胆胰管隔膜切开法在困难性经内镜逆行胰胆管造影术胆管插管中应用

Endoscopic transpancreatic septotomy as precutting technique for difficult bile duct cannulation

目的探讨经胰管胆胰管隔膜预切开术在困难性经内镜逆行胰胆管造影术(ERCP)胆管插管中的应用价值。方法 2009年5月～2010年4月该院消化医学中心拟行经内镜ERCP患者1074例,除外毕氏Ⅱ式、Roux-en-Y术后、十二指肠狭窄15例找不到乳头或不能到达乳头外,1059例完成了ERCP,163例ERCP胆总管插管困难者行胰管放入导丝或塑料支架,94例胆管插管成功,仍不成功者行经胰管胆胰管隔膜预切开术(下称隔膜切开组,36例)和针状刀乳头开窗术(下称针刀组,33例),比较两种方法插管成功率及并发症发生率。结果 69例患者中的67例在乳头预切开术后可成功插入胆管,隔膜切开组成功率97.2%(35/36),针刀组成功率96.9%(32/33),两者差异无显著性(P>0.05)。69例患者中11例出现并发症,包括急性胰腺炎6例、出血2例、胆道感染3例。其中,隔膜切开组急性胰腺炎2例,胆道感染1例,针刀组急性胰腺炎4例,出血2例,胆道感染2例。两组比较,隔膜切开组总的并发症发生率低于针刀组(8.3%比24.2%),两者差异有显著性(P<0.05)。结论胰管导丝或塑料支架置入可以提高ERCP胆管插管成功率,经胰管胆胰管隔膜预切开术和针状刀乳头开窗术可进一步提高ERCP胆管插管成功率,经胰管胆胰管隔膜预切开术具有更高的安全性。

[ Objective ] To evaluate the technique of transpancreatic septum precut for cannulation of inaccessi- ble common bile duct in endoscopic retrograde cholangiopanereatography （ERCP）. [ Methods ] From May 2009 to April 2010, 1074 patients referred to our department for ERCP, excluded 16 patients who had a history of previous Billroth II gastreetomy or Roux-en-Y anastomosis or duodenal stenosis or duodenal papilla tumor. 1059 patients completed ERCP, 163 patients were difficult billiary cannulation in ERCP： With pancreatic guidewire or pancreatic duct plastic stent assistance, 94 patients completed ERCP successfully. 69 unsuccessfully patients data, of whom 36 underwent transpancreatic septum precut and 33 had needle-knife sphincterotomy, were analyzed retrospectively. [ Results ] Of 69 patients accepted precut papillotomy, common bile duct cannulation was successfully achieved in 67. The success rates of transpancreatie septum preeut group and needle-knife sphincterotomy group were 97.2%（35/36） and 96,9% （32133） respectively, which was not significantly different （P 〉0,05）. Complications occurred in 11 cases, including acute pancreatitis （rl=6）, bleeding （n=2）, cholangitis （n=3）, The total frequency of complications of the transpancreatic septum pre -cut group was lower than that of needle-knife sphineterotomy grottp （8.3% VS 24.2%, P 〈0.05）, [Conciusion] Pancreatic guidewire or pancreatic duct plastic stent assistance improves the suc- cess rate of selective billiary eannulation in ERCP. Transpancreatic septum precut and needle-knife sphincterotomy markedly improves the success rate of selective biUiary cannulation in ERCP, transpancreatic septum precut was safer compared with needle-knife sphinctemtomy.