内镜逆行胰胆管造影相关十二指肠穿孔的外科治疗

Surgical treatment for ERCP related duodenal perforations

摘要:

目的 探讨内镜逆行胰胆管造影（ERCP）相关十二指肠穿孔的原因、诊断和外科治疗。方法 对6例外科手术治疗的ERCP相关十二指肠穿孔患者的临床资料进行回顾性分析。6例穿孔患者均急诊行外科开腹手术，其中3例为外院十二指肠穿孔后转入。4例有腹部外科手术史。术前证实胆总管结石4例，胆囊癌术后阻塞性黄疸1例，胆管扩张1例。结果 穿孔原因为十二指肠镜操作不当相关穿孔2例，十二指肠乳头括约肌切开术相关3例（1例针状刀预切开），小切开联合大球囊扩张致穿孔1例。6例患者4例术中发现右肾周积气，2例术后CT发现后腹膜积气、积液。6例均行胆总管探查、T管引流、十二指肠穿孔修补和空肠造瘘术，其中2例同时行胃肠吻合术。5例痊愈，1例死亡。结论 十二指肠乳头括约肌切开指征把握不佳，有多次腹部手术史者穿孔率较高，及时发现，合理治疗是关键；对于严重的Ⅰ型及Ⅱ型穿孔，及时积极的外科手术治疗，可有效降低ERCP相关穿孔所造成的严重后果。

Abstract:

Objective To investigate the causes, diagnosis and surgical treatment of ERCP related duodenal perforation. Methods Clinical data of 6 cases of surgical treatment of ERCP related duodenal perforation were retrospective analyzed. All the 6 perforation patients underwent emergency surgical procedure, including 3 cases transfered from other hospital after duodenal perforation. 4 cases with a history of abdominal surgery. Preoperative confirmed bravery manager stone 4 cases, 1 case of obstructive jaundice after gallbladder surgery, bile duct expansion in 1 case. Results Perforation causes include duodenum mirror improper operation related in 2 cases, duodenal papilla sphincterotomy related 3 cases (1 case of pre-dissection operation with needle knife), small endoscopic sphincterotomy combined with endoscopic papillary balloon dilation lead to perforation in 1 case.4 cases of intraoperative found right kidney week pneumatosis, 2 cases of postoperative CT found after peritoneal pneumatosis, effusion. All patients with surgery including common bile duct exploration, T tube drainage, duodenal perforation repair, jejunum colostomy, among them 2 cases at the same time line of gastrointestinal anastomosis. 5 cases recovered, 1 case died.Conclusions Inappropriate duodenal papilla sphincter incision indications and Many previous abdominal surgery have higher perforated ration; Found in time, reasonable treatment is the most important; For serious typeⅠand typeⅡperforation, active surgical treatment in time, can effectively reduce serious consequences caused by the ERCP related perforation.