内镜下十二指肠乳头括约肌小切开术联合乳头大气囊扩张术治疗胆总管结石的临床研究
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摘要
胆总管结石是临床的常见病，多发病，可以分为原发于胆道的原发性结石和继发于胆囊的继发性结石，无论是原发性结石还是继发性结石都可以引起包括急性梗阻性化脓性胆管炎、胆源性肝脓肿、胆源性胰腺炎、阻塞性黄疸等多种严重并发症，以往治疗主要以外科手术为主，虽然近30年来微创外科飞速的发展，使得腹腔镜下切除胆囊逐渐成为治疗胆囊结石的首选治疗方案，但是胆总管结石的治疗仍然困扰着人们，当内镜下十二指肠乳头括约肌切开术（EST）、十二指肠乳头柱状气囊扩张术（EPBD）等技术的出现后，为胆总管结石的微创治疗带来了曙光。
但是十二指肠乳头括约肌切开术（EST）存在着容易出现肠穿孔、出血、胰腺炎、胆管炎等近期并发症，以及因为少数病例破坏了十二指肠乳头括约肌功能导致的反复的胆道感染。同样十二指肠乳头柱状气囊扩张术（EPBD）也有术后胰腺炎发病率高，对于可取出结石大小限制严格等缺点，故而，我们尝试应用十二指肠乳头括约肌的小切开联合十二指肠乳头柱状大气囊的扩张，期望在两种取石技术中找到平衡点，既最大程度的保留十二指肠乳头括约肌的功能，同时扩大可以取出结石大小的范围，减少术后近期及远期并发症的发生。
The common bile duct stones clinical common disease, EST, EPBD.Technology to achieve the aspirations of the minimally invasive treatmentof common bile duct stones, but is also accompanied by intestinalperforation, bleeding, postoperative pancreatitis, cholangitis, and otherrecent concurrentdisease and recurrent cholangitis, the risk ofcholangiocarcinoma increased risk of long-term complications. In thisstudy, the nipple sphincter small incision joint nipple balloon dilatationfor the treatment of common bile duct stones.
Objective
This study investigated the efficacy of application of nipplesphincter small incision joint papillary large balloon dilatation treatmentof common bile duct stones.Methods
Results
EST group and EST+EPLBD group were57cases (95%) and58cases (96.6%) successfully take the net stones, which have55cases(91.6%) and56cases (93.3%) for a complete, mechanical lithotripsyapplicationrates were9(22.5%) and17(42.5%). The overall incidence of hyperamylasemia, pancreatitis, bleeding, perforation and othercomplications after surgery were10%and6.6%, with no deaths.
Conclusion
Endoscopic papilla sphincter joint EPBD small incision surgery,reach and EST the same stone effect and compensate for the deficienciesof the EPBD, reduce the incidence of pancreatitis was significantly lowercompared to the pure EST bleeding risk, and, as far as possible, toretainduodenal papilla sphincter function, this approach combines theadvantages of EST and EPBD, in terms of efficacy, safety and reducecomplications, and achieved good results, easy to spread.
但是十二指肠乳头括约肌切开术（EST）存在着容易出现肠穿孔、出血、胰腺炎、胆管炎等近期并发症，以及因为少数病例破坏了十二指肠乳头括约肌功能导致的反复的胆道感染。同样十二指肠乳头柱状气囊扩张术（EPBD）也有术后胰腺炎发病率高，对于可取出结石大小限制严格等缺点，故而，我们尝试应用十二指肠乳头括约肌的小切开联合十二指肠乳头柱状大气囊的扩张，期望在两种取石技术中找到平衡点，既最大程度的保留十二指肠乳头括约肌的功能，同时扩大可以取出结石大小的范围，减少术后近期及远期并发症的发生。
The common bile duct stones clinical common disease, EST, EPBD.Technology to achieve the aspirations of the minimally invasive treatmentof common bile duct stones, but is also accompanied by intestinalperforation, bleeding, postoperative pancreatitis, cholangitis, and otherrecent concurrentdisease and recurrent cholangitis, the risk ofcholangiocarcinoma increased risk of long-term complications. In thisstudy, the nipple sphincter small incision joint nipple balloon dilatationfor the treatment of common bile duct stones.
