超声内镜引导顺行取石与小肠镜辅助ERCP取石治疗胃肠改道术后胆管结石的有效性与安全性比较

Endoscopic ultrasound‑guided antegrade procedures versus single‑balloon enteroscopy‑assisted endoscopic retrograde cholangiopancreatography for bile duct stones in patients with surgically altered anatomy

摘要:

目的 比较超声内镜引导顺行取石（endoscopic ultrasound‑guided antegrade procedures，EUS‑AG）与单气囊小肠镜辅助内镜逆行胰胆管造影（single‑balloon enteroscopy‑assisted endoscopic retrograde cholangiopancreatography，SB‑ERC）取石治疗胃肠改道术后患者胆管结石的有效性与安全性。方法 回顾性分析2020年9月至2024年2月在南京鼓楼医院收治的52例胃肠改道术后胆管结石行EUS‑AG（8例）和SB‑ERC（44例）的患者资料进行队列研究。采用逆概率加权法（inverse probability of treatment weighting，IPTW）平衡组间差异，对比两组患者技术成功率、完全取石率、临床缓解率、手术时间、术后不良反应发生率、术后住院时间、治疗费用等指标。结果 采用IPTW纠正组间偏倚后，EUS‑AG组和SB‑ERC组的技术成功率分别为100.0%（43.3/43.3）和85.5%（44.1/51.6）（χ2=0.11，P=0.035）。EUS‑AG组的手术时间明显短于SB‑ERC组［（56.3±10.1）min比（76.6±29.0）min，t=4.34，P0.001］。在完全取石率［100.0%（43.3/43.3）比100.0%（44.1/44.1），P=1.000］、临床缓解率［100.0%（43.3/43.3）比95.7%（49.4/51.6），χ2=1.17，P=0.221］、术后住院时间［ 2.0（2.0，4.4）d比4.0（3.0，6.0）d，Z=-2.05，P=0.197］和治疗费用上［2.55（2.47，2.90）万元比2.64（1.96，3.03）万元，Z=-0.16，P=0.551］，组间差异无统计学意义。两组加权前术后轻度不良反应分别为5例和14例，加权后轻度不良反应发生率分别为46.2%（20.0/43.3）和34.5%（17.8/51.6）（χ2=0.36，P=0.639）；两组加权前术后严重不良反应分别为0例和1例，加权后严重不良反应发生率分别为0.0%（0.0/43.3）和1.9%（1.0/51.6）（χ2=0.80，P=0.381）。结论 与SB‑ERC相比，EUS‑AG技术成功率更高，手术时间更短，术后不良反应发生率相当。EUS‑AG有潜力成为胃肠改道术后患者胆管结石取石的一线治疗方案。

Abstract:

Objective To compare the efficacy and safety of endoscopic ultrasound‑guided antegrade procedures (EUS‑AG) versus single‑balloon enteroscopy‑assisted endoscopic retrograde cholangiopancreatography (SB-ERC) for patients with surgically altered anatomy and bile duct stones (BDSs). Methods A retrospective cohort study was conducted on the data of 52 patients with surgically altered anatomy who were treated with EUS-AG (n=8) or SB-ERC (n=44) in Nanjing Drum Tower Hospital from September 2020 to February 2024. The technical success rate, complete stone removal rate, clinical Temission rate, procedure time, postoperative adverse event rates, postoperative hospital stay, and hospital cost of the two groups were compared by using inverse probability of treatment weighting (IPTW). Results After applying IPTW to correct between-group biases, the technical success rates of EUS-AG and SB-ERC were 100.0% (43.3/43.3) and 85.5% (44.1/51.6), respectively (χ2=0.11, P=0.035). The procedure time was significantly shorter in the EUS-AG group than that in the SB-ERC group (56.3±10.1 min VS 76.6±29.0 min, t=4.34, P0.001). There were no statistically significant differences in complete stone removal rate [100.0% (43.3/43.3) VS 100.0% (44.1/44.1), P=1.000], clinical remission rate [100.0% (43.3/43.3) VS 95.7% (49.4/51.6), χ2=1.17, P=0.221], postoperative hospital stay [2.0 (2.0, 4.4) days VS 4.0 (3.0, 6.0) days, Z=-2.05, P=0.197], or hospital cost ［25.5（24.7，29.0）thousand yuan VS 26.4（19.6，30.3）thousand yuan， Z=-0.16, P=0.551]. The number of mild postoperative adverse event before weighting in the two groups was 5 and 14 respectively, and the severe postoperative adverse event was 0 and 1 respectively. After weighting, the mild postoperative adverse event rates were 46.2% (20.0/43.3) and 34.5% (17.8/51.6), respectively (χ2=0.36, P=0.639), and the severe postoperative adverse event rates were 0.0% (0.0/43.3) and 1.9% (1.0/51.6), respectively (χ2=0.80, P=0.381). Conclusion Compared with SB-ERC, EUS-AG demonstrates a higher technical success rate, a shorter procedure time and a comparable postoperative adverse event incidence. Therefore, EUS-AG can be considered as a first-line treatment option for stone extraction in patients with surgically altered anatomy.