Analysis of risk factors of recurrence of common bile duct stones after endoscopic retrograde cholangiopancreatography
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摘要: 目的 研究经内镜逆行胰胆管造影术(ERCP)中改良的内镜括约肌切开术(sEST)联合内镜乳头气囊扩张术(EPBD)术后胆总管结石复发的相关危险因素，为临床监测提供参考依据。方法 回顾性分析2018年1月—2020年4月就诊于青岛大学附属烟台毓璜顶医院并行sEST+EPBD取石治疗的胆总管结石患者的临床资料。共入组406例患者，根据ERCP胆总管取石术后胆总管结石是否复发分为复发组(n=140)和无复发组(n=266)，对可能影响胆总管结石复发的相关因素进行多因素分析。结果 经过平均37.65个月的随访，发现406例sEST+EPBD取石术后胆总管结石复发患者共140例，结石复发率为34.5%。糖尿病、年龄、初次病程、谷丙转氨酶、胆道感染、胆囊状态、胆总管直径、多发结石(结石个数≥2)、大的胆总管结石(最大胆总管结石直径≥12 mm)、泥沙样结石、机械碎石的应用及胆道支架植入为ERCP取石术后胆总管结石复发的危险因素(P < 0.05)；糖尿病、年龄≥65岁、首次病程>3 d、胆道感染、胆囊切除、结石数量≥2个是ERCP术后胆总管结石复发的独立危险因素。结论 糖尿病、年龄≥65岁、首次病程>3 d、胆道感染、胆囊切除、结石数量≥2个是ERCP术后胆总管结石复发的独立危险因素。Abstract: Objective To investigate the related risk factors of recurrent common bile duct(CBD) stones after small endoscopic sphincterotomy combined with endoscopic papillary balloon dilation(sEST+EPBD), then provide a reference for clinical mornitoring.Methods A retrospective analysis was made of 406 patients with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography from January 2018 to April 2020. According to the recurrence of CBD stones, the patients were divided into a recurrence group(n=140) and a non-recurrence group(n=266), and a multivariate analysis was performed to determine the factors that might influence recurrence of choledocholithiasis.Results A total of 406 patients were followed up with a mean duration of 37.65 months, with 140 patients in recurrent group, the recurrence rate is 34.5%. Diabetes, age, initial course of disease, alanine aminotransferase(ALT), biliary duct infection, history of cholecystectomy, diameter of CBD stones, multiple choledocholithiasis(≥2), the diameter of choledocholithiasis≥12 mm, muddy stone, mechanical lithotripsy under endoscope, and CBD stones stent implantation were risk factors for recurrence of choledocholithiasis after ERCP(P < 0.05). Multivariate analysis showed that diabetes, age≥65 years, initial course of disease>3 d, biliary duct infection, history of cholecystectomy and multiple choledocholithiasis(≥2) were the independent risk factors for recurrence of choledocholithiasis after ERCP(P < 0.05).Conclusion This study confirmed that diabetes, age ≥65 years, initial course of disease>3 d, biliary duct infection, history of choledochotomy and multiple choledocholithiasis(≥2) were independent risk factors for recurrence of CBD stones after ERCP.
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表 1 复发组与无复发组一般资料对比
例，M(P25，P75) 一般资料 复发组(n=140) 无复发组(n=266) Z/χ2 P 吸烟(是/否) 26/114 60/206 0.872 0.350 饮酒(是/否) 26/114 40/226 0.841 0.359 高血压(是/否) 53/87 85/181 1.424 0.233 糖尿病(是/否) 30/110 32/234 6.262 0.012 性别(男/女) 76/64 148/118 0.068 0.794 年龄/岁 71.00(63.00，80.00) 62.00(53.75，69.00) -7.121 ＜0.001 首次病程/d 9.50(3.00，32.00) 4.00(1.00，10.00) -5.562 ＜0.001 ALT/(U·L-1) 95.00(39.25，173.50) 131.00(36.00，251.50) -2.001 0.045 AST/(U·L-1) 57.00(27.25，114.00) 70.50(28.75，163.25) -1.444 0.149 GGT/(U·L-1) 320.00(86.25, 558.25) 375.50(131.00，701.25) -0.991 0.322 ALP/(U·L-1) 162.50(94.50，231.50) 143.50(89.00，230.75) -0.883 0.377 TBil/(μmol·L-1) 43.35(21.25，79.83) 35.20(20.18，83.9) -1.281 0.200 DBil/(μmol·L-1) 16.60(5.53，40.40) 11.90(4.58，44.83) -1.231 0.218 高脂血症(有/无) 75/65 130/136 0.810 0.386 
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表 2 不同年龄患者的乳头旁憩室、胆总管直径比较
例 年龄 例数 乳头旁憩室 胆总管直径/mm 有 无 ≥12 < 12 ≥65岁 210 164 46 130 80 < 65岁 196 112 84 85 111 χ2 20.446 13.984 P < 0.001 < 0.001
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表 3 复发组与无复发组胆总管情况对比例，M(P25，P75)
项目 复发组(n=140) 无复发组(n=266) Z/χ2 P 胆道感染(有/无) 96/44 102/164 32.889 ＜0.001 憩室(有/无) 103/37 173/93 3.069 0.080 胆道手术史(有/无) 7/133 8/258 1.023 0.312 胆总管直径/mm 13.00(10.00，15.00) 10.00(10.00，13.00) -5.662 ＜0.001 胆道狭窄(有/无) 25/115 47/219 0.002 0.962 有无胆囊(有/无) 101/39 227/39 10.290 0.001 胆囊状态 有胆囊无胆囊结石 35 126 有胆囊及胆囊结石 66 101 23.304 ＜0.001 既往切除胆囊 34 30 术后切除胆囊 5 9
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表 4 复发组与无复发组胆总管结石情况对比
例 组别 例数 胆总管结石数量/个 胆总管结石最大直径/mm 泥沙样结石 ≥2 1 ≥12 < 12 有 无 复发组 140 88 40 55 73 12 128 无复发组 266 89 88 42 135 89 177 χ2 10.402 12.678 30.400 P 0.001 < 0.001 < 0.001
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表 5 复发组与无复发组手术情况对比
例 组别 例数 机械碎石 二次取石 胆道支架植入 术后并发症 有 无 有 无 有 无 有 无 复发组 140 99 41 9 131 6 134 12 128 无复发组 266 106 160 10 256 1 265 11 255 χ2 34.955 1.465 6.128 3.378 P < 0.001 0.226 0.013 0.066
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表 6 结石复发相关危险因素的多因素logistic回归分析
危险因素 β SE Wald χ2 P OR 95%CI 下限 上限 糖尿病 0.738 0.331 4.962 0.026 2.092 1.093 4.006 年龄≥65岁 1.050 0.269 15.219 < 0.001 2.858 1.686 4.844 首次病程>3 d 0.817 0.285 8.197 0.004 2.263 1.294 3.959 胆道感染 1.013 0.264 14.719 < 0.001 2.754 1.641 4.621 胆囊切除 0.862 0.316 7.455 0.006 2.367 1.275 4.394 结石数量≥2个 0.585 0.267 4.810 0.028 1.794 1.064 3.026
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