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

doi:10.16139/j.1007-9610.2023.06.010

摘要/Abstract

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

中图分类号:

祁洋, 姚文飞, 李谦益, 姚伟, 孔雷, 徐瑞云, 吴宇权, 李能平. 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[J]. 外科理论与实践, 2023, 28(06): 540-550.

QI Yang, YAO Wenfei, LI Qianyi, YAO Wei, KONG Lei, XU Ruiyun, WU Yuquan, LI Nengping. Efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis[J]. Journal of Surgery Concepts & Practice, 2023, 28(06): 540-550.

图/表 10

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纳入文献基本信息

Serial number	Author (date of publication)	Experimental group	Control subject	Number of cases	Nation	Devise	Definition of difficult bile duct cannulation	Gender (M/F)	Age (y)	Etiology	Difficult cannulation rate (%)	Pancreatic duct stent application
1	Maeda^[11] (2003)	Pancreatic guidewire assisted technique	Persistent standard technique	27/26	Japan	Single-center	10 min	23/30	64 vs. 64	Unreported	49.50	Not use
2	Catalano^[12] (2004)	Transpancreatic sphincterotomy	Early needle- knife technique	31/32	United States of America	Single-center	30 min; multiple intra-pancreatic ductal injections of contrast media	38/25	68	11 cases of bile duct stones, 32 cases of obstructive jaundice, 15 cases of abdominal pain with abnormal liver function, 4 cases of SOD, 1 case of tumor	1.40	Selected cases
3	Tang^[13] (2005)	Early needle-knife technique	Persistent standard technique	32/30	Canada	Single-center	12 min	29/31	64.6 vs. 67.2	There were 23 cases of choledochal dilatation, 11 cases of choledochal stone, 21 cases of tumor, 12 cases of biliary pancreatitis, 34 cases of abdominal pain, 34 cases of jaundice, 40 cases of liver function abnormality, 5 cases of cholangitis.	9.70	Not use
4	Zhou^[14] (2006)	Early needle-knife technique	Persistent standard technique	43/48	China	Single-center	10 min; 3 accidental guidewire entries into pancreatic ducts	55/36	62.7 vs. 64.3	28 cases of choledochal dilatation, 20 cases of choledochal stones, 15 cases of acute cholangitis, 25 cases of tumor, 3 cases of gastrectomy type B-Ⅱ	9.60	Not use
5	Manes^[15] (2009)	Early needle-knife technique	Persistent standard technique	77/74	Italy	Multicenter	10 min; 5 accidental guidewire entries into pancreatic ducts	98/53	66 vs. 65	72 cases of choledocholithiasis, 56 cases of tumors, 4 cases of benign bile duct stenosis, 5 cases of bile leakage, 2 cases of SOD cholecystitis, 5 cases of choledocholithiasis, 2 cases of choledochal cyst, 5 cases of recurrent pancreatitis	9.50	Not use
6	Cennamo^[16] (2009)	Early needle-knife technique	Late needle-knife technique	36/32	Italy	Single-center	5 min; 3 accidental guidewire entries into pancreatic ducts	31/37	68 vs. 69	47 cases of bile duct stones, 21 cases of tumor	17.3	Not use
7	Herreros de Tejada^[17] (2009)	Pancreatic guidewire-assisted technique	Persistent standard technique	97/91	Spain	Multicenter	5 unsuccessful cannulations	76/112	69.5 vs. 65.8	100 cases of bile duct stones, 38 cases of tumor, 9 cases of acute cholangitis, 5 cases of benign bile duct stenosis, 12 cases of others, 27 cases of abnormal liver function, 7 cases of SOD	22.2	Selected cases
8	Cote^[18] (2012)	Pancreatic guidewire-assisted technique	Pancreatic stent-assisted technique	42/45	United States of America	Multicenter	6 min; 3 accidental guidewire entries into pancreatic ducts	Unreported	58.1 vs. 57.4	Unreported	19.7	Selected cases
9	Angsuwatcharakon^[19] (2012)	Pancreatic guidewire-assisted technique	Early needle- knife technique	23/21	Thailand	Single-center	10 min	23/21	66.1 vs. 64.1	23 cases of choledochal stones, 4 cases of gallbladder stones, 2 cases of Mirrizi's syndrome, 1 case of benign stenosis, 1 case of bile leakage, 13 cases of tumor	8.2	Not use
