不同内镜下乳头括约肌预切开术在经内镜逆行胰胆管造影术中困难插管时应用的效果比较

Clinical effect of different methods for endoscopic precut sphincterotomy in difficult intubation during endoscopic retrograde cholangiopancreatography: A comparative analysis

目的 探讨不同预切开术在经内镜逆行胰胆管造影术(ERCP)困难插管时应用的临床特点。方法 回顾性分析2015年5月-2018年12月在昆明医科大学第二附属医院行ERCP预切开术共185例患者的临床资料。根据内镜下乳头括约肌预切开术方式的不同分为针状刀乳头括约肌预切开术(NKP组, n =73)、乳头开窗术(NKF组, n =24)、经胰管弓状刀乳头括约肌预切开术(TPS组, n =30)和弓状刀经乳头括约肌预切开术(Erlangen组, n =58)。对4种预切开方法优缺点、对插管成功率的影响及可能对并发症发生的增加或减少进行分析。符合正态分布的计量资料多组资料组间比较采用方差分析,进一步两两比较采用LSD- t 检验;非正态分布的计量资料多组资料组间比较采用Kruskal-Wallis H 检验,进一步的两两比较采用Nemenyi法。计数资料组间比较采用χ 2 检验;单因素及多因素分析采用logistic回归分析。结果 NKF、TPS组插管成功率均较NKP组高( P 值均<0.05),TPS组总并发症发生率较NKF组低,NKF组总并发症发生率较NKP组高( P 值均<0.05)。Erlangen组总并发症发生率高于NKP组和TPS组( P 值均<0.05)。NKF[OR(比值比)=2.420,95%可信区间(95%CI):0.235~0.828, P =0.036]、TPS(OR=1.752,95%CI:0.238~0.594, P =0.029)是插管成功的影响因素;年龄>57岁(OR=0.094,95%CI:0.028~0.316, P <0.001)、手术总时间(OR=1.029,95%CI:1.002~1.057, P =0.036)是ERCP术后急性胰腺炎(PEP)的影响因素,进一步行多因素logistic回归分析显示,年龄>57岁(OR=0.065,95%CI:0.017~0.256, P <0.001)是PEP发生风险的独立保护因素,手术总时间(OR=1.040,95%CI: 1.007 ~1.074, P =0.016)是PEP发生的独立危险因素。结论 TPS在一定情况下可能较NKP、Erlangen相对安全、有效,年龄、手术总时间可影响并发症的发生率。

Objective To investigate the clinical characteristics of different methods for endoscopic precut sphincterotomy in difficult intubation during endoscopic retrograde cholangiopancreatography (ERCP). Methods A retrospective analysis was performed for the clinical data of 185 patients who underwent ERCP and precut sphincterotomy in The Second Affiliated Hospital of Kunming Medical University from May 2015 to December 2018. According to the method for endoscopic precut sphincterotomy, these patients were divided into needle-knife precut sphincterotomy (NKP) group with 73 patients, needle-knife fenestration (NKF) group with 24 patients, transpancreatic precut sphincterotomy (TPS) group with 30 patients, and arch-knife precut sphincterotomy group (Erlangen group) with 58 patients. These four precut methods were analyzed in terms of advantages and disadvantages, influence on the success rate of intubation, and increase or reduction in complications. An analysis of variance was used for comparison of normally distributed continuous data between multiple groups, and the least significant difference t -test was used for comparison within each group;the Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data between multiple groups, and the Nemenyi method was used for further comparison between two groups. The chi-square test was used for comparison of categorical data between multiple groups, and a logistic regression analysis was used to determine risk factors and perform a multivariate analysis. Results The NKF and TPS groups had a significantly higher success rate of intubation than the NKP group (both P <0.05). The TPS group had a significantly lower incidence rate of complications than the NKF group, and the NKF group had a significantly higher incidence rate of complications than the NKP group (both P <0.05). The Erlangen group had a significantly higher incidence rate of complications than the NKP and TPS groups (both P <0.05). NKF (odds ratio [OR]=2.420, 95% confidence interval [CI]: 0.235-0.828, P =0.036) and TPS (OR=1.752, 95%CI: 0.238-0.594, P =0.029) were influencing factors for successful intubation. Age >57 years (OR=0.094, 95%CI: 0.028-0.316, P <0.001) and total time of operation (OR=1.029, 95%CI: 1.002-1.057, P =0.036) were influencing factors for post-ERCP pancreatitis (PEP), and further multivariate logistic regression analysis showed that age >57 years (OR=0.065, 95%CI: 0.017-0.256, P <0.001) was an independent protective factor against the risk of PEP, while total time of operation (OR=1.040, 95%CI: 1.007-1.074, P =0.016) was an independent risk factor for PEP. Conclusion TPS may be safer and more effective than NKP and Erlangen under certain conditions. Age and total time of operation may influence the incidence rate of complications.