十二指肠乳头形态对选择性胆管插管的影响

Effects of duodenal papillary morphology on selective biliary cannulation

目的研究十二指肠乳头形态对选择性胆管插管(selective biliary cannulation,SBC)的影响。方法回顾性分析2018年1月—2020年1月西北民族大学附属医院消化内科行经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)诊疗的912例胆胰疾病患者的资料,采用Haraldsson提出的十二指肠乳头形态内镜下分类方法,分析不同十二指肠乳头形态的SBC成功率、预切开率、困难插管率及ERCP术后胰腺炎(post-ERCP pancreatitis,PEP)发生率等指标。结果86.95%(793/912)的患者十二指肠乳头形态符合Haraldsson分型中的一种,其中规则型(Ⅰ型)占77.18%(612/793)、小乳头型(Ⅱ型)占10.21%(81/793)、突出或下垂型(Ⅲ型)占8.58%(68/793)、皱折或脊状型(Ⅳ型)占4.04%(32/793)。Ⅰ~Ⅳ型乳头SBC成功率分别为98.86%(605/612)、90.12%(73/81)、88.24%(60/68)和96.60%(28/32),Ⅰ型乳头SBC成功率高于Ⅱ~Ⅳ型乳头(P均<0.008),Ⅱ型和Ⅲ型乳头SBC成功率比较差异无统计学意义(P>0.008)。Ⅰ~Ⅳ型乳头预切开率分别为7.84%(48/612)、32.10%(26/81)、50.00%(34/68)和25.00%(8/32),Ⅰ型乳头预切开率低于Ⅱ~Ⅳ型乳头(P均<0.008),Ⅱ型和Ⅲ型乳头预切开率比较差异无统计学意义(P>0.008)。Ⅰ~Ⅳ型乳头困难插管率分别为12.42%(76/612)、39.51%(32/81)、58.82%(40/68)和28.12%(9/32),Ⅰ型乳头困难插管率低于Ⅱ型和Ⅲ型乳头(P均<0.001),Ⅲ型乳头困难插管率高于Ⅳ型乳头(P=0.004),Ⅰ型与Ⅳ型乳头、Ⅱ型与Ⅲ型乳头困难插管率比较差异均无统计学意义(P均>0.008)。Ⅰ~Ⅳ型乳头PEP发生率分别为2.61%(16/612)、12.35%(10/81)、5.88%(4/68)和6.25%(2/32),Ⅱ型乳头PEP发生率高于Ⅰ型乳头(P<0.001),Ⅰ型与Ⅳ型乳头、Ⅱ型与Ⅲ型乳头PEP发生率比较差异均无统计学意义(P均>0.008)。结论十二指肠乳头形态影响SBC。Ⅰ型乳头的SBC最为容易;Ⅱ型和Ⅲ型乳头的SBC较难,且Ⅱ型乳头的SBC需警惕PEP风险。

Objective To study the effect of duodenal papillary morphology on selective biliary cannulation(SBC).Methods Data of 912 patients with biliopancreatic diseases treated with endoscopic retrograde cholangiopancreatography(ERCP)at the Department of Gastroenterology,Affiliated Hospital of Northwest Minzu University from January 2018 to January 2020 were retrospectively analyzed.Duodenal papillary morphology of patients was classified into 4 types by using Haraldsson's endoscopic classification.The success rate of SBC,the pre-incision rate,the difficult intubation rate and the incidence of post-ERCP pancreatitis(PEP)of different papillary types were analyzed.Results A total of 912 patients were enrolled in this study,and 86.95%(793/912)duodenal papilla conformed to one type of the classification,of which 77.18%(612/793)were regular type(typeⅠ),10.21%(81/793)small nipple type(typeⅡ),8.58%(68/793)protruding or drooping type(typeⅢ),and 4.04%(32/793)wrinkled or ridged type(typeⅣ).The success rates of SBC in four types of duodenal papilla were 98.86%(605/612),90.12%(73/81),88.24%(60/68)and 96.60%(28/32)respectively.The success rate of SBC of typeⅠwas higher than those of typeⅡ-Ⅳ(all P<0.008)and there was no significant difference between those of typeⅡand typeⅢ(P>0.008).The pre-incision rate in the four types of duodenal papilla were 7.84%(48/612),32.10%(26/81),50.00%(34/68)and 25.00%(8/32)respectively.The pre-incision rate of typeⅠwas lower than those of typeⅡ-Ⅳ(all P<0.008),and there was no significant difference between those of typeⅡand typeⅢ(P>0.008).The difficult intubation rate in the four types of duodenal papilla were 12.42%(76/612),39.51%(32/81),58.82%(40/68)and 28.12%(9/32)respectively.The difficult intubation rate of typeⅠwas lower than those of typeⅡand typeⅢ(both P<0.001),and that of typeⅢwas higher than that of typeⅣ(P=0.004).There was no significant difference between those of typeⅠand typeⅣor typeⅡand typeⅢ(both P>0.008).The incidences of PEP of the four types were 2.61%(16/612),12.35%(10/81),5.88%(4/68)and 6.25%(2/32)respectively.The incidences of PEP of typeⅡwas higher than that of typeⅠ(P<0.001),and there was no significant difference between those of typeⅠand typeⅣor typeⅡand typeⅢ(both P>0.008).Conclusion SBC is affected by duodenal papilla morphology,easiest for typeⅠand hard for typeⅡandⅢ.Attention should be paid to risk of PEP in SBC of typeⅡ.