妊娠期和产褥期患者行内镜逆行胰胆管造影的有效性及安全性对比分析
DOI: 10.3969/j.issn.1001-5256.2023.12.020
Efficacy and safety of endoscopic retrograde cholangiopancreatography during pregnancy and puerperium: A comparative analysis
-
摘要:
目的 对比分析妊娠期和产褥期患者行内镜逆行胰胆管造影(ERCP)的有效性及安全性。 方法 回顾性分析2007年1月—2022年8月因胆胰疾病在南昌大学第一附属医院消化内镜中心接受ERCP诊疗的妊娠期患者22例、产褥期患者39例的临床资料。收集并比较两组患者基线资料、ERCP术中诊断、干预措施、ERCP诊疗前后实验室检查结果、ERCP术后并发症、分娩结局和胎儿结局等数据。计量资料两组间比较采用成组t检验。计数资料两组间比较采用χ2检验或Fisher精确检验。 结果 妊娠期和产褥期两组患者对比,除妊娠期患者行CT检查率显著低于产褥期患者(22.73% vs 58.97%,χ2=7.44,P=0.006)以外,其余基线资料两组间均无统计学差异(P值均>0.05)。在ERCP诊疗中,妊娠期患者行胆道取石、经内镜乳头球囊扩张术均显著低于产褥期患者(χ2值分别为4.007、4.315,P值均<0.05),妊娠期患者未使用X线透视的比例高于产褥期患者(χ2=12.103,P=0.001)。两组患者ERCP术后WBC、TBil、DBil、ALT、AST较术前均有显著改善(P值均<0.05)。两组患者ERCP术后总体并发症发生率为7.04%(5/71),以术后胆系感染最为常见,两组患者术后并发症发生率无显著差异(P>0.05)。在分娩和胎儿结局方面,妊娠期患者提前终止妊娠比例高于产褥期患者(50.00% vs 0,χ2=20.528,P<0.001),妊娠期患者的剖宫产率显著低于产褥期患者(36.36% vs 76.92%,χ2=4.756,P=0.029)。胎儿异常发育及死胎等不良事件的发生率两组间无显著差异(P>0.05)。 结论 在严格把握ERCP指征和时机的情况下,无论在妊娠期还是产褥期,行ERCP诊疗是有效和相对安全的,患者ERCP并发症发生率与普通人群相当,且有较好的分娩和胎儿结局。 -
关键词:
- 胰胆管造影术, 内窥镜逆行 /
- 妊娠期 /
- 产后期 /
- 对比研究
Abstract:Objective To investigate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy and puerperium through a comparative analysis. Methods A retrospective analysis was performed for the clinical data of 22 patients in pregnancy and 39 patients in puerperium who received ERCP in Digestive Endoscopy Center of The First Affiliated Hospital of Nanchang University from January 2007 to August 2022. The two groups of patients were compared in terms of baseline data, diagnosis during ERCP, interventions, laboratory results before and after ERCP, post-ERCP complications, and delivery and fetal outcomes. The independent-samples t test was used for comparison of continuous data between two groups, and the chi-square test or the Fisher’s exact test was used for comparison of categorical data between two groups. Results There were no significant differences between the patients in pregnancy and those in puerperium in all baseline data (all P>0.05) except the rate of CT examination (22.73% vs 58.97%, χ2=7.44, P=0.006). During the ERCP procedure, compared with the patients in puerperium, the patients in pregnancy had a significantly lower proportion of the patients who underwent biliary stone extraction or endoscopic papillary balloon dilation (χ2=4.007 and 4.315, both P<0.05) and a significantly higher proportion of the patients who did not receive X-ray fluoroscopy (χ2=12.103, P=0.001). After ERCP, both groups had significant improvements in white blood cell count, total bilirubin, direct bilirubin, alanine aminotransferase, and aspartate aminotransferase (all P<0.05). The overall incidence rate of post-ERCP complications was 7.04% (5/71) for all patients, with post-ERCP biliary infection as the most