ERCP和EST治疗胆总管结石复发危险因素分析
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摘要
目的分析影响胆总管结石患者行逆行胰胆管造影(ERCP)和内镜下乳头括约肌切开取石术(EST)治疗后结石复发的危险因素。方法我院诊治的胆总管结石患者357例,常规行ERCP检查,发现胆管内有结石后行EST。对结石直径<1.0 cm者,用取石网篮取石;对结石直径≥1.0 cm者,用碎石篮碎石取出;对巨大结石,于胆管内置入支架,再择期取石。采用Logistic回归分析影响治疗后结石复发的危险因素。结果在357例患者,行ERCP插管成功349例(97.8%),行EST取石成功334例(93.6%),其中一次取石成功者297例(88.9%),两次取石成功者37例(11.1%);随访发现结石复发138例,未复发219例;单因素分析结果显示,复发组病程、年龄和乳头切口分别为(10.9±2.5)年、(66.8±7.2)岁和(15.6±1.9) mm,显著长于或大于未复发组【分别为(7.6±1.7)年、(57.3±8.7)岁和(7.9±2.2) mm,P均<0.05】,复发组有胆道手术史、乳头旁憩室、胆道狭窄、合并胆管或胰腺炎、结石数量≥2枚和结石直径≥10 mm比率分别为18.8%、29.7%、30.4%、78.9%、81.9%和40.6%,显著高于未复发组的1.8%、7.3%、11.4%、40.6%、64.8%和9.6%(P均<0.05);进一步行Logistic回归分析显示,胆总管直径≥10 mm和乳头切口≥15mm为患者术后结石复发的独立危险因素。结论对于乳头切口和胆总管直径较大的患者,临床应该警惕其术后结石复发,增加随访次数,以早期发现。
Objective To analyze the risk factors for stone recurrence in patients with common bile duct stones after endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic sphineterotomy(EST) therapy. Methods 357 patients with common bile duct stones were recruited in our hospital,and routine ERCP examination were done. The stone were removed by EST. All patients were followed-up and routine imaging examination were carried out to find the stone recurrence. The risk factors of stone recurrence after ERCP and EST treatment were evaluated by Logistic analysis. Results Out of the 357 patients,ERCP were successfully performed in 349(97.8%) patients,and the stones were successfully removed in 334(93.6%) patients;138 patients were found to have,and 219 have not stone recurrence during the followed-up period;univariate Logistic analysis showed that there were no significant differences in gender,BMI,and presence or absence of gallstones between patients with and without stone recurrence(P >0.05),while there were significant differences as respect to the course of disease,age and incision size between patients with recurrent stone and those without [(10.9±2.5) yr vs.(7.6±1.7) yr,(66.8±7.2) years old vs.(57.3±8.7) years old,and(15.6±1.9) mm vs.(7.9±2.2) mm,P<0.05];the percentages of biliary surgery history,diverticulum,biliary stricture,biliary or pancreatic inflammation,stone numbers more than 2 and stone diameters greater than 10 mm in patients with stone recurrence were 18.8%,29.7%,30.4%,78.9%,81.9%,and 40.6%,significantly higher than 1.8%,7.3%,11.4%,40.6%,64.8%,and 9.6% in patients without stone recurrence(P <0.05);multivariate Logistic regression analysis showed that the diameter of common bile duct greater than 10 mm and incision size greater than 15 mm were the independent factors for stone recurrence after operation. Conclusion Patients with larger papillary incision and dilated diameters of common bile duct might have stone recurrence after ERCP and EST operation,and they must be followedup for early diagnosis.
Objective To analyze the risk factors for stone recurrence in patients with common bile duct stones after endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic sphineterotomy(EST) therapy. Methods 357 patients with common bile duct stones were recruited in our hospital,and routine ERCP examination were done. The stone were removed by EST. All patients were followed-up and routine imaging examination were carried out to find the stone recurrence. The risk factors of stone recurrence after ERCP and EST treatment were evaluated by Logistic analysis. Results Out of the 357 patients,ERCP were successfully performed in 349(97.8%) patients,and the stones were successfully removed in 334(93.6%) patients;138 patients were found to have,and 219 have not stone recurrence during the followed-up period;univariate Logistic analysis showed that there were no significant differences in gender,BMI,and presence or absence of gallstones between patients with and without stone recurrence(P >0.05),while there were significant differences as respect to the course of disease,age and incision size between patients with recurrent stone and those without [(10.9±2.5) yr vs.(7.6±1.7) yr,(66.8±7.2) years old vs.(57.3±8.7) years old,and(15.6±1.9) mm vs.(7.9±2.2) mm,P<0.05];the percentages of biliary surgery history,diverticulum,biliary stricture,biliary or pancreatic inflammation,stone numbers more than 2 and stone diameters greater than 10 mm in patients with stone recurrence were 18.8%,29.7%,30.4%,78.9%,81.9%,and 40.6%,significantly higher than 1.8%,7.3%,11.4%,40.6%,64.8%,and 9.6% in patients without stone recurrence(P <0.05);multivariate Logistic regression analysis showed that the diameter of common bile duct greater than 10 mm and incision size greater than 15 mm were the independent factors for stone recurrence after operation. Conclusion Patients with larger papillary incision and dilated diameters of common bile duct might have stone recurrence after ERCP and EST operation,and they must be followedup for early diagnosis.
