胰管导丝占据法在困难内镜逆行胰胆管造影中的应用价值

目的评价胰管导丝占据法在内镜逆行胰胆管造影（ERCP）中胆管选择性插管困难时的应用价值。方法2008年6月至2012年6月间共3505例患者符合入选条件。开始均尝试对患者用导丝辅助的括约肌切开刀行选择性胆管插管（标准法），若导丝反复进入胰管5次仍未插管成功则导丝留置于胰管，退出切开刀另用一根导丝尝试插管（占据法），尝试失败则行经胰预切开或针状刀乳头开窗术（占据法失败行预切开），若尝试插管达5次胰管亦未能进入则行针状刀乳头开窗术（胆胰管插管失败行预切开）。比较各组间胆管插管成功率及并发症的发生率。结果标准法插管成功率（93．4％）明显高于占据法（54．8％，P〈0．001）、占据法失败行预切开（81．3％，P〈0．001）及胆胰管插管失败行预切开（84．6％，P=0．011）；占据法失败行预切开及胆胰管插管失败行预切开插管成功率均明显高于占据法（P值均〈0．001）；各组间术后胰腺炎发生率差异无统计学意义。标准法插管成功后行括约肌切开有2例出血，行预切开插管患者中有5例出血、1例穿孔，无死亡病例。结论胰管导丝占据法胆管插管成功率虽不高，但当标准插管法困难时应首先尝试，以尽量避免预切开的风．呤．

Pancreatic duct guidewire pre-occupying for difficult biliary cannulation in ERCP

Objective To investigate the efficacy of pancreatic duct guidewire pre-occupying in ERCP with difficult biliary cannulation. Methods During a four-year study period from June 2008 to June 2012, a total of 3505 patients were included in this retrospective analysis. Initial biliary cannulation method consisted of single-guidewire technique for up to 5 attempts, followed by double-guidewire technique when repeated unin- tentional pancreatic duct cannulation had taken place. Pre-cut papillotomy technique was reserved for when double-guidewire technique had failed or no pancreatic duct cannulation had been previously achieved. Biliary cannulation success and post- ERCP complication rate were compared. Results Single-guidewire technique was characterized by statistically significant higher success rate （93.4%）, compared with the double-guide- wire technique （54. 8%, P 〈 0. 001 ）, pre-cut failed double-guidewire technique （81.3%, P 〈 0. 001 ） or pre- cut as first step method （84. 6%, P =0. 011 ）. Pre-cut failed double-guidewire technique and pre-cut as first step method offered a statistically significantly more favorable outcome compared with the double-guidewire technique （both P 〈 0. 001 ）. The incidence of post-ERCP pancreatitis did not differ in a statistically signifi- cant manner among the four methods. Numbers of patients who got bleeding in pre-cut papillotomy technique and sphincterotomy after successful single-guidewire technique were 5 and 2 respectively. One case of perfora- tion was recorded using pre-cut papillotomy technique. There was no procedure-related mortality within 30 days. Conclusion Although double-guidewire technique success rate proved not to be superior to single- guidewire technique or pre-cut papillotomy, it is considered highly satisfactory in terms of safety in order to avoid the risk of a pre-cut when biliary therapy is necessary in difficuh-to-cannulate cases.