Objective
This study investigated the efficacy of application of nipplesphincter small incision joint papillary large balloon dilatation treatmentof common bile duct stones.Methods
Results
EST group and EST+EPLBD group were57cases (95%) and58cases (96.6%) successfully take the net stones, which have55cases(91.6%) and56cases (93.3%) for a complete, mechanical lithotripsyapplicationrates were9(22.5%) and17(42.5%). The overall incidence of hyperamylasemia, pancreatitis, bleeding, perforation and othercomplications after surgery were10%and6.6%, with no deaths.
Conclusion
Endoscopic papilla sphincter joint EPBD small incision surgery,reach and EST the same stone effect and compensate for the deficienciesof the EPBD, reduce the incidence of pancreatitis was significantly lowercompared to the pure EST bleeding risk, and, as far as possible, toretainduodenal papilla sphincter function, this approach combines theadvantages of EST and EPBD, in terms of efficacy, safety and reducecomplications, and achieved good results, easy to spread.
引文
[1]李益农陆星华消化内镜学第二版科学出版社
[2] Barbara L,Samac,Morselli-Labate AM et al.10-year incidence of gallstone disease:the Sirmione study.J Hepatol1993;18:S43
[3] Courvoisier OG(1890). Kasuistisch-statistische Beitrage zur Pathologie undChirurgie der Gallenwege, pp.57-8. Liepzig, FCW Vogel.
[4] Calvo MM Bujanda L, Calderon A et al. Role of magnetic resonancecholangiopancreatography in patients with suspected choledocho lithiasis. MayoClin Proc2002;77;422-8.
[5] De Waele E, Op de Beeck B, De Waele B, et al. Magnetic resonancecholangiopancreatography in the preoperative assessment of patients with biliarypancreatitis[J]. Pancreatology,2007,7(4):347.
[6] Amouyal P, Amouyal G, Levy P et al. Diagnosis of choledocholithiasis byendoscopic ultrasonography. Gastroenterology1994;106:1062-7
[7] Prat F, Amouyal G,Pelletier V et al, Prospective of controlled study of endoncopicultrasonography and endoscopic retrograde cholagio graphy in patients withsuspected common bile duct lithiasis. Lancet1996;346:75-9
[8] Canto M, Chak A,Stellato T, Sivak MV Jr. Endoscoic ultrasonography versuscholangiography for the diagnosis of choledocholithiasis. Gastrointest Endosc1998;47:439-48.
[9] Kawai K,Akasaka Y,Murakrumi K.Endoscopic shincterotomy of the ampulla ofVater.Gastrointest Endo,1974，20:148.
[10] Classen M,Demling L.Endoskpische sphincterotomie der papilla Va teri undstainextrakion aus ductus choledochus.Dtsch Med Wochens
[14] Starizu Oo M.Ewek.Meyer Z.Endoscopic papiliary dilatation(EPD) for treatmentof common bile duct stones and papillary stenosis.En doscopy.1983，15:197.chr,1974，99:496.
[15] Bergman JJGH, Rauws EAJ, Fockens P, van Berkel A-M,Bossuyt PM, TijssenJGP, et al. Randomised trial of endoscopicballoon dilation versus endoscopicsphincterotomy for removal of bile duct stones. Lancet.1997;349:1124–9.Jul;33(7):563-7.
[16] Bergman JJGHM, van Berkel A-M, Bruno MJ, Fockens P, Rauws EAJ, TijssenJGP, et al. A randomized trial of endoscopic balloon dilation and endoscopicsphincterotomy for removal of bile duct stones in patients with
[17] Endoscopic papillary balloon dilation vs. sphincterotomy for removal ofcommon bile duct stones: a prospective randomized pilot study. Arnold JC, BenzC, Martin WR, Adamek HE, Riemann JF.Endoscopy.2001a prior Billroth IIgastrectomy. Gastroin-test Endosc.2001;53:19–26.
