Donatelli Gianfranco, Dumont Jean-Loup, Cereatti Fabrizio, Tuszynski Thierry, Vergeau Bertrand Marie, Meduri Bruno
Unité d'Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France.
Digestive Endoscopy and Gastroenterology Unit, A.O. Istituti Ospitalieri di Cremona, Cremona, Italy.
Endosc Int Open. 2017 May;5(5):E395-E401. doi: 10.1055/s-0043-106183.
Revision of endoscopic retrograde cholangiopancreatography (ERCP) may be necessary following previous biliary endoscopic sphincterotomy for recurrent biliary symptoms related to biliary stone recurrence, cholangitis or post-biliary endoscopic sphincterotomy (bEST) papillary stenosis and cholestasis. The aim of this retrospective study was to evaluate the clinical outcome and complication rate associated with re-cut, balloon dilation and biliary metal stenting in revision ERCP. From January 2010 to January 2015, 139 subjects with stigma of a previous sphincterotomy required a revision ERCP (64 Men/75 Women; mean age 71 years; range 32 - 101 years). The most appropriate technique (re-cut, balloon dilation or fully covered self-expandable metal stent [FCSEMS] placement) was tailored according to underlying pathologies and anatomical features. Technical success was achieved in all cases (100 %). Clinical success (definitive clearance of common bile duct stones and liver test normalization) was achieved in 127 out of 139 patients (91.4 %) with a mean follow up of 12 months. 12 clinical failures occurred: 11 patients required a new ERCP after an average of 9 months meanwhile 1 patient required surgery for definite treatment. The overall complication rate was 9 % (13 /139) with 5 acute complications (intra-procedural) and 8 short-term complications (before 1 month). Group specific overall complication rates were as follow: re-cut 11.5 % (8 bleeds and 3 perforations), balloon dilation 25 % (4 mild PEP [post-ERCP pancreatitis]), FCSEMS 14.3 % (1 moderate PEP), re-cut + balloon dilation and re-cut + FCSEMS 0 %. A statistically significant higher risk of post-ERCP pancreatitis was highlighted in the balloon dilation group meanwhile re-cut was burdened by a higher risk of bleeding and perforation. Revision ERCP following previous bEST is a feasible procedure enabling clinical success in most cases. Different approaches are available and must be considered according to underlying pathologies. Re-cut is burdened by a higher risk of perforation and bleeding compared to balloon dilation and SEMS meanwhile balloon dilation is associated to increased risk of PEP.
对于既往接受过胆管内镜括约肌切开术的患者，若因胆石复发、胆管炎或胆管内镜括约肌切开术后（bEST）乳头狭窄及胆汁淤积出现复发性胆道症状，可能需要进行内镜逆行胰胆管造影术（ERCP）修正。本回顾性研究的目的是评估在ERCP修正术中再次切开、球囊扩张和胆道金属支架置入的临床结局及并发症发生率。2010年1月至2015年1月，139例有既往括约肌切开术痕迹的患者需要进行ERCP修正（64例男性/75例女性；平均年龄71岁；范围32 - 101岁）。根据潜在病理情况和解剖特征选择最合适的技术（再次切开、球囊扩张或全覆膜自膨式金属支架[FCSEMS]置入）。所有病例均取得技术成功（100%）。139例患者中有127例（91.4%）取得临床成功（胆总管结石完全清除且肝功能检查正常），平均随访12个月。发生12例临床失败：11例患者平均9个月后需要再次进行ERCP，1例患者需要手术进行确定性治疗。总体并发症发生率为9%（13/139），其中5例急性并发症（术中），8例短期并发症（1个月内）。各亚组总体并发症发生率如下：再次切开11.5%（8例出血和3例穿孔），球囊扩张25%（4例轻度ERCP后胰腺炎[PEP]），FCSEMS 14.3%（1例中度PEP），再次切开 + 球囊扩张和再次切开 + FCSEMS为0%。球囊扩张组ERCP后胰腺炎风险在统计学上显著更高，而再次切开出血和穿孔风险更高。既往bEST后的ERCP修正术是一种可行的手术，大多数情况下能取得临床成功。有多种方法可供选择，必须根据潜在病理情况加以考虑。与球囊扩张和SEMS相比，再次切开穿孔和出血风险更高，而球囊扩张与PEP风险增加相关。
