP; early needle-knife technique and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered as a choice of difficult biliary cannulation.

Key words: Endoscopic retrograde cholangio-pancreatography, Difficult biliary cannulation, Network meta-analysis

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