[18] Long-term prognosis of bile duct stones: endoscopic papillary balloon dilatationversus endoscopic sphincterotomy. Kojima Y, Nakagawa H, Miyata A, Hirai T,Ohyama I, Okada A, Hiramatsu T, Ohhara Y, Kuwahara T.Dig Endosc.2010Jan;22(1):21-4.
[19] Chang WH, Chu CH, Wang TE, Chen MJ, Lin CC. Outcome of simple use ofmechanical lithotripsy of difficult common bile duct stones. World JGastroenterol.2005;11:593–596.
[20] Garg PK, Tandon RK, Ahuja V, Makharia GK, Batra Y. Predictors ofunsuccessful mechanical lithotripsy and endoscopic clearance of large bile ductstones. Gastrointest Endosc.2004;59:601–605.
[21] Cipolletta L, Costamagna G, Bianco MA, et al. Endoscopic mechanicallithotripsy of difficult common bile duct stones. Br J Surg.1997;84:1407–1409.
[22] Hintze RE, Adler A, Veltzke W. Outcome of mechanical lithotripsy of bile ductstones in an unselected series of704patients. Hepatogastroenterology.1996;43:473–476.
[23] Schneider MU, Matek W, Bauer R, Domschke W. Mechanical lithotripsy of bileduct stones in209patients: effect of technical advances. Endoscopy.1988;20:248–253.
[24] Bogardus ST, Hanan I, Ruchim M, et al."Mother-baby" biliary endoscopy: theUniversity of Chicago experience. Am J Gastroenterol,1996,91(1):105-110.
[25] Farrell JJ, Bounds BC, Al-Shalabi S, et al. Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management ofchole-docholithiasis not removed by conventional methods, including mechanicallithotripsy. Endoscopy,2005,37(6):542-547.
[26] Muratori R, Azzaroli F, Buonfiglioli F, Alessandrelli F, Cecinato P, Mazzella G,Roda E.World J Gastroenterol.2010Sep7;16(33):4159-63.
[27]张澍田，王拥军.胆总管结石的内镜治疗[J].中华实用内科杂志，2007，27（11）：836-840
[1] Cotton PB,Lehman G,Vennes J, Geenen JE, Russell RC, Meyers WC etal.Endoscopic sphincterotomy complications and their management：an attempt atconsensus. Gastrointest Endosc1991;37:383-93
[2] Goodall RJR.Bleeding after endonscopic shincterotomy.Ann R Coll Surg1985;67:87-8.
[3] Loperfido S,Angelini G, Benedetti G, Chilovi F, De Berardinis F et al.Majorearly complications from diagnostic and therapeutic ERCP: a prospectivemulticenter study. Gastrointest Endosc1998;48:1-10
[4] Masci E,Toti G,Mariani A,Curoni S,Lomazzi A, Dinelli M et al.Complicationsof diagnostic and therapeutic ERCP:a prospective multicenter study.Am JGastroenterol2001；96:417-23
[5] Freeman ML，Nelson DB，Sherman S, Haber GB,Herman ME, Dorsher PJ etal.Complications of endonscopic biliary sphincterotom. N Engl J MED1996;335:909-18
[6]叶萍,李兆申,等.稀钡检测十二指肠乳头括约肌切开术后患者乳头功能[J].中华消化内镜杂志,2006,23(2):94-97
[7] Stsritz M, Ewe K，Meyer zum Buschenfelde KH. Endonscopic papillary balloondilation (EPD) for the tretment of common duct stones and papillarysenosis.Endoscopy1983；15:197-8
[8] Bader M，Geenen JE，Hogan W et al.Endoscopic balloon dilatation of the sphincter of Oddi in patients with suspected biliary dyskinesia: results of a prospectiverandomized trial. Gastrointest Endosc1986;32:158A
[9] Kozarek RA. Balloon dilatation of rhe sphincter of Oddi.Endoscopy1988;20:207-10
[10] May GR，Cotton PB， Edmunds SE，Chong W.Removal of stones from thebileduct at ERCP without sphincterotomy.Gastrointest Endosc1993;39:749-54.
