ERCP fasaha ce mai mahimmanci don ganowa da kuma kula da cututtukan biliary da pancreatic. Da zarar ya fito, ya ba da sababbin ra'ayoyi da yawa don maganin cututtukan biliary da pancreatic. Ba'a iyakance ga "radiography". Ya canza daga ainihin fasahar gano cutar zuwa wani sabon nau'i. Dabarun jiyya sun haɗa da sphincterotomy, kawar da dutsen bile duct, magudanar ruwa da sauran hanyoyin magance cututtukan bile da tsarin pancreatic.
Nasarar zaɓin intubation na bile duct na ERCP na iya kaiwa sama da 90%, amma har yanzu akwai wasu lokuta inda wahalar samun biliary ke haifar da gazawar intubation na bile duct. Bisa ga sabuwar yarjejeniya kan ganewar asali da kuma kula da ERCP, za a iya bayyana ma'anar intubation mai wuya a matsayin: lokacin zaɓin ɗigon bile na babban nono na ERCP na al'ada ya fi minti 10 ko kuma yawan ƙoƙarin intubation ya fi sau 5. Lokacin yin ERCP, idan intubation na bile duct yana da wahala a wasu lokuta, ya kamata a zaɓi ingantattun dabaru a cikin lokaci don inganta ƙimar nasarar shigar bile ducts. Wannan labarin yana gudanar da nazari na yau da kullun na dabarun intubation na taimako da yawa da aka yi amfani da su don warware matsalar intubation mai wuyar gaske, tare da ra'ayi don samar da tushen ka'idar don endoscopy na asibiti don zaɓar dabarun amsawa lokacin da aka fuskanci matsala mai wahala don ERCP.
I.Singleguidewire Technique,SGT
Dabarar SGT ita ce a yi amfani da catheter don ci gaba da ƙoƙarin shigar da bile duct bayan wayar jagora ta shiga cikin bututun pancreatic. A farkon farkon haɓaka fasahar ERCP, SGT wata hanya ce ta gama gari don shigar da biliary mai wahala. Amfaninsa shine yana da sauƙi don aiki, yana gyara nono, kuma yana iya mamaye buɗewar bututun pancreatic, yana sauƙaƙa samun buɗewar bile duct.
Akwai rahotanni a cikin adabi cewa bayan intubation na al'ada ya kasa, zabar intubation mai taimakon SGT zai iya samun nasarar kammala intubation na bile a cikin kusan 70% -80% na lokuta. Rahoton ya kuma nuna cewa a lokuta na gazawar SGT, har ma da daidaitawa da aikace-aikacen sau biyujagorafasahar ba ta inganta yawan nasarar da ake samu na intubation na bile duct ba kuma bai rage yawan abin da ya faru na ciwon daji na bayan-ERCP (PEP).
Wasu nazarin kuma sun nuna cewa yawan nasarar shigar SGT ya yi ƙasa da na ninki biyujagorafasaha da fasaha na papillary sphincterotomy transpancreatic. Idan aka kwatanta da maimaita ƙoƙarin SGT, fara aiwatar da sau biyujagorafasaha ko fasahar riga-kafi na iya samun kyakkyawan sakamako.
Tun lokacin da aka haɓaka ERCP, an haɓaka sabbin fasahohi iri-iri don intubation mai wahala. Idan aka kwatanta da guda ɗayajagorafasaha, abũbuwan amfãni sun fi bayyane kuma yawan nasarar ya fi girma. Saboda haka, aurejagorafasahar a halin yanzu ba kasafai ake amfani da ita a asibiti ba.
II.Biyu-guide waya dabara,DGT
Ana iya kiran DGT tsarin aikin wayoyi jagora na pancreatic duct, wanda shine barin wayar jagora ta shiga cikin bututun pancreatic don ganowa da mamaye shi, sannan kuma za a iya sake amfani da wayar jagora ta biyu sama da wayar jagorar pancreatic. Zaɓan bututun bile.
Fa'idodin wannan hanya sune:
(1) Tare da taimakon ajagora, Buɗewar buɗaɗɗen bile yana da sauƙin samun, yana sa intubation ɗin bile ya fi sauƙi;
(2) Wayar jagora na iya gyara nono;
(3) Karkashin jagorancin bututun pancreaticjagora, ana iya guje wa maimaita gani na bututun pancreatic, ta haka ne za a rage kuzarin bututun pancreatic wanda ya haifar da maimaitawa.
