急性梗阻性化脓性胆管炎急诊内镜治疗方法的研究

Emergency endoscopic treatment of acute obstructive suppurative cholangitis

目的探究急诊内镜治疗急性梗阻性化脓性胆管炎的最佳手术方式。方法回顾性分析近3年来兰州大学第一医院内镜诊疗中心收治的急性梗阻性化脓性胆管炎（AOSC）并且急诊接受ERCP治疗的93例患者，按照内镜治疗方式不同分为3组：ENBD组（单纯右肝管内留置鼻胆管1枚）、ENBD＋ERBD组（于右肝管留置胆道塑料支架联合左肝管留置鼻胆管1枚）和ERBD（双）组（左右肝管分别留置胆道塑料支架1枚），观察术后是否出现发热，胆红素水平是否降低及住院期间死亡率等指标。结果对于高位梗阻患者，左右肝管同时引流[ENBD＋ERBD组及ERBD（双）组）]术后发热发生率明显低于单侧胆管引流组（ENBD组）（1／18比4／10；0比4／10），差异均有统计学意义（P〈0．05）；ENBD＋ERBD组与ERBD（双）组在术后发热发生率（1／18比0）及胆红素水平降低发生率（17／18比14／15）相比，差异无统计学意义（P〉0．05）。对于高位梗阻患者术中使用造影剂行胆道造影与不使用造影剂造影相比，会显著增加术后发热的发生率[4／10比3．45％（1／28）]及住院期间死亡率（3／11比0），同时也会降低术后胆红素水平下降率[10／14比96．55％（28／29）]，且差异均有统计学意义（P〈0．05）。结论高位胆道梗阻术中应尽可能行双侧胆道引流以达到彻底引流效果。术中尽可能减少胆道造影时造影剂的用量，尤其是对于高位梗阻患者，术中尽可能不使用造影剂，必要时可用空气胆道造影明确狭窄位置。

Objective To determine the best endoscopic treatment for acute obstructive suppurative cholangitis （AOSC）. Methods Data of 93 patients who were diagnosed as having AOSC in endoscopic center in the last three years were retrospectively analyzed. All patients were divided into three groups according to the different treatment methods： ENBD group, ENBD＋ERBD group and double ERBD group. Postoperative temperature, bilirubin levels and mortality were compared. Results For patients with high level obstruction, incidence of fever in ENBD＋ERBD group and double ERBD group were significantly higher than that of ENBD group （ 1/18 VS 4/10, P 〈 0. 05 ; 0 VS 4/10, P 〈 0. 05 ）. There were no significant differences in incidence of fever （ 1/18 VS 0 ） or bilirubin level decrease （ 17/18 VS 14/15 ） between ENBD＋ERBD group and double ERBD group. For high level obstruction, if the patient had biliary imaging with contrast medium during operation, they would have higher incidence of high fever[ （4/10 VS 3.45% （1/28） ] and mortality （ 3/11 VS 0）, lower declining rate of bilirubin level [ 10/14 VS 96. 55 % （ 28/29 ） ] than those without. Conclusion Both left and right hepatic ducts drainage should be recommended for high level biliary obstruction. During the operation, contrast medium should be limited to minimum dose, and should be avoided in high level obstruction cases. Air biliary imaging could be used when necessary.