common complication (3/71,4.23%), and there was no significant difference in the incidence rate of post-ERCP complications between the two groups (P>0.05). As for delivery and fetal outcomes, compared with the patients in puerperium, the patients in pregnancy had a significantly higher proportion of patients with early termination of pregnancy (50.00% vs 0,χ2=20.528, P<0.001) and a significantly lower proportion of patients with cesarean section (36.36% vs 76.92%, χ2=4.756, P=0.029). There were no significant differences in the incidence rates of adverse events such as abnormal fetal development and stillbirth between the two groups (P>0.05). Conclusion With strict control of ERCP indications and timing, ERCP is effective and relatively safe in both pregnancy and puerperium and has a comparable incidence rate of post-ERCP complications to that in the general population, with relatively good delivery and fetal outcomes. -
表 1 两组患者基线资料
Table 1. Baseline information of patients
项目 妊娠期患者(n=22) 产褥期患者(n=39) χ2值 P值 年龄[例(%)] 15~20岁 1(4.55) 2(5.13) 0.000 >0.05 21~30岁 14(63.64) 32(82.05) 2.572 0.109 31~40岁 7(31.82) 5(12.82) 2.123 0.145 临床表现[例(%)] 腹痛腹胀 22(100.00) 37(94.87) 0.531 恶心呕吐 15(68.18) 29(74.36) 0.267 0.605 黄疸 9(40.91) 14(35.90) 0.150 0.698 发热 8(36.36) 6(15.38) 3.501 0.061 ERCP术前诊断[例(%)] 胆总管结石 20(90.91) 33(84.62) 0.093 0.761 胆管炎 9(40.91) 10(25.64) 1.529 0.216 急性胰腺炎 13(59.09) 23(58.97) 0.000 0.993 轻症 10(76.92) 13(56.52) 0.745 0.388 中度重症 1(7.69) 4(17.39) 0.094 0.759 重症 2(15.38) 6(26.09) 0.105 0.746 胆道蛔虫 1(4.55) 2(5.13) 0.000 >0.05 胆胰肿瘤性病变 1(4.55) 1(2.56) >0.05 胰管结石 0(0.00) 2(5.13) 0.531 胆管狭窄 0(0.00) 2(5.13) 0.531 既往史[例(%)] 胆石症 7(31.82) 9(23.08) 0.555 0.456 胆囊切除史 3(13.64) 1(2.56) 1.297 0.255 ERCP手术史 1(4.55) 1(2.56) >0.05 胰腺炎病史 1(4.55) 1(2.56) >0.05 多囊卵巢 1(4.55) 2(5.13) 0.000 >0.05 影像学检查[例(%)] B超 21(95.45) 37(94.87) 0.000 >0.05 MRCP 18(81.82) 36(92.31) 0.666 0.414 CT 5(22.73) 23(58.97) 7.442 0.006 超声内镜 2(9.09) 2(5.13) 0.004 0.951 术前使用抗生素[例(%)] 18(81.82) 27(69.23) 1.152 0.283 表 2 两组患者ERCP术中诊断及治疗措施
Table 2. ERCP diagnosis and therapeutic measures
项目 妊娠期ERCP例次(n=24) 产褥期ERCP例次(n=47) χ2值 P值 操作次数[例(%)] 1次 20(83.33) 31(65.96) 0.635 0.425 ≥2次 2(8.33) 8(17.02) 0.635 0.425 技术成功[例(%)] 24(100.00) 46(97.87) >0.05 术中诊断[例(%)] 胆总管结石 18(75.00) 32(68.09) 0.365 0.546 胆囊结石 7(29.17) 7(14.89) 1.242 0.265 十二指肠胆管瘘 1(4.17) 0(0.00) 0.338 十二指肠乳头旁憩室 3(12.50) 1(2.13) 1.560 0.212 化脓性胆管炎 4(16.67) 3(6.38) 0.910 0.340 乳头结石嵌顿 4(16.67) 1(2.13) 3.149 0.076 胰管结石 0(0.00) 1(2.13) >0.05 胰腺假性囊肿 1(4.17) 0(0.00) 0.338 胆总管蛔虫 1(4.17) 2(4.26) 0.000 >0.05 胆总管狭窄 0(0.00) 2(4.26) 0.546 Mirrizi综合征 0(0.00) 1(2.13) >0.05 胰腺分裂 0(0.00) 1(2.13) >0.05 胰胆管汇合异常 0(0.00) 1(2.13) >0.05 胆道肿瘤 1(4.17) 0(0.00) 0.338 十二指肠乳头癌 0(0.00) 1(2.13) >0.05 硬化性胆管炎 0(0.00) 1(2.13) >0.05 干预措施[例(%)] 胆道取石 11(45.83) 