Consensus of Chinese experts on the endoscopic diagnosis and treatment of pancreatic leak(2020, Beijing)

doi:10.3877/cma.j.issn.2095-7157.2020.03.001

Abstract

Chinese Society of Digestive Endoscopy, Chinese Digestive Endoscopy Association, Beijing Digestive Endoscopy Society. Consensus of Chinese experts on the endoscopic diagnosis and treatment of pancreatic leak(2020, Beijing)[J]. Chinese Journal of Gastrointestinal Endoscopy(Electronic Edition), 2020, 07(03): 97-107.

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References 99

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高质量	进一步研究也不可能改变该疗效评估结果的可信度
中等质量	进一步研究很可能影响该疗效评估结果的可信度，且可能改变该评估结果
低质量	进一步研究极有可能影响该疗效评估结果的可信度，且该评估结果很可能改变
极低质量	任何疗效评估结果都很不确定

高质量	进一步研究也不可能改变该疗效评估结果的可信度
中等质量	进一步研究很可能影响该疗效评估结果的可信度，且可能改变该评估结果
低质量	进一步研究极有可能影响该疗效评估结果的可信度，且该评估结果很可能改变
极低质量	任何疗效评估结果都很不确定

定义与病因
?	1.胰瘘是指各种原因引起的富含胰酶的液体在胰管上皮和其他上皮组织之间的异常交通所引起的一系列临床综合征。
?	2.胰瘘常见的病因主要为胰腺外伤、胰腺及胰周外科手术、急性坏死性胰腺炎等。
诊断
?	3.经内镜逆行胰胆管造影(endoscopic retrograde cholangio-pancreatography, ERCP)及窦道造影是胰瘘诊断金标准。
?	4.外科术后胰瘘的诊断标准为：术后≥3 d后腹腔引流管仍有液体流出，且其淀粉酶浓度高于血清淀粉酶正常值上限的3倍。
?	5.急慢性胰腺炎相关胰瘘诊断标准为：(1)存在急性坏死性胰腺炎发作病史；(2)影像学支持胰瘘诊断。
分型分级
?	6.胰瘘分型建议根据胰瘘部位、开口方式及既往胰腺切除术式分型。外科术后分级建议采用ISGPS制定的2016版更新术后胰瘘(postoperative pancreatic fistula，POPF)分级。
适应证
?	7.内镜下胰瘘治疗主要用于有明显症状且保守治疗无效的患者。
预防性治疗
?	8.不推荐常规内镜下处理来预防外科术后胰瘘的发生。
内镜下手术治疗
?	9.对于与近端胰管相通的胰瘘，内镜下鼻胰管引流术、内镜下胰管支架置入术是内镜下常规治疗方式。
?	10.内镜下常规治疗失败的胰瘘，可尝试行内镜下封堵剂封堵治疗。
?	11. EUS引导下支架引流术可作为胰瘘所致胰周液体积聚的一线治疗方式，必要时可行内镜直视下坏死组织清创术。
?	12. EUS引导下引流术的支架选择(塑料/金属)目前尚存争议，但对于合并坏死的胰周液体积聚，更倾向于新型两端膨大式金属支架。

定义与病因
?	1.胰瘘是指各种原因引起的富含胰酶的液体在胰管上皮和其他上皮组织之间的异常交通所引起的一系列临床综合征。
?	2.胰瘘常见的病因主要为胰腺外伤、胰腺及胰周外科手术、急性坏死性胰腺炎等。
诊断
?	3.经内镜逆行胰胆管造影(endoscopic retrograde cholangio-pancreatography, ERCP)及窦道造影是胰瘘诊断金标准。
?	4.外科术后胰瘘的诊断标准为：术后≥3 d后腹腔引流管仍有液体流出，且其淀粉酶浓度高于血清淀粉酶正常值上限的3倍。
?	5.急慢性胰腺炎相关胰瘘诊断标准为：(1)存在急性坏死性胰腺炎发作病史；(2)影像学支持胰瘘诊断。
分型分级
?	6.胰瘘分型建议根据胰瘘部位、开口方式及既往胰腺切除术式分型。外科术后分级建议采用ISGPS制定的2016版更新术后胰瘘(postoperative pancreatic fistula，POPF)分级。
适应证
?	7.内镜下胰瘘治疗主要用于有明显症状且保守治疗无效的患者。
预防性治疗
?	8.不推荐常规内镜下处理来预防外科术后胰瘘的发生。
内镜下手术治疗
?	9.对于与近端胰管相通的胰瘘，内镜下鼻胰管引流术、内镜下胰管支架置入术是内镜下常规治疗方式。
?	10.内镜下常规治疗失败的胰瘘，可尝试行内镜下封堵剂封堵治疗。
?	11. EUS引导下支架引流术可作为胰瘘所致胰周液体积聚的一线治疗方式，必要时可行内镜直视下坏死组织清创术。
?	12. EUS引导下引流术的支架选择(塑料/金属)目前尚存争议，但对于合并坏死的胰周液体积聚，更倾向于新型两端膨大式金属支架。

是否外科手术	胰瘘类型	特点	亚型	内镜下干预方式
否	Ⅰ	发生在胰腺实质损伤和小分支胰管或胰管末端损伤	头体型(Ⅰa)	胰管支架引流术，鼻胰管引流术
?	?	?	尾型(Ⅰb)	胰管支架引流术，鼻胰管引流术，瘘管封堵术
否	Ⅱ	胰瘘主要发生在MPD，伴随胰管离断综合征	近端胰管残端开放(Ⅱa)	EUS引导下支架引流术，鼻胰管引流/胰管支架引流
?	?	?	近端胰管残端闭合(Ⅱb)	EUS引导下支架引流术
是	Ⅲ	?	近端胰腺切除术后(Ⅲa)	胰管支架引流术，鼻胰管引流术
?	?	?	远端胰腺切除术后(Ⅲb)	EUS引导下支架引流术

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不良事件	生化瘘	B级	C级
1.引流液淀粉酶浓度>3倍血清正常值上限	是	是	是
2.引流管持续引流>3周	否	是	是
3.影响临床治疗或进程^a	否	是	是
4.经皮或内镜引流	否	是	是
5.需要介入栓塞治疗的出血	否	是	是
6.外科手术	否	否	是
7.胰瘘相关的感染	否	是	是
8.胰瘘相关的器官衰竭^b	否	否	是
9.胰瘘相关的死亡	否	否	是

英文缩写	英文名称	中文名称
ASGE	American society for gastrointestinal endoscopy	美国胃肠内镜学会
ERCP	endoscopic retrograde cholangiopancreatography	经内镜逆行胰胆管造影术
ESGE	European society of gastrointestinal endoscopy	欧洲胃肠内镜学会
ISGPS	International Study Group of Pancreatic Surgery	国际胰腺外科组织
LAMS	lumen-apposing metal stents	双蘑菇头金属支架
MPD	mian pancreatic duct	主胰管
PFCs	pancreatic fluid collections	胰周液体积聚
POPF	postoperative pancreatic fistula	术后胰瘘
PS	plastic stent	塑料支架
SEMS	self-expanding metal stents	直线型自膨式金属支架
WON	walled-off necrosis	包裹性坏死

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