内镜治疗胆总管结石远期疗效观察及结石复发危险因素分析

目的 探讨内镜下十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)治疗胆总管结石患者的远期疗效,分析术后胆总管结石复发的危险因素.方法 收集2006年1月至12月因胆总管结石而行EST治疗患者154例,对患者的有关指标与术后胆总管结石复发的关系进行多因素分析.结果 出现远期并发症22例(14.29%),其中胆总管结石复发18例(11.69%),16例伴发胆管炎;单纯胆管炎1例(0.65%);急性胰腺炎2例(1.30%);胆管癌1例(0.65%).胆总管结石复发的危险因素有高体重指数和血清胆固醇水平;而十二指肠乳头中小切口(0.5 cm～1.5 cm)是胆总管结石复发的保护因素.结论 体重指数、血清胆固醇水平、十二指肠乳头切口大小与EST术后胆总管结石复发相关.     

内镜治疗胆总管结石远期疗效观察及结石复发危险因素分析

目的 探讨内镜下十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)治疗胆总管结石患者的远期疗效,分析术后胆总管结石复发的危险因素.方法 收集2006年1月至12月因胆总管结石而行EST治疗患者154例,对患者的有关指标与术后胆总管结石复发的关系进行多因素分析.结果 出现远期并发症22例(14.29%),其中胆总管结石复发18例(11.69%),16例伴发胆管炎;单纯胆管炎1例(0.65%);急性胰腺炎2例(1.30%);胆管癌1例(0.65%).胆总管结石复发的危险因素有高体重指数和血清胆固醇水平;而十二指肠乳头中小切口(0.5 cm～1.5 cm)是胆总管结石复发的保护因素.结论 体重指数、血清胆固醇水平、十二指肠乳头切口大小与EST术后胆总管结石复发相关.     

胆总管结石术后复发风险因素

目的:寻找胆总管结石术后复发的风险因素,指导胆总管结石的治疗.方法:回顾性分析唐山市工人医院肝胆外科2002-01/2007-01共收治的523例胆总管结石患者的临床资料,采用COX比例风险模型分别对患者性别、年龄、手术方法、是否存在十二指肠憩室等8种可能影响胆总管结石复发的因素进行单因素及多因素分析.结果:患者术后3、5、10年的累积结石复发率别为6.5%,9.5%和15.1%.患者的性别、年龄、胆总管结石数目以及是否存在胆囊结石4种因素对胆总管结石手术后复发的影响无统计学意义;罹患十二指肠乳头旁憩室的患者术后再次发生胆总管结石的风险比是无憩室患者的1.37倍(95%CI:1.02-4.04,P0.05);胆总管直径≥15 mm的患者术后胆总管结石复发的风险比是15 mm患者的2.16倍(95%CI:1.12-5.08,P0.01);接受内镜下十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)治疗的患者术后结石复发的风险比是接受传统手术患者的2.20倍(95%CI:1.13-6.87,P0.05).结论:罹患十二指肠乳头旁憩室或者胆总管扩张或者接受过EST治疗的患者,再次复发胆总管结石的风险显著增加.     

乳头切开术治疗胆总管结石远期并发症及其与胆囊结石关系的研究

目的 探讨内镜下十二指肠乳头括约肌切开术（EST）治疗胆总管结石患者的远期治疗效果,评估EST术后胆囊切除的必要性.方法 对2006年1月至12月因胆总管结石而行EST治疗257例患者进行随访,所有患者平均随访时间为34.8个月（26～48个月）.根据不同病情和处理情况分为3组进行比较,合并有胆囊结石的患者EST术后行胆囊切除为A1组,EST术后未行胆囊切除为A2组;B组为未合并胆囊结石者.结果 出现远期并发症者31例（12.1%）,胆总管结石复发25例（9.7%）,胆管炎27例（10.1%）,胰腺炎2例（0.8%）,胆管癌1例（0.4%）;A2组患者远期并发症发生率、胆总管结石复发率均高于A1组（P均〈0.05）.结论 从远期疗效来看,EST是治疗胆总管结石的安全、有效的方法,对于合并有胆囊结石的患者EST术后行胆囊切除是有必要的.     

