失代偿期肝硬化合并胆总管结石患者行十二指肠镜治疗的安全和有效性分析

Safety and effectiveness of ERCP for patients with decompensated cirrhosis combined with choledocholithiasis

摘要:

目的 评价失代偿期肝硬化合并胆总管结石患者行ERCP治疗的安全性和有效性。方法 收集2012年12月至2016年12月在兰州大学第一医院ERCP诊疗技术培训中心经ERCP治疗的失代偿期肝硬化合并胆总管结石的患者79例（肝硬化组）、慢性病毒性肝炎患者92例（慢性病毒性肝炎组）以及无肝病患者随机抽取114例（无肝病组），对比分析ERCP治疗操作情况、肝功能指标术后改善情况以及并发症情况。结果 肝硬化组ERCP术前凝血酶原时间为（12.9±2.2） s，多于慢性病毒性肝炎组（12.1±1.9） s和无肝病组（11.7±1.4） s，差异有统计学意义（F=21.530，P＜0.001）。术中操作肝硬化组所用时间（58.58±19.40） min，多于慢性病毒性肝炎组（52.53±16.74） min和无肝病组（49.81±14.82） min，差异有统计学意义（F=6.444，P=0.002）。术后各组均无穿孔、死亡的病例。肝硬化组中3例（3.8％）患者行EST后出现十二指肠乳头少量渗血，其中2例为Child-Pugh C级，1例为Child-Pugh B级；1例（1.27％）Child-Pugh C级患者出现食管下段曲张静脉渗血，但该项与其他术中、术后并发症同样，3组间差异均无统计学意义（P＞0.05）。肝硬化组ERCP术前、术后肝功能指标谷草转氨酶（66.0比53.0 IU／L）、谷丙转氨酶（61.0比52.0 IU／L）、γ-谷氨酰转移酶（318.0比231.0 IU／L）、碱性磷酸酶（232.0比210.0 μmol／L）、总胆红素（65.7比56.3 μmol／L）比较，差异均有统计学意义（P＜0.05），显示肝功能较术前明显改善。结论 Child-Pugh A级、B级失代偿期肝硬化患者行ERCP治疗胆总管结石安全性和有效性良好，对于Child-Pugh C级患者，应尽量在改善肝功能、凝血功能情况后行ERCP。

Abstract:

Objective To evaluate safety and effectiveness of endoscopic retrograde cholangiopancreatography （ERCP） for patients with decompensated cirrhosis combined with choledocholithiasis. Methods A retrospective analysis was performed on data of 79 patients with decompensated cirrhosis combined with choledocholithiasis， 92 patients with chronic viral hepatitis， and 114 patients without liver disease who underwent ERCP at the First Hospital of Lanzhou University from December 2012 to December 2016. Intraoperative operating conditions， postoperative improvement of liver function indices， and complications among the three groups were compared and analyzed. Results The level of serum prothrombin time before ERCP in patients with cirrhosis （12.9±2.2） s was higher than that in patients with chronic viral hepatitis （12.1±1.9） s and those without liver disease （11.7±1.4） s， the difference was statistically significant （F=21.530， P＜0.001）. Operating time in patients with cirrhosis was longer than that of two other groups （58.58±19.40 min VS 52.53±16.74 min VS 49.81±14.82 min， F=6.444， P=0.002）. In patients with cirrhosis， postoperative liver function indices of aspartate aminotransferase （66.0 IU／L VS 53.0 IU／L）， alanine aminotransferase （61.0 IU／L VS 52.0 IU／L）， γ-glutamyltransferase （318.0 IU／L VS 231.0 IU／L）， alkaline phosphatase （232.0 μmol／L VS 210.0 μmol／L）， and total bilirubin （65.7 μmol／L VS 56.3 μmol／L） were all lower compared with preoperative ones （all P＜0.05）. No perforation or death occurred in the three groups. There were 3 cases （3.8％） of mild bleeding at duodenal papilla after endoscopic sphincteropapillotomy in cirrhosis patients， i.e.， 2 cases of Child-Pugh C and 1 case of Child-Pugh B. Errhysis occurred in one case （1.27％） of Child-Pugh C patient at lower esophagus varices. There were no statistical differences on incidences of complications among the three groups （P＞0.05）. Conclusion ERCP is safe and effective for Child-Pugh A and B patients with decompensated cirrhosis combined with choledocholithiasis. Liver function and blood coagulation function should be improved in Child-Pugh C patients before ERCP.