伴发多器官功能不全综合征的重症急性胆管炎的内镜治疗

Endoscopic treatment of severe acute cholangitis accompanied with multiple organ dysfunction syndrome

目的探讨伴发多器官功能不全综合征（MODS）的重症急性胆管炎（ACST）患者的内镜治疗价值。方法对2000年1月-2008年10月期间122例伴发多器官功能不全综合征的ACST病例，分两个阶段进行内镜治疗。危重期以挽救患者生命为目的，治疗性ERCP＋ENBD为首选方法。病情平稳后，针对病因择期进行EST＋胆道取石术、EST＋胆道内支架置入术和（或）腹腔镜联合治疗。结果122例ACST患者危重期急诊内镜治疗均获成功，术后第3天，患者黄疸指数、白细胞总数、体温以及有休克、精神症状、脓性胆汁的患者例数，均比治疗前有明显下降；术后1周功能不全器官恢复率60．2％，术后2周功能不全器官恢复率82．6％。择期治疗结果：36例行择期胆道取石术，一次取石成功率为91．7％；85例行腹腔镜胆囊切除术，手术成功率95．3％；16例行胆道内支架置入术，术后3个月支架有效率81．3％。急诊及择期内镜治疗全程无严重并发症及死亡病例。10例肿瘤患者，随访6个月生存率70％。结论治疗性ERCP＋ENBD是救治伴发多器官功能不全综合征的ACST患者的首选方法，而EST＋胆道取石术或EST＋胆道内支架置入术以及联合腹腔镜手术，是后续治疗ACST的理想方法。

Objective To evaluate the endoscopic managements of acute cholangitis of severe type （ACST） accompanied with multiple organ dysfunction syndrome （MODS）. Methods A total of 122 ACST patients accompanied with MODS from January 2000 to October 2008 underwent endoscopic treatment in two time periods. In critical phase, emergent endoscopic retrograde cholangiopancreatography （ERCP） plus endoscopic naso-biliary drainage （ENBD） were performed to correct critical situation of the patients. After stabilization, endoscopic sphincterotomy （EST） plus stone removal, EST plus stent placement, or laparoscopy was performed according to the causes of ACST. Results Emergent endoscopic managements succeeded in all patients of critical phase. At third day post-operation, a reduction in white blood cell count, serum total bilirubin, body temperature, and rate of patients with shock, mental symptoms and purulent bile juice was achieved. Recovery rate of dysfunction organs was 60.2% at one week after emergent procedure, and 82.6% at 2 weeks post-operation. Selective EST plus stone removal was performed in 36 patients with a success rate on one session at 91.7%. Laparoscopic cholecystectomy was performed in 85 patients with a success rate of 95.3%. Stent was placed in 16 patients with an effective rate of 81.3% at 3 months post the procedure. No severe complication or death occurred during the whole therapeutic course. The 6-month survival rate of 10 cancer cases was 70%. Conclusion Therapeutic ERCP plus ENBD is the first choice for acute severe cholangitis accompanied with MODS, while EST plus biliary lithotomy, or EST plus stent placement, or combined laparoscopy are ideal methods for subsequent treatment.