不同内镜术式治疗胆总管结石青年患者的长期随访研究

目的探讨不同的常用内镜治疗方法对胆总管结石青年患者治疗后结石复发的影响以及结石近期复发、远期复发的危险因素。方法选择经一次性治疗性内镜逆行胰胆管术（ERCP）成功取石后随访资料完整的胆总管结石青年（21～45岁）患者,按手术方式分为内镜下乳头球囊扩张术（EPBD）组、乳头括约肌切开术（EST）组、EST（切开〈0．5cm）＋EPBD组,进行随访,统计近期（≤3年）及远期（〉3年）结石复发率,并对复发危险因素进行Logistic回归分析。结果资料完整的327例患者平均随访76．5个月,54例（16．5％）结石复发,其中近期复发35例（10．7％）,远期复发19例（5．8％）。近期胆总管结石复发率EPBD组（11．3％）和EST组（13．2％）均高于EST＋EPBD组（8．1％）,但无统计学差异（P均〉0．05）。远期胆总管结石复发率EPBD组（11．3％）和EST组（6．6％）均显著高于EST＋EPBD组（0．8％）,差异具统计学意义（P均〈0．05）。Logistic回归分析结果表明,胆囊结石、结石最大径、结石个数、机械碎石与近期结石复发显著相关（P〈0．05）,而远期胆总管结石复发则与结石最大径及单纯球囊扩张显著相关（P〈0．05）。结论对于胆总管结石青年患者,单纯EPBD取石固然可保留乳头括约肌功能,但增加了结石的远期复发风险,而乳头括约肌小切开联合EPBD取石可显著降低胆总管结石复发率。     

内镜黏膜切除术治疗直肠类癌的价值评估

目的 探讨内镜下十二指肠乳头括约肌切开术（EST）治疗胆总管结石患者的远期治疗效果,评估EST术后胆囊切除的必要性.方法 对2006年1月至12月因胆总管结石而行EST治疗257例患者进行随访,所有患者平均随访时间为34.8个月（26～48个月）.根据不同病情和处理情况分为3组进行比较,合并有胆囊结石的患者EST术后行胆囊切除为A1组,EST术后未行胆囊切除为A2组;B组为未合并胆囊结石者.结果 出现远期并发症者31例（12.1%）,胆总管结石复发25例（9.7%）,胆管炎27例（10.1%）,胰腺炎2例（0.8%）,胆管癌1例（0.4%）;A2组患者远期并发症发生率、胆总管结石复发率均高于A1组（P均〈0.05）.结论 从远期疗效来看,EST是治疗胆总管结石的安全、有效的方法,对于合并有胆囊结石的患者EST术后行胆囊切除是有必要的.     

ERCP和EST治疗胆总管结石复发危险因素分析

目的 分析影响胆总管结石患者行逆行胰胆管造影（ERCP）和内镜下乳头括约肌切开取石术（EST）治疗后结石复发的危险因素。方法 我院诊治的胆总管结石患者357例,常规行ERCP检查,发现胆管内有结石后行EST。对结石直径<1.0 cm者,用取石网篮取石;对结石直径≥1.0 cm者,用碎石篮碎石取出;对巨大结石,于胆管内置入支架,再择期取石。采用Logistic回归分析影响治疗后结石复发的危险因素。结果 在357例患者,行ERCP插管成功349例(97.8%),行EST取石成功334例（93.6%),其中一次取石成功者297例（88.9%）,两次取石成功者37例（11.1%）;随访发现结石复发138例,未复发219例;单因素分析结果显示,复发组病程、年龄和乳头切口分别为（10.9±2.5）年、（66.8±7.2）岁和（15.6±1.9） mm,显著长于或大于未复发组【分别为（7.6±1.7）年、（57.3±8.7）岁和（7.9±2.2） mm,P均<0.05】,复发组有胆道手术史、乳头旁憩室、胆道狭窄、合并胆管或胰腺炎、结石数量≥2枚和结石直径≥10 mm比率分别为18.8%、29.7%、30.4%、78.9%、81.9%和40.6%,显著高于未复发组的1.8%、7.3%、11.4%、40.6%、64.8%和9.6%（P均<0.05）;进一步行Logistic回归分析显示,胆总管直径≥10 mm和乳头切口≥15 mm为患者术后结石复发的独立危险因素。结论 对于乳头切口和胆总管直径较大的患者,临床应该警惕其术后结石复发,增加随访次数,以早期发现。     

