ESGE最新指南 | 治疗性超声内镜的技术综述
2022/3/23 18:00:00 消化界
Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review
治疗性超声内镜：ESGE技术综述
SOURCE AND SCOPE 来源和范围
This Technical review complements the recent European Society of Gastrointestinal Endoscopy (ESGE) Guideline on therapeutic endoscopic ultrasound. The aim of this Technical review is to discuss the technical considerations of therapeutic endoscopic ultrasound and the management of adverse events. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence.
本技术综述补充了最近欧洲胃肠内镜学会(ESGE)关于治疗性超声内镜的指南。本技术综述旨在讨论治疗性超声内镜操作的技术要点以及不良事件的管理。采用建议、评估、发展和评价分级(GRADE)系统来定义建议的推荐强度以及证据的质量。
3.1?Key question1: What are the general pre- and post-procedural precautions that should be taken when performing therapeutic EUS?
关键问题1：进行治疗性EUS时，术前和术后一般有哪些注意事项？
RECOMMENDATION 建议
ESGE recommends therapeutic EUS procedures should be performed by endoscopists with adequate training and experience, at centers where interventional radiology and hepatopancreaticobiliary surgical expertise are available.
ESGE建议：治疗性EUS应由接受过充分培训并有经验的内镜医师在具备介入放射学和肝胆胰外科专业技术的临床试验机构进行。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
3.1.2?Preprocedural considerations
术前注意事项
RECOMMENDATIONS 建议
ESGE recommends temporary discontinuation of anticoagulant therapy before embarking on therapeutic EUS procedures.
ESGE建议：在开始进行治疗性EUS前暂时停止抗凝治疗。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
ESGE recommends temporarily switching dual antiplatelet therapy to aspirin monotherapy, whenever possible, before embarking on therapeutic EUS procedures.
ESGE建议：在开始治疗性EUS前，应尽可能将双联抗血小板治疗暂时转换为阿司匹林单药治疗。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
ESGE suggests prophylactic administration of an intravenous broad-spectrum antibiotic in all patients undergoing therapeutic EUS procedures.
ESGE建议：对所有接受治疗性EUS的患者预防性给予广谱抗生素静脉注射。
Weak recommendation, low quality evidence.
弱推荐，证据质量较低。
ESGE recommends a prolonged course of a prophylactic broad-spectrum antibiotic in patients with ascites who are undergoing therapeutic EUS procedures.
ESGE建议：对于接受治疗性EUS的腹水患者，应延长广谱抗生素预防性治疗的疗程。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
3.2.2?General technical principles in EUS-assisted and EUS-guided techniques
EUS辅助和EUS引导技术的一般技术原则
RECOMMENDATIONS 建议
ESGE suggests a fistulous tract be created using a 6-Fr cystotome or alternatively by mechanical dilation.
ESGE建议：使用6-Fr囊肿切开刀或通过机械扩张建立瘘道。
Weak recommendation, low quality evidence.
弱推荐，证据质量较低。
ESGE recommends that endoscopists should undergo rigorous training in lumen-apposing metal stent placement and the management of adverse events before undertaking therapeutic EUS procedures using these devices.
ESGE建议：在使用这些器械进行治疗性EUS之前，内镜医师应接受腔内并置金属支架置入和不良事件管理的严格培训。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
3.2.3?When should a therapeutic EUS procedure be aborted?
何时应中止治疗性EUS？
RECOMMENDATION 建议
ESGE recommends discontinuation of the procedure when tumor infiltration, significant ascites, or large intervening blood vessels are identified at the desired puncture site of the gastrointestinal wall or target organ.
ESGE建议：在胃肠壁或目标器官的预期穿刺部位发现肿瘤浸润、大量腹水或大型血管介入时停止手术。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
RECOMMENDATION 建议
ESGE recommends the placement of partially or fully covered self-expandable metal stents or small caliber lumen-apposing metal stents during EUS-guided choledochoduodenostomy.
