初次ERCP选择性胆管插管困难的研究进展

Research progress of difficult selective biliary cannulation in the first ERCP session

摘要:

内镜逆行胰胆管造影术（ERCP）是最具技术挑战性的治疗性内镜操作之一，ERCP成功的首要条件是胆管插管，常规标准胆管插管技术的成功率约为75%~85%，但仍有8.1%的患者出现胆管插管困难。目前关于插管困难的定义尚无统一的国际共识，大多数研究根据插管尝试次数和（或）插管时间来定义胆管插管困难。插管困难的发生取决于患者解剖结构（如憩室内乳头、粗而长的十二指肠乳头、胆胰管汇合异常等）、疾病特定因素（如十二指肠乳头或壶腹肿瘤、消化道重建术后的胆管取石等）以及操作者经验等不可控因素。插管困难与ERCP术后不良事件的增加密切相关，其中ERCP术后胰腺炎（PEP）是最常见且最严重的并发症。因此，对PEP高危人群进行早期危险分层是至关重要的，目前有越来越多的学者致力于开发具有临床实用性的PEP风险预测评分系统。当发生插管困难时，应用先进的辅助插管技术可将总体胆管插管成功率提高到95%，目前常用的基于ERCP的辅助插管技术主要有双导丝技术、胰管支架占据法导丝引导插管、经胰管括约肌预切开术、针刀乳头预切开术、针刀瘘管预切开术。这些先进的辅助插管技术也增加了并发症发生风险，并且技术的实施受限于十二指肠乳头的解剖形态、导丝进入胰管的情况以及操作者的技术水平等不同因素。当应用上述先进的辅助插管技术仍导致插管失败时，可考虑及时终止手术，数天后行第2次ERCP联合经皮肝穿刺胆道引流、经皮经肝胆囊穿刺引流及较新颖的内镜超声引导（EUS）下胆道穿刺引流术、EUS引导会合术以及EUS引导顺行干预术等措施。本文旨在阐述胆管插管困难的定义、相关风险因素以及不良影响，对不同辅助插管技术的安全性及有效性进行重点回顾比较，并从不同的胆管插管困难场景出发阐述不同辅助插管技术的选择应用。本文还介绍了初次ERCP胆管插管失败后的替代措施及选择依据，以期能对临床建立规范化ERCP插管程序提供参考。

Abstract:

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most technically challenging therapeutic endoscopic procedures. The primary condition for successful implementation of ERCP is biliary cannulation, which has a success rate of about 75%-85% with conventional standard biliary cannulation technique, but there is still 8.1% of patients with difficult biliary cannulation. At present, there is no unified international consensus on the definition of difficult cannulation, and most studies define difficult biliary cannulation based on the number of cannulation attempts and/or duration of cannulation. The occurrence of difficult cannulation depends on some uncontrollable factors such as patient anatomy (eg, diverticulum papilla, thick and long duodenal papilla, abnormal confluence of biliopancreatic duct, etc.), disease-specific factors (eg, duodenal papilla or ampulla tumor, biliary lithoyomy after digestive tract reconstruction, etc.), and operators' experience. Difficult cannulation is closely associated with the increase of adverse events after ERCP, of which post-ERCP pancreatitis (PEP) is the most common and serious complication. Therefore, early risk stratification of population with high-risk of PEP is crucial. At present, an increasing number of scholars are attempting to develop clinically practical PEP risk prediction score systems. When difficult intubation is encountered, the overall success rate of bile duct intubation can be increased to 95% by using advanced rescue intubation techniques. The current commonly used rescue intubation techniques based on ERCP mainly include double-guidewire technique, wire-guided cannulation over a pancreatic stent, transpancreatic precut sphincterotomy, needle-knife precut papillotomy, and needle-knife precut fistulotomy. However, these advanced techniques also increase the risk of complications and their implementations are limited by factors such as the anatomical structure of the duodenal papilla, the process of the guidewire insertion into the pancreatic duct, and the skill level of the surgeon. If cannulation still fails despite the use of above-mentioned rescue intubation techniques, the operation should be terminated immediately and a second ERCP should be considered to be performed a few days later, in combination with the measures such as percutaneous transhepatic cholangial drainage, percutaneous transhepatic gallbladder drainage, and the newer endoscopic ultrasound (EUS)-guided interventions, EUS-guided rendezvous or EUS-guided anterograde interventions. The purpose of this paper is to describe the definition, related risk factors and adverse impacts of difficult cannulation, to review and compare the safety and effectiveness of different rescue intubation techniques, and to discuss the selection and application of different rescue intubation techniques from different difficult intubation scenarios. In addition, this article also introduces the alternative measures and the selection basis after the failed cannulation in the first ERCP procedure, so as to provide a reference for the establishment of standardized ERCP intubation procedure in clinical practice.