Lai Kwok-Hung, Lo Gin-Ho, Lin Chiun-Ku, Hsu Ping-I, Chan Hoi-Hung, Cheng Jin-Shiung, Wang E-Ming
Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, National Yang Ming University, Taiwan, Republic of China.
Gastrointest Endosc. 2002 Apr;55(4):523-6. doi: 10.1067/mge.2002.122611.
As many as 24% of patients who undergo endoscopic sphincterotomy for the removal of bile duct stones have recurrent biliary complications develop for which there is no effective method of prevention. The aim of this study was to determine whether patients who undergo routine clinical follow-up after endoscopic sphincterotomy for bile duct stones have a different outcome than those who do not.
All patients who had endoscopic sphincterotomy for bile duct stones were scheduled for follow-up visits, liver function tests, and transabdominal US every 3 to 6 months. ERCP was performed whenever symptoms recurred, or abnormal liver function or US was noted. The patients themselves decided whether to adhere to the follow-up schedule; this was not a randomized trial.
Seven hundred sixty-seven patients underwent endoscopic sphincterotomy for bile duct stones from October 1990 to July 1999. Seventy-seven (10%) were found to have recurrent bile duct stones. Three patients who had undergone Billroth II gastrectomy were excluded. Among the remaining 74 patients (52 men, 22 women; mean age 65 years), 42 (57%) had a juxtapapillary diverticulum and 21 (28%) an intact gallbladder. The mean time to recurrence of bile duct stones was 19.7 months (range 5-72 months). Sixty-four patients (87%) had recurrent bile duct stones within 3 years. Fifty-one (69%) were followed regularly (Group A) and 23 (31%) were not (Group B). At the time of stone recurrence, 20 patients in Group A (39%) and 1 in Group B (4%) were asymptomatic (p = 0.002). Liver function tests were normal in 17 patients (13 Group A, 4 Group B). Endoscopic treatment for recurrent bile duct stones was successful in 46 patients (90%) in Group A and 16 (70%) in Group B (p = 0.04); surgical treatment was successful in all 5 patients in Group A and 4 of the 7 patients in Group B. Two patients in Group B were treated by nasobiliary drainage and biliary endoprosthesis insertion caused by extremely large stones and poor condition; both died (acute pancreatitis and sepsis).
Regular follow-up after endoscopic sphincterotomy detects recurrent bile duct stones early and thus avoids complications of bile duct stones.
接受内镜括约肌切开术以清除胆管结石的患者中，多达24%会出现复发性胆道并发症，目前尚无有效的预防方法。本研究的目的是确定接受胆管结石内镜括约肌切开术后进行常规临床随访的患者与未进行随访的患者预后是否不同。
所有接受胆管结石内镜括约肌切开术的患者均安排每3至6个月进行随访、肝功能检查和经腹超声检查。每当出现症状、肝功能或超声检查异常时，均进行内镜逆行胰胆管造影（ERCP）。患者自行决定是否遵守随访计划；这不是一项随机试验。
1990年10月至1999年7月，767例患者接受了胆管结石内镜括约肌切开术。其中77例（10%）被发现有复发性胆管结石。3例接受毕罗Ⅱ式胃切除术的患者被排除。在其余74例患者（52例男性，22例女性；平均年龄65岁）中，42例（57%）有十二指肠乳头旁憩室，21例（28%）胆囊完整。胆管结石复发的平均时间为19.7个月（范围5 - 72个月）。64例（87%）患者在3年内出现复发性胆管结石。51例（69%）患者接受了定期随访（A组），23例（31%）未接受定期随访（B组）。结石复发时，A组20例患者（39%）无症状，B组1例患者（4%）无症状（p = 0.002）。17例患者（A组13例，B组4例）肝功能检查正常。A组46例（90%）复发性胆管结石患者的内镜治疗成功，B组16例（70%）成功（p = 0.04）；A组5例患者的手术治疗均成功，B组7例患者中的4例成功。B组2例患者因结石极大且病情较差接受了鼻胆管引流和胆道内支架置入治疗；两人均死亡（急性胰腺炎和败血症）。
内镜括约肌切开术后的定期随访可早期发现复发性胆管结石，从而避免胆管结石的并发症。
