手术治疗内镜逆行胰胆管造影相关十二指肠穿孔的疗效分析

Analysis of operative treatment of endoscopic retrograde cholangiopancreatography-related duodenal perforation

目的:分析外科手术治疗内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)相关十二指肠穿孔的临床疗效。方法:回顾性分析2011年1月至2014年5月收治的外科手术治疗病人14例(瑞金医院13例,瑞金医院北院1例)ERCP相关十二指肠穿孔的临床资料,包括手术时机、手术方法和效果。根据Stapfer提出的ERCP术后十二指肠穿孔类型进行分型。结果:Ⅰ型穿孔2例,Ⅱ型穿孔10例,Ⅲ型穿孔2例。Ⅰ、Ⅱ、Ⅲ型穿孔的手术治疗距ERCP时间分别为ERCP术中和术后(2.0±1.1)(0~5.0)d、(6.0±2.8)(4.0~8.0)d。3种类型间差异有统计学意义(P<0.05),说明腹腔感染进展速度不同。十二指肠憩室化治疗3例Ⅱ型穿孔,1例死亡,2例治愈。与未行十二指肠憩室化的7例Ⅱ型穿孔手术病例比较,住院时间、病死率差异均无统计学意义(P=0.451,P=0.300)。Ⅰ、Ⅱ、Ⅲ型平均住院时间分别为(49.0±32.5)d、(81.6±30.0)d、(51.0±22.6)d,差异无统计学意义(P=0.239)。死亡2例,均为壶腹部癌病人,年龄80岁和86岁;治愈病例年龄60~76岁,两组差异有统计学意义(P<0.05)。结论:外科手术是治疗ERCP相关十二指肠穿孔的重要方法。根据穿孔类型、腹腔感染情况选择合理的手术方式,是提高疗效的关键。恶性肿瘤和高龄病人预后差。

Objective To analyze operative outcomes of endoscopic retrograde cholangiopancreatography(ERCP)related duodenal perforations.Methods Retrospective analysis was performed with the clinical data of 14 patients who had duodenal perforation during ERCP including 13 cases in Ruijin Hospital and one case in Ruijin Hospital North from January 2011 to May 2014.Surgical timing and procedure were analyzed.Duodenal perforations were classified into types according to Stapfer.Results There were typeⅠlesions in 2 cases,typeⅡlesions in 10 cases,and typeⅢlesions in 2 cases.The time to operation was during ERCP of typeⅠinjuries,(2.0±1.1)(0-5.0)d of typeⅡinjuries,and(6.0±2.8)(4.0-8.0)d of typeⅢinjuries after ERCP with significant statistical difference(P<0.05),indicating different progress to abdominal infection from typeⅠ,typeⅡ,and typeⅢperforation.There were 3 cases of typeⅡperforation who had operation of duodenal diverticulation with two cases cured and one case died.No significant difference was present in hospital stay and mortality of the patients of typeⅡbetween 3 cases treated by duodenal diverticulation and 7 cases without duodenal diverticulation(P=0.451,P=0.300).Hospital stay of typeⅠ,typeⅡ,typeⅢwas(49.0±32.5)d,(81.6±30.0)d,(51.0±22.6)d respectively without significant difference(P=0.239).Two cases 80 year and 86 year died had ampullary cancer,who were elder than cured cases(60~76)y with significant statistical difference(P<0.05).Conclusions Operation remains an important treatment for ERCP-related duodenal perforation.Optimal operation based on the type of ERCP related perforation and abdominal infection could be the key to affect efficacy.Elder patients with malignant tumor have poorer prognosis.