胆管内超声用于胆总管结石内镜下取石

Intraductal ultrasonography in endoscopic removing of common bile duct calculi

目的观察胆管内超声(IDUS)用于胆总管结石内镜下取石中的价值。方法回顾性分析148例接受内镜逆行胰胆管造影(ERCP)联合内镜下括约肌切开术(EST)的胆总管结石患者,对取石后胆总管造影显示结石完全清除者行IDUS,观察有无胆总管残石;对存在较大残石(≥3 mm)者重复行ERCP联合EST取石。术后随访,观察胆总管结石复发情况及其影响因素。结果148例经ERCP联合EST取石后,胆总管造影均确认胆总管结石完全清除。IDUS发现其中61例仍存在残石,且21例残石≥3 mm;对该21例重复取石,直至结石完全清除。术中及术后均未见严重不良反应。术后随访3~24个月,IDUS显示108例结石完全清除者与40例存在残石者结石复发率分别为8.33%(9/108)、62.50%(25/40),差异有统计学意义(P<0.01);术后24个月累积无复发率差异有统计学意义(88.40%、14.40%,P<0.01)。多因素分析结果显示,IDUS所示胆总管残石、胆总管直径及角度均为结石复发的独立危险因素(P均<0.05)。结论IDUS能发现胆总管造影难以显示的胆总管残石、尤其细小结石(<3 mm),用于辅助ERCP联合EST取石有助于减少术后结石复发。

Objective To explore the application value of intraductal ultrasonography(IDUS)in endoscopic removing of common bile duct calculi.Methods Totally 148 patients with common bile duct calculi who underwent endoscopic retrograde cholangiaopancreatography(ERCP)combining endoscopic sphincterotomy(EST)were retrospectively analyzed.IDUS was performed when ERCP showed complete removal of calculi,and the presence of residual calculi of common bile duct was observed.ERCP combining EST extraction was repeatedly performed in patients who were found with≥3 mm residual calculi.Postoperative follow-up was conducted to evaluate the recurrence of common bile duct calculi and relative impact factors.Results Complete removal of common bile duct calculi was achieved according to cholangiography in all 148 cases after ERCP combining EST,whereas IDUS detected residual choledochal calculi in 61 cases among them,and 21 cases with residual calculi≥3 mm underwent repeatedly extraction until completely removal was observed.No serious adverse reaction occurred during and after operation.The recurrence rate of common bile duct calculi in 108 cases with complete removal calculi and 40 cases with residual calculi was 8.33%(9/108)and 62.50%(25/40)(P<0.01),while significant difference of cumulative recurrence free rates was found 24 months later(88.40%and 14.40%,P<0.01).Multivariate analysis showed that common bile duct residual calculi detected with IDUS,common bile duct diameter and angle were all independent risk factors for recurrence(all P<0.05).Conclusion IDUS could detect common bile duct residual calculi,esp.<3 mm calculi tended to be missed by ERCP,assisting ERCP combining EST for extraction of common bile duct residual calculi and being helpful to reduce the recurrence of calculi.