Dumonceau et al. An lura cewa ana iya shigar da wani catheter guidewire anda contrast catheter a cikin ramin biopsy lokaci guda, sa'an nan kuma ya ba da rahoton nasarar nasarar hanyar da ake amfani da ita ta hanyar pancreatic duct guidewire, kuma ta kammala da cewajagorashagaltar da hanyar bututun pancreatic yana da nasara don shigar da bile ducts. ƙimar yana da tasiri mai kyau.
Nazarin kan DGT na Liu Deren et al. An gano cewa bayan da aka yi DGT a kan marasa lafiya da ke da wuyar ERCP bile duct intubation, yawan nasarar intubation ya kai kashi 95.65%, wanda ya fi girma fiye da 59.09% nasara na intubation na al'ada.
Wani bincike mai yiwuwa na Wang Fuquan et al. ya nuna cewa lokacin da aka yi amfani da DGT ga marasa lafiya da ke da wuyar ERCP bile duct intubation a cikin rukuni na gwaji, yawan nasarar intubation ya kai 96.0%.
Nazarin da ke sama ya nuna cewa aikace-aikacen DGT ga marasa lafiya da ke da wuyar shigar da bututun bile don ERCP na iya inganta ƙimar nasarar shigar bile duct yadda ya kamata.
Kasawar DGT galibi sun haɗa da maki biyu masu zuwa:
(1) Ciwon cikijagorakila a rasa yayin shigar bile duct, ko na biyujagorana iya sake shiga cikin bututun pancreatic;
(2) Wannan hanyar ba ta dace da lamuran kamar ciwon daji na pancreatic, tortuosity na pancreatic duct, da fission na pancreatic ba.
Daga hangen abubuwan da suka faru na PEP, abubuwan da suka faru na PEP na DGT sun yi ƙasa da na al'ada na intubation na bile duct. Wani bincike mai yiwuwa ya nuna cewa abin da ya faru na PEP bayan DGT shine kawai 2.38% a cikin marasa lafiya na ERCP tare da wuyar shigar da bile ducts. Wasu wallafe-wallafen sun nuna cewa duk da cewa DGT yana da babban nasara na intubation na bile ducts, abin da ya faru na bayan-DGT pancreatitis har yanzu yana da girma idan aka kwatanta da sauran matakan gyara, saboda aikin DGT na iya haifar da lalacewa ga duct na pancreatic da budewa. Duk da haka, ijma'i a gida da waje har yanzu yana nuni da cewa a cikin mawuyacin hali na intubation na bile ducts, lokacin da intubation ke da wuya kuma an yi kuskuren kuskuren duct na pancreatic, DGT ita ce zabi na farko saboda fasahar DGT ba ta da wahala a aiki, kuma in mun gwada da sauki. don sarrafawa.An yi amfani da shi sosai a cikin zaɓin intubation mai wuyar gaske.
III.Wire jagorar cannulation-pan-creatic stent,WGC-P5
WGC-PS kuma ana iya kiransa hanyar aikin ma'auni na pancreatic duct stent. Wannan hanyar ita ce sanya stent na pancreatic tare dajagorawanda kuskure ya shiga cikin bututun pancreatic, sannan ya fitar dajagorada kuma yin cannulation bile duct sama da stent.
Nazarin Hakuta et al. ya nuna cewa baya ga inganta yawan nasarar intubation gabaɗaya ta hanyar jagorantar intubation, WGC-PS kuma na iya kare buɗewar bututun pancreatic kuma yana rage yawan faruwar PEP.
Nazarin kan WGC-PS ta Zou Chuanxin et al. Ya yi nuni da cewa, nasarar da aka samu na wahalar shigar da ruwa ta hanyar amfani da hanyar aikin noman pancreatic na wucin gadi ya kai kashi 97.67%, kuma an rage yawan abin da ya faru na PEP.
Ɗaya daga cikin binciken ya gano cewa lokacin da aka sanya stent na pancreatic daidai, damar da za a iya haifar da mummunan pancreatitis a cikin lokuta masu wuyar ƙwayar cuta yana raguwa sosai.