[11] MacMathuna P,White P,Clarke E et al.Endoscopic balloon sphincteroplasty(papillary dilation) for bile duct stones: efficacy, safety and follow-up in100patients.Gastrointest Endosc1995;42:468-74
[12] Bergman JJGHM, van Berkel A-M, Bruno MJ, Fockens P, Rauws EAJ,Tijssen JGP, et al. A randomized trial of endoscopic balloon dilation and endoscopicsphincterotomy for removal of bile duct stones in patients with
[13] Bergman JJ，Tytgat GN，Huibregtse K。Endoscopic dilatation of the biliarysphincter for removal of bile duct stones: an overview of current indications andlimitations.Scand J Gastioenterol Suppl1998;225:59-65
[14]李益农，陆星华，消化内镜学第二版科学出版社
[15]王蓉，王富文，等.内镜下乳头括约肌小切开联合气囊扩张术在胆总管结石治疗中的应用价值[J].胃肠病学和肝病学杂志2011,20(2):185-186
[16]孙思予，刘治军，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
[17]RAJASEKH ARA R, M UM M ADI, NORIO FUKAM I, et al. Safety andefficacy of endoscopic sphincterotom y (ES) followed by endoscopic papillary largeballoon dilation (EPLBD) for extraction of large com m on bile duct stones (LBDS):A system atic review and meta-analysis[J]. Gastrointestinal Endoscopy,2010: AB161.
[18] Ostamagna G，Tringali A， Shah SK，etal.Long-term follow-up of patients afterEndoscopic sphincterotomy for choledocholithiasis， and risk factors forrecurrence[J].Endoscopy2002，34(4):273一279.
[19] PratF， MalakNA，PelletierG，etal.Biliary symptoms and complications morethan8years after endoscopic sphincterotomy forcholedocholithiasis.Gastroenterology，1996，110:894一899，
[20]6LaiKH，pengNJ，LoGH，etal，Does a fatty meal improve hepatic clearance inPatients after endoscopic sphincterotomy?JGastroen terol HePatol，2002，17;337-341
[21]SugiyamaM， Aiomi Y. Periampullary diverticula cause panereatobiliaryrefiux[J].Scand J Gastroenterol2001，36(9):994一997.
[22]Stewart L, Oesterle AL, Erdan I, et a1. Pathogenesis of pigment gall－stones inWestern societies: the central role of bacteria. GastrointestSurg,2002,6:891-903.
[23]Man dryka Y, Klimczak J, Duszewski M, et a1. Bile duct infections as a latecomplication after endoscopic sphincterotomy. Pol Merkur Lekarski,2006,21:525-527.
[2] Barbara L,Samac,Morselli-Labate AM et al.10-year incidence of gallstone disease:the Sirmione study.J Hepatol1993;18:S43
[3] Courvoisier OG(1890). Kasuistisch-statistische Beitrage zur Pathologie undChirurgie der Gallenwege, pp.57-8. Liepzig, FCW Vogel.
[4] Calvo MM Bujanda L, Calderon A et al. Role of magnetic resonancecholangiopancreatography in patients with suspected choledocho lithiasis. MayoClin Proc2002;77;422-8.
[5] De Waele E, Op de Beeck B, De Waele B, et al. Magnetic resonancecholangiopancreatography in the preoperative assessment of patients with biliarypancreatitis[J]. Pancreatology,2007,7(4):347.
[6] Amouyal P, Amouyal G, Levy P et al. Diagnosis of choledocholithiasis byendoscopic ultrasonography. Gastroenterology1994;106:1062-7
[7] Prat F, Amouyal G,Pelletier V et al, Prospective of controlled study of endoncopicultrasonography and endoscopic retrograde cholagio graphy in patients withsuspected common bile duct lithiasis. Lancet1996;346:75-9
[8] Canto M, Chak A,Stellato T, Sivak MV Jr. Endoscoic ultrasonography versuscholangiography for the diagnosis of choledocholithiasis. Gastrointest Endosc1998;47:439-48.
