Fueldner Frank, Meyer Frank, Will Uwe
Klinik für Gastroenterologie, Hepatologie und Allgemeine Innere Medizin, SRH Wald-Klinikum Gera gGmbH, Gera.
Universitätsklinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A.ö.R. Magdeburg; Deutschland.
Z Gastroenterol. 2020 Nov;58(11):1081-1090. doi: 10.1055/a-1250-8834. Epub 2020 Nov 16.
To investigate feasibility and outcome the novel and favorable option of an endoscopic ultrasonography(EUS)-guided antegrade or even retrograde gall stone extraction via a transhepatic route in patients (pats.) with no option for the usual gold standard, ERCP.
MATERIAL/METHODS: All consecutive pats. with cholangiolithiasis and surgically altered anatomy of the upper GI tract with and without previous attempts of an ERCP were enrolled in this unicenter case study and were characterized with regard to the technical and clinical success of this approach.
From 2004 to 03/2020, overall 449 pats. underwent EUS-guided cholangiodrainage (n = 37 pats. with cholangiolithiasis). In 8 of these 37 pats., gall stone extraction was achieved using EUS-ERCP rendezvous technique (not included in the study since there was no surgically altered anatomy of the upper GI tract). In 13 of the remaining 29 subjects (45 %), there was a failure of previous attempts to reach the papilla of Vater or biliodigestive anastomosis using balloon-enteroscopy-guided ERCP. EUS-guided access to the biliary system was achieved in all 29 pats. Stone extraction was performed in 26 individuals (90 %) by means of antegrade push-technique after balloon dilatation of the papilla of Vater and biliodigestive anastomosis, respectively, before. In 11/29 cases (42 %), double pigtail prostheses were subsequently placed to track papilla of Vater/biliodigestive anastomosis ("ring drainage"), which were removed with gastroscopy three months later after previous ultrasound- and lab parameter-based follow-up control. In two pats. (7 %), gall stones were extracted via a retrograde route using a transhepatic access site; in one patient (3 %), stones were removed by means of a combined ante-/retrograde technique. In two subjects (7 %), cholangioscopy with electrohydraulic lithotripsy was used.Technical as well as clinical success rate was 100 % (29 of 29 pats.). Re-interventions became necessary in 6/29 cases (21 %), complications occurred in 6 individuals (21 %).
EUS-guided stone extraction in antegrade or retrograde technique for pats. with surgically altered anatomy of the upper GI tract can be considered a favorable and safe but challenging approach of interventional endoscopy/EUS. It can provide high technical and clinical success and low complication rates; it has the potential to substitute the time-consuming balloon-enteroscopy-guided ERCP as well as, in particular, PTCD and, thus, secundary and tertiary therapeutic alternatives.
探讨对于那些无法采用常规金标准——内镜逆行胰胆管造影术（ERCP）的患者，经肝途径进行内镜超声（EUS）引导下顺行甚至逆行胆结石取出这一新颖且有益方法的可行性及结果。
材料/方法：本单中心病例研究纳入了所有连续性患有胆管结石且上消化道解剖结构经手术改变的患者，无论其之前是否尝试过ERCP，并对该方法的技术和临床成功情况进行了特征描述。
2004年至2020年3月，共有449例患者接受了EUS引导下胆管引流（其中37例患有胆管结石）。在这37例患者中，8例使用EUS-ERCP会师技术成功取出胆结石（因上消化道无手术改变的解剖结构，未纳入本研究）。在其余29例患者中的13例（45%），之前使用气囊小肠镜引导的ERCP尝试到达 Vater壶腹或胆肠吻合口失败。所有29例患者均成功实现了EUS引导进入胆道系统。在分别对Vater壶腹和胆肠吻合口进行气囊扩张后，26例患者（90%）通过顺行推注技术成功取出结石。在11/29例（42%）病例中，随后放置了双猪尾支架以追踪Vater壶腹/胆肠吻合口（“环形引流”），在基于超声和实验室参数的随访控制3个月后，通过胃镜将其取出。2例患者（7%）经肝穿刺部位采用逆行途径取出胆结石；1例患者（3%）通过顺行/逆行联合技术取出结石。2例患者（7%）使用了带有电液压碎石术的胆管镜检查。技术成功率和临床成功率均为100%（29例患者中的29例）。6/29例（21%）病例需要再次干预，6例患者（21%）出现并发症。
对于上消化道解剖结构经手术改变的患者，EUS引导下顺行或逆行技术取石可被视为介入性内镜检查/EUS中一种有益且安全但具有挑战性的方法。它可实现较高的技术成功率和临床成功率以及较低的并发症发生率；有可能替代耗时的气囊小肠镜引导的ERCP，特别是经皮肝穿刺胆管引流术（PTCD），从而成为二级和三级治疗选择。
