壶腹周围憩室对内镜逆行胰胆管造影术后胰腺炎发生率的影响分析

Analysis of the impact of periampullary diverticula on the incidence of post?endoscopic retrograde cholangiopancreatography pancreatitis

摘要:

目的 分析壶腹周围憩室（periampullary diverticulum，PAD）与内镜逆行胰胆管造影术后胰腺炎（post?endoscopic retrograde cholangiopancreatography pancreatitis，PEP）发生率之间的关系，并进一步对憩室进行分类，研究不同种类憩室对PEP的影响。方法 回顾性分析2021年5月至2022年5月于宁夏医科大学总医院因各种原因需行内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography， ERCP）治疗的共505例患者的临床资料，按是否患有PAD将患者分为憩室组（n=133）及无憩室组（n=372），并按照Li?Tanaka分型将憩室组患者分为Ⅰ型（n=29）、Ⅱ型（n=57）、Ⅲ型（n=34）、Ⅳ型（n=13）4个亚组。比较憩室组与无憩室组，以及憩室组内4个亚组的PEP发生率等指标。利用多因素logistic回归分析PEP发生的独立危险因素。结果 憩室组与无憩室组患者在中位年龄（72岁比66岁，Z=-4.626， P<0.001）、胆总管结石［80.45%（107/133）比 59.94%（223/372），χ2=18.191，P<0.001］、急性胆管炎［81.20%（108/133）比67.10%（231/372），χ2=16.208，P<0.001］、胆道恶性狭窄［8.27%（11/133）比23.39%（87/372），χ2=14.314，P<0.001］及胰腺恶性疾病发生率［7.52%（10/133）比18.55%（69/372），χ2=9.032，P=0.003］方面差异有统计学意义。憩室组PEP发生率高于无憩室组［24.81%（33/133）比7.26%（27/372）］，差异有统计学意义（χ2=28.835，P<0.001）。在4种分型中，Ⅱ型PEP发生率（36.84%，21/57）最高，且与Ⅲ型（11.76%，4/34）相比，差异有统计学意义（χ2=6.984，P=0.008）。PAD（OR=5.045，95%CI：2.898~11.194，P<0.001）及困难插管（OR=4.123，95%CI：1.968~8.490，P<0.001）是PEP发生的独立危险因素。相较于非PAD患者，Ⅰ型PAD（OR=3.055，95%CI：1.131~8.251，P=0.028）及Ⅱ型PAD（OR=6.082，95%CI：3.468~13.344，P<0.001）PEP发生的风险更高。结论 PAD是PEP发生的独立危险因素之一，且与非PAD的患者相比，Li?Tanaka分型为Ⅰ型及Ⅱ型的PAD患者PEP发生风险更高。

Abstract:

Objective To analyze the association between periampullary diverticula (PAD) and the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), and to further classify diverticula types, and explore the impact of different types of diverticula on PEP. Methods Data of 505 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for various reasons in General Hospital of Ningxia Medical University from May 2021 to May 2022 were retrospectively analyzed. Patients were classified into the diverticula group (n=133) and the non-diverticula group (n=372) based on the presence of PAD. The diverticula group was subdivided into types Ⅰ (n=29), Ⅱ (n=57), Ⅲ (n=34), Ⅳ (n=13) according to the Li-Tanaka classification. The incidences of PEP were compared between the diverticula group and the non-diverticula group, as well as among the four subgroups within the diverticula group. Multivariate logistic regression analysis was used to identify the independent risk factors for PEP. Results There were significant differences in median age (72 years VS 66 years, Z=-4.626, P<0.001), common bile duct stones [80.45% (107/133) VS 59.94% (223/372), χ2=18.191, P<0.001], acute cholangitis [81.20% (108/133) VS 67.10% (231/372), χ2=16.208, P<0.001], malignant biliary stricture [8.27% (11/133) VS 23.39% (87/372), χ2=14.314, P<0.001] and pancreatic malignant diseases [7.52% (10/133) VS 18.55% (69/372), χ2=9.032, P=0.003] between the diverticula group and the non-diverticula group. The incidence of PEP in the diverticula group was significantly higher than that in the non-diverticula group [24.81% (33/133) VS 7.26% (27/372), χ2=28.835, P<0.001]. The incidence of PEP (36.84%,21/57) in type Ⅱ PAD patients was the highest, showing a significant difference compared with that of type Ⅲ [11.76% (4/34), χ2=6.984, P=0.008]. PAD (OR=5.045, 95%CI: 2.898-11.194, P<0.001) and difficult cannulation (OR=4.123, 95%CI: 1.968-8.490, P<0.001) were independent risk factors for PEP. In the Li-Tanaka classification, type Ⅰ (OR=3.055, 95%CI: 1.131-8.251, P=0.028) PAD and type Ⅱ PAD (OR=6.082, 95%CI: 3.468-13.344, P<0.001) had a higher risk of PEP compared with non-PAD patients. Conclusion PAD is one of the independent risk factors for PEP. Types Ⅰ and Ⅱ PAD, according to the Li-Tanaka classification, are associated with an elevated risk of PEP when compared with non-PAD patients.