3种不同支撑方法在胆肠吻合术后吻合口狭窄中的对比研究

Comparison of three supporting methods in anastomotic stricture after choledochojejunostomy

摘要:

目的   比较3种不同支撑方法在胆肠吻合术后吻合口狭窄中的应用价值。方法   回顾性分析2008年12月－2014年12月该科采用胆道内镜治疗的18例胆肠吻合术后吻合口狭窄患者的临床资料。采取胆道镜下高频电切和/或球囊扩张解除吻合口狭窄，取净肝内外胆管结石后放置支撑管，包括：树脂支架（A组）、全覆膜自膨氏可回收金属支架（B组）、持续性球囊扩张导管（C组）。结果   A组8例，平均放置（2.75±0.89）枚（2～4枚）树脂支架，置管时间（5.63±3.82）min（4.0～15.0 min），支撑（6.75±1.04）个月（6～9个月），取管时间（1.19±0.80）min（0.5～3.0 min）；支架取出前胆道镜下观察：支架均为胆泥堵塞，吻合口处黏膜及支架外壁可见大量胆泥及纤维素附着；取出支架后观察：吻合口相对狭窄，黏膜水肿并有渗血，肝内外胆管黏膜轻度水肿，胆管壁上有大量胆泥及纤维附着，并可见支架压迫性组织增生痕迹。B组6例，支架长度4 cm，直径1 cm，放置耗时（0.67±0.26）min，支撑（5.17±0.75）个月（4～6个月），取出耗时（4.50±2.72）min（3.0～10.0 min）；支架取出前胆道镜下观察：吻合口及支架内外壁上见少许胆泥及纤维附着，胆汁流出顺畅；取出支架后观察：吻合口无狭窄，吻合口黏膜轻度水肿，局部黏膜少许渗血，肝内外胆管黏膜正常；C组4例，放置耗时（0.63±0.25）min，支撑（5.50±0.58）个月（5～6个月），取出耗时（0.63±0.25）min；球囊扩张导管取出后观察：吻合口无狭窄，吻合口及肝内胆管黏膜均正常。随访3个月～6年，A组复发4例，B组复发2例，C组无复发。结论   持续性球囊扩张导管支撑治疗胆肠吻合术后吻合口狭窄具有操作简单、损伤小和预后好等优点，临床效果优于树脂支架及全覆膜自膨氏可回收金属支架，值得临床推广。

Abstract:

Abstract: Objective To compare the value of three supporting methods in anastomotic stricture after choledochojejunostomy. Methods The clinical data of 18 cases of anastomotic strictures after choledochojejunostomy from December 2008 to December 2014 were retrospectively analyzed. After the anastomotic strictures were resolved by endoscopic high frequency electrotomy and/or balloon dilatation, plastic stents (group A), full-covered self-expanding removable metal stent (FCSERMS) (group B) or persistent balloon dilatation catheter (group C) were used to support the anastomotic stomas if all of the residual stones were removed. Results There were 8 cases in group A with the average plastic stents number of (2.75 ± 0.89) (2～4), stenting time of (5.63 ± 3.82) min (4.0 ～ 15.0 min), extraction time of (1.19 ± 0.80) min (0.5 ～ 3.0 min) and supporting time of (6.75 ± 1.04) months (6 ～ 9 months). A large number of biliary sludge and fiber were attached to the mucosa of anastomotic stomas and the wall of stents, which had been blocked. Anastomotic stomas seemed to be narrow relatively with mucosal edema and bleeding, bile duct mucosa was mild edema with the attachment of biliary sludge and fiber, and oppressive mucosa hyperplasia could be seen in extrahepatic bile duct caused by stents when the stents removed. There were 6 cases in group B with the stenting time of (0.67 ± 0.26) min, supporting time of (5.17 ± 0.75) months (4 ～ 6 months), average extraction time of (4.50 ± 2.72) min (3.0 ～ 10.0 min). There was a little biliary sludge and fiber attached to the mucosa of anastomotic stomas and the wall of stents with bile flowing smoothly. Anastomotic stomas were a little mucosal edema and bleeding, but bile duct mucosa was normal without anastomotic stricture. There were 4 cases in group C with the stenting time of (0.63 ± 0.25) min and extraction time of (0.63 ± 0.25) min and supporting time of (5.50 ± 0.58) months (5 ～ 6 months). Anastomotic stomas and bile duct mucosa was normal without anastomotic stricture. Followed up for 3 months ～6 years, there were 4 case of anastomotic stricture recurrence in group A, 2 in group B and no one in group C. Conclusions Persistent balloon dilatation catheter supporting for anastomotic stricture after choledochojejunostomy has the advantages of simpler operation, less damage, better prognosis than plastic stents and FCSERMS, which is worth the clinical promotion.