经内镜逆行性胰胆管造影选择性插管困难的影响因素研究

目的　探讨经内镜逆行性胰胆管造影（ERCP）选择性插管困难的影响因素，为评估患者手术风险、较早设计出合理的应对策略提供参考依据。方法　选取2012—2016年上海市浦东医院普外科首次行ERCP患者1 120例，按照是否出现选择性插管困难将其分为插管顺利组（918例）和插管困难组（202例）。记录两组性别、年龄、合并症、术前结石嵌顿及壶腹部肿瘤发生情况、急诊ERCP、ERCP指征、憩室分布情况、胆胰管汇合方式、乳头形态、瘘管、疑似胆管狭窄及Oddi括约肌功能紊乱（SOD）发生情况。结果　多因素Logistic回归分析结果显示，术前结石嵌顿〔OR=11.420，95%CI（5.569，23.414）〕、术前壶腹部肿瘤〔OR=3.370，95%CI（2.023，5.609）〕、乳头中心不对称憩室〔OR=4.970，95%CI（2.862，8.623）〕、憩室内乳头〔OR=26.210，95%CI（8.126，84.533）〕、隔壁型（V型）胆胰管〔OR=6.990，95%CI（1.121，43.557）〕、共同通道型（Y型）胆胰管〔OR=16.670，95%CI（2.621，106.073）〕、乳头轴向偏斜〔OR=20.180，95%CI（11.748，34.655）〕、乳头膨大〔OR=16.710，95%CI（8.753，31.896）〕、乳头狭窄〔OR=13.640，95%CI（5.199，35.764）〕、疑似胆管狭窄〔OR=2.100，95%CI（1.067，4.129）〕、SOD〔OR=2.900，95%CI（1.516，5.564）〕是ERCP选择性插管困难的影响因素（P<0.05）。202例选择性插管困难患者中，行乳头切开者131例（64.8%），行长镜身技术者100例（49.5%），行双导丝者92例（45.5%），行更换导丝者90例（44.6%）；单独使用1种辅助策略技术者50例（24.8%），2种技术联合使用者95例（47.0%），3种技术联合使用者57例（28.2%）；行辅助策略后成功者151例（74.8%）。插管顺利组患者与选择性插管困难成功亚组患者高淀粉酶血症、消化道出血及穿孔、胰腺炎、胆管炎发生率比较，差异均无统计学意义（P>0.05）。结论　相关解剖因素和疾病特征对ERCP选择性插管困难具有预测作用，可根据患者具体指标选择针对性的辅助策略，从而减少选择性插管次数和操作时间，提高胆胰系统疾病的诊疗水平。

Influencing Factors of Difficulties in Elective Endotracheal Intubation during Endoscopic Retrograde Cholangiopancreatography

Objective　To explore the influencing factors for the difficulties in elective endotracheal intubation during endoscopic retrograde cholangiopancreatography（ERCP），providing a reference for assessing the patient's surgical risk，and formulating targeted strategy for such difficulties.Methods　We recruited 1 120 patients who initially underwent ERCP in Department of General Surgery，Shanghai Pudong Hospital from 2012 to 2016.Of them，202 with difficulties in endotracheal intubation during ERCP and 918 without were assigned to difficult intubation group，and successful intubation group，respectively.We reviewed their data such as gender，age，preoperative incidence rates of comorbidity，stone incarceration，ampullary neoplasms，emergency ERCP，and indications of ERCP，as well as the anatomical variants〔duodenal diverticulum，pancreaticobiliary maljunction，papilla abnormalities，fistula，suspected biliary stricture and sphincter of Oddi dysfunction（SOD）〕.Results　Multivariate Logistic regression analysis showed that the preoperative stone incarceration〔OR=11.420，95%CI（5.569，23.414）〕，preoperative ampullary neoplasms〔OR=3.370，95%CI（2.023，5.609）〕，central asymmetrical diverticulum of the papilla〔OR=4.970，95%CI（2.862，8.623）〕，intradiverticular papilla〔OR=26.210，95%CI（8.126，84.533）〕，confluence of pancreaticobiliary duct wall〔OR=6.990，95%CI（1.121，43.557）〕，common channel of pancreaticobiliary ducts〔OR=16.670，95%CI（2.621，106.073）〕，axial deflection of papilla〔OR=20.180，95%CI（11.748，34.655）〕，papillae enlargement〔OR=16.710，95%CI（8.753，31.896）〕，papillary stenosis〔OR=13.640，95%CI（5.199，35.764）〕，suspected biliary stricture〔OR=2.100，95%CI（1.067，4.129）〕 and SOD〔OR=2.900，95%CI（1.516，5.564）〕 were influencing factors for difficulties in elective endotracheal intubation during ERCP（P<0.05）．Of the 202 patients with difficulties in endotracheal intubation，131（64.8%） underwent papillotomy，100（49.5%） used deep enterscopy technique，92（45.5%） used double wire-guided technique，and 90（44.6%） changed the guidewire for another.Fifty（24.8%） used one assistant technique，95（47.0%） used two，and 57（28.2%） used three.And 151（74.8%） achieved successful endotracheal intubation by using assistant techniques.Additionally，the incidence rates of hyperamylasaemia，digestive tract bleeding and perforation，pancreatitis，as well as cholangitis did not differ significantly between those achieved successful endotracheal intubation after overcoming difficulties and those achieved it without difficulties（P>0.05）．Conclusion　Related anatomical factors and disease characteristics may be used as the predictors for difficulties in elective endotracheal intubation during ERCP.What's more，these assistant techniques can be adopted to reduce the intubation failure and operative time based on the patient's conditions.These results provide a rationale for improving the diagnosis and treatment of pancreatobiliary disease.