Pereira Lima Julio Carlos, Moresco Giusepe Saifert, Sanmartin Ivan David Arciniegas, Contin Isabela, Pereira-Lima Guilherme, Watte Guilherme, Altmayer Stephan, Oliveira Dos Santos Carlos Eduardo
Department of Gastroenterology, Endoscopy Division, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital, Porto Alegre 90020-090, RS, Brazil.
Department of Biostatistics and Epidemiology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90619-900, RS, Brazil.
World J Gastrointest Endosc. 2022 Jul 16;14(7):424-433. doi: 10.4253/wjge.v14.i7.424.
Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.
To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.
Data from 1289 endoscopic retrograde cholangiopancreatography (ERCP) procedures were obtained from two prospective studies. While 258 cases had difficult stones (> 1 cm, multiple > 8, impacted, or having a thin distal duct), 191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy. Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number. Primary outcomes were clearance rate at first ERCP and complications.
Of the 191 patients (122 women and 69 men; mean age: 60 years) who underwent biliary dilation for difficult stones, 113 (59%) had a nondilated or tapered distal duct. Patients with a dilated distal duct were older than those with nondilated distal ducts (mean 68 and 52 years of age, respectively; < 0.05), had more stones (median 4 and 2 stones per patient, respectively; < 0.05), and had less need for additional mechanical lithotripsy (6.4% 25%, respectively; < 0.05). Clearance rate at first ERCP was comparable between patients with a dilated (73/78; 94%) and nondilated distal ducts (103/113; 91%). Procedures were faster in patients with a dilated distal duct (mean 17 24 min, respectively; < 0.005). Complications were similar in both groups (6.4% 7.1%, respectively).
Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.
当前指南建议不对远端胆管未扩张的患者进行乳头大球囊扩张术。
评估球囊扩张术在远端胆管未扩张患者中清除困难结石的可行性。
从两项前瞻性研究中获取了1289例内镜逆行胰胆管造影（ERCP）手术的数据。其中258例有困难结石（结石直径>1cm、多个结石>8个、结石嵌顿或远端胆管狭窄），191例在内镜括约肌切开术后进行了最大直径达15mm的胆管扩张。对这些病例的胆管造影进行回顾性分析，以对远端胆管以及结石大小和数量进行分类。主要结局指标为首次ERCP时的结石清除率和并发症。
在191例因困难结石接受胆管扩张的患者中（122例女性，69例男性；平均年龄60岁），113例（59%）远端胆管未扩张或呈锥形。远端胆管扩张的患者比未扩张的患者年龄更大（平均年龄分别为68岁和52岁；P < 0.05），结石更多（每位患者的结石中位数分别为4个和2个；P < 0.05），且更少需要额外的机械碎石术（分别为6.4%和25%；P < 0.05）。远端胆管扩张的患者与未扩张的患者首次ERCP时的结石清除率相当（分别为73/78，94%和103/113，91%）。远端胆管扩张的患者手术时间更短（平均分别为17分钟和24分钟；P < 0.005）。两组并发症相似（分别为6.4%和7.1%）。
对于远端胆管未扩张甚至呈锥形的患者，采用大球囊扩张术清除困难结石是可行的。
