不同内镜术式治疗胆总管结石青年患者的长期随访研究

目的探讨不同的常用内镜治疗方法对胆总管结石青年患者治疗后结石复发的影响以及结石近期复发、远期复发的危险因素。方法选择经一次性治疗性内镜逆行胰胆管术（ERCP）成功取石后随访资料完整的胆总管结石青年（21～45岁）患者,按手术方式分为内镜下乳头球囊扩张术（EPBD）组、乳头括约肌切开术（EST）组、EST（切开〈0．5cm）＋EPBD组,进行随访,统计近期（≤3年）及远期（〉3年）结石复发率,并对复发危险因素进行Logistic回归分析。结果资料完整的327例患者平均随访76．5个月,54例（16．5％）结石复发,其中近期复发35例（10．7％）,远期复发19例（5．8％）。近期胆总管结石复发率EPBD组（11．3％）和EST组（13．2％）均高于EST＋EPBD组（8．1％）,但无统计学差异（P均〉0．05）。远期胆总管结石复发率EPBD组（11．3％）和EST组（6．6％）均显著高于EST＋EPBD组（0．8％）,差异具统计学意义（P均〈0．05）。Logistic回归分析结果表明,胆囊结石、结石最大径、结石个数、机械碎石与近期结石复发显著相关（P〈0．05）,而远期胆总管结石复发则与结石最大径及单纯球囊扩张显著相关（P〈0．05）。结论对于胆总管结石青年患者,单纯EPBD取石固然可保留乳头括约肌功能,但增加了结石的远期复发风险,而乳头括约肌小切开联合EPBD取石可显著降低胆总管结石复发率。     

内镜下十二指肠乳头括约肌小切开术联合球囊扩张术治疗胆管结石的疗效观察

目的 探讨内镜下乳头括约肌小切开术（smallendoscopicsphincterotomy,SEST）联合球囊扩张术（endo—scopicpapillaryballoondilatation,EPBD）治疗胆管结石的远期疗效和并发症。方法选择青岛市海慈医疗集团消化内科2009年3月至2011年12月住院治疗的127例结石直径〉10mm的胆管结石患者,随机分为4组,SEST＋EPBD组33例,先行乳头括约肌小切开（切开范围小于乳头肌三分之一）,然后球囊扩张,再碎石取石;EPBD＋SEST组32例,先行球囊扩张术,再行乳头括约肌小切开,再碎石取石;EST组32例,仅行十二指肠乳头括约肌大切开（切开范围大于乳头肌三分之二）取石;EPBD组30例,仅行球囊扩张碎石取石。比较4组的疗效和并发症发生率。结果SEST＋EPBD组术后结石取净率为93．93％（31／33）,EPBD＋SEST组为93．75％（30／32）,EST组为96．77％（30／31）,EPBD组为66．67％（20／30）,EPBD组与其他三组比较差异有统计学意义（P〈0．05）;SEST＋EPBD组和EPBD＋SEST组均无远期并发症发生,EST组远期并发症发生率为16．67％,EPBD组为3．57％,EST组与其他三组比较有显著性差异（P〈0．05）。结论SEST与EPBD联合治疗胆管结石安全有效,可有效降低经内镜治疗胆管结石的远期并发症发生率,提高胆管结石患者术后的生活质量。     

内镜下乳头括约肌小切开联合气囊扩张术对胆总管结石患者并发症的作用

目的探讨内镜下乳头括约肌小切开联合乳头气囊扩张术(EPBD)在减少胆总管结石治疗近、远期并发症中的作用。方法选取我院胆总管结石患者73例,随机分为乳头括约肌小切开联合EPBD术取石组(n=38)和单纯乳头括约肌切开术(EST)取石组(n=35),观察两组的治愈率,近期、远期并发症情况。结果两组取石成功率分别为94.7%vs97.1%,无显著性差异(P(0.05);两组近期并发症(胰腺炎各1例,出血分别0例vs2例,胆道感染分别2例vs1例)发生率分别为7.9%和11.4%,无显著性差异(P0.05);远期并发症(反流性胆管炎分别1例、3例,结石复发分别1例vs6例)发生率分别为5.3%vs25.7%,有显著性差异(P0.05)。结论内镜下乳头括约肌小切开联合EPBD术扩大了胆总管结石治疗手术适应证,减少了手术的近期、远期并发症。     

