导丝占据胰管法在困难ERCP中的临床应用

Clinical application of guide of occupation of wire in the pancreatic duct for inaccessible ERCP

目的评价导丝占据胰管法在困难胆道插管中的临床应用价值。方法回顾性分析2007年1月-2009年12月在沈阳军区总医院内窥镜科行内镜逆行胰胆管造影(ERCP)患者的临床资料。对常规切开刀胆管插管失败且导丝反复进入胰管(>3次)者,将导丝留置于胰管内,重新插入切开刀,接近乳头后,利用抬钳器将留置的导丝轻轻向下压,将乳头固定,同时将胆管和胰管间的隔膜向胰管侧牵拉,使胆管和胰管开口稍分离,以利切开刀在胰管左上方11点方向寻找胆管开口,并在导丝的辅助下进行胆管深插管,胆管插管成功后,导丝留置胆管内,继续完成胆管括约肌切开及相应治疗。统计插管的成功率及并发症的发生率。结果共行ERCP 2318例次,需胆管深插管1579例次,利用导丝占据胰管法行胆管插管185例次,胆管深插管成功率95.1%(176/185),8例(4.3%)发生并发症,为高淀粉酶血症,无出血、穿孔、术后胰腺炎等严重并发症发生。结论在困难胆道插管中采用导丝占据胰管法行胆道深插管是一种安全有效的方法。

Objective To assess the clinical application of occupation of guide wire in the pancreatic duct in cannulation of the inaccessible bile duct. Methods All data of consecutive endoscopic retrograde cannulation of the pancreatic duct （ERCP） performed at our institution from Jan. 2007 to Dec. 2009 were retrospectively analyzed, and the method of occupation of a guide wire in the pancreatic duct for inaccessible bile duct was sunamarized. To the patients with failure in cannulation of bile duct by routine incision followed by entrance of the guide wire into the pancreatic duct repeatedly （〉3 attempts）, the guide wire was retained in the pancreatic duct, and the knife was then inserted again to approach papilla as far as possible. The inserted guide wire was lightly pressed to fix the papilla. Then the guide wire was manipulated to pull the interseptum between the bile duct and the pancreatic duct towards the pancreatic duct in order to separate these two entrances. Then the knife was used to search the entrance of bile duct from the tolyleft of the entrance of pancreatic duct. Then deep cannulation of bile duct was performed with the aid of guide wire. After the successful cannulation, the guide wire was retained in the bile duct to continue the division of the sphincter of Oddi and necessary treatment. The rate of successful cannulation and the incidence of complications were analyzed. Results Two thousand three hundred and eighteen cases of ERCP were performed in the period, among them deep cannulation of bile duct was done in 1579 cases, cannulation of bile duct by guide wire occupying the pancreatic duct was done in 185 cases. Successful cannulation of the bile duct was achieved in 95. 1% （176/185） of patients. Hyperamylasemia as a complication occurred in 8 patients （4. 3 %）. No serious complications occurred such as hemorrhage, perforation and post-ERCP pancreatitis. Conclusion In case of difficult bile duct cannulation, with the guide wire to occupy the pancreatic duct appears to be an effective and safe technique.