内镜超声在非确定性胆总管结石经内镜逆行胰胆管造影术前的应用价值

Clinical value of endoscopic ultrasonography in preoperative endoscopic retrograde cholangiopancreatography for undetermined common bile duct stones

目的研究非确定性胆总管结石患者在经内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)术前行内镜超声检查术(endoscopic ultrasound,EUS)的临床价值。方法回顾性分析2017年1月—2019年12月天津市南开医院因临床表现和磁共振胰胆管成像术(magnetic resonance cholangiopancreatography,MRCP)结果不相符的132例非确定性胆总管结石患者的资料。将患者分为A、B两组:A组MRCP显示有结石、临床表现可疑无结石,B组MRCP显示无结石、临床表现可疑有结石。患者均行EUS,根据EUS结果决定是否行ERCP,以ERCP结果和随访结果为金标准分析EUS的诊断准确率。结果132例患者经诊断金标准最终确认胆总管结石阳性87例,阴性45例。44例(33.3%)患者EUS阴性,经随访结果确认无结石,避免了不必要的ERCP。EUS诊断胆总管结石的灵敏度、特异度、准确率、阳性预测值、阴性预测值分别为95.40%(83/87)、97.78%(44/45)、96.21%(127/132)、98.81%(83/84)、91.67%(44/48),MRCP诊断胆总管结石的灵敏度、特异度、准确率、阳性预测值、阴性预测值分别为66.67%(58/87)、82.22%(37/45)、71.97%(95/132)、87.88%(58/66)、56.06%(37/66)。两者灵敏度、准确率、阳性预测值、阴性预测值相比,差异均有统计学意义(P均<0.05)。EUS对胆总管结石的诊断和最终诊断结果具有显著一致性(Kappa=0.917,P<0.001),MRCP对胆总管结石的诊断和最终诊断结果一致性较好(Kappa=0.439,P<0.001)。EUS对A组MRCP假阳性的检出率高于对B组MRCP假阴性的检出率[8/8比89.66%(26/29),P<0.001]。结论EUS对非确定性胆总管结石的诊断优于MRCP,ERCP术前应用EUS可减少不必要的ERCP操作或避免结石遗漏。

Objective To study the clinical value of endoscopic ultrasonography(EUS)before endoscopic retrograde cholangiopancreatography(ERCP)in patients with non-deterministic choledocholithiasis.Methods Data of 132 patients with unconfirmed common bile duct calculi diagnosed in Tianjin Nankai Hospital from January 2017 to December 2019,whose clinical manifestations were not consistent with magnetic resonance cholangiopancreatography(MRCP)results,were retrospectively analyzed.Patients were divided into two groups:group A showed calculi under MRCP with no suspicious clinical manifestations,while group B showed no calculi under MRCP with suspected clinical manifestations.All patients underwent EUS.Necessity of ERCP was determined according to EUS results,and the diagnostic accuracy of EUS was analyzed compared with ERCP results and follow-up results as the gold standard.Results Of the 132 patients,87 were confirmed as choledocholithiasis,and 45 had no common bile duct calculi by the golden standard.Forty-four(33.3%)cases were negative in EUS and were confirmed free of calculi by follow-up.The sensitivity,specificity,accuracy,positive predictive value and negative predictive value of EUS for choledocholithiasis were 95.40%(83/87),97.78%(44/45),96.21%(127/132),98.81%(83/84)and 91.67%(44/48),respectively.The sensitivity,specificity,accuracy,positive predictive value and negative predictive value of MRCP for choledocholithiasis were 66.67%(58/87),82.22%(37/45),71.97%(95/132),87.88%(58/66)and 56.06%(37/66),respectively.There were significant differences in the sensitivity,accuracy,positive predictive value or negative predictive value between EUS and ERCP(all P<0.05).There was significant consistency between the EUS results and the final diagnosis(Kappa=0.917,P<0.001),and good consistency between MRCP results and the final diagnosis(Kappa=0.439,P<0.001).The detection rate of false positive MRCP in group A was higher than that of false negative MRCP in group B[8/8 VS 89.66%(26/29),P<0.001]under EUS.Conclusion EUS is superior to MRCP in the diagnosis of uncertain choledocholithiasis,and EUS prior to ERCP can reduce unnecessary ERCP operations and avoid missing stones.