Sivak M V
Department of Gastroenterology, Cleveland Clinic Foundation, Ohio 44195-5164.
Am J Surg. 1989 Sep;158(3):228-40. doi: 10.1016/0002-9610(89)90256-0.
Endoscopic sphincterotomy is the procedure of choice for choledocholithiasis in patients who have had a cholecystectomy. The bile duct is cleared of stones in about 80 to 90 percent of patients. Available data, largely retrospective, suggest that surgery and endoscopic sphincterotomy are about equal with respect to removal of stones, morbidity, and mortality. Certain technical problems are discussed, including inability to insert the papillotome, the large stone, and problems relating to anatomy such as peripapillary diverticulum and prior gastrectomy. The treatment of patients with bile duct stones who have not had a cholecystectomy, with and without cholelithiasis, is controversial. Endoscopic sphincterotomy without subsequent cholecystectomy is adequate treatment for the majority of patients who are unfit for surgery, even if there are stones in the gallbladder, provided they are asymptomatic after endoscopic removal of stones from the bile ducts. Endoscopic sphincterotomy has been performed in the treatment of gallstone-induced pancreatitis, acute obstructive cholangitis, and sump syndrome. The complication rate for endoscopic sphincterotomy ranges from 6.5 to 8.7 percent, with a mortality rate of 0 to 1.3 percent. The most common serious complications are perforation, hemorrhage, acute pancreatitis, and sepsis.
内镜括约肌切开术是已行胆囊切除术患者胆总管结石的首选治疗方法。约80%至90%的患者胆管结石可被清除。现有数据大多为回顾性研究，表明手术和内镜括约肌切开术在结石清除、发病率和死亡率方面大致相当。文中讨论了一些技术问题，包括无法插入乳头切开刀、结石较大以及与解剖结构相关的问题，如乳头周围憩室和既往胃切除术。对于未行胆囊切除术的胆管结石患者，无论有无胆结石，其治疗存在争议。对于大多数不适合手术的患者，即使胆囊中有结石，只要在内镜下从胆管取出结石后无症状，不行后续胆囊切除术的内镜括约肌切开术就是充分的治疗方法。内镜括约肌切开术已用于治疗胆结石性胰腺炎、急性梗阻性胆管炎和残端综合征。内镜括约肌切开术的并发症发生率为6.5%至8.7%，死亡率为0至1.3%。最常见的严重并发症是穿孔、出血、急性胰腺炎和败血症。
