SpyGlass胆道镜在不明原因胆管狭窄中诊断价值

Value of SpyGlass choledochoscopy to the diagnosis of indeterminate biliary strictures

目的观察不明原因胆管狭窄患者SpyGlass胆道镜下表现,探讨SpyGlass胆道镜对不明原因胆管狭窄良、恶性的鉴别诊断价值。方法56例不明原因胆管狭窄患者均行SpyGlass胆道镜检查,观察胆管狭窄部位镜下表现,对狭窄部位进行视觉印象诊断;47例患者行SpyBite靶向活检组织病理检查;记录不良事件发生情况。术后随访1~6个月,随访过程中出现恶性征象如远处转移等判定为恶性,最终诊断由组织病理检查、实验室检查、影像学检查和随访情况综合判定。以最终诊断为金标准,评价SpyGlass胆道镜视觉印象和SpyBite靶向活检诊断不明原因胆管狭窄良、恶性的效能。56例患者根据是否有内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)操作史分为无ERCP操作史组36例和有ERCP操作史组20例,比较2组SpyGlass胆道镜视觉印象诊断准确率、SpyBite靶向活检诊断准确率、SpyGlass胆道镜操作时间及不良事件发生率。结果56例患者最终诊断为正常胆管5例,良性病变20例,恶性肿瘤31例。SpyGlass胆道镜视觉印象诊断为良性病变22例,恶性肿瘤34例;诊断不明原因胆管狭窄良、恶性的灵敏度为93.5%,特异度为80.0%,准确率为87.5%。SpyBite靶向活检诊断为良性病变26例,恶性肿瘤21例;诊断不明原因胆管狭窄良、恶性的灵敏度为70.0%,特异度为100.0%,准确率为80.9%。56例患者发生不良事件8例(14.3%),其中高淀粉酶血症4例,ERCP术后胰腺炎2例,急性胆管炎1例,消化道出血1例,均经对症处理后好转;无穿孔等其他并发症。无ERCP操作史组SpyGlass胆道镜视觉印象诊断准确率(97.2%)高于有ERCP操作史组(70.0%)(χ^(2)=6.400,P=0.011),SpyBite靶向活检诊断准确率(88.9%)、SpyGlass胆道镜操作时间[(70.86±36.79)min]、不良反应发生率(16.7%)与有ERCP操作史组[70.0%、(66.45±22.55)min、10.0%]比较差异均无统计学意义(P>0.05)。结论SpyGlass胆道镜视觉印象鉴别诊断不明原因胆管狭窄良、恶性的准确率高,安全性好;不明原因胆管狭窄患者首次ERCP时行SpyGlass胆道镜可提高良、恶性鉴别诊断准确率,不增加手术时间和不良反应。

Objective To observe the manifestations of SpyGlass choledochoscopy in patients with indeterminate biliary strictures,and to explore the value of SpyGlass choledochoscopy to the differential diagnosis of indeterminate benign and malignant biliary strictures.Methods SpyGlass choledochoscopy was performed in 56patients with indeterminate biliary strictures to observe the choledochoscopic manifestations and to evaluate the visual impression of strictures,in which 47patients underwent SpyBite targeted biopsy for histopathologic examination.The occurrence of adverse events was recorded.The patients were followed up for 1to 6months.If malignant signs as distant metastasis occurred during the follow-up,the disease was diagnosed as malignancy,and the final diagnosis was made on the basis of histopathological examination,imaging examination,laboratory examination and follow-up.The final diagnosis was regarded as the gold standard to evaluate the efficiencies of SpyGlass choledochoscopy visual impression and SpyBite targeted biopsy on the differential diagnosis of indeterminate benign and malignant biliary strictures.According to the history of endoscopic retrograde cholangiopancreatography(ERCP),56patients were divided into non-ERCP history group(n=36)and ERCP history group(n=20).The diagnostic accuracies of SpyGlass choledochoscopy visual impression and SpyBite targeted biopsy,the operation time of SpyGlass choledochoscopy and the incidence of adverse events were compared between two groups.Results The final diagnosis of 56patients was normal bile duct in 5patients,benign lesions in 20,and malignancies in 31.SpyGlass choledochoscopy visually diagnosed benign lesions in 22patients and malignancies in 34,with a sensitivity,specificity and accuracy in the differential diagnosis of indeterminate benign and malignant biliary strictures of 93.5%,80.0%and 87.5%,respectively.SpyBite targeted biopsy diagnosed benign lesions in 26patients and malignancies in 21,with a sensitivity,specificity and accuracy in differential diagnosis of indeterminate benign and malignant biliary strictures of 70.0%,100.0%and 80.9%,respectively.The adverse events occurred in 8patients(14.3%),including 4cases of hyperamylasemia,2cases of post-ERCP pancreatitis,1case of acute cholangitis,and 1case of gastrointestinal bleeding,all of which were relieved after symptomatic treatment.There was no other complication as perforation.The diagnostic accuracy of SpyGlass choledochoscopy visual impression was higher in non-ERCP history group(97.2%)than that in ERCP history group(70.0%)(χ^(2)=6.400,P=0.011).The diagnostic accuracy of SpyBite targeted biopsy,the operation time of SpyGlass choledochoscopy and the incidence of adverse events showed no significant differences between non-ERCP history group[88.9%,(70.86±36.79)min,16.7%]and ERCP history group[70.0%,(66.45±22.55)min,10.0%](P>0.05).Conclusions SpyGlass choledochoscopy visual impression has a high accuracy and safety in differential diagnosis of indeterminate biliary strictures.SpyGlass choledochoscopy used in the first ERCP for indeterminate biliary strictures can improve the accuracy of differential diagnosis of benign and malignant biliary strictures,without increasing the operation time and adverse events.