ERCP失败:超声内镜下胆囊引流作为第一选择?

时间:2020-02-25 作者:翻译:张卫 点击:521次
ERCP failure: EUS gallbladder drainage as first alternative?

ERCP失败:超声内镜下胆囊引流作为第一选择?

翻译:张卫    审校:张立超 侯森林
 
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is gaining popularity as an option for drainage of the gallbladder in patients suffering from acute cholecystitis who are at high risk forcholecystectomy. The procedure could also be used to convert permanent cholecystostomy to internal drainage. EUS-GBD has been shown bymultiple retrospective studies to be associated with reduced adverse events (AEs), reinterventions and readmissions.
因行胆囊切除术风险较高的急性胆囊炎患者,选择行超声内镜下胆囊穿刺引流术越来越受到欢迎。该方法也可用于将固有的胆囊造瘘术转化为内引流术。多项回顾性研究表明,EUS-GBD与减少不良事件(AEs)、再干预和再入院有关。
 
The advent of a cauterytippedlumen-apposing stent also significantly reduced the complexity of the procedure and allowed for creation of a secureanastomosis. In this issue ofEndoscopy International Open, Chang et al presented a series of nine patients who received EUS-GBD as a method of drainage in malignant biliary obstruction with failed ERCP . They reported a clinical success rate of 77.78%. One patient suffered from recurrent obstruction at 7 months after EUS-GBD and received EUS-guidedcholedochoduodenostomy.
双蘑菇头支架的出现也大大降低了手术的复杂性,并为安全吻合创造了条件。Chang等人在本期《Endoscopy International Open》中报道了9例采用EUS-GBD引流术治疗恶性胆道梗阻合并ERCP失败的患者。他们的临床成功率为77.78%。
1例于EUS-GBD术后7个月复发胆道梗阻并且行超声内镜下胆管十二指肠引流术。
 
Performance of EUS-GBD in the setting of malignant biliary obstruction (MBO) is similar to the principle of surgical cholecystojejunostomy. In the 1980s and 1990s, there was extensive debate in the surgical literature about whether cholecystojejunostomy or hepaticojejunostomy provided better palliation ofMBO.
There are several concerns about using the gallbladder as a conduit for biliary drainage. First, effectiveness of the biliary drainage depends on the patency of the cystic duct.
EUS-GBD在解决恶性胆道梗阻的作用上类似于外科手术中的胆囊空肠吻合术,在19世纪80-90年代,在外科界对于解决MBO是选择胆囊空肠吻合术还是肝管空肠吻合术饱受质疑。也存在一些担心对于把胆囊作为胆道引流的一个管道。首先,有效的胆道引流需要依靠胆囊管的开放。
 
In aretrospective study assessing incidence of patent cystic ducts on cholangiograms performed by endoscopic retrograde cholangiopancreatography (ERCP) in patients with MBO, only 50% of patients had a patent hepatocysticjunction . Furthermore, two-thirds of the remaining patients had obstructions less than 1cm from the hepatocystic junction, potentially increasing risk of future cystic duct obstruction. Results from multiple surgical series demonstrated that the overall rate of recurrent biliary obstruction was between 8% and 48%. Thus,proximity of the cystic duct opening to the site of obstruction may be a risk factor for recurrent obstruction。
在一项回顾性研究中,调查MBO的患者行ERCP的时胆囊管开口显影的发生率,发现仅仅有50%患者找到胆囊管的开口。甚至有2/3的患者胆道梗阻的位置与胆囊管开口的位置小于1cm,增加了胆囊管梗阻的潜在性风险。多个外科手术证实胆道梗阻总复发率为8%-48%,因此胆囊管的开口接近胆道梗阻的位置可能会增加再次胆道梗阻的风险。
 
EUS-guided biliary drainage (EUS-BD) can be achieved by a number of approaches, either transpapillary or transmurally. For transpapillary approaches, EUS-rendezvous ERCP or antegrade stenting could be performed. For transmural procedures, EUS-guidedcholedochoduodenostomy (CDS) and hepaticogastrostomy (HGS) could be performed.
超声内镜下胆道引流术(EUS-BD)可以通过多途径实现,无论是经乳头还是经粘膜。对于经乳头的途径而言,EUS会师ERCP或者顺行放置支架从而被实现胆道引流。对于经粘膜途径,超声内镜下引导的胆管十二指肠吻合和肝胃吻合术能够实现胆道引流。
 
Performance of these procedures during the learning curve can be associated with a risk of AEs. Performance of them by an endoscopist fluent in them is associated with procedural AE ratescomparable to that of ERCP. The availability of single-step devices for CDS and hepaticogastrostomy will further improve the ease and safety of performing these procedures.
在学习期间完成这些操作会带来一些不良事件,相对于ERCP解决胆道梗阻,熟练操作的内镜医师完成这些操作会有良好的效果。选择合适的设备完成CDS和肝脏与胃肠道的吻合将极大的提升操作的便捷性及安全行。
 
The benefit of transmural drainage is that the stent is placed in the bile duct far from the tumor, thus risk of tumor in-growth is significantly reduced. Indeed, a recent randomized study demonstrated that EUS-BD may provide higher stent patency rates and lower AE rates (particularly for pancreatitis) as compared to ERCP in unresectable MBO.
经粘膜的放置胆管支架的引流优势在于支架离肿瘤的位置较远,肿瘤长入支架内的风险要降低很多。的确,相对于ERCP无法实施胆道引流的MBO,最近一项随机对照试验研究证实,EUS-BD能够提供更好的支架通畅率和较低的不良事件发生率(特别是胰腺炎)。
 
Hence, in the presence of available expertise and devices, EUS-BD should still be the first choice for draining MBO. In the event that EUS-BD cannot be performed, EUS-GBD can then potentially provide another option for biliary drainage.
因此,在现有的知识和设备的情况下,EUS-BD应该被认为是解决MBO的第一选择,在EUS-BD无法实施的情况下,EUS-GBD可以作为提供胆道引流的另一潜在性的选择。