ERCP治疗胆总管结石的临床疗效及术后复发危险因素

摘要/Abstract

摘要： 目的探讨内镜逆行胰胆管造影(ERCP)治疗胆总管结石的临床疗效,并分析术后结石复发的相关危险因素,为临床预防复发及优化治疗策略提供依据。方法分析2022年1月至2024年12月于中国人民解放军联勤保障部队第九〇四医院接受ERCP治疗胆总管结石患者的临床资料,根据随访期间是否发生胆总管结石复发分为复发组(n=16)和非复发组(n=55)。比较两组基线资料、ERCP手术相关因素、术后并发症及近期疗效情况,并探讨胆总管结石术后复发的独立危险因素。结果共纳入71例患者,其中复发组16例(22.5%),非复发组55例(77.5%)。复发组年龄为(68.4±9.2)岁,显著高于非复发组[(61.7±10.5)岁](P<0.05);合并糖尿病比例为43.8%(7/16),高于非复发组[18.2%(10/55)](P<0.05)。在手术相关因素方面,复发组结石最大径为(1.5±0.4)cm,高于非复发组[(1.1±0.4)cm,P<0.05];多发结石比例为68.8%(11/16),高于非复发组[36.4%(20/55)](P<0.05);胆道支架留置比例为56.3%(9/16),高于非复发组[27.3%(15/55)](P<0.05)。复发组术后住院时间为[(9.4±2.1)d],长于非复发组[(7.6±1.8)d,P<0.05];术后第3 d ALT为(78.5±21.3)U/L,TBil为(32.6±8.4)μmol/L,均高于非复发组[(61.2±18.7)U/L、(24.1±6.9)μmol/L,P<0.05]。复发组术后结石残留率为25.0%(4/16),高于非复发组[5.4%(3/55),P<0.05];临床治愈率为75.0%(12/16),低于非复发组92.7%(51/55)(P<0.05)。多因素logistic回归分析显示,年龄≥65岁(OR=2.84,95%CI:1.12～7.21)、合并糖尿病(OR=3.16,95%CI:1.18～8.46)、结石最大径≥1.5 cm(OR=4.02,95%CI:1.45～11.18)、多发结石(OR=2.67,95%CI:1.01～7.06)及胆道支架留置(OR=2.91,95%CI:1.09～7.79)均为术后复发的独立危险因素(P<0.05)。结论 ERCP治疗胆总管结石安全有效,但术后仍存在一定复发风险。高龄、糖尿病、结石负荷较大及胆道支架留置可显著增加结石复发的发生率。针对高危患者,应加强围手术期管理和术后随访,以降低胆总管结石复发风险并改善长期预后。

关键词: 胆总管结石, 内镜逆行胰胆管造影, 复发, 危险因素

Abstract: Objective To investigate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of common bile duct (CBD) stones and to analyze the risk factors associated with postoperative stone recurrence, so as to provide evidence for recurrence prevention and optimization of treatment strategies. Methods Clinical data of patients with CBD stones treated by ERCP at the PLA Joint Logistics Support Force No.904 Hospital from January 2022 to December 2024 were retrospectively analyzed. According to whether recurrence of CBD stones occurred during follow-up, patients were divided into a recurrence group (n=16) and a non-recurrence group (n=55). Baseline characteristics, ERCP-related factors, postoperative complications, and short-term outcomes were compared between the two groups, and independent risk factors for postoperative recurrence were explored. Results A total of 71 patients were included, comprising 16 patients in the recurrence group (22.5%) and 55 patients in the non-recurrence group (77.5%). The mean age of the recurrence group was (68.4 ± 9.2) years, which was significantly higher than that of the non-recurrence group[(61.7 ± 10.5) years, P<0.05]. The proportion of patients with diabetes mellitus was 43.8% (7/16) in the recurrence group, higher than 18.2% (10/55) in the non-recurrence group (P<0.05). Regarding ERCP-related factors, the maximum stone diameter in the recurrence group was (1.5 ± 0.4) cm, significantly larger than that in the non-recurrence group[(1.1 ± 0.4) cm, P<0.05]. The proportion of multiple stones was 68.8% (11/16) in the recurrence group, higher than 36.4% (20/55) in the non-recurrence group (P<0.05). The rate of biliary stent placement was 56.3% (9/16) in the recurrence group, compared with 27.3% (15/55) in the non-recurrence group (P<0.05). The postoperative hospital stay was longer in the recurrence group[(9.4±2.1) days] than in the non-recurrence group[(7.6±1.8) days, P<0.05]. On postoperative day 3, ALT[(78.5±21.3) U/L] and TBil[(32.6±8.4) μmol/L] levels in the recurrence group were significantly higher than those in the non-recurrence group[(61.2±18.7) U/L and (24.1±6.9) μmol/L, respectively; P<0.05]. The postoperative residual stone rate was 25.0% (4/16) in the recurrence group, significantly higher than 5.4%(3/55) in the non-recurrence group (P<0.05). The clinical cure rate was 75.0% (12/16) in the recurrence group, lower than 92.7% (51/55) in the non-recurrence group (P<0.05). Multivariate logistic regression analysis demonstrated that age ≥65 years (OR=2.84, 95%CI: 1.12~7.21), diabetes mellitus (OR=3.16, 95%CI: 1.18~8.46), maximum stone diameter ≥1.5 cm (OR=4.02, 95%CI: 1.45~11.18), multiple stones (OR=2.67, 95%CI: 1.01~7.06), and biliary stent placement (OR=2.91, 95%CI: 1.09~7.79) were independent risk factors for postoperative recurrence (P<0.05). Conclusion ERCP is a safe and effective treatment for CBD stones; however, there remains a certain risk of postoperative recurrence. Advanced age, diabetes mellitus, a higher stone burden, and biliary stent placement significantly increase the risk of stone recurrence. Enhanced perioperative management and postoperative follow-up are warranted for high-risk patients to reduce recurrence and improve long-term outcomes.

