双导丝技术及经胰管乳头预切开术在困难性ERCP胆管插管中的应用
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摘要
目的探讨双导丝技术及经胰管乳头预切开术在困难性经内镜逆行胰胆管造影(ERCP)胆管插管中的应用。方法选取2015年1月至2018年1月在我院消化内镜中心收治的困难性ERCP胆管插管患者81例,分三组采用不同插管方法,其中双导丝技术(A组)33例,经胰管乳头预切开术(B组)18例,常规插管法(C组)30例。比较3种方法胆管插管成功率及并发症发生率。结果 A组患者28例插管进入胆总管,成功率84.8%,B组患者17例进入胆总管,成功率94.4%,C组患者16例进入胆总管,成功率53.3%。A、B两组插管成功率比较,差异无统计学意义(P>0.05),A、C两组,B、C两组插管成功率比较,差异有统计学意义(P<0.05),A组患者术后并发高淀粉酶血症4例,胰腺炎1例,无出血、穿孔,并发症发生率15.2%;B组患者术后并发高淀粉酶血症3例,消化道出血1例,急性胰腺炎1例,无穿孔患者,并发症发生率27.8%;C组患者术后并发高淀粉酶血症5例,胰腺炎1例,无出血、穿孔患者,并发症发生率20.0%。A、B、C三组并发症发生率差异无统计学意义(P>0.05)。结论 ERCP选择性胆管插管困难,反复进入胰管,采用双导丝技术或经胰管乳头预切开术可明显提高插管成功率,且并发症无明显增加。
Objective To investigate the application of double-guidewire technique and transpancreatic precut sphincterotomy in patients with difficult biliary cannulation in endoscopic retrograde cholangiopancreatography(ERCP).Methods Eighty-one cases with difficult biliary cannulation in ERCP were collected from Jan. 2015 to Jan. 2018. According to the cannulation method, they were divided into 3 groups, 33 cases in double-guidewire technique group(group A), 18 cases in transpancreatic precut sphincterotomy group(group B), and 30 cases in conventional cannulation technique group(group C). The success rates of cannulation and incidence rate of postoperative complications among the three groups were compared.Results The success rate of cannulation was 84.8%(28/33) in group A, 94.4%(17/18) in group B, and 53.3%(16/30) in group C.There was no significant difference between group A and group B(P>0.05), and significant differences could be found in group A and group C, group B and group C(P<0.05). In group A, 4 cases were complicated with hyperamylasemia, 1 case with acute pancreatitis, no bleeding or perforation, the incidence rate of complications was 15.2%. In group B, 3 cases were complicated with hyperamylasemia, 1 case with gastrointestinal bleeding, 1 case with acute pancreatitis, no perforation, the incidence rate of complications was 27.8%. In group C, 5 cases were complicated with hyperamylasemia, 1 case with pancreatitis, no bleeding or perforation, the incidence rate of complications was 20.0%. There was no significant differences among three groups(P>0.05).Conclusion When guidewire gets into the pancreative duct repeatedly in difficult biliary cannulation in ERCP, double-guidewire technique or transpancreatic precut sphincterotomy can be applied to improve the success rate of cannulation effectively, with no obvious increase in the incidence of complications.
