早期经胰管括约肌预切开术在导丝误入胰管的ERCP困难插管中的临床应用

Clinical application of early transpancreatic sphincterotomy in patients with unintentional pancreatic duct cannulation during difficult ERCP biliary access

摘要:

目的 探讨早期经胰管括约肌预切开术（transpancreatic sphincterotomy，TPS）应用于导丝进入胰管的ERCP困难插管患者的有效性和安全性。 方法 回顾性分析2019年1月-2021年11 月于昆明医科大学第二附属医院消化内镜室行ERCP诊疗患者的临床资料，排除在常规选择性胆管插管技术尝试 5 min内即成功进入胆管者，共纳入154例导丝误入胰管的ERCP困难插管患者。将导丝首次进入胰管且插管时间5-10min时即行TPS的患者设为早期TPS组（n=62例），而将导丝反复进入胰管（ ≥ 2次）或插管时间≥ 10min时才实施TPS的患者设为延迟TPS组（n=92例），比较两组的一般资料、插管时间、手术时间、ERCP术后胰腺炎、出血、穿孔等并发症发生率。结果 早期TPS组和延迟TPS组在性别、年龄、ERCP指征等一般资料比较差异均无统计学意义（P值均>0.05），早期TPS组的插管时间[ 12（10,15）min 比 21（16,27）min, Z =8.262, P <0.001]、手术时间[29（25,34）min 比 50.5（41,67.75）min, Z =9.097, P <0.001]显著短于延迟TPS组，而胰管支架留置率［9.7%（6/62）比16.30%（15/92）］，差异无统计学意义（ χ 2=1.381，P =0.240）。早期TPS组的插管成功率［100%（62/62） 比 88.0%（81/92），χ2 =6.282，P =0.012］显著高于延迟TPS组，ERCP术后胰腺炎发生率［0%（0/62）比16.30%（15/92），χ2 =11.2，P =0.001］以及总并发症发生率37.1%（23/62）比59.8%（55/92），χ2 =7.626，P =0.006］显著低于延迟TPS组，高淀粉酶血症发生率［21.0%（13/62）比31.5%（29/92），χ2 =2.08，P =0.149］以及术中出血发生率［21.0%（13/62）比30.4%（28/92），χ2 =1.699，P =0.192］差异无统计学意义，两组均无穿孔和操作相关的死亡发生。结论 在导丝误入胰管的ERCP困难插管患者中，早期实施TPS可以提高胆管插管成功率并减少ERCP术后胰腺炎发生率，是安全和有效的。

Abstract:

Objective To investigate the efficacy and safety of early transpancreatic sphincterotomy (TPS) in patients with guide wire entering the pancreatic duct during difficult ERCP biliary cannulation. Methods A retrospective analysis was performed on the clinical data of patients who underwent ERCP treatment in the Digestive endoscopy Room of the Second Affiliated Hospital of Kunming Medical University from January 2019 to November 2021. The patients who successfully entered the bile duct within 5 minutes by using the conventional selective biliary cannulation technique were excluded. A total of 154 patients with guide wire entering the pancreatic duct during difficult ERCP biliary cannulation were included. Patients who had sphincterotomy immediately after guidewire running into pancreatic duct for the first time during the cannulation time was 5-10 min were set as early TPS group (n=62), while patients who underwent TPS when the guide wire had repeatedly entered the pancreatic duct (≥ 2 times) or when the cannulation time was ≥ 10min were set as delayed TPS group (n=92). The general data, cannulation time, procedure time, incidence of complications such as pancreatitis, bleeding and perforation after ERCP were compared. Results There was no significant difference between the early TPS group and the delayed TPS group in terms of general information such as gender, age and ERCP indications (all P >0.05), while the cannulation time [ 12 (10,15) min vs 21 (16,27) min, Z=8.262, P<0.001] and procedure time [29 (25,34) min vs 50.5 (41,67.75) min, Z=9.097, P<0.001] were significantly shorter than those in the delayed TPS group, and the pancreatic duct stent placement rate [9.7% (6/62) vs 16.30% (15/92)] was not statistically significant (χ2=1.381, P=0.240). The early TPS group had a significantly higher rate of successful biliary intubation [100% (62/62) vs 88.0% (81/92), χ2=6.282, P=0.012] than the delayed TPS group. The incidence of post-ERCP pancreatitis [0% (0/62) vs 16.30% (15/92), χ2=11.2, P=0.001] and total complications [37.10% (23/62) vs 59.8% (55/92), χ2=7.626, P=0.006] were significantly lower than those in the delayed TPS group, while the incidence of hyperamylasemia [21.0% (13/62) vs 31.5% (29/92), χ2=2.08, P=0.149] and intraoperative bleeding [21.0% (13/62) vs 30.4% (28/92), χ2=1.699, P=0.192] were not significantly different, and no perforation or procedure-related death occurred in either group. Conclusion Early TPS can improve the success rate of biliary cannulation and reduce the incidence of post-ERCP pancreatitis, which is safe and effective in patients with a miss-intubated guidewire into the pancreatic duct during difficult ERCP biliary cannulation.