Kim M H, Myung S J, Kim Y S, Kim H J, Seo D W, Nam S W, Ahn J H, Lee S K, Min Y I
Dept. of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Endoscopy. 1998 Oct;30(8):697-701. doi: 10.1055/s-2007-1001391.
It is generally accepted that biliary sphincterotomy is mandatory to avoid possible cholestasis and infection due to edema after pancreatic sphincterotomy. However, biliary sphincterotomy is an invasive procedure and the above claim on dual sphincterotomy has not been proven by a prospective randomized study. The aim of our study was to determine whether cholangitis develops more frequently when the patients have not undergone concomitant biliary sphincterotomy during the endoscopic pancreatic sphincterotomy.
From January 1990 to November 1997, 60 patients (38 men, 22 women, age range 19-45 years) with non-alcoholic chronic calcifying pancreatitis were prospectively enrolled. The patients with jaundice (bilirubin > or = 3 mg/dl), cholangitis, or parenchymal liver disease were excluded. The patients were randomly subjected either to dual sphincterotomy (group I, n = 30) or to pancreatic sphincterotomy alone (group II, n = 30). Groups I and II were further classified as IA (or IIA) and IB (or IIB), according to the level of serum alkaline phosphatase (sALP) and the diameter of the common bile duct (CBD). Group IA (or IIA) was defined when abnormal in both sALP (> or = 2 times the upper limit of normal) and CBD diameter (> or = 12 mm), whereas group IB (or IIB) was defined when normal, or solely abnormal in sALP or CBD diameter.
As a complication after sphincterotomy, pancreatitis developed in one of eight patients (12.5%) in group IA, whereas cholangitis occurred in one of 22 (4.5%) and hemorrhage in one of 22 (4.5%) cases in group IB. By contrast, in group IIA, the cholangitis developed in 56% (five of nine patients), which was significantly more frequent than in any other groups (P < 0.05). Hemorrhage (one of 21, 4.8%) and pancreatitis (one of 21, 4.8%) occurred in group IIB.
Our results suggest that dual sphincterotomy may be indicated only in patients who have both dilated choledochus and elevated alkaline phosphatase in chronic pancreatitis. Routine biliary sphincterotomy may not be indispensable for pancreatic sphincterotomy.
人们普遍认为，为避免胰腺括约肌切开术后因水肿导致的胆汁淤积和感染，胆管括约肌切开术是必要的。然而，胆管括约肌切开术是一种侵入性操作，关于双重括约肌切开术的上述说法尚未得到前瞻性随机研究的证实。我们研究的目的是确定在内镜下胰腺括约肌切开术期间未同时进行胆管括约肌切开术的患者是否更易发生胆管炎。
1990年1月至1997年11月，前瞻性纳入60例非酒精性慢性钙化性胰腺炎患者（38例男性，22例女性，年龄范围19 - 45岁）。排除黄疸（胆红素≥3mg/dl）、胆管炎或实质性肝病患者。患者被随机分为双重括约肌切开术组（I组，n = 30）或仅行胰腺括约肌切开术组（II组，n = 30）。根据血清碱性磷酸酶（sALP）水平和胆总管（CBD）直径，I组和II组进一步分为IA（或IIA）和IB（或IIB）亚组。当sALP（≥正常上限的2倍）和CBD直径（≥12mm）均异常时定义为IA（或IIA）亚组，而当sALP或CBD直径正常或仅一项异常时定义为IB（或IIB）亚组。
作为括约肌切开术后的并发症，IA组8例患者中有1例（12.5%）发生胰腺炎，而IB组22例中有1例（4.5%）发生胆管炎，22例中有1例（4.5%）发生出血。相比之下，IIA组胆管炎发生率为56%（9例患者中有5例），显著高于其他任何组（P < 0.05）。IIB组发生出血（21例中有1例，4.8%）和胰腺炎（21例中有1例，4.8%）。
我们的结果表明，双重括约肌切开术可能仅适用于慢性胰腺炎中胆总管扩张且碱性磷酸酶升高的患者。常规胆管括约肌切开术对于胰腺括约肌切开术可能并非必不可少。