33(70.21) 4.007 0.045 胆道取蛔虫 1(4.17) 2(4.26) 0.000 >0.05 EST 18(75.00) 34(72.34) 0.057 0.811 ENBD 6(25.00) 15(31.91) 0.365 0.546 ERBD 14(58.33) 17(36.17) 3.173 0.075 ERPD 2(8.33) 6(12.77) 0.026 0.871 EPBD 0(0.00) 10(21.28) 4.315 0.038 胆道探条扩张术 0(0.00) 2(4.26) 0.546 取支架 0(0.00) 3(6.38) 0.411 0.521 预切开 4(16.67) 1(2.13) 3.149 0.076 胆道镜 0(0.00) 4(8.51) 0.860 0.354 进入胰管次数[例(%)] 0次 21(87.50) 39(82.98) 0.023 0.880 1次 3(12.50) 3(6.38) 0.181 0.670 ≥2次 0(0.00) 5(10.64) 1.362 0.243 未使用X线透视[例(%)] 7(29.17) 0(0.00) 12.103 0.001 表 3 ERCP术前术后实验室检查结果
Table 3. Pre-ERCP and post-ERCP blood tests
指标 妊娠期患者(n=22) t值 P值 产褥期患者(n=39) t值 P值 术前 术后 术前 术后 TBil(μmol/L) 55.15±12.32 34.16±7.62 3.243 0.004 58.72±10.39 28.85±4.34 3.593 0.001 DBil(μmol/L) 35.00±7.81 20.84±4.92 3.188 0.004 39.12±7.98 14.25±2.60 3.78 <0.001 ALT(U/L) 155.56±35.51 91.56±21.39 2.236 0.035 99.06±17.92 47.01±7.60 3.978 <0.001 AST(U/L) 99.47±17.86 47.59±8.29 2.689 0.013 87.28±13.46 27.90±1.911) 4.524 <0.001 ALP(U/L) 181.89±23.58 174.44±20.78 0.714 0.483 238.70±28.35 176.38±13.18 3.294 0.002 GGT(U/L) 136.27±29.62 111.46±18.39 1.779 0.088 146.71±20.14 105.28±11.68 3.262 0.002 WBC(×109/L) 10.58±1.11 8.69±0.70 2.536 0.018 9.69±0.60 7.65±0.42 3.762 <0.001 注:与妊娠期术后相比,1)P<0.05。 表 4 分娩及胎儿结局
Table 4. Delivery and fetal outcomes
项目 妊娠期患者(n=22) 产褥期患者 (n=39) χ2值 P值 分娩结局[例(%)] 20.528 <0.001 提前终止妊娠 11(50.00) 0(0.00) 顺利分娩 11(50.00) 39(100.00) 分娩方式[例(%)] 4.756 0.029 剖宫产 4(36.36) 30(76.92) 阴道分娩 7(63.64) 9(23.08) 胎儿结局[例(%)] >0.05 死胎 0(0.00) 1(2.56) 活胎 11(100.00) 38(97.44) -
[1] de BARI O, WANG TY, LIU M, et al. Cholesterol cholelithiasis in pregnant women: Pathogenesis, prevention and treatment[J]. Ann Hepatol, 2014, 13( 6): 728- 745. [2] DENG J, HAN ZY, LU MN, et al. Analysis of prevalence, epidemic trend and characteristics of cholelithiasis[J]. Mod Dig Interv, 2022, 27( 1): 80- 83. DOI: 10.3969/j.issn.1672-2159.2022.01.018.邓江, 韩致毅, 卢梦楠, 等. 胆石症患病率、流行趋势及特征分析[J]. 现代消化及介入诊疗, 2022, 27( 1): 80- 83. DOI: 10.3969/j.issn.1672-2159.2022.01.018. [3] KO CW. Risk factors for gallstone-related hospitalization during pregnancy and the postpartum[J]. Am J Gastroenterol, 2006, 101( 10): 2263- 2268. DOI: 10.1111/j.1572-0241.2006.00730.x. [4] BIAN DP, DONG JP, NIU HX, et al. Value of nasobiliary cholangiography in the diagnosis of residual common bile duct stones after endoscopic retrograde cholangiopancreatography and related factors of residual common bile duct stones[J]. J Clin Hepatol, 2021, 37( 4): 868- 871. DOI: 10.3969/j.issn.1001-5256.2021.04.028.边大鹏, 董锦沛, 牛海霞, 等. 鼻胆管造影对经内镜逆行胰胆管造影取石术后结石残留的诊断价值及结石残留相关因素分析[J]. 临床肝胆病杂志, 2021, 37( 4): 868- 871. DOI: 10.3969/j.issn.1001-5256.2021.04.028. [5] ERCP Group, Chinese Society of Digestive Endoscopology; Group Biliopancreatic, Chinese Association of Gastroenterologist; Hepatologist National Clinical Research Center for Digestive Diseases. China ERCP guide(2018 edition)[J]. Chin J Dig Endosc, 2018, 35( 11): 777- 813. DOI: 10.3760/cma.j.issn.1007-5232.2018.11.001.