超声内镜引导下经胃经肝胆管穿刺置支架术的最佳胆道穿刺点及学习曲线

超声内镜引导下经胃经肝胆管穿刺置支架术的最佳胆道穿刺点及学习曲线
Dongwook Oh, Do Hyun Park, Tae Jun Song, Sang Soo Lee, Dong-Wan Seo, Sung Koo Lee and Myung-Hwan Kim
翻译 王浩 审校 张立超 侯森林
摘要
背景：虽然超声内镜引导下经胃经肝胆管穿刺（EUS-HGS）并置入支架作为一项胆管减压术在乳头难以触及的病人中的应用有所增加，但EUS-HGS的最佳胆道穿刺点和学习曲线还未被研究。我们评估了操作成功的EUS-HGS的最佳胆道穿刺点和学习曲线。
 
方法：纳入了129例因乳头不可触及而行EUS-HGS的病人（男性81例，62.3%；恶性113例，87.6%）。根据EUS-HGS操作时的每次穿刺尝试来前瞻性监测记录EUS结果和操作时间。分别采用移动平均法和累积和分析法计算两种主要记录结果（手术时间和不良事件）的EUS-HGS学习曲线。分别用移动平均法和累积和（CUSUM）分析计算两种主要观察指标(手术时间和不良事件)的EUS-HGS学习曲线。
 
结果：129例患者共进行了174次EUS-HGS。平均穿刺数为1.35±0.57。采用logistic回归模型，穿刺部位胆管直径⩽5mm[比值比（OR）3.7，95%可信区间（CI）：1.71-8.1，p<0.01]和经肝段长度[EUS下胃壁到所穿刺胆管壁的直线距离；平均经肝段长度为27mm（范围10-47mm）]>3cm（OR 5.7，95%可信区间：2.7-12，p<0.01）与低成功率相关。在进行24例手术后手术时间和不良事件会相对缩短和减少，当进行33例EUS-HGS后会逐渐稳定。
结论：我们的数据表明胆管直径>5mm，经肝段长度1cm～3cm可能是EUS-HGS成功的最佳选择。根据我们的学习曲线分析，当进行33例以上后可能会达到EUS-HGS操作成功的平台期。
Optimal biliary access point and learning curve for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting
Abstract
Background: Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) with transmural stenting has increased for biliary decompression in patients with an inaccessible papilla, the optimal biliary access point and the learning curve of EUS-HGS have not been studied. We evaluated the optimal biliary access point and learning curve for technically successful EUS-HGS.
Methods: 129 consecutive patients (male n = 81, 62.3%; malignant n = 113, 87.6%) who underwent EUS-HGS due to an inaccessible papilla were enrolled. EUS finding and procedure times according to each needle puncture attempt in EUS-HGS were prospectively measured. Learning curves of EUS-HGS were calculated for two main outcome measurements (procedure time and adverse events) by using the moving average method and cumulative sum (CUSUM) analysis, respectively.
Results: A total of 174 EUS-HGS attempts were performed in 129 patients. The mean number of needle punctures was 1.35 ± 0.57. Using the logistic regression model, bile duct diameter of the puncture site ⩽ 5 mm [odds ratio (OR) 3.7, 95% confidence interval (CI): 1.71–8.1, p < 0.01] and hepatic portion length [linear distance from the mural wall to the punctured bile duct wall on EUS; mean hepatic portion length was 27 mm (range 10–47 mm)] > 3 cm (OR 5.7, 95% CI: 2.7–12, p < 0.01) were associated with low technical success. Procedure time and adverse events were shorter after 24 cases, and stabilized at 33 cases of EUS-HGS, respectively.
Conclusions: Our data suggest that a bile duct diameter > 5 mm and hepatic portion length  1 cm to ⩽ 3 cm on EUS may be suitable for successful EUS-HGS. In our learning curve analysis, over 33 cases might be required to achieve the plateau phase for successful EUS-HGS.