ERCP相关十二指肠穿孔诊治的经验和教训  

ERCP-related duodenal perforation

作　　者：毛志海[1] 吴卫泽[1] 王建承[1] 王明亮[1] 李健文[1] 陆爱国[1] 孙延军[1] 郑民华[1] 

机构地区：[1]上海交通大学医学院附属瑞金医院外科上海市微创外科临床医学中心,上海200025

出　　处：《外科理论与实践》2007年第6期562-565,共4页Journal of Surgery Concepts & Practice

摘　　要：目的:ERCP相关的十二指肠穿孔虽然发生率低,但死亡率很高,诊断是否及时、处理是否得当直接关系到这一严重并发症的预后。本文结合文献资料及我院的具体病例,总结与ERCP有关的十二指肠穿孔方面的经验和教训。方法:回顾我院2003年至2006年间所进行的2450例ERCP操作,有9例病人发生了十二指肠穿孔,发生率为0.37%。本文将具体分析相关的基础疾病、ERCP操作情况、穿孔的诊断、治疗手段及治疗效果。结果:7例病人经B超、MRCP或术中造影证实有胆总管结石,2例肝功能异常伴胆管扩张,怀疑胆总管结石;ERCP操作中除2例乳头插管顺利外,其余7例插管困难,运用预切开技术后6例插管成功;除3例穿孔明显的病例外,其余6例取石成功,并留置鼻胆管;穿孔的主要诊断依据为:腹膜炎2例,皮下气肿7例。3例病人进行了急诊手术,切除胆囊,胆总管切开取石后留置T管,并游离十二指肠,在后腹膜间隙放置引流;其中1例因为引流不畅,后腹腔脓肿形成而再次清创引流,平均住院50d。另外6例采用了非手术治疗,禁食,胃肠减压,鼻胆管引流,抗菌抑酶止酸;治疗过程中某些病人有局限性腹痛和发热,但无加重趋势,无病人中转治疗,平均住院13d。无死亡病例。结论:预切开技术应用不当可能导致十二指肠穿孔;皮下气肿是较为敏感的穿孔指标;如果能够早期及时诊断,非手术治疗一般能取得良好结果,建立通畅的胆道和胃肠引流是治疗成功的关键。Objective To summarize the experiences of periduodenal perforation during endoscopic retrograde cholangiopancreatography （ERCP） and endoscopic sphincterotomy （EST） procedures, Methods The clinical data from 2 450 ERCP/EST procedures,from 2003 to 2006,were analyzed retrospectively; among which 9 patients （0,37%） developed perlduodenal perforation. Charts were reviewed focusing on the following parameters： clinical presentation, ERCP findings, diagnostic methods,theraputic strategies （surgical or conservative）, complications and outcome, Results Of all the 9 patients,7 were confirmed to have common bile duct stones,2 had abnormal liver functions and dilatation of the biliary tract being suspected to have bile duct stones. Cannulation was considered difficult in 7 patients and precut sphincterotomy was employed in 6 of them.Diagnosis was made by presence of subcutaneous emphysema in 7 and signs of peritonitis in 2. Three patients were converted to emergency open surgery （external biliary drainage or retroperitoneal drainage）, while one of them underwent reoperation because of retroperitoneal abscess;their median length of hospital stay was 50 days . The other 6 were treated conservatively with naso-duodenal and naso-biliary drainage;their median length of hospital stay was 13 days. There was no mortality. Conclusions Precut sphincterotomy may be a potential risk factor of duodenal perforation. Early diagnosis of duodenal perforation is essential for optimal outcome. Subcutaneous emphysema could probably be considered as a sensitive sign, Management of perforation after ERCP/EST is still a controversial problem. Duodenal and biliary drainage are essential measures both during surgical and conservative management.

关 键 词：胰胆管造影术 内窥镜逆行 十二指肠穿孔 手术中并发症 诊断 

分 类 号：R656.7[医药卫生—外科学]