内镜下Dual-knife开窗术在困难胆管插管中的应用

Application of Dual-knife endoscopic fenestration in difficult bile duct intubation

目的探讨Dual-knife在内镜下逆行胰胆管造影术(endoscopic retrograde cholangiopan-creatography,ERCP)胆总管困难插管中应用的安全性和有效性。方法回顾性分析华中科技大学同济医学院附属协和医院2014年3月至2019年8月间2564例行ERCP病人的临床资料,共215例病人在术中被诊断为胆总管插管困难,应用Dual-knife行乳头开窗术(Dual-knife fistulosphincterotomy,DKF)。结果所有215例病人中,212例实现胆管插管,成功率为98.60%;平均时间为3.5 min(2~8 min)。与标准插管相比,并发症发生率无明显增加(P>0.05)。15例病人发生轻度切缘出血,经局部喷洒去甲肾上腺素、Dual-knife凝血、和谐夹夹闭后成功止血;3例病人因开窗后出现潜在穿孔,但未造成后腹膜腔感染,遂保守治疗好转。Dual-knife开窗术后,共有21例(9.8%)出现轻、中度胰腺炎,15例病人出现胆管炎(6.9%),均保守治疗成功;没有病人因穿孔行手术治疗,也没有与该手术相关的死亡。结论采用Dual-knife行乳头开窗术,可实现标准插管失败病人选择性胆管插管;其并不增加病人术后并发症和死亡率,是一种有效、简便、安全的方法。

Objective To investigate the safety and efficacy of Dual-knife in difficult bile duct intubation during ERCP.Methods The clinical data of 2564 patients who underwent ERCP from March 2014 to August 2019 in Union Hospital,Tongji medical college of Huazhong University of Science and Technology were analyzed retrospectively.A total of 215 patients were diagnosed with difficulty in bile duct intubation during ERCP,and Dual-Knife Fistulosphincterotomy(DKF)was applied.Results Among the 215 patients,212 patients were successfully intubated,and the success rate of intubation was 98.60%.The mean intubation time was 3.5 minutes(2-8 minutes).Compared with standard intubation,the complication rate was not significantly increased(P>0.05).Mild surgical marginal bleeding occurred in 15 patients,followed by local spraying of norepinephrine,Dual-Knife coagulation and Metal clamp hemostasis.3 patients showed potential perforation after DKF,but no peritoneal infection was found after the operation,and these patient was discharged after conservative treatment.A total of 21 patients(9.8%)with mild or moderate pancreatitis and 15 patients(6.9%)with cholangitis after DKF were cured with conservative treatment.No patients were surgically treated for perforation and no deaths were associated with the procedure.Conclusion For patients with failed difficult bile duct intubation,DKF can complete ERCP selective biliary intubation,and this procedure does not increase the incidence or mortality of postoperative complications after ERCP.It is an effective,simple and safe method in difficult bile duct intubation.