10	Swan^[20] (2013)	Early needle-knife technique	Persistent standard technique	39/34	Australia	Single-center	5 min; 5 cannulations; 2 accidental guidewire entries into pancreatic ducts	23/50	59 vs. 57	46 cases of choledocholithiasis, 8 cases of SOD, 6 cases of obstructive jaundice, 9 cases of benign bile duct stenosis, 4 cases of bile leaks	15.7	Selected cases
11	Yoo^[21] (2013)	Pancreatic guidewire-assisted technique	Transpancreatic sphincterotomy	34/37	South Korea (Republic of Korea)	Single-center	10 min; 10 unsuccessful cannulation	41/30	67 vs. 63.7	30 cases of choledochal stones, 13 cases of gallbladder stones, 18 cases of tumors, 10 cases of other	7.4	Not use
12	Zang^[22] (2014)	Transpancreatic sphincterotomy	Early needle-knife technique	73/76	China	Single-center	10 min; 5 accidental guidewire entries into pancreatic ducts	71/78	53.7 vs. 54.6	127 cases of choledocholithiasis, 17 cases of benign bile duct obstruction, 5 cases of bile leakage	13.9	Not use
13	Mariani^[23] (2016)	Early needle-knife technique	Persistent standard technique	185/190	Italy	Multicenter	5 min; 3 accidental guidewire entries into pancreatic ducts	165/210	70.4 vs. 68.2	223 cases of bile duct stones, 139 cases of tumors, 33 cases of cholangitis, 18 cases of SOD, 18 cases of benign bile duct stenosis, 12 cases of bile leaks, 11 cases of other	9.5	Not use
14	Zagalsky^[24] (2016)	Early needle-knife technique	Persistent standard technique	50/51	Argentina	Multicenter	8 min; 3 accidental guidewire entries into pancreatic ducts	31/70	52 vs. 49	Choledocholithiasis 78% vs. 82.3%, tumor 22% vs. 17.7%, acute pancreatitis 6% vs. 13.7%, recurrent pancreatitis 2% vs. 2%, others 14% vs. 15.7	8.7	Selected cases
15	Sugiyama^[25] (2018)	Transpancreatic sphincterotomy	Pancreatic guidewire-assisted technique	34/34	Japan	Single-center	15 min; 3 accidental guidewire entries into pancreatic ducts	37/31	69.8 vs. 67.3	18 cases of choledocholithiasis, 34 cases of tumor, 9 cases of benign bile duct stenosis, 3 cases of hepatocellular carcinoma, 1 case of SOD, 3 cases of other	25.8	All cases
16	Eminler^[26] (2019)	Pancreatic guidewire-assisted technique	Pancreatic stent-assisted technique	50/50	Istanbul	Single-center	5 min; 5 accidental guidewire entries into pancreatic ducts	40/60	56 vs. 52.9	76 cases of choledochal stones, 13 cases of tumors, 5 cases of benign strictures, and 6 cases of bile leaks	11	All cases
17	Tabak^[27] (2021)	Early needle knife technique	Transpancreatic sphincterotomy	43/43	China	Single-center	5 min; 5 unsuccessful cannulations; 2 guidewire entries into pancreatic ducts	51/35	61 vs. 59.4	57 cases of biliary stones, 16 cases of tumors, 18 cases of benign strictures, 3 cases of cholangitis, 5 cases of biliary pancreatitis	12.8	Selected cases
18	Kylanpaa^[28] (2021)	Transpancreatic sphincterotomy	Pancreatic guidewire-assisted technique	104/99	Finland, Denmark, Norway, Sweden	Multicenter	5 min; 5 unsuccessful cannulations	98/105	66 vs. 68	87 cases of choledocholithiasis, 91 cases of stricture, 12 cases of primary sclerosing cholangitis, and 17 cases of bile leakage, 20 cases of other	17.1	Selected cases

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Cannulation techniques	SUCRA (%)	PrBest (%)	MeanRank
Transpancreatic sphincterotomy	95.3	82.2	1.2
Early needle-knife technique	67.2	5.8	2.6
Pancreatic guidewire-assissted technique	50.7	1.7	3.5
Standard technique	35.8	0.7	4.2
Late needle-knife technique	27.2	6.3	4.6
Pancreatic stent-assisted technique	23.7	3.2	4.8

Cannulation techniques	SUCRA (%)	PrBest (%)	MeanRank
Early needle-knife technique	88	62.3	1.5
Transpancreatic sphincterotomy	75.2	28.5	2
Persistent standard technique	40.8	0.7	3.4
Pancreatic guidewire-assissted technique	23.2	0.2	4.1
Pancreatic stent-assisted technique	22.8	8.3	4.1