引文
[1]Cheng CT,Yeh CN,Chiang KC,et al.Effects of cholecystectomy on recurrent biliary complications after endoscopic treatment of common bile duct stone:a population-based cohort study.Surg Endosc,2018,32(4):1793-1801.
[2]黄健.腹腔镜下胆总管切开取石术与经胆囊管取石术治疗胆总管结石伴胆囊结石患者疗效分析.实用肝脏病杂志,2018,21(2):269-272.
[3]Rawal KK.Migration of surgical clips into the common bile duct after laparoscopic cholecystectomy.Case Rep Gastroenterol,2017,10(3):787-792.
[4]闫凌,张盈,张晨光.两种手术方案治疗胆囊结石合并胆总管结石患者效果比较研究.实用肝脏病杂志,2018,21(2):301-302.
[5]Baucom RB,Feurer ID,Shelton JS,et al.Surgeons,ERCP,and laparoscopic common bile duct exploration:do we need a standard approach for common bile duct stones Surg Endosc,2016,30(2):414-423.
[6]Park JS,Jeong S,Bang BW,et al.Endoscopic papillary large balloon dilatation without s Sphincterotomy for the treatment of large common bile duct stone:long-term outcomes at a single center.Dig Dis Sci,2016,61(10):3045-3053.
[7]Kim SB,Kim KH,Kim TN.Comparison of outcomes and complications of endoscopic common bile duct stone removal between asymptomatic and symptomatic patients.Dig Dis Sci,2016,61(4):1172-1177.
[8]中华医学会外科学分会胆道外科学组.肝胆管结石病诊断治疗指南.中华消化外科杂志,2007,7(2):156-160.
[9]Saito H,Kakuma T,Kadono Y,et al.Increased risk and severity of ERCP-related complications associated with asymptomatic common bile duct stones.Endosc Int Open,2017,5(9):E809-E817.
[10]Bhanthumkomol P,Aswakul P,Prachayakul V.Argon plasma coagulation for the resolution of basket impaction from large common bile duct stones.Endosc Int Open,2016,4(4):E389-E390.
[11]Wang X,Dai C,Jiang Z,et al.Endoscopic retrograde cholangiopancreatography versus laparoscopic exploration for common bile duct stones in post-cholecystectomy patients:a retrospective study.Oncotarget,2017,8(47):82114-82122.
[12]Chong CC,Chiu PW,Tan T,et al.Correlation of CBD/CHDangulation with recurrent cholangitis in patients treated with ERCP.Endosc Int Open,2016,4(1):E62-E67.
[13]Feng H,Hu Y,Jin P,et al.Intensity-modulated radiotherapy combined with iodine-125 seed implantation in non-central recurrence of cervical cancer:a case report and literature review.Oncol Lett,2017,14(4):4085-4091.
[14]石玉琪,许春芳.ERCP联合腹腔镜胆囊切除术治疗胆总管结石合并胆囊结石术后胆总管结石复发的危险因素分析.中华消化内镜杂志,2016,33(10):689-692.
[15]Jun LU,Zhang J,Chen HC.Laparoscopic transcystic common bile duct exploration:T-shaped incision of cystic duct.J Laparoendosc Adv Surg Tech A,2016,26(8):646-651.
[16]Yoo ES,Yoo BM,Kim JH,et al.Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy.Scand J Gastroenterol,2018,53(4):466-470.
[17]Jin J,Lim S U,Park C H,et al.Restoration of common bile duct diameter within 2 weeks after endoscopic stone retraction is a preventive factor for stone recurrence.Hepatobiliary Pancreat Dis Int,2018,17(3):251-256.
[18]Wang CY,Wang CH,Tzeng YS,et al.Intraoperative assessment of the relationship between nipple circulation and incision site in nipple-sparing mastectomy with implant breast reconstruction using the SPY imaging system.Ann Plast Surg,2018,80(Suppl 1):S59-S65.
