Oddi括约肌小切开结合气囊扩张对胆汁胰淀粉酶、脂肪酶含量的影响
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摘要
目的观察内镜下逆行胰胆管造影(ERCP)行十二指肠乳头括约肌小切开(SEST)结合乳头气囊扩张(EPBD)对胆汁中胰淀粉酶、脂肪酶含量的影响,以验证SEST+EPBD后可能存在的十二指肠液的反流,并研究不同直径球囊扩张与反流的关系。方法选取2014年1月至2018年12月因胆石症入院的患者,根据操作方法不同,分为SEST+球囊扩张组(n=90)和胆道探查+T管引流组(n=48)。前者根据球囊直径大小再分为SEST+小球囊扩张(直径<12 mm)和SEST+大球囊扩张(直径≥12 mm)两个亚组。分别在SEST前或胆总管切开前抽取胆汁5 mL,术后第5天经T管或鼻胆管(ENBD)抽取胆汁,检验胰淀粉酶、脂肪酶含量。结果与同组内术中胰淀粉酶、脂肪酶比较,胆道探查+T管引流组术后第5天变化无统计学差异(P>0.05);而SEST+EPBD组明显升高(P<0.01)。组间比较,SEST+EPBD组术后第5天胰淀粉酶、脂肪酶较胆道探查+T管引流组上升(P<0.01),SEST+EPBD组胆肠反流阳性率明显高于胆道探查+T管引流组(P<0.01)。而SEST+大球囊扩张组和SEST+小球囊扩张组之间胆肠反流阳性率无统计学差异(P>0.05)。结论SEST+EPBD术后早期由于Oddi括约肌损伤,可导致十二指肠液反流,但球囊扩张的大小与十二指肠液反流情况无明显的关系。故用ERCP处理困难的大结石时,行SEST结合大球囊扩张是可行的,并不会引起术后早期更为严重的胆肠反流。
Objective To observe the effect of endoscopic retrograde cholangiopancreatography(ERCP)with small endoscopic sphincterotomy(SEST) combine with endoscopic papillary balloon dilatation(EPBD)on the levels of pancreatic amylase and lipase in bile, to verify the presence of duodenobiliary reflux after SEST+EPBD, and to study the relationship between balloon dilatation with different diameters and reflux.Methods Patients with cholelithiasis admitted in Wenzhou Central Hospital from Jan. 2014 to Dec. 2018 were divided into SEST+EPBD group(n=90) and biliary exploration+T-tube drainage group(n=48). The former group was then divided into two subgroups according to the diameter of balloon: SEST+small balloon dilatation group(diameter<12 mm) and SEST+large balloon dilatation group(diameter≥ 12 mm). 5 mL bile was extracted before SEST or before choledochotomy respectively, and bile was extracted by T tube or naso-biliary tube(ENBD) on the 5~(th) day after operation, then the levels of pancreatic amylase and lipase were tested and compared. Results Compared with the intraoperative pancreatic amylase and lipase in the same group, there was no statistical significance on the 5~(th) day after operation in the biliary exploration+T tube drainage group(P>0.05), while the SEST+EPBD group increased significantly(P<0.01). Comparison between groups, the levels of amylase and lipase in SEST+EPBD group were higher than those in biliary exploration+T-tube drainage group on the 5~(th) day after operation(P<0.01),the positive rate of duodenobiliary reflux in SEST+EPBD group was significantly higher than that in biliary exploration+T-tube drainage group(P<0.01), but there was no significant difference between SEST+big balloon dilatation group and SEST+small balloon dilatation group(P>0.05). Conclusion In the early stage after SEST combine with EPBD, duodenal fluid reflux may be caused by injury of the Oddi sphincter, but the situation of duodenal fluid reflux has no obvious relationship with the size of balloon dilatation. Therefore,SEST+big balloon dilatation is feasible for ERCP treatment with difficult large stones, and it will not cause more severe duodenobiliary reflux in the early postoperative period.
