胆总管结石内镜逆行胰胆管造影术选择性胆管插管影响因素及辅助插管价值的临床研究

Risk factors of selective biliary cannulation in endoscopic retrograde ch ly for choledocholithiasis and the value of assistant cannulation methods

目的探讨胆总管结石经内镜逆行胰胆管造影术（ERCP）治疗时常规选择性胆管插管的影响因素及辅助插管的作用和安全性。方法回顾性分析2014年1月至2014年12月，皖南医学院弋矶山医院372例胆总管结石行ERCP治疗患者的临床资料。运用单因素分析和多因素Logistic回归分析方法分析常规选择性胆管插管的影响因素；统计常规选择性胆管插管失败后辅助插管的插管成功率及术后胰腺炎（PEP）发生率，并行对比分析。结果单因素分析提示十二指肠乳头长且松弛（P=0．000）、胆总管弯曲成角（P=0.013）是常规选择性胆管插管的危险因素，进一步多因素回归分析发现乳头长且松弛（P=0.000，OR=0．131，95％ CI：0．056-0.307）、胆总管弯曲成角（P=0．003，OR=0．378，95％CI：0.197—0．726）是常规选择性胆管插管的独立危险因素。310例常规选择性胆管插管成功，成功率为83．3％（310／372），62例常规选择性胆管插管失败者采用双导丝法及预切开法协助插管后最终插管成功率提升至99．7％（371／372）。371例插管成功者中29例发生PEP，其中单纯常规插管者18例（5．8％，18／310）、联合双导丝法辅助插管者8例（16．3％，8／49）、联合预切开法辅助插管者3例（25．0％，3／12）。联合双导丝法辅助插管成功者（X2=5．532，P=0.019）和联合预切开法辅助插管成功者（X2=6994，P=0．008）的PEP发生率均明显高于单纯常规选择性胆管插管成功者，但两种联合方法间的PEP发生率差异无统计学意义（X2=0．079，P=0．778）。结论胆总管结石行ERCP治疗时，存在十二指肠乳头长且松弛或胆总管弯曲成角时，易导致常规选择性胆管插管失败。失败后，双导丝法及预切开法是有效辅助方法。

Objective To investigate the risk factors of standard selectivity biliary cannulation in endoscopic retrograde cholangiopancreatography （ERCP） for patints with choledocholithiasis, and the effect and safety of assistant cannulation methods. Methods The clinical data were retrospectively analyzed in 372 patients, who received ERCP for choledocholithiasis in the Yijishan Hospital of Wannan Medical College from January 2014 to December 2014. The risk factors of standard biliary cannulation were assessed by univariate and multivariate logistic regression analysis. The success rate of assistant biliary cannulation and the incidence of post-ERCP pancreatitis （PEP） of standard biliary cannulation were compared with doubleguide wire technique （DGT） and precut sphincterotomy （PS）, which were used when standard biliary cannulation failed. Results The univariate analysis showed that floppy and long duodenal papilla （P= 0. 000）, angulated common bile duct（ P= 0. 013） were related to failure of standard biliary cannulation. Multivariate analysis showed that floppy and long papilla （ P = 0. 000, OR = 0. 131, 95 % CI： 0. 056-0. 307 ）, angulated common bile duct （P=0. 003, OR=0. 378, 95%CI：0. 197-0. 726） were independent risk factors for standard biliary cannulation. The success rate of standard biliary cannulation was 83.3% （310/372） , 62 cases undergone DGT or PS after standard biliary cannulation failure, and the total success rate of eannulation was 99. 7% （371/372）. There were 29 cases suffered from PEP in 371 successful cases of biliary cannulation, including 18 cases （5.8%,18/310） of standard biliary eannulation, 8 cases （16. 3%, 8/49） of DGT, and 3 cases （25.0% ,3/12） of PS. The incidence of PEP by DGT （X2 =5. 532,P=0. 019） and PS （X2= 6. 994,P= 0. 008） was significantly higher than that of standard biliary cannulation, but there was no statistical difference on the incidence of PEP between DGT and PS （X2 = 0. 079, P = 0. 778 ）. Conclusion Floppy and long duodenal papilla and angulated common bile duct could easily induce the failure of standard biliary eannulation in ERCP for patients with choledoeholithiasis. DGT and PS are effective assistant cannulation methods when the standard cannulation fails.