十二指肠镜2种方法治疗胆管结石的比较

目的比较分析内镜下十二指肠乳头括约肌切开术（EST）和十二指肠乳头球囊扩张术（EPBD）治疗胆总管结石的临床疗效。方法选取河池市人民医院及右江民族医学院附属医院2010年3月2011年10月住院治疗的60例胆管结石患者,其中38例进行EST治疗,22例进行EPBD治疗．比较两组的疗效及并发症的发生率。结果EST组术后结石取净率为94．74％,EPBD组为95．45％．两者比较差异无统计学意义（x2=0．015,P〉0．05）;EST组近期并发症的发生率为5．56％明显低于EPBD组的23．80％（X2=4．102,P〈0．05）;EPBD组胰腺炎的发生率为19．04％明显高于EST组的2．78％（X2=4．387,P〈0．05）。EST组远期并发症的发生率为19．4％,而EPBD组未出现远期并发症,二者有显著性差异（x2=4．655,P〈0．05）。结论EST术和EPBD术治疗胆总管结石的结石清除率接近,但EST的并发症特别是术后胰腺炎的发生率较低,而EPBD的远期并发症较低,说明两种方法各有利弊,但均安全有效,临床应根据患者结石数目和结石大小选择适合的手术方式。     

内镜下十二指肠乳头小切开后球囊扩张术治疗胆总管结石的临床研究

目的探讨内镜下十二指肠乳头括约肌小切开后球囊扩张术在胆总管结石治疗中的有效性和安全性。方法将150例临床确诊为胆总管结石的患者随机分为乳头括约肌切开组(EST组)和乳头括约肌小切开后球囊扩张术组(SEST+EPBD组),比较两组疗效及并发症的发生率。结果 EST组和SEST+EPBD组取石成功率分别为92%和97%(χ2=1.19,P0.05)。EST组术后出现急性胰腺炎2例,出血4例,结石复发11例,逆行性胆道感染15例。SEST+EPBD组术后出现急性胰腺炎1例,出血1例,结石复发2例,逆行性胆道感染6例。两组取石成功率及近期并发症比较差异无统计学意义(P0.05),远期并发症比较差异有统计学意义(P0.05)。结论内镜下乳头括约肌小切开后球囊扩张术治疗胆总管结石安全、有效,并发症少,并且尽可能的保留了十二指肠乳头括约肌的功能,值得临床推广。     

内镜下乳头括约肌小切开联合乳头球囊扩张术治疗胆总管结石的临床分析

内镜下乳头括约肌切开术（EST）治疗胆总管结石已得到临床广泛认可,并成为治疗胆总管结石的首选方法,但该技术引起并发症的比例仍较高。单纯乳头球囊扩张术（EPBD）后取石具有与单纯EST术后取石相近的成功率,并发症少,创伤小,且对十二指肠乳头括约肌有保护功能,多数学者认为EPBD是EST的最有价值的替代方法,但因球囊压迫胰管开口,术后胰腺炎的发生率相对较高。如何在胆总管结石内镜取石中取得更好的疗效,如何减少内镜取石术近期、远期并发症？本研究采用内镜下乳头括约肌小切开联合EPBD术治疗胆总管结石,从手术成功率、疗效、并发症等方面对乳头括约肌小切开联合EPBD术和单纯EST术两者进行比较,旨在探讨该方法的临床应用价值和疗效。     

乳头括约肌小切口联合球囊扩张治疗胆总管结石的疗效及安全性

目的探究胆总管结石患者采取乳头括约肌小切口联合球囊扩张治疗术(EPBD)的临床疗效及安全性。方法选取我院消化科收治的72例胆总管结石患者,随机分为研究组和对照组,每组各36例。其中对照组进行单纯乳头括约肌切开术(EST),研究组行乳头括约肌小切口联合EPBD治疗。对比两组患者取石成功率及近远期并发症发生率。结果研究组取石成功率为97.2%,对照组为88.9%,差异有统计学意义(P0.05)。两组近期并发症发生率差异无统计学意义(P0.05)。研究组远期并发症发生率低于对照组,差异有统计学意义(P0.05)。结论乳头括约肌小切口联合EPBD术较EST术应用于胆总管结石患者,能够提高取石成功率,且安全性更佳,值得在临床上进一步推广。     

