应用和谐夹行十二指肠乳头成型术对Oddi括约肌功能恢复效果的初探

A preliminary study of sphincter-preserving effect of SureClip from MicroTech on duodenal papilla occlusion

摘要:

目的 为减少胆管巨大结石取石中十二指肠乳头大切开所导致的复发性胆管结石，初步尝试应用和谐夹行十二指肠乳头成型术，探讨此技术对恢复胆管括约肌功能的效果。 方法 选择2018年3月至2018年5月间，在北医三院消化科诊断为胆总管结石（结石大小1.0～2.5 cm，胆总管内径1.2～3.0 cm），且既往无ERCP史的患者3例，内镜下行胆管括约肌大切开（EST切口≥1.0 cm），取石成功后分别于胆管及胰管内放置塑料支架，然后应用和谐夹行十二指肠乳头成型术。并在EST术前、术后即刻及乳头成型术后3周取出胰胆管支架后，分别行胆管及Oddi括约肌测压，并随访观察十二指肠乳头愈合情况及并发症。另取5只家猪，进行相似的实验（除胆管取石外）。 结果 患者及实验动物测压结果均显示十二指肠乳头切开术后，Oddi括约肌压力显著降低，而在十二指肠乳头成型术后3周有明显恢复。3例患者均成功完整取石，术后未出现ERCP术后胰腺炎、出血及穿孔等并发症；十二指肠乳头成型术后3周拔除支架后，内镜下可见乳头愈合。动物解剖显示与未作处理的十二指肠乳头比较，未行乳头成型术的十二指肠乳头肌层完全断裂无愈合，行乳头成型术的肌层可见瘢痕性修复愈合。 结论 十二指肠乳头切开后，应用和谐夹进行夹闭的十二指肠乳头成型术，可加速乳头愈合，保留括约肌压力，恢复乳头的抗反流屏障功能。

Abstract:

Objective To reduce the occurrence of recurrent choledocholithiasis caused by biliary sphincter dysfunction after extensive endoscopic sphincterotomy （EST） for large stone extraction， and to investigate the sphincter-preserving effects of duodenal papilla occlusion by SureClip from MicroTech. Methods Three patients with large biliary stones （1.0-2.5 cm in stone size， 1.2-3.0 cm in common bile duct diameter） and without ERCP history underwent EST （larger than 1.0 cm） in Peking University Third Hospital from March 2018 to May 2018. Biliary and pancreatic stents were placed after stone extraction， followed by duodenal papilla occlusion with SureClip from MicroTech. Pressures of biliary duct and Oddi sphincter were measured at pre-EST， immediately after EST， and when stents were removed 3 weeks after EST， respectively. Healing conditions of papilla and complications were documented. Five pigs underwent similar experiments without stone extraction. Results The pressure of Oddi sphincter was significantly reduced after EST， and recovered after papilla occlusion 3 weeks after operation both in pigs and human. All stones were completely removed in the 3 patients without any post-ERCP complications. The papilla was healed under endoscopic observation when stents were removed 3 weeks after papilla occlusion. In animal experiments， histology revealed completely muscularis propria disruption of post-EST papilla without occlusion. In contrast， the muscle layer of post-EST papilla with occlusion by SureClip from MicroTech appeared scar healing. Conclusion The duodenal papilla occlusion by SureClip from MicroTech after EST works as “papilla remolding”， which accelerates healing of papilla， and retains the sphincter pressure and anti-reflux barrier function.