[19]Tsai TJ,Lin CK,Lai KH,et al.Does preserved sphincter of Oddi function prevent common bile duct stones recurrence in patients after endoscopic papillary balloon dilation J Chin Med Assoc,2018,81(4):311-315.
[20]Galimberti V,Vicini E,Corso G,et al.Nipple-sparing and skin-sparing mastectomy:Review of aims,oncological safety and contraindications.Breast,2017,34(Suppl 1):S82-S84.
[2]黄健.腹腔镜下胆总管切开取石术与经胆囊管取石术治疗胆总管结石伴胆囊结石患者疗效分析.实用肝脏病杂志,2018,21(2):269-272.
[3]Rawal KK.Migration of surgical clips into the common bile duct after laparoscopic cholecystectomy.Case Rep Gastroenterol,2017,10(3):787-792.
[4]闫凌,张盈,张晨光.两种手术方案治疗胆囊结石合并胆总管结石患者效果比较研究.实用肝脏病杂志,2018,21(2):301-302.
[5]Baucom RB,Feurer ID,Shelton JS,et al.Surgeons,ERCP,and laparoscopic common bile duct exploration:do we need a standard approach for common bile duct stones Surg Endosc,2016,30(2):414-423.
[6]Park JS,Jeong S,Bang BW,et al.Endoscopic papillary large balloon dilatation without s Sphincterotomy for the treatment of large common bile duct stone:long-term outcomes at a single center.Dig Dis Sci,2016,61(10):3045-3053.
[7]Kim SB,Kim KH,Kim TN.Comparison of outcomes and complications of endoscopic common bile duct stone removal between asymptomatic and symptomatic patients.Dig Dis Sci,2016,61(4):1172-1177.
[8]中华医学会外科学分会胆道外科学组.肝胆管结石病诊断治疗指南.中华消化外科杂志,2007,7(2):156-160.
[9]Saito H,Kakuma T,Kadono Y,et al.Increased risk and severity of ERCP-related complications associated with asymptomatic common bile duct stones.Endosc Int Open,2017,5(9):E809-E817.
[10]Bhanthumkomol P,Aswakul P,Prachayakul V.Argon plasma coagulation for the resolution of basket impaction from large common bile duct stones.Endosc Int Open,2016,4(4):E389-E390.
[11]Wang X,Dai C,Jiang Z,et al.Endoscopic retrograde cholangiopancreatography versus laparoscopic exploration for common bile duct stones in post-cholecystectomy patients:a retrospective study.Oncotarget,2017,8(47):82114-82122.
[12]Chong CC,Chiu PW,Tan T,et al.Correlation of CBD/CHDangulation with recurrent cholangitis in patients treated with ERCP.Endosc Int Open,2016,4(1):E62-E67.
[13]Feng H,Hu Y,Jin P,et al.Intensity-modulated radiotherapy combined with iodine-125 seed implantation in non-central recurrence of cervical cancer:a case report and literature review.Oncol Lett,2017,14(4):4085-4091.
[14]石玉琪,许春芳.ERCP联合腹腔镜胆囊切除术治疗胆总管结石合并胆囊结石术后胆总管结石复发的危险因素分析.中华消化内镜杂志,2016,33(10):689-692.
[15]Jun LU,Zhang J,Chen HC.Laparoscopic transcystic common bile duct exploration:T-shaped incision of cystic duct.J Laparoendosc Adv Surg Tech A,2016,26(8):646-651.
[16]Yoo ES,Yoo BM,Kim JH,et al.Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy.Scand J Gastroenterol,2018,53(4):466-470.
[17]Jin J,Lim S U,Park C H,et al.Restoration of common bile duct diameter within 2 weeks after endoscopic stone retraction is a preventive factor for stone recurrence.Hepatobiliary Pancreat Dis Int,2018,17(3):251-256.
[18]Wang CY,Wang CH,Tzeng YS,et al.Intraoperative assessment of the relationship between nipple circulation and incision site in nipple-sparing mastectomy with implant breast reconstruction using the SPY imaging system.Ann Plast Surg,2018,80(Suppl 1):S59-S65.
[19]Tsai TJ,Lin CK,Lai KH,et al.Does preserved sphincter of Oddi function prevent common bile duct stones recurrence in patients after endoscopic papillary balloon dilation J Chin Med Assoc,2018,81(4):311-315.
[20]Galimberti V,Vicini E,Corso G,et al.Nipple-sparing and skin-sparing mastectomy:Review of aims,oncological safety and contraindications.Breast,2017,34(Suppl 1):S82-S84.