Maxton D G, Tweedle D E, Martin D F
Am J Gastroenterol. 1996 Mar;91(3):615-6.
Maxton and colleagues report their experience using biliary endoprostheses for treatment of failed common bile duct stone clearance after sphincterotomy. Of 283 patients with choledocholithiasis referred to their tertiary facility, 85 failed to have their ducts cleared with the first ERCP. There were 21 male and 64 female subjects; mean age was 77.5 yr. Clinical presentations were jaundice (39), cholangitis (23), and biliary colic and/or abnormal liver blood tests in the remainder. The patients were characterized as "elderly and ill with either jaundice or cholangitis present in almost 75%." Follow-up data were obtained for all patients. ERCP was first performed using a duodenoscope with a 3.2-mm instrument channel. A 7-French double pigtail stent was placed in each of the 85 patients with retained stones. Subsequent ERCP were performed at 2- to 3-month intervals using a therapeutic duodenoscope (4.2-mm instrument channel). A second stent was placed if stones remained in the bile duct after repeated extraction attempts. Patients deemed too frail and elderly for frequent ERCP had their first stent left in place, with stent exchanges and attempts at stone extraction every 6-12 months. Mechanical lithotripsy was used in 23 patients, extracorporeal shock wave lithotripsy (ESWL) in 11, and dissolution therapy via nasobiliary catheter in 10. Acute illnesses resolved in 84 of 85 patients, with significant decreases in bilirubin and alkaline phosphatase levels by the second ERCP. Six patients died with temporary stents in situ, one form a respiratory arrest the day of ERCP; the other deaths were unrelated to ERCP or choledocholithiasis. Fifty of the remaining 79 patients had successful stone clearance; 68% of these required two ERCP, 20% three ERCP, 6% four ERCP, and, in another 6%, a total of five ERCP were required before their ducts were free of stones. Seven cases of cholangitis among these 50 patients were treated successfully with i.v. antibiotics, fluids, and "early" stent replacement. Twenty-six patients had long term biliary drainage with the original stents in situ over 12 months. Four of these patients were among the six deaths, all unrelated to biliary stones or ERCP. Three patients were referred for surgical stone removal. The authors conclude that placement of a single 7-French stent after failure to clear common duct stones is safe, provides affective biliary drainage, can prevent the need for urgent surgical intervention, and allows for transfer of sick patients to centers of expertise. Further attempts at bile duct clearance were successful in most cases.
马克斯顿及其同事报告了他们使用胆道内支架治疗括约肌切开术后胆总管结石清除失败的经验。在转诊至他们三级医疗机构的283例胆总管结石患者中，85例首次内镜逆行胰胆管造影（ERCP）未能清除胆管结石。其中男性21例，女性64例；平均年龄77.5岁。临床表现为黄疸（39例）、胆管炎（23例），其余患者表现为胆绞痛和/或肝功能检查异常。这些患者的特点是“年老体弱，近75%伴有黄疸或胆管炎”。所有患者均获得了随访数据。首次ERCP使用的是器械通道为3.2毫米的十二指肠镜。85例残留结石患者均置入了一根7法式双猪尾支架。随后每隔2至3个月使用治疗性十二指肠镜（器械通道为4.2毫米）进行ERCP。如果反复取石尝试后胆管内仍有结石，则置入第二根支架。对于那些被认为过于虚弱和年老而无法频繁进行ERCP的患者，将其第一根支架留在原位，每6至12个月进行支架更换和取石尝试。23例患者使用了机械碎石术，11例使用了体外冲击波碎石术（ESWL），10例通过鼻胆管导管进行了溶石治疗。85例患者中有84例急性疾病得到缓解，第二次ERCP时胆红素和碱性磷酸酶水平显著下降。6例患者在临时支架在位时死亡，1例在ERCP当天因呼吸骤停死亡；其他死亡与ERCP或胆总管结石无关。其余79例患者中有50例成功清除结石；其中68%的患者需要进行两次ERCP，20%需要三次ERCP，6%需要四次ERCP，另有6%的患者在胆管结石清除前总共需要进行五次ERCP。这50例患者中有7例胆管炎通过静脉注射抗生素、补液和“早期”支架置换成功治愈。26例患者使用原支架进行了超过12个月的长期胆道引流。这26例患者中有4例在6例死亡患者之中，所有死亡均与胆石症或ERCP无关。3例患者被转诊进行手术取石。作者得出结论，胆总管结石清除失败后置入一根单一7法式支架是安全的，能提供有效的胆道引流，可避免紧急手术干预的需要，并允许将病情较重的患者转至专业中心。在大多数情况下，进一步的胆管结石清除尝试是成功的。