Key words: Common bile duct stones, Endoscopic retrograde cholangiopancreatography, Recurrence, Risk factors

汤燕, 徐谦. ERCP治疗胆总管结石的临床疗效及术后复发危险因素[J]. 肝脏, 2026, 31(6): 900-904.

Tang Yan, Xu Qian. Clinical efficacy of ERCP in the treatment of common bile duct stones and analysis of risk factors for postoperative recurrence[J]. Chinese Hepatolgy, 2026, 31(6): 900-904.

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参考文献

[1] Mohseni S, Bass G A, Forssten M P, et al. Common bile duct stones management: a network meta-analysis[J]. J Trauma Acute Care Surg, 2022, 93(5): e155-e165.
[2] Masuda S, Koizumi K, Shionoya K, et al. Comprehensive review on small common bile duct stones[J]. World J Gastroenterol, 2023, 29(13): 1955-1968.
[3] 尼加提江·艾比不拉,阿力木江·阿布力米提,阿里旦·艾尔肯,等. LC联合LCHTD治疗胆总管结石合并胆囊结石的效果及术后胆总管结石复发的相关因素分析[J]. 肝胆胰外科杂志, 2021, 33(7): 419-422.
[4] 王平. LCBDE+LC+PC和ERCP+EST+LC在治疗胆囊结石合并胆总管结石的临床对比分析[D]. 南京:南京医科大学, 2021.
[5] García-Cano J, Viñuelas Chicano M, Valiente González L. ERCP for common bile duct stones in the elderly: refining the procedure to improve outcomes[J]. Rev Esp Enferm Dig, 2024, 116(5): 241-243.
[6] Sperna Weiland C J, Verschoor E C, Poen A C, et al. Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP[J]. Surg Endosc, 2023, 37(2): 1194-1202.
[7] Das S, Jha A K, Kumar M. Laparoscopic common bile duct exploration in cases of common bile duct stones: can LCBDE replace ERCP as first line treatment[J]. Am J Surg, 2023, 226(2): 290.
[8] García-Cano J, Domper F. The best approach to treat concomitant gallstones and common bile duct stones. Is ERCP still needed?[J]. Rev Esp Enferm Dig, 2019, 111(3): 173-175.
[9] Crichton J, Cox S, Tong C, et al. Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review[J]. ANZ J Surg, 2023, 93(7-8): 1839-1846.
[10] Shi Y, Lin J, Zhu J, et al. Predicting the recurrence of common bile duct stones after ERCP treatment with automated machine learning algorithms[J]. Dig Dis Sci, 2023, 68(7): 2866-2877.
[11] 李泓锐. ERCP取石术后胆总管结石复发危险因素分析及发生风险评分系统的初步建立[D]. 大连:大连医科大学, 2021.
[12] Liu J, Wei X J, Yang Z L, et al. Risk factors of common bile duct stones recurrence and nomogram for predicting recurrence after endoscopic retrograde cholangiopancreatography: a dual-center retrospective cohort study[J]. Eur Rev Med Pharmacol Sci, 2023, 27(6): 2504-2513.
[13] García-Cano J, Viñuelas Chicano M, Valiente González L. ERCP for common bile duct stones in the elderly: refining the procedure to improve outcomes[J]. Rev Esp Enferm Dig, 2024, 116(5): 241-243.
[14] Kivivuori A, Mattila L, Siiki A, et al. Wait-and-see strategy is justified after ERCP and endoscopic sphincterotomy in elderly patients with common biliary duct stones[J]. J Trauma Acute Care Surg, 2023, 94(3): 443-447.
[15] Khoury T, Sbeit W. Diabetes mellitus is associated with a higher rate of acute cholangitis among patients with common bile duct stones: a retrospective study[J]. Medicine (Baltimore), 2022, 101(4): e28687.
[16] Wen N, Wang Y, Cai Y, et al. Risk factors for recurrent common bile duct stones: a systematic review and meta-analysis[J]. Expert Rev Gastroenterol Hepatol, 2023, 17(9): 937-947.
[17] Alhaddad O, Elsabaawy M, El-Azab G, et al. Efficacy and safety of immediate vs. delayed endoscopic retrieval of large or multiple common bile duct stones in high-risk elderly patients: a prospective, randomized comparative study[J]. Clin Exp Med, 2025, 25(1): 183.
[18] Nihei S, Hasegawa S, Honda Y, et al. Prevention of cholangitis by spontaneously dislodging biliary stent after an endoscopic procedure in patients with asymptomatic bile duct stones[J]. DEN Open, 2025, 6(1): e70194.
[19] Paspatis G A, Papastergiou V, Mpitouli A, et al. Distal biliary stent migration in patients with irretrievable bile duct stones: long-term comparison between straight and double-pigtail stents[J]. Dig Dis Sci, 2022, 67(9): 4557-4564.
[20] Choi J H, Lee T Y, Cheon Y K. Effect of stent placement on stone recurrence and post-procedural cholangitis after endoscopic removal of common bile duct stones[J]. Korean J Intern Med, 2021, 36(Suppl 1): S27-S34.