单用内镜下球囊扩张与联合内镜下括约肌切开治疗胆总管结石疗效对比的Meta分析

目的系统性地评价单用内镜下球囊扩张(EPBD)与联合内镜下括约肌切开(EST)治疗胆管结石的疗效对比。方法运用计算机检索Pubmed、Cochrane、Embase、中国知网(CNKI)、万方数据库(WanFang)和维普数据库(VIP),纳入所有符合条件的随机对照试验,利用RevMan5.3软件进行数据分析。结果纳入9个研究,共848例患者,其中EPBD组432例,EST+EPBD组416例,Meta分析显示,EST+EPBD治疗胆总管结石的一次性取石成功率高于单用EPBD患者[MD=2.27,95%CI(1.15,4.49),P=0.02],且EST+EPBD组的取石时间也较单用EPBD短[MD=-1.04,95%CI(-2.00,-0.09),P=0.03]。但两者在总取石成功率[OR=1.42,95%CI(0.80,2.51),P=0.23]、机械碎石率[MD=0.76,95%CI(0.47,1.21),P=0.25]、并发症[MD=0.90,95%CI(0.60,1.35),P=0.60]方面是相似的。结论内镜下治疗胆总管结石时,EST+EPBD术可以缩短取碎石时间和提高一次性取石成功率,其总取石成功率、机械碎石率与术后并发症的发生率与单用EPBD相当,是一种安全有效的胆总管结石的内镜治疗方式。     

十二指肠乳头括约肌小切开联合气囊扩张术治疗胆总管结石

经内镜乳头括约肌切开术（EST）取石用于治疗胆总管结石已得到广泛认可,但并发症发生率仍较高,经内镜乳头气囊扩张术（EPBD）取石具有与EST取石相近的成功率,出血、穿孔并发症相对较少,且保护了十二指肠乳头括约肌功能,但因球囊压迫胰管开口,术后胰腺炎的发生率相对较高。我们采用内镜下乳头括约肌小切开联合EPBD治疗了38例胆总管结石,现总结资料,探讨其有效性、安全性和在减少近期、远期并发症方面的作用。     

内镜下乳头括约肌切开术与球囊扩张术治疗肝外胆管结石临床疗效及安全性的比较

目的:比较内镜下十二指肠乳头扩约肌切开术(endoscopic sphincterotomy,EST)与十二指肠乳头括约肌球囊扩张术(endoscopic papillary balloon dilatation,EPBD)治疗肝外胆管结石的有效性及安全性.方法:217例经内镜下EST或EPBD治疗肝外胆管结石的患者纳入该研究,并对其取石效果、术中X线暴露时间及近远期并发症进行比较分析.结果:EST组与EPBD组的结石完全清除率为93.8%和94.3%(P0.05),EST组与EPBD组的术中X线暴露时间具有显著差异(P0.05),EPBD组具有更短的X线暴露时间.EST组与E P B D组近期并发症发生率分别为16.3%和15.9%(P0.05);内镜后胰腺炎发生率EPBD组明显高于EST组(12.5%vs 4.7%,P0.05),所有17内镜后胰腺炎均为轻型胰腺炎;出血发生率EST组明显高于EPBD组(11.6%vs3.4%,P0.05),所有18例出血均为可控制出血;远期复发胆管结石合并急性胆管炎的发生率EST组明显高于EPBD组(44.1%vs18.2%,P0.05).结论:内镜下EST与EPBD是两种相对成熟、安全的治疗肝外胆管结石的方法,但EPBD能最大程度地保护Oddi括约肌的功能,降低远期并发症的发生.     

What is an appropriate indication for endoscopic papillary balloon dilation?

OBJECTIVE: There are a number of views on the indication for endoscopic papillary balloon dilation (EPBD) in the management of bile duct stones. In this study, we have evaluated the efficacy and safety of EPBD compared with endoscopic sphincterotomy (EST). DESIGN: Prospective randomized trial. SETTING: One university hospital and one general hospital. PARTICIPANTS AND MAIN OUTCOME MEASURES: One hundred and forty patients were randomly allocated to EPBD or EST. Outcomes and complications were observed for a median period of 30 months. RESULTS: Both treatment approaches finally achieved similar success rates and needed similar numbers of treatment sessions for patients with stones less than 10 mm in diameter. However, for patients with stones of 10 mm or more, EPBD required a significantly greater mean number of treatment sessions than EST (2.4 vs 1.6, P < 0.01). Early complications occurred in seven EPBD (four pancreatitis, two cholangitis and one basket impaction) and eight EST (three pancreatitis, two bleeding and three cholangitis) patients. Late complications occurred in four EPBD (three recurrent bile duct stones and one cholecystitis) and six EST (three recurrent stones and three cholecystitis) patients. CONCLUSIONS: EPBD has little risk of bleeding. The technique removed small bile duct stones just as easily as did EST. These two procedures had approximately the same risk of pancreatitis and incidence of recurrent bile duct stones. Therefore, both procedures appear to be appropriate treatments for small bile duct stones. Whether or not EPBD becomes an established treatment will depend on further long-term studies.     

