内镜逆行胰胆管造影及内镜括约肌切开术治疗1.0cm以上胆总管结石的临床研究

Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy in treatment of choledocholithiasis with stones up to 1.0 cm in diameter

目的探讨内镜逆行胰胆管造影及内镜括约肌切开术治疗胆总管结石直径1.0 cm以上的临床应用和并发症的观察。方法对102例诊断胆总管结石、直径大于1.0 cm结石采用经内镜治疗,其中49例采用内镜下机械碎石治疗。对于多次插管导致乳头水肿、胆总管下段狭窄、泥沙样结石、碎石术后难以确定结石是否取净,有胆系感染者放置鼻胆管引流。结果102例中89例取石成功,成功率为87.25%;一次取尽结石68例,二次取尽结石21例;单次操作时间最长154 min,平均约78 min;并发症发生率为12.7%,其中急性胆管炎2例,急性胰腺炎3例,结石嵌顿3例,出血2例,穿孔2例,死亡1例。结论内镜括约肌切开术治疗直径1.0 cm以上胆总管结石是一种安全有效的方法,结石越大内镜操作难度越大、手术时间越长、并发症越高。机械碎石是治疗胆总管大结石的重要手段,采用分次取石以缩短单次操作时间,结合鼻胆管引流是降低并发症的关键。

Objective To investigate the chnical value and the incidence of complication of endoscopic retrograde cholangiopan-creatography and endoscopic sphincterotomy （EST） in treatment of choledochohthiasis with stones up to 1.0 cm in diameter. Methods All 102 patients with stones up to 1.0 cm in diameter underwent endoscopic treatment. Of them 49 were treated with endoscopic mechanical hthotripsy （EML）. Nasobiliary drainage under X-ray radiation was adopted when such conditions occurred as papilla edema after repeated intubation, lower segment choledochus stenosis, multiple calculis, unknown calculus remaining after lithotrity, cholangitis before operation or billary pancreatitis.Results Stones were removed in 89 of 102 choledocholithiasis patients, The overall success rate of complete stones clearance was 87.25 % （89/102） ; the complication rate was 12.7 % （13/102）, including acute cholangitis in 2 patients, acute pancreafitis in 3 patients, embedding of stone in 3 patients, clinically significant hemorrhage in 2, perforation in 2, and death in 1. Conclusions EST is safe and effective for treating choledocholithiasis with stones up to 1.0cm in diameter. The more difficult and the longer the endoscopic operation, the higher occurrence rate of complication. EML is an important treatment means of common bile duct stones; fractional stone removal and endoscopic nasobiliary drainage play important role in decreasing occurrence of complication.