内镜胆管引流术治疗胆瘘的临床价值

Clinical value of endoscopic biliary drainage for biliary fistula

摘要:

目的 探讨内镜胆管引流术治疗胆瘘的有效性和安全性。方法 回顾性分析2002年11月—2022年11月在解放军总医院第一医学中心诊治的连续性409例胆瘘患者的临床资料，最终纳入53例内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography， ERCP）下行胆管引流术的胆瘘患者，分析患者的一般情况、手术操作情况、治疗结局和不良事件等。将患者分为支架引流组（n=46）与鼻胆管引流组（n=7），比较两组术中特点、手术结果以及手术时间。结果 53例患者中，男36例、女17例，年龄（52.2±12.7）岁，其中58.5%（31/53）的患者继发于胆囊切除术。其临床成功率为83.0%（44/53），手术时间为27.0（13.5，33.5） min，治疗1（1，2） 次，治愈时间89 （47，161） d。ERCP治疗轻度胆瘘相较于重度胆瘘成功率较高［96.4%（27/28）比 68.0% （17/25）， χ2=7.57， P=0.006］。跨瘘口引流相较于非跨瘘口引流治疗胆瘘的成功率更高［91.7% （33/36） 比64.7% （11/17）， χ2=5.95， P=0.015］，而使用较大口径（≥10 Fr）与较小口径（<10 Fr）的支架治疗胆瘘的成功率相近［81.8% （27/33）比84.6%（11/13）， χ2=0.05， P=0.822］。18.9%（10/53）的患者出现不良事件，其中胰腺炎6例、出血2例、胆管炎1例，死亡1例。除1例死亡外，其余9例不良事件均为轻度，且经保守治疗后好转。鼻胆管引流组和胆管支架引流组在临床成功率［6/7比82.6%（38/46）， χ2=0.04，P=0.838］、中位手术时间（28.0 min 比 23.0 min， Z=0.38， P=0.774）方面差异无统计学意义。结论 内镜胆管引流术治疗胆瘘是安全有效的。鼻胆管和胆管支架引流的临床疗效相似，ERCP治疗轻度胆瘘以及跨瘘口引流可能具有更高的临床成功率。

Abstract:

Objective To evaluate the efficacy and safety of endoscopic biliary drainage for biliary fistula. Methods Data of consecutive 409 biliary fistula patients who were treated and diagnosed at the First Medical Center of Chinese PLA General Hospital from November 2002 to November 2022 were reviewed, and 53 patients who received endoscopic retrograde cholangiopancreatography (ERCP) drainage were finally included. General information, procedural conditions, clinical outcomes and adverse events were analyzed. The patients were categorized into two groups: the endoscopic retrograde biliary drainage (ERBD) group (n=46) and the endoscopic nasobiliary drainage (ENBD) group (n=7). Procedural characteristics, operation outcomes, and operation time were compared between the two groups. Results There were 36 males and 17 females, with the age of 52.2±12.7 years, among whom 58.5% (31/53) were secondary to cholecystectomy. Clinical success was achieved in 83.0% (44/53) patients, with the operation time of 27.0 (13.5, 33.5) minutes and the treatment session of 1 (1, 2). The time to resolution was 89 (47, 161) days. The success rate of ERCP for low‑grade biliary fistula was higher compared with that of high‑grade biliary fistula [96.4% (27/28) VS 68.0% (17/25), χ2=7.57, P=0.006]. Bridging drainage achieved higher success rate compared with that of non‑bridging drainage [91.7% (33/36) VS 64.7% (11/17), χ2=5.95, P=0.015], while different diameters of stents (≥10 Fr VS <10 Fr) achieved similar success rate [81.8% (27/33) VS 84.6% (11/13), χ2=0.05, P=0.822]. Adverse events occurred in 10 patients (18.9%), including 6 pancreatitis, 2 bleeding, 1 cholangitis and 1 death. Except for 1 death, 9 other adverse events were mild and managed with conservative treatment without interventions. There was no significant difference in clinical success rate [6/7 VS 82.6% (38/46), χ2=0.04, P=0.838] or the median operation time [28.0 min VS 23.0 min, Z=0.38, P=0.774] between ENBD group and ERBD group. Conclusion Endoscopic biliary drainage is safe and effective for biliary fistula. ENBD and ERBD have comparable clinical efficacy. ERCP for low‑grade biliary fistula may achieve a higher success rate, and bridging drainage may facilitate fistula resolution.