Objective To observe the effect of endoscopic retrograde cholangiopancreatography(ERCP)with small endoscopic sphincterotomy(SEST) combine with endoscopic papillary balloon dilatation(EPBD)on the levels of pancreatic amylase and lipase in bile, to verify the presence of duodenobiliary reflux after SEST+EPBD, and to study the relationship between balloon dilatation with different diameters and reflux.Methods Patients with cholelithiasis admitted in Wenzhou Central Hospital from Jan. 2014 to Dec. 2018 were divided into SEST+EPBD group(n=90) and biliary exploration+T-tube drainage group(n=48). The former group was then divided into two subgroups according to the diameter of balloon: SEST+small balloon dilatation group(diameter<12 mm) and SEST+large balloon dilatation group(diameter≥ 12 mm). 5 mL bile was extracted before SEST or before choledochotomy respectively, and bile was extracted by T tube or naso-biliary tube(ENBD) on the 5~(th) day after operation, then the levels of pancreatic amylase and lipase were tested and compared. Results Compared with the intraoperative pancreatic amylase and lipase in the same group, there was no statistical significance on the 5~(th) day after operation in the biliary exploration+T tube drainage group(P>0.05), while the SEST+EPBD group increased significantly(P<0.01). Comparison between groups, the levels of amylase and lipase in SEST+EPBD group were higher than those in biliary exploration+T-tube drainage group on the 5~(th) day after operation(P<0.01),the positive rate of duodenobiliary reflux in SEST+EPBD group was significantly higher than that in biliary exploration+T-tube drainage group(P<0.01), but there was no significant difference between SEST+big balloon dilatation group and SEST+small balloon dilatation group(P>0.05). Conclusion In the early stage after SEST combine with EPBD, duodenal fluid reflux may be caused by injury of the Oddi sphincter, but the situation of duodenal fluid reflux has no obvious relationship with the size of balloon dilatation. Therefore,SEST+big balloon dilatation is feasible for ERCP treatment with difficult large stones, and it will not cause more severe duodenobiliary reflux in the early postoperative period.
引文
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[9]Mu H,Gao J,Kong Q,et al.Prognostic factors and postoperative recurrence of calculus following small-incision sphincterotomy with papillary balloon dilation for the treatment of intractable choledocholithiasis:a 72-month follow-up study[J].Dig Dis Sci,2015,60(7):2144-2149.
[2]邹多武.功能性胃肠病罗马III标准解读:胆囊及Oddi括约肌功能紊乱[J].临床消化病杂志,2006,18(5):262-263.
[3]Wu CH,Chiu HM,Liu KL,et a1.Sonographic demonstration of duodenobiliary reflux with soda enhancement[J].J Clin Ultrasound,2004,32(5):249-252.
[4]Doi S,Yasuda I,Mukai T,et a1.Comparison of long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation:a propensity score-based cohort analysis[J].J Gastroenterol,2013,48(9):1090-1096.
[5]刘治军,郭瑾陶,王晟,等.内镜下乳头括约肌切开加大球囊扩张与常规乳头括约肌切开治疗胆总管结石的比较研究[J].中国内镜杂志,2011,17(9):924-928.
[6]Fujisawa T,Kagawa K,Hisatomi K,et a1.Is endoscopic papillary balloon dilatation really a risk factor for post-ERCPpancreatitis?[J].World J Gastroenterol,2016,22(26):5909-5916.
[7]李兆申,许国铭.胆道疾病内镜诊断与治疗学[M].上海:第二军医大学出版社,2006:140-149.
[8]潘俊,董卫国,刘敏,等.ERCP中SEST联合EPBD对比单纯EST对胆总管结石取石的临床分析[J].胃肠病学和肝病学杂志,2015,24(3):341-343.
[9]Mu H,Gao J,Kong Q,et al.Prognostic factors and postoperative recurrence of calculus following small-incision sphincterotomy with papillary balloon dilation for the treatment of intractable choledocholithiasis:a 72-month follow-up study[J].Dig Dis Sci,2015,60(7):2144-2149.