中华医学会消化内镜学分会ERCP学组, 中国医师协会消化医师分会胆胰学组, 国家消化系统疾病临床医学研究中心. 中国ERCP指南(2018版)[J]. 中华消化内镜杂志, 2018, 35( 11): 777- 813. DOI: 10.3760/cma.j.issn.1007-5232.2018.11.001. [6] CAPPELL MS, STAVROPOULOS SN, FRIEDEL D. Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography[J]. World J Gastrointest Endosc, 2018, 10( 10): 308- 321. DOI: 10.4253/wjge.v10.i10.308. [7] SHABANZADEH DM. Incidence of gallstone disease and complications[J]. Curr Opin Gastroenterol, 2018, 34( 2): 81- 89. DOI: 10.1097/MOG.0000000000000418. [8] SHERGILL AK, BEN-MENACHEM T, CHANDRASEKHARA V, et al. Guidelines for endoscopy in pregnant and lactating women[J]. Gastrointest Endosc, 2012, 76( 1): 18- 24. DOI: 10.1016/j.gie.2012.02.029. [9] ARCE-LIÉVANO E, DEL RÍO-SUÁREZ I, VALENZUELA-SALAZAR C, et al. Endoscopic retrograde cholangiopancreatography results for the treatment of symptomatic choledocholithiasis in pregnant patients: A recent experience at a secondary care hospital in Mexico City[J]. Rev Gastroenterol Mex(Engl Ed), 2021, 86( 1): 21- 27. DOI: 10.1016/j.rgmx.2019.12.001. [10] KONDUK BT, BAYRAKTAR O. Efficacy and safety of endoscopic retrograde cholangiopancreatography in pregnancy: A high-volume study with long-term follow-up[J]. Turk J Gastroenterol, 2019, 30( 9): 811- 816. DOI: 10.5152/tjg.2019.18799. [11] TALUKDAR R. Complications of ERCP[J]. Best Pract Res Clin Gastroenterol, 2016, 30( 5): 793- 805. DOI: 10.1016/j.bpg.2016.10.007. [12] MENDEZ-SANCHEZ N, CHAVEZ-TAPIA NC, URIBE M. Pregnancy and gallbladder disease[J]. Ann Hepatol, 2006, 5( 3): 227- 230. [13] MAGNO-PEREIRA V, MOUTINHO-RIBEIRO P, MACEDO G. Demystifying endoscopic retrograde cholangiopancreatography(ERCP) during pregnancy[J]. Eur J Obstet Gynecol Reprod Biol, 2017, 219: 35- 39. DOI: 10.1016/j.ejogrb.2017.10.008. [14] SMITH I, GAIDHANE M, GOODE A, et al. Safety of endoscopic retrograde cholangiopancreatography in pregnancy: Fluoroscopy time and fetal exposure, does it matter?[J]. World J Gastrointest Endosc, 2013, 5( 4): 148- 153. DOI: 10.4253/wjge.v5.i4.148. [15] LEE JJ, LEE SK, KIM SH, et al. Efficacy and safety of pancreatobiliary endoscopic procedures during pregnancy[J]. Gut Liver, 2015, 9( 5): 672- 678. DOI: 10.5009/gnl14217. [16] OTHMAN MO, STONE E, HASHIMI M, et al. Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits[J]. Gastrointest Endosc, 2012, 76( 3): 564- 569. DOI: 10.1016/j.gie.2012.04.475. [17] NEUHAUS H. Choledocholithiasis in pregnancy: When and how to perform ERCP?