内镜下十二指肠乳头小切开后球囊扩张术治疗胆总管结石的临床研究

目的探讨内镜下十二指肠乳头括约肌小切开后球囊扩张术在胆总管结石治疗中的有效性和安全性。方法将150例临床确诊为胆总管结石的患者随机分为乳头括约肌切开组(EST组)和乳头括约肌小切开后球囊扩张术组(SEST+EPBD组),比较两组疗效及并发症的发生率。结果 EST组和SEST+EPBD组取石成功率分别为92%和97%(χ2=1.19,P0.05)。EST组术后出现急性胰腺炎2例,出血4例,结石复发11例,逆行性胆道感染15例。SEST+EPBD组术后出现急性胰腺炎1例,出血1例,结石复发2例,逆行性胆道感染6例。两组取石成功率及近期并发症比较差异无统计学意义(P0.05),远期并发症比较差异有统计学意义(P0.05)。结论内镜下乳头括约肌小切开后球囊扩张术治疗胆总管结石安全、有效,并发症少,并且尽可能的保留了十二指肠乳头括约肌的功能,值得临床推广。     

单纯十二指肠乳头气囊扩张治疗胆总管结石合并乳头旁憩室的安全性

目的评价内镜下单纯十二指肠乳头气囊扩张(EPBD)治疗胆总管结石合并乳头旁憩室的安全性。方法对65例胆总管结石合并十二指肠乳头旁憩室患者进行内镜下取石治疗,其中35例行单纯EPBD术后取石,30例行十二指肠乳头括约肌小切开(sEST)联合EPBD取石。比较两组取石取净率、术中出血情况及并发症。结果两组取石取净率差异无统计学意义(P0.05);单纯EPBD组术后无出血,明显少于EST+EPBD组(P=0.04)。术后胰腺炎及胆管炎相当,差异无统计学意义,两组均未发生穿孔。结论单纯EPBD术治疗胆总管结石合并十二指肠乳头旁憩室比EST联合EPBD安全,且操作方便,能够减少十二指肠乳头出血的风险。     

经皮胆管置管乳头扩张与内镜乳头切开治疗胆总管结石的临床比较

目的比较经皮顺行性球囊扩张乳头括约肌并将胆总管结石推入十二指肠与内镜乳头切开取石的临床效果。方法回顾性分析2010年3月至2014年5月威海市立医院肝胆外科就诊的71例胆总管结石患者,根据手术方式不同分为顺行乳头扩张组(APBD)35例及内镜乳头切开组(EST)36例。APBD组采用经皮穿肝胆管造影并置管球囊扩张乳头并推出结石。比较两组患者:术前既往胃空肠吻合术后出现率、结石数量及大小、血清直接胆红素、胆总管直径、胆囊储存排空功能指标;术中结石彻底清除率;术后血液检查指标、近期并发症(胰腺炎、胆管炎、胆管出血)发生率及术后2年随访胆囊储存排出功能、胆管结石复发、胆管炎症、胆囊结石、胆管积气发生率。结果术前既往胃空肠吻合术后出现率、术前胆总管直径及血清直接胆红素APBD组高于EST组[37.1%vs.5.6%,(14.9±7.4)mm vs.(11.1±6.5)mm,(31.4±9.5)μmol/L vs.(26.4±7.8)μmol/L];差异均有统计学意义(P0.05)。APBD组与EST组术中彻底清除胆总管结石成功率及术后近期并发症总发生率比较(91.4%vs.91.7%,8.6%vs.11.1%),差异均无统计学意义(P0.05)。术后随访2年APBD组与EST组胆总管结石复发率(12.5%vs.33.3%)、胆管积气发生率(25%vs.71.9%)、空腹胆囊容积[(21.3±3.3)ml vs(12.1±2.3)ml]、餐后胆囊排出量[(9.9±2.3)mm vs.(6.5±1.9)mm]、急性胆管炎症发生率(15.6%vs.36.3%)比较,差异均有统计学意义(P0.05)。APBD组胆囊结石发生率(15.6%)低于EST组(18.1%),差异均无统计学意义(P0.05)。结论经皮经胆管扩张乳头括约肌清除胆总管结石与内镜乳头切除取石近期疗效类似,前者在保存Oddi括约肌及胆囊功能、减少术后胆总管结石复发方面具有优势。     

Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy.

