胰管支架表面括约肌预切开与经胰管括约肌预切开在ERCP困难胆管插管中的应用效果比较

doi:10.16139/j.1007-9610.2024.05.11

摘要/Abstract

摘要：

目的：比较胰管支架表面括约肌预切开（PPDS）与经胰管括约肌预切开(TPS)在内镜逆行胰胆管造影(ERCP)困难胆管插管中的应用效果。方法：回顾性分析2019年4月至2023年3月本院连续收治并由同一医师操作的ERCP病例资料，将在ERCP操作过程中导丝意外进入胰管的困难胆管插管者，根据术中选择插管方法，分为PPDS组（先放置胰管支架，然后用针刀于胰管支架表面切开胆管括约肌，保留胰管括约肌，再选择性胆管插管）和TPS组（先行经胰管括约肌预切开，然后放置胰管支架，再选择性胆管插管）。分析比较两组胆管插管成功率、ERCP相关并发症发生率。结果：762例ERCP病人中，84例符合入选标准，其中，PPDS组44例，TPS组40例。PPDS组成功胆管插管42例，成功率95.4%（42/44），无ERCP术后胰腺炎（PEP）、出血、穿孔并发症发生。TPS组成功胆管插管39例，成功率97.5%（39/40）。TPS组PEP 4例（10.0%，4/10），无出血、穿孔病例。所有病例均治愈。两组胆管插管成功率无显著差异（P>0.05），PEP发生率差异有统计学意义（P<0.05）。结论：PPDS法、TPS法均是在困难胆管插管情况下可以选择的好方法，具有较高的胆管插管成功率。PPDS法更适合于有PEP高危因素的病人,而TPS法操作简单。

关键词: 内镜逆行胰胆管造影术, 困难胆管插管, 胰管支架表面括约肌预切开, 经胰管括约肌预切开

Abstract:

Objective To compare the efficacy of precut over a pancreatic duct stent (PPDS) and transpancreatic precut sphincterotomy (TPS) for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP). Methods A retrospective analysis was conducted on the clinical data of all consecutive patients underwent ERCP by the same doctor in our hospital between April 2019 and March 2023. According to the selected method during difficult biliary cannulation when guidewire entered pancreatic duct unintendedly, the patients were divided into two groups,1) PPDS group: placing a pancreatic duct stent first, then using a needle knife to cut bile duct sphincter on the surface of the pancreatic duct stent, preserving pancreatic duct sphincter, and then selectively cannulate bile duct; 2) TPS group: precut through pancreatic duct sphincter first, then a pancreatic duct stent was placed, and bile duct was selectively cannulated. The success rate of biliary cannulation and ERCP-related complication between the two groups were compared. Results Among 762 ERCP patients, 84 patients were enrolled in this study, 44 patients in PPDS group, and 40 patients in TPS group. In PPDS group, 42 patients (95.4%, 42/44) had successful biliary cannulation. No post-ERCP pancreatitis(PEP), bleeding, perforation occurred in PPDS group. In TPS group, 39 patients (97.5%, 39/40) had successful biliary cannulation. Four patients (10.0%, 4/40) had PEP in PPDS group, no bleeding or perforation occurred. All patients were cured. The success rate of biliary cannulation between two groups had no significant difference（P>0.05）, while the rate of PEP had significant difference(P<0.05). Conclusions Both PPDS and TPS are good choice for difficult biliary cannulation with high success rate of biliary cannulation. PPDS is more suitable for patients with high-risk factors for PEP, while TPS is a simple technique.

Key words: Endoscopic retrograde cholangiopancreatography(ERCP), Difficult biliary cannulation, Precut over a pancreatic duct stent(PPDS), Transpancreatic precut sphincterotomy(TPS)

中图分类号:

R576
R575.7

姚文飞, 祁洋, 李谦益, 吴宇权, 徐瑞云, 姚伟, 孔雷, 李能平. 胰管支架表面括约肌预切开与经胰管括约肌预切开在ERCP困难胆管插管中的应用效果比较[J]. 外科理论与实践, 2024, 29(05): 434-440.

YAO Wenfei, QI Yang, LI Qianyi, WU Yuquan, XU Ruiyun, YAO Wei, KONG Lei, LI Nengping. Comparative efficacy of precut over a pancreatic duct stent and transpancreatic precut sphincterotomy for difficult biliary cannulation in ERCP[J]. Journal of Surgery Concepts & Practice, 2024, 29(05): 434-440.

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参考文献 14

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Item	PPDS group（n=44）	TPS group（n=40）	t/χ²value	P value
Age（years）	67.1±10.3	63.0±12.4	t=0.654	0.515
Gender (male/female)	24(54.5)/20(45.5)	22(55.0)/18(45.0)	χ²=0.002	0.967
Common bile duct diameter（mm）	13.3±4.2	11.5±4.2	t=1.845	0.069
Periampullary diverticulum（yes/no）	7(15.9)/37(84.1)	8(20.0)/32(80.0)	χ²=0.239	0.625
Etiology [n（%）]
Common bile duct stone	28 (63.6)	24 (60.0)	χ²=0.117	0.732
Acute biliary pancreatitis	4 (9.1)	8 (20.0)	χ²=1.243	0.265
Pancreaticobiliary malignancy.	11 (25.0)	6 (15.0)	χ²=1.298	0.255
Inflammatory stenosis of duodenal papilla	1 (2.3)	2 (5.0)	χ²=0.007	0.933

Item	PPDS group （n=44）	TPS group （n=40）	χ² value	P value
Success rate of biliary cannulation by PPDS/TPS	41（93.2）	26（65.0）	10.309	0.001
Final success rate of biliary cannulation	42（95.5）	39（97.5）	0.255	0.614
Complication rate of biliary cannulation
PEP	0	4（10.0）	4.190	0.041
Bleeding	0	0	NS	NS
Perforation	0	0	NS	NS

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