[9] Kawai K,Akasaka Y,Murakrumi K.Endoscopic shincterotomy of the ampulla ofVater.Gastrointest Endo,1974，20:148.
[10] Classen M,Demling L.Endoskpische sphincterotomie der papilla Va teri undstainextrakion aus ductus choledochus.Dtsch Med Wochens
[14] Starizu Oo M.Ewek.Meyer Z.Endoscopic papiliary dilatation(EPD) for treatmentof common bile duct stones and papillary stenosis.En doscopy.1983，15:197.chr,1974，99:496.
[15] Bergman JJGH, Rauws EAJ, Fockens P, van Berkel A-M,Bossuyt PM, TijssenJGP, et al. Randomised trial of endoscopicballoon dilation versus endoscopicsphincterotomy for removal of bile duct stones. Lancet.1997;349:1124–9.Jul;33(7):563-7.
[16] Bergman JJGHM, van Berkel A-M, Bruno MJ, Fockens P, Rauws EAJ, TijssenJGP, et al. A randomized trial of endoscopic balloon dilation and endoscopicsphincterotomy for removal of bile duct stones in patients with
[17] Endoscopic papillary balloon dilation vs. sphincterotomy for removal ofcommon bile duct stones: a prospective randomized pilot study. Arnold JC, BenzC, Martin WR, Adamek HE, Riemann JF.Endoscopy.2001a prior Billroth IIgastrectomy. Gastroin-test Endosc.2001;53:19–26.
[18] Long-term prognosis of bile duct stones: endoscopic papillary balloon dilatationversus endoscopic sphincterotomy. Kojima Y, Nakagawa H, Miyata A, Hirai T,Ohyama I, Okada A, Hiramatsu T, Ohhara Y, Kuwahara T.Dig Endosc.2010Jan;22(1):21-4.
[19] Chang WH, Chu CH, Wang TE, Chen MJ, Lin CC. Outcome of simple use ofmechanical lithotripsy of difficult common bile duct stones. World JGastroenterol.2005;11:593–596.
[20] Garg PK, Tandon RK, Ahuja V, Makharia GK, Batra Y. Predictors ofunsuccessful mechanical lithotripsy and endoscopic clearance of large bile ductstones. Gastrointest Endosc.2004;59:601–605.
[21] Cipolletta L, Costamagna G, Bianco MA, et al. Endoscopic mechanicallithotripsy of difficult common bile duct stones. Br J Surg.1997;84:1407–1409.
[22] Hintze RE, Adler A, Veltzke W. Outcome of mechanical lithotripsy of bile ductstones in an unselected series of704patients. Hepatogastroenterology.1996;43:473–476.
[23] Schneider MU, Matek W, Bauer R, Domschke W. Mechanical lithotripsy of bileduct stones in209patients: effect of technical advances. Endoscopy.1988;20:248–253.
[24] Bogardus ST, Hanan I, Ruchim M, et al."Mother-baby" biliary endoscopy: theUniversity of Chicago experience. Am J Gastroenterol,1996,91(1):105-110.
[25] Farrell JJ, Bounds BC, Al-Shalabi S, et al. Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management ofchole-docholithiasis not removed by conventional methods, including mechanicallithotripsy. Endoscopy,2005,37(6):542-547.
[26] Muratori R, Azzaroli F, Buonfiglioli F, Alessandrelli F, Cecinato P, Mazzella G,Roda E.World J Gastroenterol.2010Sep7;16(33):4159-63.
[27]张澍田，王拥军.胆总管结石的内镜治疗[J].中华实用内科杂志，2007，27（11）：836-840
[1] Cotton PB,Lehman G,Vennes J, Geenen JE, Russell RC, Meyers WC etal.Endoscopic sphincterotomy complications and their management：an attempt atconsensus. Gastrointest Endosc1991;37:383-93
[2] Goodall RJR.Bleeding after endonscopic shincterotomy.Ann R Coll Surg1985;67:87-8.