BACKGROUND: Endoscopic biliary sphincterotomy (EST) is a well-established procedure for bile duct stone extraction. Bile duct stones can be classified as primary or secondary. However, few data are available on the recurrence of primary and secondary bile duct stones after EST. Therefore risk factors for the recurrence of primary bile duct stones after EST were prospectively studied. METHODS: Between 1991 and 1997, 61 patients underwent EST for primary bile duct stones. All met the following criteria: (1) previous cholecystectomy without bile duct exploration, (2) detection of bile duct stones at least 2 years after initial cholecystectomy. Mean follow-up was 2.2 years. Fourteen patients were lost to follow-up. The recurrence of primary bile duct stones was defined as the detection of bile duct stones no sooner than 6 months after complete clearance of primary bile duct stones. RESULTS: The overall recurrence rate of primary bile duct stones was 21% (10 of 47). Two significant risk factors for recurrence were identified by multivariate analysis: (1) patients with a bile duct diameter of 13 mm or greater after stone removal had recurrences more frequently than those with a duct diameter of 13 mm or less, and (2) patients whose papilla was located on the inner rim or deep within a diverticulum, so that the papillary orifice was not visible endoscopically, had more frequent recurrences than patients with a papilla outside the diverticulum, or no peripapillary diverticulum. CONCLUSION: The independent risk factors for recurrence of primary bile duct stones were sustained dilation of the bile duct even after complete removal of stones and location of the papilla on the inner rim or deep within a diverticulum.     

LONG‐TERM PROGNOSIS OF PATIENTS AFTER ENDOSCOPIC SPHINCTEROTOMY FOR CHOLEDOCHOLITHIASIS

Introduction: The aims of the present study were to clarify the long‐term prognosis of endoscopic sphincterotomy (EST) for choledocholithiasis and to evaluate the need for cholecystectomy after EST. Methods: Between 1993 and 2007, 262 patients who underwent successful EST for choledocholithiasis were followed up for more than 6 months). Eighteen patients had previously undergone cholecystectomy (Group A), 129 had a calculous gallbladder (GB) and underwent cholecystectomy after EST (Group B), 46 had a calculous GB in situ (Group C), and 69 had an acalculous GB in situ (Group D). Late complications, including recurrence of choledocholithiasis, acute cholecystitis and biliary carcinoma, were evaluated. Results: Of the 262 patients, late complications occurred in 34 patients (13.0%) and recurrence of choledocholithiasis occurred in 29 patients (11.1%). The rate of late complications was higher in Group C (23.9%) than in Group B (7.8%) (P < 0.001). The rate of recurrent choledocholithiasis was higher in Group C (17.4%) than in Group B (7.8%) (P < 0.05). Univariate analysis indicated that pneumobilia after EST was associated with the recurrence of choledocholithiasis (P < 0.001). Acute cholecystitis occurred in eight (7.0%) of 115 patients with intact GB. A gallbladder carcinoma was found after EST. Late complications were not serious and endoscopically or surgically manageable. Conclusions: EST for choledocholithiasis is safe and effective. Cholecystectomy after EST is recommended in patients with calculous GB, but is not necessary in patients with acalculous GB. Pneumobilia was associated with the recurrence of choledocholithiasis.     

内镜治疗胆总管结石的临床研究

目的 探讨内镜在胆总管探查取石中的应用价值。方法 对227例拟诊胆总管结石 的患者采用经内镜治疗,其中14例直径<1.0 cm的结石采用经内镜乳头球囊扩张术治疗,194例直 径1.0-1.5cm的结石采用内镜乳头括约肌切开治疗,19例直径>1.5cm的结石采用内镜下机械碎 石治疗。结果 15％(34例)胆管造影未见结石,经内镜探查阴性。余193例中,187例取石成功,成 功率为96.9％(187／193)。并发症发生率为5.29%(12／227),其中急性胆管炎3例,急性胰腺炎8 例,消化道出血1例。结论 内镜治疗胆总管结石安全有效,并发症少,应当首选。但对ERCP无法 明确的胆总管结石,不主张行乳头括约肌切开及内镜下的胆管探查,以最大限度地减少并发症。     

Evaluation by biliary scintigraphy of recurrence of choledocholithiasis after endoscopic sphincterotomy

