胆道镜下高频电切技术在肝内胆管狭窄中的应用

Application of choledochoscopic high-frequency electrotomy for intrahepatic bile duct strictures

目的探讨胆道镜下高频电切技术对肝内胆管狭窄的疗效及安全性。方法回顾性分析2011年1月至2013年1月我科胆道镜下高频电切技术治疗58例肝内胆管狭窄的临床资料。结果 58例患者共发现134处狭窄胆管,119处合并肝内胆管结石;35处胆管狭窄直接实施胆道镜下高频电切术,84处因狭窄胆管上方结石堵塞或胆管过细致球囊扩张导管置入失败而行电切术,15处因球囊扩张后膜状狭窄未解除而行电切术。电切术平均操作时间为5.6 min（1~15 min）,切开过程中发生出血8处,采取针状刀高频电凝成功止血。29例患者均成功取净狭窄远端胆管内结石,所有狭窄解除后均放置支撑管。术后发生胆管炎14例、迟发性胆道出血3例、肝脓肿1例、支撑管脱落7例,给予对症治疗及重新放置支撑管;胆道内支撑管平均支撑7个月（6~9个月）,取出支撑管2周后行胆道镜观察,胆管无狭窄及复发结石,切开处胆管黏膜移行佳。平均随访12~48个月,复发肝内胆管结石5例,采取经皮经肝胆道镜取石而治愈。结论胆道镜下高频电切术是治疗胆管狭窄的一种简单、安全、有效的方法,尤其适用于球囊导管扩张失败患者。

Objective To investigate the feasibility and effectiveness of choledochoscopic high-frequency needle-knife electrotomy for the treatment of intrahepatic biliary strictures. Methods Clinical data of 58 patients sufferred from intrahepatic bile duct strictures from Jan. 2011 to Jan. 2013 were retrospectively analyzed. Choledochoscopic electrotomy was used to resolve the strictures. Results One hundred and thirty-four sites of intrahepatic bile duct were discovered in 58 patients and 119 sites were with bile duct stones. Thirty-five sites directly received choledochoscopic high frequency electrotomy. 84 sites received electrotomy after a failure balloon dilatation catheters for stones blocking the bile duct or bile duct diameter smaller than the balloon dilatation catheter. Fifteen sites received electrotomy for unsolved membranous strictures after balloon dilation. The average operating time of electrotomy is 5.6 rain （range, 1 - 15 min）. Structured bile duct tissue bleeding occurred in 8 sites but were resolved by endoscopic high-frequency electric cautery. After the operations, 14 cases of cholangitis, 3 cases of delayed hemobilia, 1 case of liver abscess and 7 cases of stenting exodus were observed despite conservative treatment and stenting reset. The average supporting time was 7 months （6-9 months）. No abnormal bile duct structure or presence of stone was found according to choledochoscopy. The follow-up period ranged from 12 to 48 months. Hepatolithiasis recurred in 5 cases cured with PTCS. Conclusion Choledochoscopic high frequency electrotomy is a simple, safe and effective method for intrahepatic bile duct stricture. It is especially suitable for balloon dilatation failure patients.