胰胆管合流异常的诊断和内镜治疗:MDT讨论

Diagnosis and endoscopic therapy of pancreaticobiliary maljunction: MDT discussion

目的通过多学科协作团队(MDT)探讨胰胆管合流异常的诊断和内镜治疗。方法对遵义市第五人民医院2019年收治的1例胰胆管合流异常患者术前进行的MDT讨论及病例诊治过程进行总结。结果本例患者因"上腹疼痛约10 h"入院,入院时影像检查发现存在明显的胰胆管十二指肠壁外汇合,共同通道长约1.8 cm,但胰胆管汇合处明显受Oddi括约肌控制,胆汁淀粉酶值较血清淀粉酶值明显升高,经MDT讨论后对诊断胰胆管合流异常还是胰胆管高位汇合仍有疑惑,行左肝外叶切除和胆总管探查术后经T管反复查胆汁淀粉酶值升高更为显著,再行经内镜乳头括约肌切开术,术后胆汁淀粉酶值则明显降低,出院后随访半年未见异常。结论胰胆管合流异常临床诊疗指南中胰胆管合流异常的概念和诊断标准有冲突且不够精准,胰胆间反流严重程度及胆汁淀粉酶值的变化可能更具有诊断价值;经内镜乳头括约肌切开术可能适用于少数特殊类型胰胆管合流异常。

Objective To discuss the diagnosis and endoscopic therapy of pancreaticobiliary maljunction by multidisciplinary team(MDT). Method The preoperative MDT discussion and the diagnosis and treatment process of patient with pancreaticobiliary maljunction in the Fifth People’s Hospital of Zunyi in 2019 were summarized.Results The patient was admitted for "upper abdominal pain approximately 10 h". The obvious extramural confluence of the pancreaticobiliary tract was observed and the length of common channel was approximately 1.8 cm.But the junction of the pancreaticobiliary tract was obviously controlled by the sphincter of Oddi, and the amylase value of the bile was higher than that of the serum. After the MDT discussion, there were still doubts about the diagnosis of pancreaticobiliary maljunction or high confluence of pancreaticobiliary ducts. After the left hepatic lateral lobectomy and exploration of common bile duct, the amylase value of bile, which was collected by the T-tube, was still obviously increased. Then the endoscopic sphincterotomy was performed, the amylase value of the bile decreased obviously and no abnormality was found in the follow-up for half a year after discharge. Conclusions Concept and diagnostic criteria of "Japanese clinical practice guidelines for pancreaticobiliary maljunction" are conflicting and inaccurate. Severity of pancreaticobiliary reflux and change of amylase value of bile might have a more important diagnostic value. Endoscopic sphincterotomy might be suitable for a few special types of pancreaticobiliary maljunction.