胆总管结石的内镜治疗

目的总结内镜下乳头括约肌切开术（endoscopic sphincterotomy，EST）治疗胆总管结石的疗效及随访结果，分析可能导致取石失败的危险因素。方法2001年4月～2006年1月我院96例经内镜逆行胰胆管显影（endoscopic retrograde cholangiopancreatography，ERCP）证实胆总管结石后行EST及内镜下取石。通过随访术后疗效．对可能影响EST取石结果的因素进行分析。结果第1次EST未取出或未取净结石15例，第1次EST结石清除率84．4％（81／96）。第1次取石失败后5例再次行EST取净结石，3例自发排石，2例服中药或其他药物后排石，术后B超或ERCP检查证实结石已经排出，总结石清除率为94．8％（91／96）。术后近期并发症10例，其中急性胰腺炎5例、明显出血3例、急性胆囊炎和（或）急性胆管炎2例。5例因并发症或结石未取净行开腹手术。单因素和多因素分析表明，胆总管结石〉1．5cm和既往有胆总管探查手术史是取石失败的危险因素。85例随访10—59个月，胆总管结石复发3例、急性胆管炎1例；19例单纯胆总管结石在EST取净结石后没有切除胆囊，随访未见异常。结论EST是治疗胆总管结石安全有效的方法。结石〉1．5cm和既往有胆总管探查手术史时，应警惕EST有取石失败的可能。对于单纯性胆总管结石，在EST清除胆总管结石后不必预防性切除胆囊。

Clinical analysis of endoscopic sphincterotomy for choledocholithiasis

Objective To evaluate therapeutic effects and follow-up outcomes of endoscopic sphincterotomy (EST) for treating choledocholithiasis, and to analyze risk factors leading to the failure of stone clearance. Methods Ninety-six patients with choledocholithiasis were treated by EST under endoscopic retrograde cholangiopancreatograhpy (ERCP) from April 2001 to January 2006 in this hospital. Postoperative data were analyzed retrospectively with univariate analysis and multivariate logistic regression analysis. Results The stone clearance rate after one session of EST was 84.4% (81/96), with a faliure of stone removal in 15 patients. Of the 15 patients, stones were completely removed after a second EST in 5 patients, stones were spontaneously extracted in 3 patients, and stones were expelled by drug administration in 2 patients, all of whom were confirmed stone-free by B-ultrasonography or ERCP. The overall rate of stone clearance was 94.8% (91/96). Postoperative short-term complications occurred in 10 patients, including acute pancreatitis in 5 patients, clinically significant hemorrhage in 3, and acute cholangitis and/or acute cholecystitis in 2. Open surgery was required in 5 patients for complications or residual stones. Univariate analysis and multifactor analysis showed that a history of common bile duct exploration and relatively large stones (> 1.5 cm in diameter) were significant risk factors for the failure of stone clearance. Follow-up examinations in 85 patients for 10~59 months showed recurrent choledocholithiasis in 3 patients and acute cholangitis in 1 patient. In 19 patients with an acalculous gallbladder, no biliary symptoms were observed. Conclusions EST is a safe and effective method for treating choledocholithiasis. A history of common bile duct exploration and relatively large stones (>1.5 cm in diameter) are significant risk factors for the failure of stone clearance. Prophylactic cholecystectomy of an acalculous gallbladder is unnecessary.