目的：研究内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）治疗胆总管巨大结石,分析先乳头球囊扩张再机械碎石与先碎石再乳头球囊扩张两组对取石效率及术后并发症发生的影响。方法：对 2021年1月至2022年1月期间,于我院行 ERCP 取石治疗的 40例胆总管巨大结石病人进行前瞻性研究。采用随机数字表法将病人随机分为先碎后扩组和先扩后碎组,每组各20例。比较两组的取石时间、取石效率（cm³/min）、结石残留率及术后胰腺炎发生率等参数的差异。结果：所有病人均通过一次ERCP完成取石。两组病人的结石最大径、结石单发或多发、结石总体积（cm³）、取石时间、操作时间差异均无统计学意义。先碎后扩组的取石效率高于先扩后碎组[（0.91±0.58）（cm³/min）比（0.51±0.17）（cm³/min）,P=0.048],而器械出入乳头口次数少于先扩后碎组[（4.9±1.7）次比（7.9±2.2）次,P=0.021]。两组术后结石残留率和ERCP术后胰腺炎发生率差异无统计学意义。先碎后扩组术后24 h淀粉酶水平[（196±158） U/L比（332±265） U/L,P=0.02]和高淀粉酶血症发生病例（2例比8例,P=0.028）显著低于先扩后碎组。两组均未出现重症胰腺炎、胃肠道出血、十二指肠穿孔等严重并发症。结论：ERCP治疗困难胆总管结石时采用先机械碎石后乳头球囊扩张的顺序可提高取石效率,减少取石器械出入乳头次数,并降低术后高淀粉酶血症的发生率。

Objective To investigate endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of large common bile duct stone with endoscopic papillary balloon dilatation (EPBD) first or mechanical lithotripsy first. EPBD first or lithotripsy first were compared for stone removal efficiency and post-ERCP complications. Methods A prospective study of 40 patients with choledocholithiasis from January 2021 to January 2022 was done. Patients were divided into lithotripsy first group and EPBD first group each 20 cases using random number table. Stone remove time, stone removal efficiency (cm³/min), the rate of residual stones and rate of post-ERCP pancreatitis were compared between two groups. Results All cases underwent stone removal one time successfully. There was no statistically significant difference in maximum diameter of stone, single or multiple stone, stone volumes (cm³), time for stone remove and operative time between two groups. The stone removal efficiency (cm³/min) in lithotripsy first group was significantly higher than that in EPBD first group, (0.91±0.58) cm³/min vs. (0.51±0.17) cm³/min, P=0.048. While the procedure numbers of stone tool passing papilla in lithotripsy first group were less than those in EPBD first group, (4.9±1.7) vs. (7.9±2.2), P=0.021. The differences in the rate of residual stone and the rate of post-ERCP complications were not significant statistically. Post-ERCP serum amylase level [(196±158) U/L vs. (332±265) U/L, P=0.02] and the cases with hyperamylasemia (2 cases vs. 8 cases, P=0.028) in lithotripsy first group were significantly lower than those in EPBD first group. No case with severe pancreatitis,gastrointestinal bleeding or duodenal perforation occurred in either group. Conclusions Using lithotripsy before EPBD procedure in treatment of difficult common bile duct stone could increase stone removal efficiency and reduce both procedure number of stone tool passing papilla and rate of post-ERCP hyperamylasemia.