针状刀乳头开窗术在ERCP困难插管中的应用

目的 探讨采用针状刀实施十二指肠乳头开窗术,在ERCP困难胆管插管中的应用价值及其安全性.方法 回顾性分析近年来接受ERCP治疗的患者中,当常规插管方法和（或）其他预切开技术无法进入胆管时,采用针状刀在主乳头背部选点进行电灼造口,完成胆管深插管及后续治疗.观察本方法的成功率和术后并发症,并对相关影响因素进行分析.结果 共有108例患者接受开窗术,其中97例（91.2%）成功插至胆管;11例胆管恶性梗阻患者虽经开窗仍无法进入胆管,其中远端恶性梗阻失败率（25.8%,8/31）,明显高于近端梗阻（5.3%,3/57）,（P=0.014,χ^2=5.983）.ERCP术后发生胰腺炎5例（4.6%）,其中插管失败组（18.2%,2/11）明显高于成功组（3.1%,3/97）（P=0.006,χ^2=7.418）;另有肠道穿孔1例、胆管炎4例,均经保守治疗控制.结论 在困难胆管插管的ERCP病例中,应用针状刀行乳头开窗术可以有效提高ERCP诊治的成功率,对于有经验的操作者该方法是较为安全的;但远端胆管恶性梗阻行乳头开窗术的成功率较低.

Needle-knife fistulotomy for difficult cannulation during ERCP

Objective To evaluate the effectiveness and safety of needle-knife fistulotomy (NKF)for difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP). Methods Data of patients, who received NKF on the back of major papilla when bile duct could not be accessed by conventional cannulation and/or other pre-cut methods during ERCP, were retrospectively reviewed. The success rate of deep cannulation and its complications were observed and analyzed. Results NKF was performed in 108patients due to difficult cannulation, which succeeded in 97 (91.2%) in access to the bile duct and failed in 11 patients with malignant biliary strictures. The failure rate in patients with distal malignant obstruction was higher (25. 8%, 8/31) than those with proximal lesions (5.3%, 3/57) (P = 0. 014, χ2 = 5. 983).Post-ERCP pancreatitis occurred in 5 cases (4. 6%), with the incidence significantly higher in NKF-failure group (18. 2%, 2/11) than that in NKF-suocess group (3.1% ,3/97) (P = 0. 006, χ2 = 7.418). Intestinal perforation occurred in 1 patient and cholangitis developed in 4 others, which all recovered after conservative managements. Conclusion NKF for difficult cannulations in ERCP is safe and effective, especially in hands of experienced operators, but cannulation success rate is relatively low in distal malignant biliary obstruction.