内镜治疗胆总管结石合并胆总管十二指肠乳头旁瘘的疗效及安全性分析

Analysis of effectiveness and safety of endoscopic treatment of common bile duct stones with peripapillary choledochoduodenal fistula

摘要:

目的 探讨内镜逆行胰胆管造影术（ERCP）经瘘口或原始乳头治疗胆总管结石合并胆总管十二指肠乳头旁瘘（PCDF）的临床疗效及安全性。方法 回顾性分析2008年1月－2019年12月该院收治的259例胆总管结石合并PCDF患者的临床资料，根据不同取石方式，分为乳头组（n = 141）和瘘口组（n = 118），比较两组患者一次性取石成功率、总取石成功率、机械碎石率、操作时间、术中扩张或切开使用率和术后并发症发生率。结果 共9 390例患者行ERCP下胆总管结石取石。其中，259例（2.8%）胆总管结石合并PCDF。经瘘口胆管造影成功率为100.0%，145例因各种原因经十二指肠乳头胆总管插管造影，成功率为97.2%（141/145）。两组患者一次性取石成功率［77.1%（91/118）和79.4%（112/141），P = 0.652］、取石总成功率［86.4%（102/118）和87.9%（124/141），P = 0.718］、机械碎石率［9.3%（11/118）和8.5%（12/141），P = 0.819］和操作时间［（19.83±12.24）和（18.52±11.90）min，P = 0.500］比较，差异均无统计学意义。瘘口组术中使用切开或扩张的比例明显低于乳头组［44.9%（53/118）和88.7%（125/141），P < 0.05］，瘘口组术后急性胰腺炎［0.0%（0/118）和9.2%（13/141）］和并发症总发生率［5.1%（6/118）和22.0%（31/141）］低于乳头组，差异均有统计学意义（P < 0.05）。结论 胆总管结石合并PCDF，经瘘口行ERCP取石，可达到经原始乳头取石的同等疗效，且可降低术后急性胰腺炎发生率，操作更简单。对于胆总管结石合并PCDF患者，行ERCP应优先考虑经瘘口取石。

Abstract:

Objective To compare the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in treatment of common bile duct stones complicated with peripapillary choledochoduodenal fistula (PCDF).Methods Clinical data of 259 patients with choledocholithiasis complicated with PCDF from January 2008 to December 2019 were analyzed retrospectively. According to the stone removal method, they were divided into the pappila group (n = 141) and the fistula group (n = 118). The success rate of one-time stone removal, the total success rate of stone removal, the rate of mechanical lithotripsy, the operation time, the use rate of intraoperative expansion or incision and the incidence of postoperative complications were compared between the two groups.Results During this period, 9 390 patients underwent ERCP for choledocholithiasis, and 259 cases (2.8%) of choledocholithiasis complicated with PCDF. The success rate of transfistula cholangiography was 100.0%, 145 cases of duodenal papillary bile duct catheterization for various reasons, the success rate was 97.2% (141/145). There were no significant differences between the two groups in one-time stone removal success rate [77.1% (91/118) vs 79.4% (112/141), P = 0.652], total stone removal success rate [86.4% (102/118) vs 87.9% (124/141), P = 0.718], mechanical lithotripsy rate [9.3% (11/118) vs 8.5% (12/141), P = 0.819] and operation time [(19.83 ± 12.24) min vs (18.52 ± 11.90) min, P = 0.500). The proportion of incision or expansion in the fistula group was significantly lower than that in the pappila group [44.9% (53/118) vs 88.7% (125/141), P < 0.05], the proportion of postoperative acute pancreatitis and the total complications rate in the fistula group were significantly lower than those in the pappila group [0.0% (0/118) vs 9.2% (13/141), P < 0.05; 5.1% (6/118) vs 22.0% (31/141), P < 0.05].Conclusion ERCP for choledocholithiasis combined with PCDF through the fistula can achieve the same effect as that through the original pappila, reduce the incidence of postoperative acute pancreatitis and make the operation simpler; Therefore, ERCP is preferred to take stones through fistula for patients with common bile duct stones complicated with PCDF.