经皮经肝穿刺Fogarty球囊推石治疗胆总管结石

Percutaneous transhepatic papilla balloon dilatation combined with Fogarty balloon pushing technique for the treatment of common bile duct stones

目的探讨经皮经肝穿刺入路,十二指肠乳头球囊扩张联合Fogarty球囊推送治疗胆总管结石的安全性及有效性。方法回顾性分析14例胆管结石患者。常规经皮经肝穿刺胆管,置入8 F血管鞘,超滑加硬导丝置入十二指肠内,应用半顺应性球囊扩张十二指肠乳头,扩张2次,每次持续1~2 min;后撤出球囊,应用Fogarty球囊缓慢经结石上方沿导丝,向肠道内推送结石。若结石较大,更换大于原扩张球囊直径2 mm的球囊再次扩张乳头,并再次尝试推送结石,球囊最大直径不超过18 mm。若仍取出困难,停止手术。术后置入8 F外引流管于胆总管内,持续外引流。术后常规禁食、抗炎等治疗。1个月以后复查CT及超声,若无结石残留,拔出引流管,其后1、3和6个月复查彩超。结果13例成功取出,成功率92.6%(13/14),其中1例因结石较大,最大径大于25 mm,未能成功取出。术后1周无感染加重,发热、黄疸、腹痛等症状逐渐消失。合并急性胰腺炎及胆囊炎患者均保守治疗治愈。肝被膜下出血1例,胆道少量出血1例,保守治疗好转。随访期内无结石复发。结论经皮经肝穿刺十二指肠乳头球囊扩张球囊推迭治疗胆总管结石,技术可行,安全有效,局麻下即可实施,是胆管结石的有效微创治疗方法,特别适合于高龄、基础疾病多、心肺功能差、不能耐受全麻,或者毕Ⅱ(BillrothⅡ)式术后内镜无合适路径的胆总管结石患者。

Objective To evaluate the safety and efficacy of percutaneous transhepatic papilla balloon dilatation combined with Fogarty balloon pushing technique for the treatment of common bile ductstones.Methods The clinical data of 14 patients with common bile duct stone were retrospectively analyzed.Routine percutaneous transhepatic puncture of bile duct was performed,which was followed by insertion of 8 F vascular sheath.The super-lubricity stiff guide-wire was advanced across the papilla until into the distal part of the duodenum.Semi-compliance balloon was employed to dilate the papilla of duodenum for two times,the balloon dilatation lasted for 1-2 minutes every time.The semi-compliance balloon was pulled out and the Fogarty balloon catheter was slowly inserted along the wire until to the stone site,then,the balloon pushed stones into the duodenum.If the stone was very bigger,a new semi-compliance balloon catheter with a balloon diameter 2 mm larger than the former one was used to dilate the papilla of duodenum and to push the stone into the duodenum again.The maximum diameter of the semi-compliance balloon catheter should be no larger than 18 mm.If it was still difficult to push the stone into the duodenum,the operation should be stopped.After operation,an 8 F external drainage catheter was inserted into the common bileduct and the sustained external drainage should be kept on.Postoperative routine fasting and anti-inflammatory treatment were executed.CT and ultrasonography reexaminations were performed one month after treatment.If there was no residual stones,the drainage tube could be pulled out,and at one,3 and 6 months after retrieval of drainage tube reexamination of color sonography was carried out.Results Successful removal of stones was achieved in 13 patients,the success rate was 92.6%(13/14).Stone removal operation failed in one patient because the stone was very big,the maximum diameter of which was over 25 mm.One week after treatment,no aggravation of infection was observed,and the symptoms of fever,jaundice and abdominal pain gradually disappeared.All the patients with associated acute pancreatitis and cholecystitis were cured after conservative treatment.Complications included hepatic subcapsular haemorrhage(n=1)and small amount of hemobilia(n=1),which were improved after conservative treatment.No recurrence of biliary stones was observed during the follow-up period.Conclusion For the treatment of common bile duct stones,percutaneous transhepatic papilla balloon dilatation combined with Fogarty balloon pushing technique is technically feasible,clinically safe and effective.It can be performed even under local anesthesia and is an effective minimally-invasive method for bile duct stones.It is particularly suitable for the aged patients,and also for the patients who have multiple underlying diseases,poor cardiopulmonary function,who are unable to tolerate general anesthesia,or who have a history of Billroth typeⅡgastrectomy and have no appropriate route for endoscopic treatment.(J Intervent Radiol,2020,29:995-999)