毕Ⅱ式胃切除术后ERCP进镜失败的危险因素分析

Factors affecting ampullary access of ERCP after Billroth Ⅱ gastrectomy

摘要:

目的探讨毕Ⅱ式胃切除术后经内镜逆行胰胆管造影术（ERCP）进镜失败的危险因素。方法回顾性分析2008年1月至2017年12月在上海长海医院消化内镜中心行ERCP治疗的261例毕Ⅱ式胃切除术后患者的临床资料，对可能影响其进镜失败的相关因素进行多因素logistic回归分析，并采用受试者工作特征（ROC）曲线分析评估所获得的潜在因素对事件的预测能力。结果纳入的261例患者共行345例次ERCP操作，进镜成功率为82.3%（284/345），插管成功率为89.1%（253/284）。ERCP技术性操作失败的主要原因是内镜未能到达十二指肠盲端及找到壶腹乳头（66.3%，61/92）和选择性胆胰管插管失败（33.7%，31/92）。ERCP术后并发症发生率为14.2%（49/345），其中术后胰腺炎发生率为3.2%（11/345）。多因素logistic回归分析显示，首次ERCP操作（OR=7.717，95%CI：2.581~23.068，P<0.001）、合并Braun吻合（OR=8.737，95%CI：2.479~30.797，P=0.001）和无透明帽辅助前视镜（OR=2.774，95%CI：1.283~5.997,P=0.009）是进镜失败的独立危险因素。根据各危险因素在logistic回归分析中的B值进行赋分，无透明帽辅助前视镜为1分，首次ERCP操作为2分，合并Braun吻合为2分，所绘制的ROC曲线下面积为0.773。当临界值为2.5分时，敏感度和特异度分别为75.0%和70.8%。结论首次ERCP操作、合并Braun吻合和无透明帽辅助前视镜是影响毕Ⅱ式胃切除术后ERCP进镜失败的危险因素。对操作失败高危患者早期识别干预有助于提高进镜成功率。

Abstract:

ObjectiveTo investigate factors affecting ampullary access of endoscopic retrograde cholangiopancreatography (ERCP) in patients undergoing Billroth Ⅱ gastrectomy. MethodsA retrospective analysis was performed on data of 261 patients with Billroth Ⅱ gastrectomy who underwent ERCP at Changhai Hospital from January 2008 to December 2017. Multivariate logistic regression analysis was used to analyze the potential factors affecting successful ampullary access, and receiver operating characteristic (ROC) curve was used to assess the predictive ability of potential factors. ResultsA total of 345 ERCP sessions were collected. The successful ampullary access and cannulation rate were 82.3% (284/345) and 89.1% (253/284), respectively. The main reasons for ERCP procedural failure were unable to reach the duodenal blind end and find the papilla (66.3%, 61/92) and failure of selective cannulation (33.7%, 31/92). The ERCP-related complication rate was 14.2% (49/345), with post-ERCP pancreatitis rate was 3.2% (11/345). Multivariate logistic regression analysis indicated that the first ERCP attempt (OR=7.717, 95%CI: 2.581-23.068. P<0.001), with Braun anastomosis (OR=8.737, 95%CI: 2.479-30.797, P=0.001), and no cap-assisted forward-viewing gastroscope (OR=2.774, 95%CI: 1.283-5.997, P=0.009) were independent risk factors for failure of ampullary access. According to the B value of each risk factor in logistic regression analysis, that is, no cap-assisted as 1 point, the first ERCP attempt as 2 points, and Braun anastomosis as 2 points, the area under ROC curve was 0.773. When the cut-off point was 2.5, the sensitivity and specificity were 75.0% and 70.8%, respectively. ConclusionThe first ERCP attempt, with Braun anastomosis, and no cap-assisted forward-viewing gastroscope are risk factors for failure of ampullary access of ERCP in Billroth Ⅱ gastrectomy patients. Early identification of high-risk patients may help to improve the success rate of ampullary access.