Endoscopic sphincterotomy and papillary balloon dilation for bile duct stones

BACKGROUND/AIMS: There are many reports of the results of endoscopic sphincterotomy (EST) for common bile duct stones. Recently, there were several reports on the results of endoscopic papillary balloon dilation (EPBD) for this condition. However, there have been few reports about a comparison between EST and EPBD. METHODOLOGY: Between Oct. 1994 and Dec. 1998, 196 consecutive patients underwent 102 EST or 94 EPBD. RESULTS: EST and EPBD were successful in 100 of 102 (98.0%), and all 94 patients. Bile duct clearance was achieved in 88 (88.0%) in the EST group and 88 (95.7%) in the EPBD group. Early complications occurred in 13 (13.0%: 3 acute pancreatitis, 4 cholangitis, 2 cholecystitis, 2 bleeding, 2 perforation) in the EST group and 16 (17.0%: 7 acute pancreatitis, 4 cholangitis, 4 cholecystitis, 1 basket impaction) in the EPBD group. Three patients (1 bleeding, 2 perforations) underwent emergent surgery after EST. CONCLUSIONS: The rate of bile duct clearance with EPBD was comparable to that with EST. Early complications did not differ between EST and EPBD. The use of EST tended to be associated with a lower incidence of acute pancreatitis, a higher incidence of bleeding, and a higher rate of perforation.     

内镜下乳头球囊扩张术和乳头括约肌切开术治疗胆总管结石的比较

目的 探讨内镜下乳头球囊扩张术(EPBD)治疗胆总管结石的有效性和安全性.方法 2005年6月至2007年5月山东大学齐鲁医院320例拟行内镜下取石的胆总管结石患者,随机分为EPBD组及内镜下乳头括约肌切开术(EST)组,每组160例.EPBD组在乳头球囊扩张后用取石网篮或气囊取石,当结石较大时先行机械碎石网篮碎石后再取石;EST组按常规操作.两组术后均常规鼻胆管引流3 d,并造影复查.结果 EST组及EPBD组分别有156例(97.5%)及157例(98.1%)成功取净结石,其中各有112例(70.0%)及104例(65.0%)一次完成;机械碎石网篮应用比例分别为20.0%(32/160)和22.5%(36/160);术后早期并发症的总发生率分别为5.6%及8.1%,无死亡病例.随访3年,EST组胆管结石复发率(7.5%)高于EPBD组(2.5%),P＜0.05.结论 EPBD取石具有与EST取石相近的成功率,经术后常规鼻胆管引流处理后,胰腺炎发生率无明显升高.EPBD可以作为胆总管结石的备选治疗措施,尤其是对不适于EST的患者.

Abstract：

Objective To explore the effectiveness and safety of endoscopic papillary balloon dilation( EPBD ) for the removal of common bile duct stones. Methods Three hundred and twenty consecutive patients with common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP) who met all eligibility criteria were randomly assigned endoscopic sphincterotomy (EST) or EPBD.Complications were classified by an expert panel unaware of treatment allocation and outcome. Results After a single ERCP, all stones were removed from 112 patients ( 70% ) assigned EST and 104 ( 65% )assigned EPBD. Mechanical lithotripsy was used to fragment stones in 36 (22. 5% ) EPBD procedures and 32 ( 20. 0% ) EST procedures. Early complications occurred in 5.6% EST patients and 8.1% EPBD patients. No patient died. Gallstone disease recurrence, which is a long-term complication, is 7. 5% ( 12/160) in EST patients and 2.5% (4/160) in EPBD patients, P ＜0. 05. Conclusions The success rate of EPBD was similar to that of EST. We found no evidence of previously suggested higher risk of pancreatitis with EPBD, and suggest that EPBD is preferred in patients who are not suitable for EST, such as those with high risk of bleeding. This procedure is a valuable alternative to EST in patients with bile duct stones.     

