早期经胰管括约肌预切开术在导丝误入胰管的内镜逆行胰胆管造影术困难插管中的临床应用

Clinical application of early transpancreatic sphincterotomy to difficult cannulation during endoscopic retrograde cholangiopancreatography with unintentional guide wire entering pancreatic duct

目的探讨早期经胰管括约肌预切开术(transpancreatic sphincterotomy,TPS)应用于导丝进入胰管的内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)困难插管的有效性和安全性。方法回顾性分析2019年1月至2021年11月于昆明医科大学第二附属医院消化内镜室行ERCP诊疗的胆道疾病患者临床资料,排除在常规选择性胆管插管技术尝试5 min内即成功进入胆管者,共纳入154例导丝误入胰管的ERCP困难插管患者。将导丝首次进入胰管且插管时间5~<10 min时即行TPS的患者设为早期TPS组(n=62例),而将导丝反复进入胰管(≥2次)或插管时间≥10 min时才实施TPS的患者设为延迟TPS组(n=92例),比较两组的一般资料、插管时间、手术时间、插管成功率、ERCP术后胰腺炎、出血、穿孔等并发症发生率。结果早期TPS组和延迟TPS组的性别、年龄、ERCP指征等一般资料比较差异均无统计学意义(P>0.05),早期TPS组的插管时间[12.0(10.0,15.0)min比21.0(16.0,27.0)min,Z=8.262,P<0.001]、手术时间[29.0(25.0,34.0)min比50.5(41.0,67.8)min,Z=9.097,P<0.001]显著短于延迟TPS组,两组胰管支架留置率差异无统计学意义[9.7%(6/62)比16.3%(15/92),χ^(2)=1.381,P=0.240]。早期TPS组的插管成功率[100.0%(62/62)比88.0%(81/92),χ^(2)=6.282,P=0.012]显著高于延迟TPS组,ERCP术后胰腺炎发生率[0.0%(0/62)比16.3%(15/92),χ^(2)=11.200,P=0.001]以及总并发症发生率[37.1%(23/62)比59.8%(55/92),χ^(2)=7.626,P=0.006]显著低于延迟TPS组,两组高淀粉酶血症发生率[21.0%(13/62)比31.5%(29/92),χ^(2)=2.080,P=0.149]以及术中出血发生率[21.0%(13/62)比30.4%(28/92),χ^(2)=1.699,P=0.192]差异无统计学意义。两组均无穿孔和操作相关的死亡发生。结论在导丝误入胰管的ERCP困难插管中,早期实施TPS可以提高胆管插管成功率并减少ERCP术后胰腺炎发生率,是安全和有效的。

Objective To investigate the efficacy and safety of early transpancreatic sphincterotomy(TPS)to difficult endoscopic retrograde cholangiopancreatography(ERCP)biliary cannulation with guide wire entering the pancreatic duct.Methods A retrospective analysis was performed on the clinical data of patients who underwent ERCP at the Digestive Endoscopy Department of the Second Affiliated Hospital of Kunming Medical University from January 2019 to November 2021.The patients whose bile ducts were successfully entered within 5 minutes by using the conventional selective biliary cannulation technique were excluded.A total of 154 patients with guide wire entering the pancreatic duct during difficult ERCP biliary cannulation were included.Patients who underwent TPS immediately after guidewire running into pancreatic duct for the first time during the cannulation within 5~<10 min were assigned to early TPS group(n=62),while patients who underwent TPS when the guide wire repeatedly entered the pancreatic duct(≥2 times)or whose cannulation time≥10 min were to delayed TPS group(n=92).The general data,cannulation time,procedure time,biliary intubation success rate,incidence of complications such as pancreatitis,bleeding and perforation after ERCP were compared.Results There was no significant difference between the early TPS group and the delayed TPS group in terms of general information such as gender,age or ERCP indications(P>0.05),while the cannulation time[12.0(10.0,15.0)min VS 21.0(16.0,27.0)min,Z=8.262,P<0.001]and procedure time[29.0(25.0,34.0)min VS 50.5(41.0,67.8)min,Z=9.097,P<0.001]of the early TPS group were significantly shorter than those in the delayed TPS group,and there was no significant difference in the rate of pancreatic duct stent placement between the two groups[9.7%(6/62)VS 16.3%(15/92),χ^(2)=1.381,P=0.240].The rate of successful biliary intubation of the early TPS group was significantly higher[100.0%(62/62)VS 88.0%(81/92),χ^(2)=6.282,P=0.012]than that of the delayed TPS group.The incidences of post-ERCP pancreatitis[0.0%(0/62)VS 16.3%(15/92),χ^(2)=11.200,P=0.001]and total complications[37.1%(23/62)VS 59.8%(55/92),χ^(2)=7.626,P=0.006]were significantly lower than those in the delayed TPS group,while there was no significant difference in the incidence of hyperamylasemia[21.0%(13/62)VS 31.5%(29/92),χ^(2)=2.080,P=0.149]or intraoperative bleeding[21.0%(13/62)VS 30.4%(28/92),χ^(2)=1.699,P=0.192]between the two groups,and no perforation or procedure-related death occurred in either group.Conclusion Early TPS can improve the success rate of biliary cannulation and reduce the incidence of post-ERCP pancreatitis,which is safe and effective for patients with a missed guide wire into the pancreatic duct during difficult ERCP biliary cannulation.