不同内镜术式治疗胆总管结石青年患者的长期随访研究

Long-term follow-up of different endoscopic strategies in management of choledocholithiasis in young patients

目的探讨不同的常用内镜治疗方法对胆总管结石青年患者治疗后结石复发的影响以及结石近期复发、远期复发的危险因素。方法选择经一次性治疗性内镜逆行胰胆管术（ERCP）成功取石后随访资料完整的胆总管结石青年（21～45岁）患者，按手术方式分为内镜下乳头球囊扩张术（EPBD）组、乳头括约肌切开术（EST）组、EST（切开〈0．5cm）＋EPBD组，进行随访，统计近期（≤3年）及远期（〉3年）结石复发率，并对复发危险因素进行Logistic回归分析。结果资料完整的327例患者平均随访76．5个月，54例（16．5％）结石复发，其中近期复发35例（10．7％），远期复发19例（5．8％）。近期胆总管结石复发率EPBD组（11．3％）和EST组（13．2％）均高于EST＋EPBD组（8．1％），但无统计学差异（P均〉0．05）。远期胆总管结石复发率EPBD组（11．3％）和EST组（6．6％）均显著高于EST＋EPBD组（0．8％），差异具统计学意义（P均〈0．05）。Logistic回归分析结果表明，胆囊结石、结石最大径、结石个数、机械碎石与近期结石复发显著相关（P〈0．05），而远期胆总管结石复发则与结石最大径及单纯球囊扩张显著相关（P〈0．05）。结论对于胆总管结石青年患者，单纯EPBD取石固然可保留乳头括约肌功能，但增加了结石的远期复发风险，而乳头括约肌小切开联合EPBD取石可显著降低胆总管结石复发率。

Objective To investigate the rate of stone recurrence in young patients with common bile duct （CBD） stones after removal of stones by different endoscopic strategies and the risk factors of re- cent and long-term CBD stone recurrence. Methods After successful CBD stones removal in one ERCP ses- sion, young patients （aging 21-45 years） with complete follow-up data were recruited to the study. They were divided into endoscopic papillary balloon dilation （EPBD） group, endoscopic sphincterotomy （EST） group and EST ＋ EPBD group according to the endoscopic approaches they experienced. The recent （ ≤3 years） and long-term （ 〉 3 years） recurrent frequencies of CBD stone were counted, and the possible risk factors were determined with multivariate logistic regression analysis. Results A total of 327 young pa- tients were followed up at a mean duration of 76. 5 months, and CBD stone re-occurred in 54 cases （16. 5% ） , among which, the recent recurrence was 35 cases （ 10. 7% ） and the long-term recurrence was 19 cases （5.8%）. The recent CBD stone recurrence rates in EPBD group and the EST group were higher than that of EST ＋ EPBD group but with no significant difference （ P all 〉 13.05 ）. The long-term CBD stone recurrence rates in EPBD group and the EST group were significantly higher than that of the EST ＋ EPBD group （P all 〈 0. 05 ）. Logistic regression analysis showed that, gallbladder stone, the maximum diameter of the stone, the stone number and mechanical lithotripsy were significantly related to the recent CBD stone recurrence （P 〈 0. 05 ）. The long-term CBD stone recurrence was significantly related to the maximum diameter of the stone and balloon dilatation alone （P 〈 0. 05 ）. Conclusion Removal of CBD stones by EPBD a- lone for young patients may preserve the papillary sphincter function, but would increase the risk of long-term CBD stone recurrence. Small endoscopic sphincterotomy plus EPBD could significantly reduce the CBD stone recurrence rate.