ESGE建议：在EUS引导下胆总管十二指肠吻合术中放置部分覆膜或全覆膜自膨式金属支架或小口径腔内并置金属支架。
Strong recommendation, moderate quality evidence.
强推荐，中等质量证据。
4.1?Key question 3: How should EUS-BD be performed?
关键问题3：应该如何进行EUS-BD？
Fig. 1a–c Illustrations of therapeutic endoscopic ultrasound(EUS)interventions of the pancreaticobiliary and gastrointestinal tract showing: a EUS-assisted rendezvous (biliary); b EUS-guided antegrade stenting; c EUS-guided choledochoduodenostomy. Source: Martha Meisen.
图1a-c：胰胆管和胃肠道治疗性超声内镜(EUS)介入图示：a. EUS辅助会师技术(胆道)；b. EUS引导下顺行性支架置入术；c. EUS引导下胆总管十二指肠吻合术。
4.1.4?EUS-guided hepaticogastrostomy
EUS引导下肝胃吻合术
RECOMMENDATIONS 建议
ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) during EUS-guided hepaticogastrostomy for biliary drainage in malignant disease.
ESGE建议：在EUS引导下肝胃吻合术期间置入部分覆膜或全覆膜自膨式金属支架(SEMS)，用于恶性疾病的胆管引流。
Strong recommendation, moderate quality evidence.
强推荐，中等质量证据。
ESGE recommends temporary placement of fully covered SEMSs during EUS-guided hepaticogastrostomy for biliary drainage in benign disease.
ESGE建议：在EUS引导下肝胃吻合术期间临时置入全覆膜SEMS，用于良性疾病的胆管引流。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
4.1.5?EUS-guided hepaticoduodenostomy
EUS引导下肝管十二指肠吻合术
RECOMMENDATION 建议
ESGE recommends EUS-guided hepaticoduodenostomy be performed only at expert centers and after careful consideration of all therapeutic options.
ESGE建议：仅在专家中心并仔细考虑所有治疗选择后，进行EUS引导下肝管十二指肠吻合术。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
Fig. 1d–f Illustrations of therapeutic endoscopic ultrasound(EUS)interventions of the pancreaticobiliary and gastrointestinal tract showing: d EUS-guided hepaticogastrostomy; e EUS-assisted rendezvous (pancreas); f EUS-guided pancreaticogastrostomy. Source: Martha Meisen.
图1d-f：胰胆管和胃肠道治疗性超声内镜(EUS)介入图示：d. EUS引导下肝胃吻合术；e. EUS辅助会师技术(胰腺)；f. EUS引导下胰胃吻合术。
4.2?Key question 4: What adverse events may occur when EUS-BD is performed and how should these be managed?
关键问题4：在进行EUS-BD时可能发生哪些不良事件，应如何处理？
4.2.1?Stent maldeployment and perforation
支架置入不当和穿孔
RECOMMENDATION 建议
ESGE recommends endoscopic stent-in-stent therapy when maldeployment occurs during EUS-guided hepaticogastrostomy and, if this is not feasible, that percutaneous transhepatic biliary drainage or emergency salvage surgery should be considered.
ESGE建议：在EUS引导下肝胃吻合术期间发生支架置入不当的情况下，可在内镜下进行stent-in-stent处理，如果不可行，则应考虑进行经皮经肝胆管引流或紧急挽救性外科手术。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
4.2.2?Endoscopic treatment of long-term adverse events
长期不良事件的内镜治疗
RECOMMENDATION 建议
ESGE recommends placement of a stent through the metal stent when EUS-guided choledochoduodenostomy or EUS-guided hepaticogastrostomy is complicated by stent occlusion.
ESGE建议：EUS引导下胆总管十二指肠吻合术或EUS引导下肝胃吻合术并发支架堵塞时，可在金属支架中再放置一个支架。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
4.3?Key question 5: How should EUS-guided PD drainage be performed?
