肝胰壶腹特征对内镜逆行胰胆管造影术困难胆管插管的影响

Impact of hepatopancreatic ampulla features on difficult bile duct catheterization during endoscopic retrograde cholangiopancreatography

摘要:

目的 探讨肝胰壶腹特征对内镜逆行胰胆管造影术（ERCP）困难胆管插管的影响。方法 回顾性分析2023年6月－2024年4月于该院行ERCP治疗的800例患者的临床资料，对肝胰壶腹内镜下宏观特征进行分类：1）不突出（n = 544）；2）突出（n = 120）；3）憩室、黏膜褶皱（n = 96）；4）扭曲、肿瘤累及（n = 40）。所有纳入病例行ERCP操作时，均从标准胆管插管方法开始，标准胆管插管不成功的归类为困难插管。对所有困难胆管插管病例行高级插管技术［双导丝技术（DGT）和乳头括约肌预切开术（PST）］。记录插管成功率和手术相关并发症等情况。结果 肝胰壶腹特征分类中使用标准胆管插管方法，4组成功率分别为：79.96%（435/544）、69.17%（83/120）、72.92%（70/96）和65.00%（26/40），差异有统计学意义（χ² = 10.90，P = 0.012）；4组困难插管率分别为：18.01%（98/544）、27.50%（33/120）、27.08%（26/96）和30.00%（12/40），差异有统计学意义（χ² = 10.41，P = 0.015）。亚分组中，4组使用DGT插管率分别为：11.95%（65/544）、15.83%（19/120）、12.50%（12/96）和20.00%（8/40），DGT插管成功率组间比较，差异无统计学意义（χ² = 6.96，P = 0.073）。亚分组中，4组使用PST插管率分别为：6.07%（33/544）、11.67%（14/120）、14.58%（14/96）和10.00%（4/40），PST插管成功率组间比较，差异无统计学意义（χ² = 5.54，P = 0.136）。169例患者使用了高级插管技术，DGT组和PST组总成功率分别为：94.23%（98/104）和89.23%（58/65），总成功率组间比较，差异有统计学意义（χ² = 19.50，P = 0.021）。困难胆管插管组ERCP术后胰腺炎（PEP）发生率明显高于标准胆管插管组，差异有统计学意义［18.34%（31/169）和2.61%（16/614），χ² = 58.64，P = 0.000］。DGT组与PST组的PEP发生率分别为：21.15%（22/104）和13.85%（9/65），差异无统计学意义（χ² = 1.17，P = 0.279）。结论 肝胰壶腹特征影响胆管插管成功率。不突出组使用标准胆管插管最为容易，困难胆管插管使用DGT和PST时，需要警惕PEP风险。

Abstract:

Objective To investigate the impact of hepatopancreatic ampulla features on difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP).Methods A retrospective analysis was conducted on 800 patients who underwent ERCP from June 2023 to April 2024. Hepatopancreatic ampullary features were categorized endoscopically into four types: 1) Non-protruding (n = 544); 2) Protruding (n = 120); 3) Diverticula or mucosal folds (n = 96); 4) Tortuosity or tumor involvement (n = 40). Standard biliary cannulation was initiated in all cases, with failure defined as difficult cannulation. Advanced cannulation techniques were employed for all difficult cannulation cases [double-guidewire technique (DGT) or precutsphincterotomy (PST)]. Success rates and procedural complications were recorded.Results Standard biliary cannulation outcomes, success rates 79.96% (435/544) in non-protruding vs. 69.17% (83/120) in protruding, 72.92% (70/96) in diverticula or mucosal folds, and 65.00% (26/40) in tortuosity or tumor groups (χ² = 10.90, P = 0.012)；Difficult cannulation rates 18.01% (98/544) in non-protruding vs. 27.50% (33/120) in protruding, 27.08% (26/96) in diverticula or mucosal folds, and 30.00% (12/40) in tortuosity or tumor groups (χ² = 10.41, P = 0.015). In the subgroups, the rates of DGT intubation in the four groups were 11.95% (65/544), 15.83% (19/120), 12.50% (12/96), and 20.00% (8/40), respectively. There was no statistically significant difference in the success rate of DGT intubation between the groups (χ² = 6.96, P = 0.073). In the subgroups, the PST intubation rates were 6.07% (33/544), 11.67% (14/120), 14.58% (14/96), and 10.00% (4/40), respectively. There was no statistically significant difference in the success rate of PST intubation between the groups (χ² = 5.54, P = 0.136). Advanced cannulation techniques were used in 169 patients，DGT success rates of 94.23% (98/104) vs. PST at 89.23% (58/65) （χ² = 19.50，P = 0.021）；PEP incidence 18.34% (31/169) in difficult cannulation vs. 2.61% (16/614) in standard group（χ² = 58.64，P = 0.000）；No significant difference in PEP between DGT (21.25%) and PST (13.85%) groups (χ² = 1.17，P = 0.279).Conclusion Hepatopancreatic ampulla features influences biliary cannulation success. Non-protruding ampullae demonstrate optimal outcomes with standard techniques. Notably, DGT and PST are associated with elevated PEP risks in difficult cannulation.