Objective To investigate the application of double-guidewire technique and transpancreatic precut sphincterotomy in patients with difficult biliary cannulation in endoscopic retrograde cholangiopancreatography(ERCP).Methods Eighty-one cases with difficult biliary cannulation in ERCP were collected from Jan. 2015 to Jan. 2018. According to the cannulation method, they were divided into 3 groups, 33 cases in double-guidewire technique group(group A), 18 cases in transpancreatic precut sphincterotomy group(group B), and 30 cases in conventional cannulation technique group(group C). The success rates of cannulation and incidence rate of postoperative complications among the three groups were compared.Results The success rate of cannulation was 84.8%(28/33) in group A, 94.4%(17/18) in group B, and 53.3%(16/30) in group C.There was no significant difference between group A and group B(P>0.05), and significant differences could be found in group A and group C, group B and group C(P<0.05). In group A, 4 cases were complicated with hyperamylasemia, 1 case with acute pancreatitis, no bleeding or perforation, the incidence rate of complications was 15.2%. In group B, 3 cases were complicated with hyperamylasemia, 1 case with gastrointestinal bleeding, 1 case with acute pancreatitis, no perforation, the incidence rate of complications was 27.8%. In group C, 5 cases were complicated with hyperamylasemia, 1 case with pancreatitis, no bleeding or perforation, the incidence rate of complications was 20.0%. There was no significant differences among three groups(P>0.05).Conclusion When guidewire gets into the pancreative duct repeatedly in difficult biliary cannulation in ERCP, double-guidewire technique or transpancreatic precut sphincterotomy can be applied to improve the success rate of cannulation effectively, with no obvious increase in the incidence of complications.
引文
[1] ZOU X P,LEUNG J W,LI Y H,et al.Comparison of sequential pancreatic duct guidewire placement technique and needle knife precut sphincterotomy for difficult biliary cannulation [J].J Dig Dis,2015,16(12):741-746.DOI:10.1111/1751-2980.12300.
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[6] 孙雄,龚镭,彭晓斌,等.经胰管胆胰管隔膜切开术及双导丝术在困难性插管ERCP 中的应用及安全性分析[J].中国内镜杂志,2017,23(8):47-50.DOI:10.3969/j.issn.1007-1989.2017.08.010.SUN X,GONG L,PENG X B,et al.Endoscopic transpancreatic precut sphincterotomy and double guidewire technique in difficult bile duct cannulation during endo-scopic retrograde cholangiopancreatography [J].China Journal of Endoscopy,2017,23(8):47-50.DOI:10.3969/j.issn.1007-1989.2017.08.010.
[7] 刘枫,李兆申,时昭红,等.经胰管乳头括约肌预切开术在困难胆道插管中的临床应用[ J].中华消化内镜杂志,2007,24(3):177-179.DOI:10.3760/cma.j.issn.1007-5232.2007.03.005.LIU F,LI Z S,SHI Z H,et al.Clinical application of transpancreatic sphincterotomy for inaccessible common bile duct [J].Chin J Dig Endosc,2007,24(3):177-179.DOI:10.3760/cma.j.issn.1007-5232.2007.03.005.
[8] CATALANO M F,LINDER J D,GEENEN J E.Endoscopic transpancreatic papillary septotomy for inaccessible obstructed bile ducts:comparison with st andard pre-cut papillotomy [ J].Gastrointest Endosc,2004,60 (4):557-561.
[9] TESTONI P A,MARIANI A,AABAKKEN L,et al.Papillary cannulation and sphincterotomy techniques at ERCP:European Society of Gastrointestinal Endoscopy ( ESGE) clinical guideline [J].Endoscopy,2016,48(7):657-683.DOI:10.1055/s-0042-108641.
[10] CENNAMO V,FUCCIO L,ZAGARI R M,et al.Can early precut implementation reduce endoscopic retrograde cholangiopancreatographyrelated complication risk?Meta-analysis of randomized controlled trials [J].Endoscopy,2010,42(3):381-388.DOI:10.1055/s-0029-1243992.
[11] 马镇坚,王小忠,许选,等.内镜逆行胰胆管造影术中选择性胆管插管失败的影响因素及辅助插管价值探讨[J].胃肠病学和肝病学杂志,2018,27(11):1290-1293.DOI:10.3969 /j.issn.1006-5709.2018.11.021.MA Z J,WANG X Z,XU X,et al.Study on the influencing factors of selective bile duct intubation in ERCP and the value of assisted intubation [J].Chin J Gastroenterol Hepatol,2008,27 (11):1290-1293.DOI:10.3969 /j.issn.1006-5709.2018.11.021.