关键问题5：应如何进行EUS引导下PD引流？
4.3.1?General principles of EUS-guided PD
EUS引导下PD的一般原则
RECOMMENDATION 建议
ESGE recommends EUS-guided pancreatic duct drainage should only be performed at high volume expert centers, owing to the complexity of this technique and the high risk of adverse events.
ESGE建议：EUS引导下胰管引流应仅在高手术量专家中心进行，因为该技术比较复杂且发生不良事件的风险较高。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
RECOMMENDATION 建议
ESGE recommends the use of rectal nonsteroidal anti-inflammatory drugs in patients undergoing EUS-guided pancreatic duct drainage.
ESGE建议：对接受EUS引导下胰管引流的患者进行非甾体类抗炎药直肠给药。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
4.3.3?EUS-guided PD drainage
EUS引导下PD引流
RECOMMENDATION 建议
ESGE recommends rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP) in patients with favorable anatomy, followed by antegrade or transmural EUS-guided pancreatic duct drainage only when RV-ERP fails or is not feasible.
ESGE建议：对于解剖结构有利的患者，进行会师技术辅助经内镜逆行性胰管造影(RV-ERP)，只有当RV-ERP失败或不可行时，才进行顺行性或透壁EUS引导下胰管引流。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
5.1?Key question 7: How should EUS-GBD be performed?
关键问题7：应如何进行EUS-GBD？
Fig. 1g–i Illustrations of therapeutic endoscopic ultrasound(EUS)interventions of the pancreaticobiliary and gastrointestinal tract showing: g EUS-guided gallbladder drainage; h EUS-guided gastroenterostomy; i EUS-guided gastrogastrostomy. Source: Martha Meisen.
图1g-i：胰胆管和胃肠道治疗性超声内镜(EUS)介入图示：g. EUS引导下胆囊引流；h. EUS引导下胃肠吻合术；i. EUS引导下胃造口术。
5.1.1?LAMS placement
LAMS的置入
RECOMMENDATIONS建议
ESGE suggests the use of an electrocautery-enhanced lumen-apposing metal stent (LAMS) or dedicated SEMS in EUS-guided gallbladder drainage (EUS-GBD), given their enhanced ease of use and safety compared with alternatives.
ESGE建议：在EUS引导下胆囊引流(EUS-GBD)中应使用搭载电灼增强系统的腔内并置金属支架(LAMS)或专用SEMS，因为与其替代品相比，这些支架更易于使用且安全性更高。
Weak recommendation, low quality evidence.
弱推荐，证据质量较低。
ESGE suggests performing transduodenal EUS-GBD with a LAMS, rather than using the transgastric route, as this may reduce the risk of stent dysfunction.
ESGE建议：使用LAMS进行经十二指肠EUS-GBD，而不是采用经胃路径，因为这可能会降低支架出现功能障碍的风险。
Weak recommendation, low quality evidence.
弱推荐，证据质量较低。
5.1.3?Stent dysfunction
支架功能障碍
RECOMMENDATION 建议
ESGE suggests considering pre-emptive placement of coaxial double-pigtail plastic stents in patients with a higher expected risk of SEMS or LAMS occlusion.
ESGE建议：对于预期SEMS或LAMS堵塞风险较高的患者，可考虑先行置入同轴双猪尾塑料支架。
Weak recommendation, low quality evidence.
弱推荐，证据质量较低。
5.1.4?Stone clearance and LAMS replacement
结石清除与LAMS更换
RECOMMENDATION 建议
ESGE suggests considering complete stone clearance and LAMS exchange for double-pigtail plastic stents when long-term drainage is required after EUS-guided gallbladder drainage.
ESGE建议：对于EUS引导下胆囊引流后需要进行长期引流的情况，可考虑完全清除结石并使用LAMS置换双猪尾塑料支架。
Weak recommendation, low quality evidence.
弱推荐，证据质量较低。
6.1?Key question 9: How should EUS-GE procedures be performed?
