Zang Jinfeng, Zhang Chi, Gao Junye
Department of Hepatobiliary Surgery, Taizhou People's Hospital, the Fifth Affiliated Hospital of Medical School of Nantong University, Taizhou, Jiangsu Province, China.
Surg Laparosc Endosc Percutan Tech. 2014 Oct;24(5):429-33. doi: 10.1097/SLE.0000000000000062.
Precut techniques have been used to facilitate biliary cannulation during difficult endoscopic retrograde cholangiopancreatography. Presently, needle-knife sphincterotomy (NKS) is a commonly used precut technique. Since its first description, transpancreatic sphincterotomy, as an alternative method for bile duct entry when conventional biliary cannulation failed, has been debated on its success rate of cannulation and its complications, such as increased incidence of pancreatitis. Guidewire techniques are another effective method to improve the success rate of selective bile duct cannulation. This is a single-center prospective randomized controlled trial aimed to compare success rate, cannulation time, and complications of guidewire-assisted transpancreatic sphincterotomy (GATS) and NKS for difficult biliary cannulation.
Between July 2010 and October 2013, consecutive patients who failed in the standard biliary cannulation were randomly assigned to the GATS and NKS groups. The outcome measures included success rate, cannulation time, and complications.
A total of 149 patients were enrolled and analyzed: 73 in the GATS group and 79 in the NKS group. The characteristics of the 2 groups were similar. Bile duct cannulation was successful in 70 patients (95.9%) in the GATS group and 64 (84.2%) in the NKS group (P=0.018). The median cannulation time spent in precut was 193 seconds in the GATS group and 485 seconds in the NKS group (P<0.001). There was no difference between the groups for the incidence of complications, pancreatitis, and hemorrhage (9.6% vs. 10.5%, 6.8% vs. 6.6%, 1.4% vs. 3.9%, respectively). No perforation occurred.
GATS compared with NKS increases biliary cannulation rate and requires less cannulation time during difficult biliary access. This technique is not associated with an increased risk for complications. It seems to be an effective and safe alternative for biliary access during difficult endoscopic retrograde cholangiopancreatography.
预切开技术已被用于在困难的内镜逆行胰胆管造影术中促进胆管插管。目前，针刀括约肌切开术（NKS）是一种常用的预切开技术。自首次描述以来，经胰腺括约肌切开术作为传统胆管插管失败时胆管进入的替代方法，其插管成功率及其并发症，如胰腺炎发生率增加，一直存在争议。导丝技术是提高选择性胆管插管成功率的另一种有效方法。这是一项单中心前瞻性随机对照试验，旨在比较导丝辅助经胰腺括约肌切开术（GATS）和NKS在困难胆管插管时的成功率、插管时间和并发症。
2010年7月至2013年10月期间，标准胆管插管失败的连续患者被随机分配到GATS组和NKS组。观察指标包括成功率、插管时间和并发症。
共纳入149例患者并进行分析：GATS组73例，NKS组79例。两组患者的特征相似。GATS组70例（95.9%）胆管插管成功，NKS组64例（84.2%）成功（P = 0.018）。GATS组预切开的中位插管时间为193秒，NKS组为485秒（P < 0.001）。两组并发症、胰腺炎和出血的发生率无差异（分别为9.6%对10.5%、6.8%对6.6%、1.4%对3.9%）。未发生穿孔。
与NKS相比，GATS提高了胆管插管率，在困难胆管通路时所需的插管时间更少。该技术与并发症风险增加无关。它似乎是困难内镜逆行胰胆管造影术中胆管通路的一种有效且安全的替代方法。
