十二指肠乳头括约肌预切开术在困难插管ERCP中的应用

Application of precut sphincteroctomy in difficulty cannula' s endoscopic retrograde cholangiopancreatography

目的总结十二指肠乳头括约肌预切开术在困难插管的内镜逆行胰胆管造影术(ERCP)中的临床应用经验及技巧。方法回顾性分析我科自2010年1月-2013年12月间开展的对于ERCP插管困难的280例患者实施的十二指肠乳头括约肌预切开术,按照实施预切开术的先后,将280例患者分成A、B两组。A组为2010年1月-2011年12月,实施预切开术初期的143例病例;B组为2012年1月-2013年12月,汲取前一阶段经验教训,采取摆正乳头、看清轴向、短距离、分层、逐步、点切的方法进行的137例病例。比较两阶段预切开术后的插管成功率及并发症发生率,总结十二指肠乳头括约肌预切开术的操作经验及技巧。结果 A组143例预切开术后插管成功113例,成功率79.02%,穿孔5例,发生率3.49%,出血4例,发生率2.80%,急性胰腺炎6例,发生率4.20%,无急性胆管炎及急性胆囊炎发生,总的并发症发生率10.49%。B组137例预切开术后插管成功134例,成功率97.81%,穿孔1例,发生率0.73%,无消化道出血病例,急性胰腺炎3例,发生率2.19%,无急性胆管炎及急性胆囊炎发生,总的并发症发生率2.92%。A组与B组比较,预切开术后插管成功率及总的并发症发生率间差异有显著性意义(P<0.05)。全组无死亡病例。结论对于困难插管的ERCP病例,应用十二指肠乳头括约肌预切开术是提高插管成功率十分必要的有效方法,然而,预切开技术难度大、风险高,在避免盲目随意应用的基础上,按照摆正乳头、看清轴向、短距离、分层、逐步、点切的要领,由资深内镜医师操作可明显提高预切开术后插管成功率和有效降低并发症的发生率。

Objective To summarize the experience and clinical skills of duodenum pre-cut sphincterotomy in difficult endoscopic retrograde cholangiopancreatography（ERCP）cannulation. Methods Retrospectively analyzed 280 patients who had been performed precut sphincterotomy in difficult ERCP cannulation in our department during Jan. 2010 to Dec. 2013. The patients were divided into two groups according to the time that they were performed precut sphincterotomy. Group A is the first stage,which includes 143 patients during Jan. 2010 to Dec. 2011. Group B is the second stage,which includes 137 patients during Jan. 2012 to Dec. 2013. And the skills of second stage of precut sphincterotomy were modified according to the experience of the first stage. We compared the success rate and morbidity rate of the two stages and summarized the skills of precut sphincterotomy. Results In group A,113 of 143 patients were performed precut sphincterotomy successfully,the success rate is 79. 02% . Duodenal perforation occurred in 5 of 143 patients,and the perforation rate is 3. 49% . Hemorrhage occurred in 4 of 143 patients, and the rate is 2. 80% . Acute pancreatitis occurred in 6 of 143 patients,and the rate is 4. 20% . No acute cholangitis and acute cholecystitis occurred. The total morbidity rate for group A is 10. 49% . In group B, 134 of 137 patients were performed precut sphincterotomy successfully,the success rate is 97. 81% . Duodenal perforation occurred in 1 of 137 patients,and the perforation rate is 0. 73% . No upper gastrointestinal bleeding occurred. Acute pancreatitis occurred in 3 of 137 patients,and the rate is 2. 19% . No acute cholangitis and acute cholecystitis occurred. The total morbidity rate for group B is 2. 92% . Group B has a significantly higher success rate and lower morbidity rate of precut sphincterotomy（P 〈 0. 05）. No death occurred in both groups. Conclusion Precut sphincterotomy is an effective procedure for difficult ERCP cannulation,but precut sphincterotomy is technically difficult and high risk. So avoiding perform precut sphincterotomy blindlessly,and perform the procedure according to the skills,and by experienced endoscopists could improve the success rate and lower the morbidity rate significantly.