十二指肠镜在高龄高危急性重症胆管炎时应用价值  

The application value of duodenum laparoscopy in elder patients with acute cholangitis of severe type

作　　者：周鸣清[1] 陆仁达[1] 陈欣然[1] 

机构地区：[1]上海市闸北区中心医院外科,上海200070

出　　处：《世界感染杂志》2007年第2期120-122,共3页World Journal of Infection

摘　　要：目的探讨十二指肠镜在高龄高危急性重症胆管炎（ACST）时的应用价值。方法应用十二指肠镜微创治疗高龄高危重症急性胆管炎45例，全组病人年龄均为70a以上，符合ACST诊断标准。病人首先行ERCP检查，明确胆道梗阻原因，梗阻部位，了解结石的大小，数目和位置。如发现晚期胆胰肿瘤导致阻塞性黄疸，先行鼻胆管5I流术（ENBD），然后择期行胆道塑料支架（ERBD）或胆道金属支架（EMBD）植入术。如发现胆道结石，可应用电刀切开乳头括约肌，而后在电透下应用取石网篮、碎石器、胆道扩张球囊和取石球囊逐一取出结石。对于乳头水肿明显、胆总管下端狭窄、乳头旁憩室畸形和胆道多发、巨大结石未能取净或胆道胰腺感染严重，取石后均放置ENBD，并保证鼻胆管引流通畅。对于病情危重，伴休克或心脏、肾脏、肝脏严重衰竭，不能耐受较长时间治疗的病人，采取分次治疗，先行ENBD术，择期再行进一步治疗。结果45例ACST病人ERCP全部成功，诊断为胆道结石40例，其中乳头结石嵌顿者5例，一次同时完成十二指肠乳头切开术（EST）＋胆道碎石取石＋ENBD并治愈者26例。对于病情危重采取分次治疗19例，其中14例先行ENBD引流术，1wk后病情平稳再行内镜下取石治疗。而5例胆胰肿瘤胆道梗阻病人，先行ENBD，病情稳定后再行内镜下胆道内支架植入术。结论应用十二指肠镜治疗高龄高危急性重症胆管炎（ACST）是一种安全有效的临床治疗方法，可明显降低并发症和死亡率。Objective To exploere the application value of laparoscopy in elder patients with acute cholangitis of severe type （ACST）. Methods Laparoscopy was used to treat 45 elder ACST patients. All patients were older than 70 years old and accordant with the ACST diagnosis criteria. Patients received ERCP first to explore the reasons and locations of biliary obstruction, the sizes, numbers and locations of gallstones. If the obstruction jaundice were induced by late gall and pancreas tumor, endoscopic nasobiliary drainage （ENBD） was performed first, then endoscopic retro-grade biliary drainage （ERBD） or endoscopic metal biliary drainage （EMBD） were performed selectively. If gallstones were found, sphinctemtomy was performed by electrocautery, then basket for take stone, lithotripter, biliary dilation balloon and ballon for take stone were used to take gallstones under electro perspective. If patients with obvious duodenum edema, narrow lower bile duct, multi and large stones, sever bile and pancreas infections, ENBD were placed and nasobiliary drainage were smooth. For severe patients complicated by shock or failure of heart, kidney or liver, and patients who could not tolerate long time treatment, ENBD was performed first and then further treatment selectively. Results ERCP in 50 patients were succeeded. Forty patients were diagnosed as biliary stone, and 5 cases were incarcerated sphinclemtomysphincter stones, and 26 cases were completed by endoscopic sphincterotomy （EST）, biliary lithotrity and ENBD. 19 severe patients were treated step by step; 14 cases were performed with ENBD ftrst, and then stone-taking were performed under endoscopy after one week; 5 biliary obstruction by gallbladder/pancreas tumor were performed with ENBD, then endoscopic biliary stent implantation were performed when illness were stable. Conclusion Treatment of elder ACST with laparoscopy is a kind of safe and effective method, and can reduce complications and mortality significantly.

关 键 词：内镜 ERCP 治疗 高龄病人 胆管炎 

分 类 号：R575.7[医药卫生—消化系统]