[12] HALTTUNEN J,KER?NEN I,UDD M,et al.Pancreatic sphincterotomy versus needle knife precut in difficult biliary cannulation [J].Surg Endosc,2009,23(4):745-749.DOI:10.1007/s00464-008-0056-0.
[2] LEE Y J,PARK Y K,LEE M J,et al.Different strategies for transpancreatic septotomy and needle knife infundibulotomy due to the presence of unintended pancreatic cannulation in difficult biliary cannulation [J].Gut Liver,2015,9(4):534-539.DOI:10.5009/gnl14223.
[3] DUMONCEAU J M,DEVIèRE J,CREMER M.A new method of achieving deep cannulation of the common bile duct during endoscpic retrograde cholangiopancreatography [J].Endoscopy,1998,30(7):S80.
[4] GOFF J S.Common bile duct pre-cut sphincterotomy:transpancreatic sphincter approach [J].Gastrointest Endos,1995,41(5):502-505.
[5] GOFF J S.Long-term experience with the transpancreatic sphincter pre-cut approach to biliary sphincterotomy [J].Gastrointest Endosc,1999,50(5):642-645.
[6] 孙雄,龚镭,彭晓斌,等.经胰管胆胰管隔膜切开术及双导丝术在困难性插管ERCP 中的应用及安全性分析[J].中国内镜杂志,2017,23(8):47-50.DOI:10.3969/j.issn.1007-1989.2017.08.010.SUN X,GONG L,PENG X B,et al.Endoscopic transpancreatic precut sphincterotomy and double guidewire technique in difficult bile duct cannulation during endo-scopic retrograde cholangiopancreatography [J].China Journal of Endoscopy,2017,23(8):47-50.DOI:10.3969/j.issn.1007-1989.2017.08.010.
[7] 刘枫,李兆申,时昭红,等.经胰管乳头括约肌预切开术在困难胆道插管中的临床应用[ J].中华消化内镜杂志,2007,24(3):177-179.DOI:10.3760/cma.j.issn.1007-5232.2007.03.005.LIU F,LI Z S,SHI Z H,et al.Clinical application of transpancreatic sphincterotomy for inaccessible common bile duct [J].Chin J Dig Endosc,2007,24(3):177-179.DOI:10.3760/cma.j.issn.1007-5232.2007.03.005.
[8] CATALANO M F,LINDER J D,GEENEN J E.Endoscopic transpancreatic papillary septotomy for inaccessible obstructed bile ducts:comparison with st andard pre-cut papillotomy [ J].Gastrointest Endosc,2004,60 (4):557-561.
[9] TESTONI P A,MARIANI A,AABAKKEN L,et al.Papillary cannulation and sphincterotomy techniques at ERCP:European Society of Gastrointestinal Endoscopy ( ESGE) clinical guideline [J].Endoscopy,2016,48(7):657-683.DOI:10.1055/s-0042-108641.
[10] CENNAMO V,FUCCIO L,ZAGARI R M,et al.Can early precut implementation reduce endoscopic retrograde cholangiopancreatographyrelated complication risk?Meta-analysis of randomized controlled trials [J].Endoscopy,2010,42(3):381-388.DOI:10.1055/s-0029-1243992.
[11] 马镇坚,王小忠,许选,等.内镜逆行胰胆管造影术中选择性胆管插管失败的影响因素及辅助插管价值探讨[J].胃肠病学和肝病学杂志,2018,27(11):1290-1293.DOI:10.3969 /j.issn.1006-5709.2018.11.021.MA Z J,WANG X Z,XU X,et al.Study on the influencing factors of selective bile duct intubation in ERCP and the value of assisted intubation [J].Chin J Gastroenterol Hepatol,2008,27 (11):1290-1293.DOI:10.3969 /j.issn.1006-5709.2018.11.021.
[12] HALTTUNEN J,KER?NEN I,UDD M,et al.Pancreatic sphincterotomy versus needle knife precut in difficult biliary cannulation [J].Surg Endosc,2009,23(4):745-749.DOI:10.1007/s00464-008-0056-0.