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

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:

ObjectiveTo 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).MethodsA 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.ResultsAmong 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).ConclusionsBoth 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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表1

两组基本情况[x±s/n(%)]

Item	PPDS group（n=44）	TPS group（n=40）	t/χ²value	Pvalue
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

表1

Item	PPDS group （n=44）	TPS group （n=40）	χ²value	Pvalue
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

表2

参考文献14

[1]	MAHARSHI S, SHARMA S S. Early precutversusprimary precut sphincterotomy to reduce post-ERCP pancreatitis: randomized controlled trial (with videos)[J].Gastrointest Endosc,2021,93(3):586-593.
[2]	DUMONCEAU J M, KAPRAL C, AABAKKEN L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) guideline[J].Endoscopy,2020,52(2):127-149.
[3]	中华医学会消化内镜学分会ERCP学组, 中国医师协会消化医师分会胆胰学组, 国家消化系统疾病临床医学研究中心. 中国ERCP指南(2018版)[J].中华消化内镜杂志,2018,35(11): 777-813.
	ERCP Group Chinese Society of Digestive Endoscopo-logy Biliopancreatic Group, Chinese Association of Gastroenterologist and Hepatologist, National Clinical Research Center for Digestive Diseases. Guidelines for ERCP (2018, China)[J].Chin J Digest Endosc,2018,35(11):777-813.
[4]	TESTONI P A, MARIANI A, AABAKKEN L, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline[J].Endoscopy,2016,48(7):657-683. doi:10.1055/s-0042-108641pmid:27299638
[5]	KUBOTA K, SATO T, KATO S, et al. Needle-knife precut papillotomy with a small incision over a pancreatic stent improves the success rate and reduces the complication rate in difficult biliary cannulations[J].J Hepatobi-liary Pancreat Sci,2013,20(3):382-388.
[6]	CHA S W, LEUNG W D, LEHMAN G A, et al. Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy-associated pancreatitis? A randomized, prospective study[J].Gastrointest Endosc,2013,77(2):209-216.
[7]	李谦益, 姚文飞, 祁洋, 等. 胰管支架表面括约肌预切开在ERCP困难胆管插管中的应用效果[J].肝胆胰外科杂志,2022,34(3):129-133.
	LI Q Y, YAO W F, QI Y, et al. Efficacy of precut over a pancreatic duct stent for difficult biliary cannulation in ERCP[J].J Hepatopancreatobiliary Surg,2022,34(3):129-133.
[8]	GOFF J S. Common bile duct pre-cut sphincterotomy: transpancreatic sphincter approach[J].Gastrointest Endosc,1995,41(5):502-505. pmid:7615231
[9]	CHOUDHARY A, WINN J, SIDDIQUE S, et al. Effect of precut sphincterotomy on post-endoscopic retrograde cholangio-pancreatography pancreatitis:a systematic review and meta-analysis[J].World J Gastroenterol,2014,20(14):4093-4101.
[10]	MAVROGIANNIS C, LIATSOS C, ROMANOS A, et al. Needle-knife fistulotomyversusneedle-knife precut papillotomy for the treatment of common bile duct stones[J].Gastrointest Endosc,1999,50(3):334-339.
[11]	KRAFFT M R, FREEMAN M L. Precut biliary sphincte-rotomy in ERCP: don't reach for the needle-knife quite so fast![J].Gastrointest Endosc,2021,93(3):594-596.
[12]	ZHANG Q S, XU J H, DONG Z Q, et al. Success and safety of needle knife papillotomy and fistulotomy based on papillary anatomy: a prospective controlled trial[J].Dig Dis Sci,2022,67(5):1901-1909.
[13]	KYLÄNPÄÄ L, KOSKENSALO V, SAARELA A, et al. Transpancreatic biliary sphincterotomyversusdouble guidewire in difficult biliary cannulation: a randomized controlled trial[J].Endoscopy,2021,53(10):1011-1019.
[14]	李甫, 张晞文, 唐睿, 等. 经胰管括约肌切开联合胰管支架植入在ERCP困难插管中的应用[J].中华肝脏外科手术学电子杂志,2020,9(4):347-351.
	LI F, ZHANG X W, TANG R, et al. Transpancreatic sphincterotomy combined with pancreatic duct stenting for difficult intubation of ERCP[J].Chin J Hepat Surg(Electronic Edition),2020,9(4):347-351.

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