Page 77 - 2021年17期

Effectiveness of Indomethacin Suppositories in the Prevention of Post-endoscopic Retrograde
Cholangiopancreatography Pancreatitis：A Reevaluation of Systematic Review
ZHAO Chengsi ，YAO Weijie ，PENG Bo ，YANG Yafei ，LAN Zhu ，DONG Tongtong ，SHI Jinping ，WANG
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1
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1
Zuozheng（1. School of Clinical Medicine，Ningxia Medical University，Yinchuan 750004，China；2. Dept. of
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Hepatobiliary Surgery，General Hospital of Ningxia Medical University，Yinchuan 750004，China）
ABSTRACT OBJECTIVE：To overview the systematic review on the effectiveness of indomethacin in the prevention of
post-endoscopic retrograde cholangiopancreatography pancreatitis（PEP），and to provide reliable evidence-based reference for the
prevention of PEP. METHODS：Retrieved from PubMed，the Cochrane Library，Embase，CBM，CNKI，Wanfang database and
VIP，systematic review on indomethacin in the prevention of PEP were collected during the inception to Nov. 2020. The
methodological quality，report quality and evidence quality of the included studies were evaluated by AMSTAR2 scale，PRISMA
statement and GRADE method. The effectiveness of PEP prevention was described. RESULTS：Finally，23 systematic reviews
were obtained，including 12 in Chinese and 11 in English. Tweenty-two systematic reviews showed that compared with placebo，
indomethacin could effectively reduce the incidence of PEP. Eight systematic reviews showed that indomethacin significantly
reduced the incidence of moderate and severe PEP compared with placebo. Five systematic reviews showed that indomethacin could
reduce the incidence of postoperative hyperamylasemia compared with placebo. Three systematic reviews showed that indomethacin
also had a good preventive effect on people with high risk of PEP. PRISMA score of included systematic reviews ranged from 15 to
25. The quality evaluation of AMSTAR2 methodology included in systematic reviews was low，and the key items of complete
report were 4，9，11 and 13. The GRADE evidence quality evaluation of the included systematic reviews showed that the quality of
the evidence was concentrated in the low level. CONCLUSIONS：Indomethacin has a certain effect in the prevention of PEP，but
the overall evidence quality of the included literatures is generally not high. It needs to be further validated by high-quality clinical
research.
KEYWORDS Post-endoscopic retrograde cholangiopancreatography pancreatitis；Indomethacin；Effectiveness； Systematic
review；Reevaluation

急性胰腺炎是消化系统常见疾病，发病率逐年上 法学质量、报告质量和证据质量等3个方面对相关系统
[1]
升，其中重症急性胰腺炎病死率可达 30％以上 。通过 评价进行再评价，旨在分析当前相关系统评价存在的不
对急性胰腺炎的发病机制的不断探索，经内镜逆行胰胆 足，同时为吲哚美辛栓预防 PEP 提供更加可靠的循证
管造影术（endoscopic retrograde cholangio-pancreatogra- 参考。
phy ，ERCP）在急性胰腺炎的诊治中被广泛应用。伴随 1 资料与方法
科技水平的提高，ERCP相关并发症的发生率不断降低， 1.1 纳入标准
但 ERCP 术后胰腺炎（post-endoscopic retrograde cholan- 1.1.1 研究类型 本文纳入关于吲哚美辛预防 PEP 的
giopancreatography pancreatitis，PEP）作为其中最危险的 Meta分析/系统评价。
并发症，其发生率仍然较高，在高危人群中甚至高达 1.1.2 研究对象 研究对象为接受 ERCP 治疗的患者，
[2]
30％ 。在一些前瞻性的研究中发现，围手术期给予直 患者年龄、性别、病程、病情不限。
肠吲哚美辛栓可降低PEP发生的风险 [3－4] 。基于这些研 1.1.3 干预措施 试验组患者给予吲哚美辛栓，直肠给
究结论，欧洲胃肠内镜学会（ESGE）指南（2014 年）及日 药；对照组患者给予安慰剂或空白对照，安慰剂的给药
本肝胆胰外科学会（2015年）建议，对接受ERCP 且无禁 方式同试验组。
忌证的患者使用 100 mg 吲哚美辛栓直肠给药预防 1.1.4 主要结局指标 本研究的主要结局指标包括
PEP [5－ 6] 。然而一些高质量的随机对照试验（RCT）并没 PEP发生率、不良反应发生率、高淀粉酶血症发生率、高
有发现吲哚美辛栓在预防PEP中的显著效果，甚至安慰 危险人群 PEP 发生率、中重度 PEP 发生率、术前或术后
剂组患者的PEP发生率更低 [7－8] 。这种相互矛盾的结论 用药与PEP发生的关系。需要说明的是，PEP和高淀粉
使得吲哚美辛在预防PEP中的有效性受到质疑。 酶血症都表现为淀粉酶水平增高，但PEP还伴有腹痛或
系统评价作为循证医学重要的证据来源，可为临床 者腹痛加重的症状，本文引入高淀粉酶血症相关指标是
治疗提供指导，因此许多学者尝试通过系统评价来评价 为了更全面地评价吲哚美辛的效果。
吲哚美辛栓在预防 PEP 中的价值。但是众多相关的系 1.2 排除标准
统评价可能存在一定的报告缺陷，导致证据质量下降， 本研究的排除标准包括：①重复发表的文献；②无
可能对医务工作者造成误导。目前尚无吲哚美辛栓预 法获取全文的文献；③以系统评价命名的综述；④非单
防PEP的系统评价再评价的相关报道，因此本文将从方 一用药或笼统概况为非甾体抗炎药的文献；⑤网状Meta

中国药房 2021年第32卷第17期 China Pharmacy 2021 Vol. 32 No. 17 ·2115 ·