关键问题9：应如何进行EUS-GE手术？
RECOMMENDATION 建议
ESGE recommends using saline instillation for small-bowel distension during EUS-guided gastroenterostomy.
ESGE建议：在EUS引导下胃肠吻合术中，灌注生理盐水有助于小肠肠管扩张。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
6.1.2?Direct EUS-GE technique
直接法EUS-GE技术(不需要器械辅助)
RECOMMENDATIONS 建议
ESGE recommends the use of electrocautery-enhanced LAMSs in EUS-guided gastroenterostomy.
ESGE建议：在EUS引导下胃肠吻合术中使用电灼增强的LAMS。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
ESGE recommends the use of LAMSs of at least 15?mm in diameter in EUS-guided gastroenterostomy.
ESGE建议：在EUS引导下胃肠吻合术中使用直径至少为15mm的LAMS。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
6.2.1?What is the optimal technique to perform an EDGE procedure?
EDGE手术的最佳技术是什么？
RECOMMENDATION 建议
ESGE recommends the use of saline instillation with a 19 G needle and an electrocautery-enhanced LAMS for EDGE procedures.
ESGE建议：在EDGE手术中使用19G穿刺针进行生理盐水灌注并使用电灼增强的LAMS。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
6.2.2?Is there a preference for LAMS diameter?
LAMS的首选直径？
RECOMMENDATION 建议
ESGE recommends the use of either 15- or 20-mm LAMSs for EDGE, with a preference for 20-mm LAMSs when considering a same-session ERCP.
ESGE建议：使用直径为15mm或20mm的LAMS进行EDGE，当考虑在同期手术中进行ERCP时，优先使用20mm LAMS。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
6.2.3?What is the optimal time that should be allowed before performing an ERCP following LAMS placement?
在LAMS置入之后、进行ERCP之前，最佳间隔时间是多少？
RECOMMENDATION 建议
ESGE suggests considering a delay of at least 7 days before performing ERCP following EDGE whenever possible.
ESGE建议：尽可能考虑在EDGE后延迟至少7天再进行ERCP。
Weak recommendation, low quality evidence.
弱推荐，证据质量较低。
6.2.4?When should the LAMS be removed and should endoscopic closure be provided?
移除LAMS的时间以及是否应进行内镜下闭合？
RECOMMENDATION 建议
ESGE recommends that LAMSs should not be removed within the first 7 days of placement and thereafter only when no additional pancreaticobiliary interventions are required.
ESGE建议：请勿在置入支架前7天内取出LAMS，此后仅在不需要再进行胰胆管介入治疗的情况下才能取出。
Strong recommendation, low quality evidence.
强推荐，证据质量较低。
6.3?Key question 11: What are the adverse events and possible rescue procedures in EUS-guided gastrointestinal anastomoses?
关键问题11：EUS引导下胃肠吻合术的不良事件以及潜在的挽救性操作是什么？
6.3.3?Endoscopic treatment of long-term adverse events
长期不良事件的内镜治疗
RECOMMENDATION 建议
ESGE suggests long-term clinical follow-up and/or intermittent stent surveillance, with or without stent exchange, after EUS-guided gastroenterostomy for benign disease.
ESGE建议：通过EUS引导下胃肠吻合术治疗良性疾病后，应进行长期临床随访和/或间歇性支架监测，无论是否需要更换支架。
Weak recommendation, low quality evidence.
弱推荐，证据质量较低。
文章信息：
van der Merwe SW, van Wanrooij RLJ, Bronswijk M, Everett S, Lakhtakia S, Rimbas M, Hucl T, Kunda R, Badaoui A, Law R, Arcidiacono PG, Larghi A, Giovannini M, Khashab MA, Binmoeller KF, Barthet M, Perez-Miranda M, van Hooft JE. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Feb;54(2):185-205. doi: 10.1055/a-1717-1391. Epub 2021 Dec 22. PMID: 34937098.
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