胃大部切除毕Ⅱ式吻合术后胆管疾病的侧视内镜下治疗

Duodenoscopic treatment of biliary tract diseases in patients after gastrectomy and Billroth Ⅱ gastrojejunostomy

目的介绍和探讨应用侧视十二指肠镜对胃大部切除毕Ⅱ式吻合术(毕Ⅱ式)合并胆管疾病病人的内镜治疗。方法25例毕II式合并胆管疾病病人常规选择侧视十二指肠镜逆行插管,插管成功者行ERCP诊断和ENBD、ERBD、EST等治疗。结果20例毕Ⅱ式无空肠-空肠侧侧吻合中,插管成功19例(95.0%),1例(5.0%)因肠道狭窄致插管失败;5例毕Ⅱ式伴空肠-空肠侧侧吻合中,插管成功2例(40.0%),3例(60.0%)因空肠输入袢过长导致插镜失败。在21例成功插管中,17例总胆管结石分别行EST+ENBD(9例)、ENBD(6例)和ERBD(2例);3例胆管癌和1例胆道手术后总胆管下段狭窄行ERBD。有2例置入ERBD后发生一过性胰腺炎,经保守治疗后痊愈。所有病例在内镜治疗过程中未发生穿孔和出血并发症。结论毕Ⅱ式后合并胆管疾病病人行ERCP和内镜下治疗,这种治疗是微创和安全的,内镜治疗的成功率与原外科手术方式有关。

Objective To introduce and discuss the treatment of patients with biliary tract diseases after gastrectomy and Billroth Ⅱ gastrojejunostomy under electronic side-view duodenoscopy. Methods Twenty-five patients with biliary tract diseases who had undergone gastrectomy and Billroth Ⅱ gastrojejunostomy before were diagnosed and treated by using electronic side-view duodenoscopic techniques including ERCP, ENBD, ERBD and EST. Results For the 20 patients without Braun＇s anastomosis （side-to-side jejunojejunostomy）, duodenoscope insertion was completed in 19 （95 % ） and failed in 1 due to the stenosis of jejune lumen （5 %）. For the patients with Braun＇s anastomosis, duodenoscope insertion was completed in 2 （40%） and failed in 3 because of the prolonged jejune loop （60%）. Of the 21 patients who had successful ERCP, 17 with common bile duct stones were treated by EST＋ENBD （n=9）, ENBD （n=6） and ERBD （n=2）, respectively, 3 with bile duct cancers by ERBD and 1 with postoperative distal common bile duct stenosis by ERBD. Two patients treated by ERBD had complication of transient acute pancreatitis and relieved soon after medical treatment. All the patients had no complications of perforation and hemorrhage caused by endoscopic management. Conclusions Electronic duodenoscopic treatment is a mini traumatic and safe therapeutic technique for patients with biliary tract diseases after gastrectomy and Billroth Ⅱ gastrojejunostomy. The success rate of the treatment is related to the ways of postgastrectomic reconstructive operation.