[3] Loperfido S,Angelini G, Benedetti G, Chilovi F, De Berardinis F et al.Majorearly complications from diagnostic and therapeutic ERCP: a prospectivemulticenter study. Gastrointest Endosc1998;48:1-10
[4] Masci E,Toti G,Mariani A,Curoni S,Lomazzi A, Dinelli M et al.Complicationsof diagnostic and therapeutic ERCP:a prospective multicenter study.Am JGastroenterol2001；96:417-23
[5] Freeman ML，Nelson DB，Sherman S, Haber GB,Herman ME, Dorsher PJ etal.Complications of endonscopic biliary sphincterotom. N Engl J MED1996;335:909-18
[6]叶萍,李兆申,等.稀钡检测十二指肠乳头括约肌切开术后患者乳头功能[J].中华消化内镜杂志,2006,23(2):94-97
[7] Stsritz M, Ewe K，Meyer zum Buschenfelde KH. Endonscopic papillary balloondilation (EPD) for the tretment of common duct stones and papillarysenosis.Endoscopy1983；15:197-8
[8] Bader M，Geenen JE，Hogan W et al.Endoscopic balloon dilatation of the sphincter of Oddi in patients with suspected biliary dyskinesia: results of a prospectiverandomized trial. Gastrointest Endosc1986;32:158A
[9] Kozarek RA. Balloon dilatation of rhe sphincter of Oddi.Endoscopy1988;20:207-10
[10] May GR，Cotton PB， Edmunds SE，Chong W.Removal of stones from thebileduct at ERCP without sphincterotomy.Gastrointest Endosc1993;39:749-54.
[11] MacMathuna P,White P,Clarke E et al.Endoscopic balloon sphincteroplasty(papillary dilation) for bile duct stones: efficacy, safety and follow-up in100patients.Gastrointest Endosc1995;42:468-74
[12] Bergman JJGHM, van Berkel A-M, Bruno MJ, Fockens P, Rauws EAJ,Tijssen JGP, et al. A randomized trial of endoscopic balloon dilation and endoscopicsphincterotomy for removal of bile duct stones in patients with
[13] Bergman JJ，Tytgat GN，Huibregtse K。Endoscopic dilatation of the biliarysphincter for removal of bile duct stones: an overview of current indications andlimitations.Scand J Gastioenterol Suppl1998;225:59-65
[14]李益农，陆星华，消化内镜学第二版科学出版社
[15]王蓉，王富文，等.内镜下乳头括约肌小切开联合气囊扩张术在胆总管结石治疗中的应用价值[J].胃肠病学和肝病学杂志2011,20(2):185-186
[16]孙思予，刘治军，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
[17]RAJASEKH ARA R, M UM M ADI, NORIO FUKAM I, et al. Safety andefficacy of endoscopic sphincterotom y (ES) followed by endoscopic papillary largeballoon dilation (EPLBD) for extraction of large com m on bile duct stones (LBDS):A system atic review and meta-analysis[J]. Gastrointestinal Endoscopy,2010: AB161.
[18] Ostamagna G，Tringali A， Shah SK，etal.Long-term follow-up of patients afterEndoscopic sphincterotomy for choledocholithiasis， and risk factors forrecurrence[J].Endoscopy2002，34(4):273一279.
[19] PratF， MalakNA，PelletierG，etal.Biliary symptoms and complications morethan8years after endoscopic sphincterotomy forcholedocholithiasis.Gastroenterology，1996，110:894一899，
[20]6LaiKH，pengNJ，LoGH，etal，Does a fatty meal improve hepatic clearance inPatients after endoscopic sphincterotomy?JGastroen terol HePatol，2002，17;337-341
[21]SugiyamaM， Aiomi Y. Periampullary diverticula cause panereatobiliaryrefiux[J].Scand J Gastroenterol2001，36(9):994一997.
[22]Stewart L, Oesterle AL, Erdan I, et a1. Pathogenesis of pigment gall－stones inWestern societies: the central role of bacteria. GastrointestSurg,2002,6:891-903.
[23]Man dryka Y, Klimczak J, Duszewski M, et a1. Bile duct infections as a latecomplication after endoscopic sphincterotomy. Pol Merkur Lekarski,2006,21:525-527.