内镜逆行胰胆管造影术中选择性胆管插管困难的循证处理

目的内镜逆行胰胆管造影（ERCP）术中选择性胆管插管困难（DSBC）是临床常见的问题,针对1例DSBC患者,通过检索当前最佳证据,为临床合理处理提供依据。方法全面检索Cochrane图书馆（2010年第1期）、ACP online、NGC（1998～2010.6）、PubMed（1950～2010.6）及CBM（1994～2010.6）,查找与ERCP及DSBC有关的系统评价和随机对照试验,并对所获得的证据进行质量评价。结果最终纳入18篇文献。当前证据表明,预切开术可提高DSBC患者插管成功率,对有经验的内镜医生而言安全有效,并能减少操作时间;胰管占据技术较预切开容易掌握,可提高插管成功率;但上述两种方法均有可能增加ERCP术后并发症的发生。根据以上证据,结合内镜医生的经验和患者及家属的愿望,我们为该例患者实施了针状刀预切开术,再行选择性胆管插管获得成功。结论当前证据显示,预切开和胰管占据均可提高DSBC的插管成功率,但应用时要结合患者具体情况和内镜医生的经验合理选择。

Evidence-Based Treatment for A Patient with Difficult Selective Biliary Cannulation during ERCP

Objective To nd the most e ective treatment for a patient with diffcult selective biliary cannulation（DSBC） during endoscopic retrograde cholangiopancreatography（ERCP） by EBM practice.Methods Evidence was retrieved from The Cochrane Library（Issue 1,2010）,ACP online,NGC（1998 to June 2010）,PubMed（1950 to June 2010）,and CBM（1994 to June 2010）.The collected evidence was then graded.Results After preliminary research,we identi ed 18 relevant articles.The evidence showed that pre-cutting technique could increase cannulation success rates in DSBC and was safe,e ective,and time-saving for an experienced endoscopist.Pancreatic duct occupation was easier to perform than pre-cutting technique and could also increase selective cannulation success rates in DSBC.According to the evidence,together with endoscopist’s experience and the preference of the patient and his family,needle-knife precut papillotomy was performed.Successful selective biliary cannulation was accomplished after pre-cutting.Conclusion The current evidence suggests that pre-cutting technique and pancreatic duct occupation could increase selective cannulation success rates in DSBC.Patients’ condition and endoscopist’s experience should be considered properly before the operation.