Walzel C
Wien Klin Wochenschr Suppl. 1976;61:1-18.
In spite of immaculate surgical technique conventional transduodenal sphincterotomy is attended by a non-lethal complication rate of about 5.8% and a mortality rate of about 4.5%, the most frequent cause being dehiscence of the duodenal suture. The primary and secondary pathogenesis hereof is explained by the particular predisposition duodenal laceration on account of its special anatomy and operative vulnerability. Bearing these facts in mind, the method of so-called perduodenal sphincterotomy (p. sph.) seemed to offer more promising results for the following reasons: 1. Splitting of the sphincter through a minute incision in the duodenum (stab incision with a tenotome). 2. The advantage of primary closure of the cystic duct in the transcystic approach with medium-sized probes for the splitting. Experimental evidence shows the cystic duct to be very resistent towards dilation and rupture, especially in the presence of inflammatory processes. From 1967 to 1973 in 1441 cases of gall-bladder surgery p. sph. was performed 374 times and transduodenal sphincterotomy only 121 times. The statistic evaluation of the outcome of both methods showed significantly better results with p. sph. with regard to the incidence of postoperative non-lethal complications and duration of hospitalization. Assessment of non-lethal postoperative mortality and follow-up studies on 79% of the operated patients over a period from 3 to 9 years showed that the results of both methods were equal. In our experience the p. sph. is not only advisable when sphincterotomy is generally indicated, but also in the following special situations: a) as so-called "emergency papillotomy" in poor-risk patients; b) if the transduodenal approach is impossible awing to technical difficulties (poor accessibility, low site of the papilla); c) if the indication for papilotomy is dubious it can be chosen as the less dangerous method; d) for reoperation on the sphincter. On account of its prevailing advantages this new method for repairing papillary drainage is practicable as a routine method in sphincteric surgery.
尽管手术技术精湛，但传统的经十二指肠括约肌切开术仍存在约5.8%的非致命并发症发生率和约4.5%的死亡率，最常见的原因是十二指肠缝线裂开。其原发性和继发性发病机制可通过十二指肠因其特殊解剖结构和手术易损性而导致的十二指肠撕裂的特殊易感性来解释。考虑到这些事实，所谓的经十二指肠括约肌切开术（p. sph.）方法似乎能提供更有前景的结果，原因如下：1. 通过十二指肠上的微小切口（用腱刀进行刺状切口）劈开括约肌。2. 在经胆囊途径中使用中型探子劈开时，对胆囊管进行一期缝合的优势。实验证据表明胆囊管对扩张和破裂具有很强的抵抗力，尤其是在存在炎症过程的情况下。1967年至1973年期间，在1441例胆囊手术中，进行了374次p. sph.手术，而经十二指肠括约肌切开术仅进行了121次。对两种方法结果的统计学评估显示，p. sph.在术后非致命并发症发生率和住院时间方面的结果明显更好。对非致命术后死亡率的评估以及对79%的手术患者进行的为期3至9年的随访研究表明，两种方法的结果相当。根据我们的经验，p. sph.不仅在一般需要进行括约肌切开术时是可取的，而且在以下特殊情况下也是如此：a）作为高危患者的所谓“急诊乳头切开术”；b）如果由于技术困难（难以接近、乳头位置低）无法采用经十二指肠途径；c）如果乳头切开术的指征不明确，可以选择它作为危险性较小的方法；d）用于括约肌的再次手术。由于其普遍的优势，这种修复乳头引流的新方法作为括约肌手术的常规方法是可行的。
