胆总管十二指肠乳头旁瘘伴胆管结石44例临床分析

Clinical analysis of 44 patients of peripapillary choledochoduodenal fistula with bile duct stones

目的探讨胆总管十二指肠乳头旁瘘(PCF)伴胆管结石的治疗。方法 44例经十二指肠镜和经内镜逆行胰胆管造影(ERCP)确诊,Ⅰ型29例,Ⅱ型15例。11例手术治疗,其中胆总管切开取石加T管引流2例,胆-肠内引流7例,胆-肠内引流加部分肝叶切除术2例;内镜治疗27例,其中经内镜括约肌切开术(EST)5例,EST加网篮碎石取石11例,瘘口气囊取石4例,瘘口单纯网篮取石5例,EST加子母镜下激光碎石及网篮取石2例;未作介入治疗6例。结果手术及内镜下治疗均取出结石,随访半年,再发胆管炎或胆管结石,手术组0,内镜组4例,未介入组1例,3组比较差异无显著性。结论十二指肠镜和ERCP是确诊的关键,治疗的选择应综合考虑,内镜治疗为首选,胆管情况复杂或内镜治疗失败则外科手术,无结石残留可内科治疗。

【Objective】To investigate the diagnosis and therapeutic treatments of patients of peripapillary choledochoduodenal fistula（PCF） with bile duct stones.【Methods】44 cases were diagnosed through duodenoscope undergoing ERCP.Fistulas were divided into type Ⅰ and Ⅱ according to its location.29 cases were Ikeda type Ⅰ,the other 15 cases were Ikeda type Ⅱ.11 cases were operated on including choledocholithotomy and ＇T＇tube drainage in 2 cases,choledochojejunostomy in 7 cases and 2 cases underwent concomitantly hepatic segmentectomy.27 cases were endoscopically treated,in which 5 cases underwent（EST）,11 cases underwent endoscopic mechanical lithotripsy after EST,multiple stones removed through fistula,4 cases with balloon sweeps,another 5 cases with reticular basket,and the other 2 cases with electrohydralic lithotripsy through biliary mother-baby endoscopy.6 cases were left untreated interventionally.【Results】Stones were removed by operation or endoscopy.During the follow-up period of half a year,the incidence of and cholangitis recurrence in the operation group was none,the endoscopic group were 4 cases and untreated group was 1 case.There were no significant difference within these groups.【Conclusion】Duodenoscope concomitant undergoing ERCP is the most voluble method in diagnosing PCF.The most appropriate treatment for PCF with bile duct stones should be considered individually.Endoscopic treatments are of choice with micro intrusive and can be undertaken repeatedly.Surgery is underwent with complicated biliary duct stones or when endoscopic treatments failed.If bile duct stones are absent,PCF could be left untreated interventionally.