Background: It is dif?cult to predict recurrence of choledocholithiasis after endoscopic sphincterotomy (EST). Because cholestasis is considered to cause recurrence of choledocholithiasis, it may be possible to predict recurrence by objective evaluation of cholestasis. The aim of the present study was to examine the relationship between cholestasis and recurrence of choledocholithiasis by biliary scintigraphy in post‐EST cases. Methods: Seventy‐?ve patients who had undergone EST were tested by biliary scintigraphy. Cases with positive and negative detection of hot spots in the duodenum within 60 min after isotope infusion were categorized as ‘maintained bile excretion’ (Group M) and ‘delayed bile excretion’ (Group D), respectively. Age, gender, biliary tract enzyme levels, diameter of the common bile duct, presence of the gallbladder, presence of juxtapapillary duodenal diverticula, and the recurrence rates of choledocholithiasis were compared between the two groups. Results: Seventy‐?ve cases were distributed into 66 cases (88%) in Group M and nine cases (12%) in Group D. There was no statistical differences in age, gender, biliary tract enzyme levels, diameter of the common bile duct, and presence of juxtapapillary diverticula. In Group D, all the cases had retained the gallbladder. Of 41 cases who had been followed up for more than 1 year, 35 cases (85%) were assigned to Group M and six (15%) to Group D. Recurrence of choledocholithiasis was observed in ?ve cases, with two in Group M and three in Group D. The recurrence rate was signi?cantly higher in Group D than in Group M. Conclusions: Biliary scintigraphy was considered useful for objectively predicting recurrence of choledocholithiasis.     

Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis

BACKGROUND: Although endoscopic papillotomy is now considered established treatment for choledocholithiasis, therapeutic results of endoscopic papillotomy alone without subsequent cholecystectomy in patients with cholecystolithiasis have not been well evaluated. The aim of this study was to assess the long-term outcome of endoscopic papillotomy for these patients. METHODS: Patients admitted with choledocholithiasis and cholecystolithiasis from 1976 to 1993 were studied retrospectively. Of 385 patients in whom the bile duct was cleared by endoscopic papillotomy and endoscopic stone extraction, 371 patients (195 men and 176 women; mean age 65.4 years) were followed. Predisposing risk factors for late complications were analyzed. RESULTS: The mean duration of follow-up was 7.7 years. Cholecystitis and recurrence of choledocholithiasis as late complications occurred in 22 cases (5.9%) and 36 cases (9.7%), respectively. Cholecystitis, including 1 severe case, resolved with conservative treatment. Recurrent choledocholithiasis was successfully treated endoscopically except in 1 case. No significant risk factors were identified for cholecystitis. The presence of pneumobilia (p = 0.0016) and the need for lithotripsy (p = 0.0342) were found to be significant risk factors for the recurrence of choledocholithiasis. CONCLUSIONS: Long-term outcome of endoscopic papillotomy in patients with choledocholithiasis and cholecystolithiasis was found to be relatively favorable. Cholecystectomy after endoscopic papillotomy is not always necessary in the management of cholecystolithiasis.     

Endoscopic sphincterotomy in the treatment of cholangiopancreatic diseases

AIM: To investigate the therapeutic effect of endoscopic sphincterotomy (EST) in the treatment of choledocholithiasis and stenosing papillitis. METHODS: A total of 1026 patients undergoing EST during July 1983 to May 2003 at the institute were retrospectively analyzed. Chronic pancreatitis was diagnosed in 63 (6.1%), cholecystolithiasis and choledocholithiasis in 549 (53.5%), stones in residual biliary duct in 249 (24.3%), stenosing papillitis in 228 (22.2%). In patients with simple stenosing papillitis, most incisions were within 0.5-1 cm in length. As for patients with chronic pancreatitis simultaneously, selective pancreatic sphincterotomy was performed, and incision was within 0.5-0.8 cm in length. For stones less than 1 cm, incision was from 1 to 1.5 cm, and for those larger than 1 cm, incision ranged from 1.5 to 3 cm. For stones more than 2 cm in diameter, detritus basket rather than simple incision was chosen. RESULTS: Of the 798 patients with choledocholithiasis, 764 (93.5%) had successful stone clearance, 215 (94.3%) out of 228 cases of stenosing papillitis were cured totally, while 63 had chronic pancreatitis developed from stenosing papillitis, 57 (90.1%) had sound remission of symptoms, though membranous stenosis emerged in 13 of 57 which was treated with balloon dilatation. After the operation, only 21 cases (2.1%) had complications such as severe pancreatitis and incision bleeding. None of the patients died. CONCLUSION: EST is an ideal surgical management with mini-invasion in the treatment of choledocholithiasis and stenosing papillitis.