内镜逆行胰胆管造影联合体外冲击波碎石治疗高龄患者难取性胆总管巨大结石

Endoscopic retrograde cholangiopancreatography combined with extracorporeal shock wave lithotrip- sy in treating intractable choledocholithiasis with huge bile ductal stones in elderly patients

目的评价内镜逆行胰胆管造影（ERCP）联合体外冲击波碎石（ESWL）治疗高龄难取性胆总管巨大结毛石的疗效。方法研究纳入46例ERCP诊断为难取性胆总管巨大结石的高龄患者。先于内镜下置入一体式鼻月日管及胰管支架，再行ESWL。待结石破碎后，行二次ERCP取净胆总管结石。结果肌总臂结石半均数日为1．8枚（1～4枚），直径为2．6cm（2．0～3．2cm）。首次ERCP操作成功率100％，未出现内镜下乳头括约肌切开相关性并发症。ESWL平均震波能量为24．2J（20．0～45．0J），震波次数为4348次（3000～5000次），疗程为3．2次（1～7次），碎石成功率为100％（最大碎石直释〈1．0cm）。ESWL术后发生急性胆管炎4例，急性胆囊炎、胆道出血各2例。其中1例急性梗阻性化脓性胆袭炎，行超声引导下经皮经肝胆囊穿刺置管引流术，其他患者采取经鼻胆管冲洗及蓟物对症治疗后缓解。二次ERCP结石取净率为100％，术后未发生呼衰、心衰、死亡等严重并发症。结论ERCP联合ESWL足治疗高龄患者难取性胆总管巨大结石的一种安全而有效的方法。

Objective To evaluate the effect of endoscopic retrograde cholangiopancreatography （ERCP） combined with extracorporeal shock wave lithotripsy （ESWL） in treating intractable choledocholi- thiasis with huge bile ductal stones in elderly patients. Methods 46 patients were diagnosed with intracta- ble choledochbolithiasis with huge bile ductal stones by ERCP. Integrated nasobiliary and pancreatic stents were placed initially. A second ERCP was performed to remove fragmented stones after ESWL. Results The average number and diameter of bile ductal stones were 1. 8 （ 1 -4） and 2. 6 cm （2. 0 -3. 2）, respec- tively. All patients successfully underwent ERCP and no ERCP-related complications occurred. The average shock wave energy, frequency and duration of treatment were 24. 2 J （20. 0 ~45.0）, 4 348 times （3 000 5 000） and 3.2 courses （ 1 -7 ）. All large common bile ductal stones were fragmented into stones with a dia- meter of less than I cm. There were 2 patients who developed acute cholecystitis, 4 patients acute cholangitis and 2 patients hemnbilia after ESWL. One patient was treated with percutaneous transhepatic gallbladder drainage for acute obstructive suppurative cholecystitis and the remaining patients were treated by medical treatment and biliary irrigation thrnugh the nasobiliary tube. The fragmented stones in the common bile ducts were removed by a second ERCP. There was no respiratory failure, heart failure, death or any other severe complications. Conclusion ERCP combined with ESWL was a safe and effective treatment for intractable choledocholithiasis with huge bile ductal stones in elderly patients.