Galetti Facundo, Moura Diogo Turiani Hourneaux de, Ribeiro Igor Braga, Funari Mateus Pereira, Coronel Martin, Sachde Amit H, Brunaldi Vitor Ottoboni, Franzini Tomazo Prince, Bernardo Wanderley Marques, Moura Eduardo Guimarães Hourneaux de
Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil.
Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA.
Arq Bras Cir Dig. 2020 Jun 26;33(1):e1491. doi: 10.1590/0102-672020190001e1491.
Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates.
To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy.
Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies.
Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%).
For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.
内镜下取出胆总管结石成功率较高，在85%至95%之间。直径大于15毫米的胆管结石取出困难，常需碎石治疗。经口胆管镜检查（POC）可进行碎石治疗，成功率相似。
确定胆管镜引导下碎石术与传统疗法相比，用于治疗难以取出的胆管结石的疗效和安全性。
检索基于医学文献数据库（Medline）、荷兰医学文摘数据库（Embase）、考科蓝中心对照临床试验注册库（Cochrane Central）、拉丁美洲和加勒比地区卫生科学数据库（Lilacs/Bireme）。纳入通过POC治疗难以取出的胆管结石患者的研究被视为合格。分别进行两项分析，一项纳入随机对照试验（RCT），另一项纳入观察性研究。
共筛选出46项研究（3项随机对照试验和43项观察性研究）。分析显示，内镜清除成功率（风险差=-0.02，可信区间：-0.17, 0.12/I²=0%）、平均透视时间（平均差=-0.14，可信区间-1.60, 1.32/I²=21%）和不良事件发生率（风险差=-0.06，可信区间：-0.14, 0.02/I²=0%）之间无统计学显著差异；相比之下，平均手术时间传统疗法更具统计学意义（平均差=27.89，可信区间：16.68, 39.10/I²=0%）。在观察性研究中，内镜清除成功率为88.29%（95%可信区间：86.9%-90.7%），首次内镜清除成功率为72.7%（95%可信区间：69.9%-75.3%），每次手术平均时间为47.50±6分钟，清除胆管结石所需手术次数为1.5±0.18次。不良事件发生率为8.7%（95%可信区间：7%-10.9%）。
对于复杂的胆总管结石，胆管镜引导下碎石术在治疗成功率、不良事件发生率和平均透视时间方面与传统内镜逆行胰胆管造影（ERCP）技术相似。传统ERCP方法的平均手术时间较短。