[J]. Endosc Int Open, 2020, 8( 10): E1508- E1510. DOI: 10.1055/a-1196-1683. [18] FENG Q, CHENG XY, LIU Z. Safety of endoscopic retrograde cholangiopancreatography during pregnancy for disease diagnosis and treatment[J]. World Chin J Dig, 2018, 26( 4): 250- 255. DOI: 10.11569/wcjd.v26.i4.250.冯琴, 程晓英, 刘展. 妊娠期间行ERCP诊治的进展[J]. 世界华人消化杂志, 2018, 26( 4): 250- 255. DOI: 10.11569/wcjd.v26.i4.250. [19] AZAB M, BHARADWAJ S, JAYARAJ M, et al. Safety of endoscopic retrograde cholangiopancreatography(ERCP) in pregnancy: A systematic review and meta-analysis[J]. Saudi J Gastroenterol, 2019, 25( 6): 341- 354. DOI: 10.4103/sjg.SJG_92_19. [20] SHARMA SS, MAHARSHI S. Two stage endoscopic approach for management of choledocholithiasis during pregnancy[J]. J Gastrointestin Liver Dis, 2008, 17( 2): 183- 185. [21] RAIJMAN I. Performing endoscopic retrograde cholangiography without radiation exposure: Are we ready for it?[J]. Gastrointest Endosc, 2016, 84( 5): 770- 772. DOI: 10.1016/j.gie.2016.04.042. [22] KAMANI L, ACHAKZAI MS, ISMAIL FW, et al. Safety of endoscopy and its outcome in pregnancy[J]. Cureus, 2019, 11( 12): e6301. DOI: 10.7759/cureus.6301. [23] HAYASHI S, TAKENAKA M, HOSONO M, et al. Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography[J]. World J Clin Cases, 2018, 6( 16): 1087- 1093. DOI: 10.12998/wjcc.v6.i16.1087. [24] LAUDANNO O, GARRIDO J, AHUMARÁN G, et al. Long-term follow-up after fetal radiation exposure during endoscopic retrograde cholangiopancreatography[J]. Endosc Int Open, 2020, 8( 12): E1909- E1914. DOI: 10.1055/a-1293-7783. [25] LI LF, WEI HP, LIU GR, et al. Changes and clinical significance of aspartate aminotransferase, alanine aminotransferase and γ-glutamyl transferase in patients with cirrhosis[J]. China Mod Med, 2022, 29( 6): 110- 113. DOI: 10.3969/j.issn.1674-4721.2022.06.031.黎灵锋, 韦慧萍, 刘桂荣, 等. 门冬氨酸转氨酶、丙氨酸转氨酶与γ谷氨酰基转移酶在肝硬化患者中的变化及临床意义[J]. 中国当代医药, 2022, 29( 6): 110- 113. DOI: 10.3969/j.issn.1674-4721.2022.06.031. [26] AKSHINTALA VS, KANTHASAMY K, BHULLAR FA, et al. Incidence, severity, and mortality of post-ERCP pancreatitis: An updated systematic review and meta-analysis of 145 randomized controlled trials[J]. Gastrointest Endosc, 2023, 98( 1): 1- 6.e12. DOI: 10.1016/j.gie.2023.03.023. [27] LIN Y, LIN XY, CHEN R, et al. Application of ERCP in treatment of common bile duct stones after cholecystectomy[J/OL]. Chin J Hepat Surg(Electronic Edition), 2021, 10( 5): 502- 505. DOI: 10.3877/cma.j.issn.2095-3232.2021.05.015.林颖, 林显艺, 陈荣, 等. ERCP在胆囊切除术后胆总管结石治疗中的应用[J/OL]. 中华肝脏外科手术学电子杂志, 2021, 10( 5): 502- 505. DOI: 10.3877/cma.j.issn.2095-3232.2021.05.015. [28] INAMDAR S, BERZIN TM, SEJPAL DV, et al. Pregnancy is a risk factor for pancreatitis after endoscopic retrograde cholangiopancreatography in a national cohort study[J]. Clin Gastroenterol Hepatol, 2016, 14( 1): 107- 114. DOI: 10.1016/j.cgh.2015.04.175.
计量
- 文章访问数: 248
- HTML全文浏览量: 71
- PDF下载量: 27
- 被引次数: 0