胆囊切除术后问题的内镜诊断和治疗

Endoscopic diagnosis and treatment of post - cholecystectomy problems

目的 探讨内镜在胆囊切除术后问题病因诊断和治疗的应用价值。方法 对386例胆囊切除术后问题病人行逆行胆胰管造影（ERCP）检查明确病因后,对胆管结石者行括约肌切开术（EST）和乳头气囊扩张术（EPBD）后取石;对乳头炎性狭窄者行EST或EPBD治疗;对乳头旁憩室压迫乳头开口和Oddi括约肌功能紊乱（SOD）者行EPBD治疗;对乳头肿瘤和肝门胆管癌行胆管内支架（EMBE）;对化脓性胆管炎、继发性胆总管多发结石、结石难以一次取净及术后胆瘘、胆管中段狭窄者行ENBD。结果 371例（96.1％）ERCP成功。未发现异常30例。胆管结石243例,235例经1-3次内镜取石后取净。乳头炎性狭窄39例,经EST或EPBD治疗1次成功。乳头旁憩室压迫乳头开口9例,SOD 7例,行EPBD治疗1次成功。胆管中段狭窄16例,11例行ENBD成功。乳头肿瘤6例,肝门胆管狭窄5例,行内支架治疗后黄疸减退。胆囊切除术后胆瘘6例,行ENBD治疗成功,避免再次外科手术。胃十二指肠溃疡6例。胆囊管结石残留4例。总的并发症发生率5.7％。结论 ERCP能及早发现胆囊切除术后问题确切病因并给予相应内镜治疗。

Objective To evaluate the value of endoscopy in etiological diagnosis and treatment of post - chole-cystectomy problems. Methods 386 patients with post - cholecystectomy problems were subjected to ERCP. After the etiology had been made clear, patients with choledocholithiasis underwent EST or EPBD to exclude stones, those with papillary inflammatory stricture underwent EST or EPBD, those with papillary diverticulum and SOD underwent EPBD, those with papillary tumor and hepatobiliary tumor underwent EMBE, and ENBD was performed in those with biliary stricture in middle segment, purulent cholangitis, choledocholithiasis and bile leakage. Results ERCP was successful in 371 cases (96.1 % ) . There were no obvious findings in 30 cases. 243 patients had choledocholithiasis and stones in 235 cases were totally removed after one to three procedures. 39 patients had papillary inflammatory stricture and underwent EST or EPBD successfully one time. 9 patients had papillary diverticulum which oppressed papillary hole, 7 patients had SOD, all of which were delt with EPBD. 16 patients had stricture in middle segment of the bile duct, 11 cases were handled with ENBD. 6 papillary tumor patients and 5 hepatobiliary stricture patients received EMBE and jaundice decreased siginficantly. 6 patients developed bile leakage after cholecystectomy and ENBD was successfully carried out to avoid another operation. 6 had gastroduodenal ulcer. Residual stones in cholecystic duct were found in 4 cases. The overall rate of complications was 21/386 (5.7% ). Conclusions ERCP could reveal definite causes of post - cholecystectomy problems at early stage and is effective in taking corresponding endoscopic therapic measures.