Long-term Biliary Stenting for the Management of Irretrievable Common Bile Duct Stones

長期置入膽管支架對摘除困難總膽管結石之處理

孫灼基(Cheuk-Kay Sun) ； 陳瑞灝(Jui-Hao Chen) ； 廖朝聖(Chao-Sheng Liao) ； 黃樹人(Shu-Jen Huang) ； 楊國卿(Kuo-Ching Yang)

《臺灣消化醫學雜誌》 19卷4期 (2002/12) Pp. 243-249

https://doi.org/10.6557/GJT.200212_19(4).0001

摘要

內視鏡乳突切開術取石法已被廣泛用於治療總膽管結石，此方式對總膽管結石的清除率約為85至90%。但有少數的膽道結石不易經由內視鏡法取出，因年齡太大或具有其它重大內科疾病，使接受外科手術具高危險性，此時使用支架引流不失為另一種可行的辦法。本研究是分析使用支架引流膽道結石病患之長期追蹤，進而探討其併發症及存活率。自1996年6月至2001年10月，共有40位膽道結石病患因內視鏡取石治療失敗，而接受總膽管7F雙豬尾巴支架引流。其中23位病患因為內視鏡取石困難，同時具有高手術危險性，而接受了膽管支架長期引流治療，其中3位在追蹤過程中失去聯絡，其餘20人（13男，7女，中值年齡80歲）中，4人於支架引流術前已接受膽囊切除，16人膽囊與支架並存，其中11人合併膽囊結石。於追蹤l至58月（中值18月）期間內，20位病患中，有7位（35%）在接受引流後之l至20個月（中值8月）產生膽管炎，其中6位成功地接受非外科內視鏡治療，另l人因膽管炎合併敗血症及肝腎症候群死亡。在合併膽囊結石與支架並存之11人中，1人(9%)於支架引流後31月發生急性膽囊炎，之後成功地接受外科手術治療。本研究發現膽管炎是唯一之併發症，且能以非手術方式處理。膽囊結石並非長期放置膽管支架之禁忌症。因為持久性膽管支架引流具低死亡率(5%)及可接受之罹病率，對於內視鏡取石困難且具有高手術危險性之病患，膽管支架引流治療是另一選擇。

關鍵字

膽管炎 ； 總膽管結石 ； 內視鏡乳突切開術 ； 膽管支架

並列摘要

Endoscopic sphincterotomy and stone extraction has been accepted as an effective therapeutic option for common bile duct stones which can be cleared in up to 85% to 90% of patients. When endoscopic sphincterotomy or stone extraction fails and surgery is hazardous to patients with associated medical problems and/or old age, insertion of biliary stent is also an alternative. The aim of this study was to investigate all the complications and outcomes during a long-term follow up of patients who underwent endoscopic stenting for irretrievable common bile duct stones. From June 1996 to October 2001, we recruited 40 patients who underwent biliary stenting for irretrievable common bile duct stone. Among them, biliary stents were inserted permanently in 23 patients who were unsuitable for surgery. Three patients were lost to follow-up. Of these 20 patients (13 male, 7 female, median age 80 years; range 54-97), 4 had received cholecystectomy before, and 11 of the remaining 16 patients with an intact gall-bladder had gallstones. During a median follow-up period of 18 months (range: 1 to 58 months), 7 of the 20 patients (35%) got cholangitis 1 to 20 months (median 8 months) after 7-French double-pigtail biliary stenting. Six of them were managed endoscopically without surgical treatment. One patient (5%) died of cholangitis with sepsis and hepatorenal syndrome. Among the 11 patients with intact gall-bladder and gallstones, acute cholecystitis developed in one patient (9%) 31 months after stenting, who then received surgical intervention with success. In this study, the only significant complication encountered was cholangitis which could be managed without resorting to operative intervention. The presence of intact gall-bladder with calculi is not a contraindication for stenting on a long-term basis. Because of the lower stent-related mortality (5%), endoscopic stenting is a reasonable mode of therapeutic alternative for elderly and surgically unfit patients with irretrievable common bile duct stones.

並列關鍵字

cholangitis ； choledocholithiasis ； endoscopic sphincterotomy ； stent