十二指肠乳头针形刀开窗术和辅助法在困难性ERCP中的应用

Applications of Needle-knife Fistulotorny and Other Complementary Techniques on the Difficult ERCP

目的探讨困难性内镜下逆行性胰胆管造影(ERCP)的操作技巧。方法 2005年1月～2010年3月,本院共行ERCP 556例,分别采用下列方法进行插管:(1)采用双腔乳头切开刀常规插管;(2)捻导丝辅助法;(3)预备性切开后插管;(4)十二指肠乳头针形刀开窗术。结果 556例采用双腔乳头切开刀常规插管,成功467例,成功率84.0%;未成功89例采用捻导丝辅助法,成功33例,总成功率89.9%;余下56例采用预备性切开后插管36例,成功31例,总成功率95.5%;余25例未成功者采用十二指肠乳头针形刀开窗术14例,成功13例,总成功率97.8%。共12例未成功者,其中1例因担心大出血和十二指肠穿孔停止开窗术,采用外科手术治疗,余下11例因无预备性切开及开窗术指征,ERCP失败。与常规插管方法比较,十二指肠乳头针形刀开窗术和辅助法插管总成功率明显升高(P<0.05)。术后无穿孔及死亡病例,高淀粉酶血症、PEP等并发症在ERCP术后总的发生率与插管成功者比较,差异无显著性(P>0.05)。结论在困难性胆管插管的ERCP病例中,应用十二指肠乳头针形刀开窗术和辅助法可以有效提高ERCP诊治的成功率,而并不增加并发症的发生率和死亡率。

Objective To approach the skill and value of difficult ERCP. Methods From January 2005 through March 2010, we had performed 556 cases of ERCP, and have made the following methods for cannulation： （ 1 ） selective eannulation of the CBD in standard method ; （ 2 ） wire-guiding introduction ; （ 3 ） eannulation after precutting papillotomy ; （ 4 ） eannulation after needle-knife fistulotorny. Results Selective cannulation of the CBD in standard method was immediate- ly achieved in 467 of 556 patients （84.0%）,and in the unsuccessfully 89 cases, cannulation by wire-guiding introduction was achieved in 33 of 89 patients and the total success rate was 89.9%. Thirty-six cases of the other 56 patients were made to cannulation after precutting papillotomy, and were achieved in 31 of 36 patients （95.5%）. In the 25 cases of unsuccess- ful cannulation by the above methods, cannulation after needle-knife fistulotorny was achieved in 13 of 14 patients, and the total success rate was 97.8%. In the last 12 cases of unsuccessfully cannulation ,one case stop needle-knife fistulotorny be. cause of worrying bleeding and perforation, and the other 11 cases have no indication for precutting papillotomy, so ERCP was unsuccessful. Applications of needle-knife fistulotorny and other complementary techniques could increase the total suc- cess rate ~ff ERCP vs. standard method,with a statistically significant difference （P 〈 0.05 ）. There was no perforation and deaths. Compared with all patients of ERCP, the incidences of hyperamylasemia and PEP in the successful intubation patients had no statistically significant difference （P 〉 0.05）. Conclusions Applications of needle-knife fistulotomy and other complementary techniques could obtain success in majority of the difficult ERCP, and there was no increase of severe complications and mortality.