Mohammed Noor, Pinder Matthew, Harris Keith, Everett Simon M
Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
Leeds institute of Biomedical and Clinical Sciences, St James's University Hospital, University of Leeds, Leeds, UK.
Frontline Gastroenterol. 2016 Jul;7(3):176-186. doi: 10.1136/flgastro-2015-100566. Epub 2015 May 22.
Conventional endoscopic duct clearance may not be possible in up to 10%-15% of common bile duct stones (CBDS). Sphincterotomy and biliary drainage by endoprosthesis have for many years been the mainstay of management in irretrievable stones. Recent years have seen the advent of sphincteroplasty or cholangioscopically-guided electrohydraulic lithotripsy (EHL) permitting duct clearance in majority of cases. However, when bile duct clearance is not possible, options include long-term stenting followed by elective stent exchange (ESE) 6-12 monthly or permanent stent insertion (PSI) in selected cases, but it is not clear which management strategy among ESE and PSI is preferable.
A retrospective review of all patients in Leeds Teaching Hospitals NHS Trust who underwent plastic stent insertion for biliary access for difficult CBDS from January 2006 to December 2011 was undertaken. Adult patients with irretrievable CBDS who had plastic stent insertions throughout the follow-up period were included. Patients who underwent PSI and ESE annually were retrospectively reviewed to determine the long-term outcomes. A detailed systematic review was also performed, examining the outcomes of CBDS managed with stents.
During the study period, 674 patients underwent 1769 biliary-stent-related procedures; of which, 246 patients met our inclusion criteria. 201 patients had subsequent duct clearance. 45 patients were, therefore, included in the final analysis, 28 of whom underwent annual ESEs and 17 PSIs. Patients in the PSI group had higher American Society of Anesthesiologists (ASA) scores compared with the ESE group. In the PSI group, 9/17 patients presented acutely with blocked stents, 5 of whom presented within 12 months. 2/9 patients were severely ill and died within a fortnight following the repeat endoscopic retrograde cholangiopancreatography (ERCP). In the ESE group, 4/28 patients had duct clearance in subsequent ERCPs, 1/28 patient presented with a blocked stent, and no biliary-related deaths were observed. The mean numbers of ERCPs performed were 0.52 and 1.95 in the PSI and ESE groups, respectively.
Over 50% of patients treated with long-term stenting re-presented acutely with stent blockage, though many of these were before 12 months, meaning planned stent exchange would not have affected the outcome. Duct clearance using all possible modalities is the preferred option, but where not possible, management with biliary stenting either with elective exchange or permanent stenting remains a possibility for carefully selected patients, though maybe best suited to those with limited life expectancy.
在高达10%-15%的胆总管结石（CBDS）患者中，传统的内镜下胆管清理可能无法实现。多年来，括约肌切开术和通过内置假体进行胆汁引流一直是处理无法取出结石的主要方法。近年来，括约肌成形术或经胆管镜引导的电液压碎石术（EHL）问世，使得大多数情况下能够实现胆管清理。然而，当无法进行胆管清理时，选择包括长期置入支架，随后每6-12个月进行选择性支架更换（ESE），或在特定病例中进行永久性支架置入（PSI），但目前尚不清楚ESE和PSI这两种管理策略中哪种更可取。
对2006年1月至2011年12月期间在利兹教学医院国民保健服务信托基金接受塑料支架置入以处理困难的CBDS的所有患者进行回顾性研究。纳入在整个随访期间接受塑料支架置入的无法取出CBDS的成年患者。对每年接受PSI和ESE的患者进行回顾性研究以确定长期结果。还进行了详细的系统评价，检查用支架处理CBDS的结果。
在研究期间，674例患者接受了1769例与胆管支架相关的手术；其中，246例患者符合我们的纳入标准。201例患者随后实现了胆管清理。因此，45例患者被纳入最终分析，其中28例接受了每年的ESE，17例接受了PSI。与ESE组相比，PSI组患者的美国麻醉医师协会（ASA）评分更高。在PSI组中，17例患者中有9例因支架堵塞急性就诊，其中有5例在12个月内出现。9例患者中有2例病情严重，在重复内镜逆行胰胆管造影（ERCP）后两周内死亡。在ESE组中，28例患者中有4例在随后的ERCP中实现了胆管清理，28例患者中有1例出现支架堵塞，未观察到与胆汁相关的死亡。PSI组和ESE组平均进行ERCP的次数分别为0.52次和1.95次。
超过50%接受长期支架置入治疗的患者因支架堵塞急性复诊，尽管其中许多发生在12个月之前，这意味着计划性支架更换不会影响结果。使用所有可能的方式进行胆管清理是首选方案，但在无法实现时，对于经过仔细挑选的患者，采用选择性更换或永久性置入胆管支架进行管理仍然是一种选择，尽管这可能最适合预期寿命有限的患者。
