中国实用外科杂志

中国实用外科杂志

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胆道镜下导丝突破法治疗困难胆管吻合口狭窄12例疗效分析

李    宇，董鼎辉，刘学民，孙    昊，吕    毅   

  1. 西安交通大学第一附属医院肝胆外科，陕西西安 710061
  • 出版日期:2022-04-01

  • Online:2022-04-01

摘要： 目的    探讨胆道镜下导丝突破法治疗困难胆管吻合口狭窄的安全性并观察临床疗效。方法    回顾性分析2019年1月至2021年9月西安交通大学第一附属医院肝胆外科收治的内镜下逆行性胆胰管造影（ERCP）或经皮经肝胆道引流（PTCD）治疗失败的12例胆管吻合口狭窄病例的临床资料。9例为肝移植术后胆管端端吻合口狭窄，使用经口单人操作胆道镜（SpyGlass）进入胆道；3例为复杂上腹部术后胆管空肠吻合口狭窄，使用经皮经肝胆道镜（PTCS）进入胆道。分析操作成功率、相关并发症及治疗效果。结果    12例病人中，4例针尖样狭窄者均通过胆道镜辅助完成导丝穿越吻合口；余8例为完全狭窄，接受导丝硬头突破法治疗9次（7次SpyGlass胆道镜和2次PTCS），其中6次成功。胆道镜下导丝突破法技术成功率为76.9%（10/13）。导丝通过狭窄后放置PTCD导管（3例）、塑料支架（3例）及全覆膜金属支架（4例）。2例失败者通过PTCD会师及十二指肠内瘘口治疗成功。术后轻度胆管炎2例，保守治疗好转，无出血、穿孔、胆瘘等与导丝突破相关的并发症。术后随访11（3~34）个月，4例已脱支架，无狭窄复发。结论    胆道镜下导丝突破法治疗ERCP或PTCD失败的困难胆管吻合口狭窄安全、可行，近期疗效满意。

关键词: 胆道镜, 胆管吻合口狭窄, 困难, 导丝, 再通

Abstract: Recanalization technique using guide-wire under cholangioscopy for difficult biliary anastomotic stricture: 12 cases reports        LI Yu，DONG Ding-hui，LIU Xue-min，et al. Department of Hepatobiliary Surgery，the First Affiliated Hospital of Xi’an Jiaotong University，Xi’an 710061，China
Corresponding author：SUN Hao，E-mail：sunhaoxjyf@126.com
Abstract    Objective    To investigate the safety and clinical efficacy of recanalization technique using guide-wire under cholangioscopy for difficult biliary anastomotic stricture. Methods    A total of 12 cases of biliary anastomotic strictures who failed in ERCP or PTCD in the Department of Hepatobiliary Surgery in the First Affiliated Hospital of Xi’an Jiaotong University from January 2019 to September 2021 were analyzed retrospectively. Per-oral single operator cholangioscopy (Spyglass) was used to enter the bile duct for the nine patients，who had bilio-biliary anastomotic stricture post liver transplantation. Meanwhile，percutaneous transhepatic cholangioscopy (PTCS) was selected for the three patients with bilio-enteric anastomotoic stricture after complicated operation. The procedure success rate，related complications and clinical efficacy were collected and analyzed. Results    Among the 12 cases，four cases were pinhole strictures，which were cannulated successfully by the guidewire under cholangioscopy. For the other eight complete strictures were performed using the hard tip of guidewire for nine times (SpyGlass=7，PTCS=2)，of which six times were successful. The technical success rate was 76.9% (10/13). PTCD catheter (3 cases)，plastic stent (3 cases) and metallic stent (4 cases) were deployed after recanalization. Two failures were successfully managed by Rendez-vous technique and bilio-duodenal fistula. Two cases suffered mild cholangitis post procedures and managed with conservative ways. No complications related to the technique，such as bleeding，perforation and biliary fistula，were observed. Followed up for 11 months (range，3-34 months)，four cases had been stent-off without stricture recurrence. Conclusion    The recanalization technique using guidewire under choledochoscopy is safe and feasible for biliary anastomotic strictures whom failed in ERCP or PTCD, and the short term effect is satisfactory.

Key words: cholangioscopy, biliary anastomostic stricture, complex, guidewire, recanalization