十二指肠镜在治疗胆胰疾病合并肝硬变中的价值

Value of Duodenoscopy in the Treatment of Biliary and Pancreatic Diseases Complicated with Hepatocirrhosis

目的探讨十二指肠镜在胆胰疾病合并肝硬化患者治疗中的临床价值。方法回顾性分析武威肿瘤医院(7例)和南京医科大学第二附属医院(40例)2002年6月～2010年11月行十二指肠镜治疗胆胰疾病合并肝硬化的资料。Child-Pugh A级9例,B级24例,C级14例。26例合并食管静脉曲张,其中轻度16例,中度3例,重度7例。单纯性胆总管结石28例,其中1例合并急性化脓性胆管炎;肝门部胆管癌6例;急性胆源性胰腺炎合并胆总管结石2例;硬化性胆管炎4例;胆总管下段炎性狭窄3例;肝移植术后吻合口狭窄3例;胆胰管合流异常1例。根据病情行内镜下乳头括约肌切开(EST)、网篮取石、碎石,内镜下胆道内引流(ERBD)、支架植入等,总结十二指肠镜的治疗效果。结果胆道插管失败2例,插管成功率95.7%(45/47)。出血3例,术中1例,术后2例,经治疗出血均停止,均为Child-Pugh C级患者。术后继发感染3例,其中1例因重症肺部感染继发肝性脑病于术后第3天死亡。无术后胰腺炎。6例失访,10例于术后1个月～6年死于原发恶性肿瘤或肝硬化相关并发症3,1例存活。结论胆胰疾病合并肝硬化患者行十二指肠镜治疗有一定难度及风险,应在内科保守治疗待肝功能和一般状态改善后进行。十二指肠镜治疗是安全有效的,值得临床广泛开展。

Objective To investigate the value of duodenoscopy for patients with biliary or pancreatic diseases complicated with hepatocirrhosis.Methods In this study,we reviewed 47 cases of biliary and pancreatic diseases complicated with liver cirrhosis who received duodenoscopy in our hospital（7 cases） and the Second Affiliated Hospital of Nanjing Medical University（40 cases） from June 2002 to November 2010.Among the patients,there were 9 cases were scored Child-Pugh A,24 were B,and 14 were C;26 cases were complicated with esophageal varices（mild in 16,medium in 3,and severe in 7）;28 patients had choledocholithiasis（including one case complicated with acute suppurative cholangitis）,6 had cholangiocarcinoma of the hilar portal,2 showed acute pancreatitis complicated with choledocholithiasis,4 had sclerosing cholangitis,3 inflammatory stenosis in the lower common bile duct,3 post-liver-transplantation biliary stricture,and 1 anomalous pancreatobiliary union.We performed EST,calculi removing,ERBD,or steting by using duodenoscopy accordingly.Results The success rate of ERCP was 95.7%（45/47,failed in two）.Intraoperative and postoperative hemorrhage（1 and 2 cases respectively） occurred only in Child-Pugh C patients（all cured afterwards）.Postoperative infection occurred in 3 patients,including one cases of server pulmonary infection followed by hepatic encephalopathy,who died in 3 days postoperation.No postoperative pancreatitis was found.Six of the patients were lost to follow-up,in the other patients,10 died of primary malignant tumors or liver cirrhosis related complications in 1 month to 6 years,31 patients survived.Conclusions Patients with cirrhosis have considerable risk and difficulty for duodenoscopy,and thus they shall not received the surgery until their liver function and general condition are improved by conservative therapies.Duodenoscopy is an effective and safe surgery,it is worth being used widely.