内镜逆行胰胆管造影并十二指肠穿孔9例分析

Analysis for 9 ERCP-related duodenal perforations

目的探讨内镜逆行胰胆管造影(ERCP)并发十二指肠穿孔的原因、诊治方法。方法对9例ER-CP术后并发十二指肠穿孔患者的病因、操作方法、穿孔的诊断及治疗效果等行回顾性分析。结果该组2002年5月～2010年5月共行ERCP6233例,行治疗6134例(98.41%),其中胆管结石3567例,胆胰恶性肿瘤977例,其他1590例。乳头预切开或开窗术283例;胃大部切除(毕Ⅱ式术后)10例。并发十二指肠穿孔9例(0.144%),其中6例有腹部外科手术史;乳头预切开穿孔3例(1.060%);胃大部切除(毕Ⅱ式)内镜穿孔2例(20%);胆管结石ERCP术后穿孔8例(0.224%),胆胰肿瘤ERCP术后穿孔1例(0.102%)。9例患者8例术中出现右肾周积气,术后出现皮下气肿;1例出现腹腔积气。3例乳头预切开穿孔者行鼻胆管引流+胃肠减压和药物治疗痊愈;2例内镜穿孔经钛夹闭合穿孔+胃肠减压+药物治疗痊愈;1例进内镜穿孔、1例取石过程穿孔、2例毕Ⅱ式穿孔均行外科手术修补治疗痊愈。无死亡病例。结论毕Ⅱ式术后乳头预切开,有腹部手术史穿孔率较高;术中肾周积气对及时诊断穿孔有重要意义;根据穿孔情况可选择手术治疗或保守治疗。

[ Objective ] To summarize the causes of duodenal perforation during endoscopic retrograde cholangiopanereatography （ERCP）, and explore the ways of diagnosis and treatment. [ Methods ] Retrospective analysis for 9 patients with duodenal perforation after ERCP, especially about the causes, operational approaches, diagnosis for perforation and the effects of treatment. [Results] ERCP 6233 cases were completed （including 6134 cases for treatment） during 2002-May, 2010, including 3567 cases with cholangiolithiasis, 977 cases with malignant tumor of pancreas and gall bladder, 1590 cases for the rest; the number of fenestration operation of nipples are 283, ten cases of subtotal gastrectomy （Billroth [[ gastrojejunostomy）. It was found that nine patients with duodenal perforations after ERCP （0.144%）, six of whom had abdominal surgical history; three in pre-dissection of nipples （1.060%）; two in subtotal gastrectomy （Billroth II gastrojejunostomy） （20%）; Eight was cholangiolithiasis after ERCP （0.224%）, one malignant tumor of pancreas and gall bladder after ERCP （0.102%）. Eight of the nine patients had pneumatosis around right kidney while undergoing ERCP, and subcutaneous emphysema after operation; one with peritoneal pneumatosis. Three patients with pre-dissection of nipple who had duodenal perforation during ERCP recovered from nasobiliary drainage, gastrointestinal decompression and drug; two patients with perforation during endoscopy examination in process were closed with titanium clips, and recovered from gastrointestinal decompression and drug; the other four perforations including one during the process of endoscopy examination ,one during calculus being re-moved, and two with Billroth Ⅱ gastrojejunostomy fully recover from surgery repair. No dead cases. [Conclusions] The patients after Billroth Ⅱ gastrojejunostomy, pre-dissection operation of nipple, or abdominal operations will have higher perforated ration. It is significant for the diagnosis of perforation timely. When there is pneumatosis around kidney during operation .We could choose surgery or conservative treatment according to the severity of perforation.