Cappell M S
Department of Medicine, Maimonides Medical Center, Brooklyn, New York, USA.
Am J Gastroenterol. 1996 Sep;91(9):1827-31.
In the general population, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is preferable to surgery as therapy for gallstone pancreatitis and acute cholangitis. It is particularly attractive to perform therapeutic. ERCP for symptomatic choledocholithiasis after recent myocardial infarction because of the increased risk of the alternative therapy of cholecystectomy and choledochal exploration. However, after myocardial infarction, patients might theoretically be particularly susceptible to the cardiopulmonary risks of ERCP. The safety of therapeutic ERCP after myocardial infarction is unknown, with only one previously reported case. In a review of 11,367 patients with acute myocardial infarction at four hospitals, four patients (0.04%) underwent therapeutic ERCP after recent myocardial infarction, for indications of recent biliary pancreatitis in three of the patients and recent cholangitis in all four. Cholangitis occurred before, simultaneous with, or after myocardial infarction in the four cases. Initially, the cholangitis was managed medically in three patients. The fourth patient underwent cholecystostomy with local anesthesia. ERCP was performed at 15, 25, 30, or 56 days after myocardial infarction. Endoscopic cholangiography revealed multiple choledocholithiasis in all cases. The calculi were successfully extracted by endoscopic papillotomy and by sweeping the choledochus with a balloon-tipped catheter or basket in all cases. During ERCP, the vital signs remained stable; no cardiac arrhythmias or cardiovascular complications occurred. However, one patient developed mild pancreatitis after ERCP, which rapidly resolved with medical therapy. The four patients rapidly improved after ERCP, with normalization of serum levels of routine biochemical parameters of liver function. These four cases and the one prior case report demonstrate that therapeutic ERCP is not absolutely contraindicated after myocardial infarction and suggest that therapeutic ERCP is preferable to surgery for symptomatic choledocholithiasis after myocardial infarction because of the increased mortality of surgery after myocardial infarction.
在普通人群中，内镜逆行胰胆管造影术（ERCP）联合内镜括约肌切开术作为胆结石性胰腺炎和急性胆管炎的治疗方法比手术更可取。对于近期心肌梗死后有症状的胆总管结石，进行治疗性ERCP尤其具有吸引力，因为胆囊切除术和胆总管探查等替代疗法的风险增加。然而，理论上心肌梗死后的患者可能特别容易受到ERCP相关心肺风险的影响。心肌梗死后治疗性ERCP的安全性尚不清楚，此前仅有一例报告。在对四家医院的11367例急性心肌梗死患者进行的一项回顾中，有4例患者（0.04%）在近期心肌梗死后接受了治疗性ERCP，其中3例患者的指征为近期胆源性胰腺炎，4例患者均有近期胆管炎。这4例患者中，胆管炎发生在心肌梗死之前、同时或之后。最初，3例患者接受了药物治疗胆管炎。第四例患者在局部麻醉下进行了胆囊造瘘术。ERCP在心肌梗死后15、25、30或56天进行。内镜胆管造影显示所有病例均有多发胆总管结石。所有病例均通过内镜乳头切开术以及用球囊导管或网篮清扫胆总管成功取出结石。在ERCP过程中，生命体征保持稳定；未发生心律失常或心血管并发症。然而，1例患者在ERCP后发生了轻度胰腺炎，经药物治疗后迅速缓解。这4例患者在ERCP后迅速好转，肝功能常规生化指标的血清水平恢复正常。这4例病例和之前的1例病例报告表明，心肌梗死后治疗性ERCP并非绝对禁忌，并且提示由于心肌梗死后手术死亡率增加，对于近期心肌梗死后有症状的胆总管结石，治疗性ERCP比手术更可取。
