Hammarström L E, Stridbeck H, Ihse I
Department of Surgery, University of Lund, Sweden.
Hepatogastroenterology. 1996 Jan-Feb;43(7):127-33.
BACKGROUND/AIMS: Endoscopic sphincterotomy is an established treatment of retained or recurrent common bile duct calculi after cholecystectomy and in the majority of patients with an intact gallbladder. In order to identify patients ultimately requiring additional endoscopic procedures or surgery, factors predictive of decreased endoscopic bile duct clearance were sought.
Between 1981 and 1992 endoscopic sphincterotomy was performed in 393 consecutive patients with either intact gallbladders (n = 246), recurrent (n = 92) or retained (n = 55) calculi.
There was a 9.4% overall early complication rate for the procedure and a 30-day mortality rate of 0.5% (two patients, non-procedure related). Complete removal of all bile duct calculi failed in 35/393 patients (8.9%). In patients with intact gallbladder the clearance rate at first attempt was higher (p = 0.002; Chi-square test) in the presence of solitary as compared to multiple stones. The same was found in patients with recurrent stones as well (p < 0.001). In non-cholecystectomized patients with single or multiple stones smaller than 10 mm, the clearance rate was higher at first (p = 0.02) as well as at final (p < 0.002) attempt as compared to patients with larger stones. Single small ( < 10 mm) compared to single large stones in patients with intact gallbladder had a higher clearance rate at final (p = 0.002) but not at first (p = 0.18) attempt. Patients with intact gallbladder and pancreatitis had higher clearance rate at first attempt compared to patients with jaundice (p = 0.001) or patients without concomitant pancreatobiliary disease (p = 0.002). Clearance rate was the same in patients with and without endoscopic sphincterotomy complications, except for patients with basket impaction, in whom the clearance rate was decreased (p = 0.02).
Thus, in patients with intact gallbladder surgery should be considered after failed complete bile duct clearance at first attempt.
背景/目的：内镜括约肌切开术是胆囊切除术后胆总管残留或复发结石以及大多数胆囊完整患者的既定治疗方法。为了确定最终需要额外内镜检查或手术的患者，我们寻找了预测内镜下胆管结石清除率降低的因素。
1981年至1992年期间，对393例连续患者进行了内镜括约肌切开术，这些患者要么胆囊完整（n = 246），要么结石复发（n = 92）或残留（n = 55）。
该手术的总体早期并发症发生率为9.4%，30天死亡率为0.5%（2例患者，与手术无关）。35/393例患者（8.9%）未能完全清除所有胆管结石。在胆囊完整的患者中，与多发结石相比，单发结石患者首次尝试时的结石清除率更高（p = 0.002；卡方检验）。复发结石患者中也发现了同样的情况（p < 0.001）。与结石较大的患者相比，在未行胆囊切除术且结石单个或多个且小于10 mm的患者中，首次（p = 0.02）以及最终（p < 0.002）尝试时的结石清除率更高。胆囊完整的患者中，与单发大结石相比，单发小（< 10 mm）结石患者最终（p = 0.002）而非首次（p = 0.18）尝试时的结石清除率更高。与黄疸患者（p = 0.001）或无胰胆疾病患者（p = 0.002）相比，胆囊完整且患有胰腺炎的患者首次尝试时的结石清除率更高。除了网篮嵌顿的患者结石清除率降低（p = 0.02）外，有内镜括约肌切开术并发症和无并发症的患者结石清除率相同。
因此，对于胆囊完整的患者，如果首次尝试未能完全清除胆管结石，应考虑手术治疗。
