胆总管结石合并肝硬化患者行ERCP的临床价值

ERCP for treatment of choledocholithiasis in patients with liver cirrhosis

目的:探讨肝硬化合并胆总管结石患者行逆行胆胰管造影术(endoscopic retrograde cholan giopancreatography,ERCP)的手术技巧,可能存在的风险及处理措施.方法:回顾性分析作者在南医大二附院消化医学中心进修以来,自2002-06/2013-06间收治的41例胆总管结石合并肝硬化患者的临床资料,总结ERCP术中的经验教训,同时观察患者于ERCP术前术后的病情变化及并发症等情况.结果:本组病例共41例患者,Child-Pugh A级9例,Child-Pugh B级19例,Child-Pugh C级13例.其中插管失败1例,插管成功率为97.6%(40/41).并发出血共2例,均为Child C级患者,其中术中并发出血1例,术后并发出血1例,经治疗出血均停止.术后继发感染1例,因重症感染继发肝性脑病于术后第3天死亡,无一例并发ERCP术后胰腺炎及穿孔.41例患者2例失访.39例中6例于术后2 mo至3年后死于肝硬化相关并发症,其中1例死于肝性脑病,4例死于上消化系大出血,1例死于继发重症感染;其余33例仍存活.结论:胆总管结石合并肝硬化患者行ERCP有一定难度及风险,要求术者有熟练的操作技巧.同时建议尽量选择ChildA及B级患者手术,C h i l d C级在术前应当尽可能改善肝功能至Child B级,可降低ERCP术中及术后并发症的发生.

AIM： To explore the indications, operational skills and risk factors of endoscopic retrograde cholangiopancreatography （ERCP） in the treat- ment of choledocholithiasis with cirrhosis. METHODS： Clinical data for 41 patients with choledocholithiasis with cirrhosis who under- went ERCP at the Second Affiliated Hospital of Nanjing Medical University from June 2002 toJune 2013 were retrospectively analyzed. Intra- ERCP and post-ERCP complications and mortal- ity rate were observed. RESULTS： Nine patients were classified as Child-Pugh A, nineteen as Child-Pugh B, and thirteen as Child-Pugh C. The success rate of ERCP was 97.6% （40/41）. Complications in- cluded bleeding and infection, which occurred only in patients with Child-Pugh C disease （all cured afterwards）. Intraoperative and postop- erative hemorrhage occurred in one respective case. Severe pulmonary infection occurred in 1 patient, who died 3 d post operation. No post- operative pancreatitis or perforation was found. Two patients were lost to follow-up. Of the other patients, 6 died of primary malignant tumor or liver cirrhosis-related complications in 2 mo to 3 years, and 33 patients are still alive. CONCLUSION： ERCP has a considerable risk and difficulty in the treatment of choledocholi- thiasis in patients with cirrhosis and therefore needs to perform by experienced endoscopists. Patients with Child-Pugh A and B disease can undergo ERCP, but those with Child-Pugh C can not undergo ERCP until their liver function and general condition are improved after conserva- tive therapies.