改良内镜下乳头气囊扩张术应用的可行性研究

目的探讨改良内镜下乳头气囊扩张术（EPBD）治疗胆管结石的可行性。方法对226例肝外胆管结石的患者应用肠道型柱状气囊行乳头扩张并在此基础上展开治疗，并比较2299例内镜乳头切开术（EST）的治疗效果及术后并发症情况。结果226例患者均顺利完成取石或碎石取石术，术后无胆道感染、穿孔等并发症，发生轻型急性胰腺炎4．7％（10例），与EST（5．2％）比较，差异无统计学意义，术后消化道出血0．47％（1例），与EST（1．2％）比较，差异有统计学意义。结论对EST困难或易发生并发症者用肠道型柱状气囊行EPBD术，能有效地钝性切割乳头，并在此基础上展开较大结石的取石或碎石取石术，同时并发症明显减少。EPBD是内镜下处理胆管结石安全有效的方法之一。     

Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of common bile duct stones during ERCP: a metaanalysis of randomized, controlled trials

OBJECTIVES: To compare the effect of endoscopic balloon dilation (EPBD) of the papilla with that of endoscopic biliary sphincterotomy (EST) in the treatment of patients with common bile duct stones. METHODS: Searches of computerized bibliographic and scientific citations, and review of citations in relevant primary articles. Eight fully published prospective, randomized trials in English that compared EPBD with EST for the removal of common bile duct stones were subjected to metaanalysis. RESULTS: EPBD compared with EST resulted in similar outcomes with regards to overall successful stone removal (94.3% vs 96.5%) and overall complications (10.5% vs 10.3%). Bleeding occurred less frequently with EPBD (0% vs 2.0%, p = 0.001). Post-ERCP pancreatitis occurred more commonly in the EPBD group (7.4% vs 4.3%, p = 0.05). No significant differences were seen in the rates of perforation or infection. Patients undergoing EPBD were more likely to require mechanical lithotripsy for stone extraction (20.9% vs 14.8%, p = 0.014). CONCLUSIONS: On the basis of lower rates of bleeding, EPBD should be the preferred strategy over EST for endoscopic removal of common bile duct stones in patients with coagulopathy. Although EPBD is theoretically attractive for use in young patients for biliary sphincter preservation, the rate of pancreatitis is higher with EPBD and cannot be routinely recommended at this time.     

内镜治疗胆总管结石的临床研究

目的 探讨内镜在胆总管探查取石中的应用价值。方法 对227例拟诊胆总管结石 的患者采用经内镜治疗,其中14例直径<1.0 cm的结石采用经内镜乳头球囊扩张术治疗,194例直 径1.0-1.5cm的结石采用内镜乳头括约肌切开治疗,19例直径>1.5cm的结石采用内镜下机械碎 石治疗。结果 15％(34例)胆管造影未见结石,经内镜探查阴性。余193例中,187例取石成功,成 功率为96.9％(187／193)。并发症发生率为5.29%(12／227),其中急性胆管炎3例,急性胰腺炎8 例,消化道出血1例。结论 内镜治疗胆总管结石安全有效,并发症少,应当首选。但对ERCP无法 明确的胆总管结石,不主张行乳头括约肌切开及内镜下的胆管探查,以最大限度地减少并发症。     

Comparison between endoscopic papillary balloon dilatation and endoscopic sphincterotomy for the treatment of common bile duct stones

Background This study was designed to evaluate the therapeutic outcome and early postoperative complications, especially pancreatitis, of endoscopic papillary balloon dilation (EPBD) and endoscopic sphincterotomy (EST) in patients with common bile duct stones in our department. Methods One hundred eighty patients with common bile duct stones were randomized to undergo EPBD or EST. An 8-mm dilatation balloon was used for EPBD. Modified Cotton's criteria, in which relatively mild pancreatitis is also included as a complication, were used to determine the incidence of postoperative complications. Results The rate of complete removal of stones was significantly higher in the EST group (95.6%) than in the EPBD group (86.6%); for stones less than 10 mm in diameter, however, the rate with EPBD (93.8%) was almost equivalent to that with EST (98.1%). According to modified Cotton's criteria, the incidence of postoperative pancreatitis was significantly higher in the EPBD group (16.7%) than in the EST group (6.7%). Bleeding was encountered in one patient (1.1%) in the EST group, but in none in the EPBD group. No fatal complication occurred in either the EPBD or the EST group. Conclusions Although EPBD appears to be comparable to EST for removal of small common bile duct stones, mild postoperative pancreatitis is more likely to occur with EPBD than with EST.