Wannan hanya har yanzu tana da wasu gazawa. Misali, stent duct na pancreatic da aka saka yayin aikin ERCP na iya zama gudun hijira; idan ana buƙatar sanya stent na dogon lokaci bayan ERCP, za a sami babbar dama ta toshe tururuwa da toshewar bututu. Rauni da sauran matsalolin suna haifar da karuwa a cikin abin da ya faru na PEP. Tuni, cibiyoyi sun fara nazarin ɗimbin bututun pancreatic na wucin gadi waɗanda za su iya ficewa daga cikin bututun na pancreatic. Manufar ita ce a yi amfani da stent na pancreatic don hana PEP. Bugu da ƙari don rage yawan haɗarin PEP, irin waɗannan stents na iya kauce wa wasu ayyuka don cire stent da rage nauyin marasa lafiya. Kodayake bincike ya nuna cewa stent na pancreatic na wucin gadi yana da tasiri mai kyau wajen rage PEP, aikace-aikacen su na asibiti har yanzu yana da manyan iyakoki. Alal misali, a cikin marasa lafiya tare da ƙananan ƙwayoyin pancreatic da kuma rassan da yawa, yana da wuya a saka ƙumburi na pancreatic. Wahalhalun za su ƙaru sosai, kuma wannan aikin yana buƙatar ƙwararrun ƙwararrun ƙwararrun endoscopists. Ya kamata kuma a lura da cewa pancreatic duct stent sanya kada ya yi tsayi da yawa a cikin duodenal lumen. Wani dogon stent fiye da kima na iya haifar da perforation duodenal. Sabili da haka, zaɓin hanyar aikin noman ƙwayar cuta na pancreatic har yanzu yana buƙatar kulawa da hankali.
IV.Trans-pancreatocsphincterotomy,TPS
Ana amfani da fasahar TPS gabaɗaya bayan wayar jagora ta shiga cikin bututun pancreatic bisa kuskure. Ana sanya septum a tsakiyar bututun pancreatic tare da hanyar wayar jagorar pancreatic daga karfe 11 zuwa 12 na rana, sannan a sanya bututun a cikin hanyar bile duct har sai wayar jagora ta shiga cikin bile. duct.
Nazarin Dai Xin et al. idan aka kwatanta TPS da wasu fasahohin intubation na taimako guda biyu. Ana iya ganin cewa nasarar fasahar TPS tana da girma sosai, ta kai kashi 96.74%, amma baya nuna kyakkyawan sakamako idan aka kwatanta da sauran fasahohin intubation na taimako guda biyu. Abubuwan amfani.
An ba da rahoton cewa halayen fasahar TPS sun haɗa da abubuwa masu zuwa:
(1) Ƙarƙashin ƙananan ƙananan ƙananan ƙwayar pancreaticobiliary septum;
(2) Abubuwan da ke faruwa na rikice-rikice na baya-bayan nan ba su da yawa;
(3) Zaɓin jagorancin yankewa yana da sauƙin sarrafawa;
(4) Ana iya amfani da wannan hanyar ga marasa lafiya masu maimaita bututun bututun pancreatic ko nonuwa a cikin diverticulum.
Yawancin karatu sun nuna cewa TPS ba kawai zai iya inganta ƙimar nasara na intubation mai wuyar ƙwayar cuta ba, amma kuma baya ƙara yawan rikitarwa bayan ERCP. Wasu malaman sun ba da shawarar cewa idan intubation na pancreatic ko ƙananan papilla na duodenal ya faru akai-akai, ya kamata a fara la'akari da TPS. Duk da haka, lokacin da ake amfani da TPS, ya kamata a ba da hankali ga yiwuwar ciwon huhu na pancreatic da kuma sake dawowa na pancreatitis, wanda zai yiwu haɗari na TPS na dogon lokaci.
V.Precut Sphincterotomy, PST
Dabarar PST tana amfani da band ɗin arcuate na papillary a matsayin babban iyaka na pre-cision da jagorar karfe 1-2 a matsayin iyaka don buɗe sphincter na duodenal papilla don nemo buɗewar bile da pancreatic duct. Anan PST musamman yana nufin daidaitaccen dabarar sphincter pre-cision dabara ta amfani da wuka mai kauri. A matsayin dabara don magance wahalar shigar bututun bile na ERCP, fasahar PST an yi la'akari da ita a matsayin zaɓi na farko don shigar da mai wahala. Endoscopic kan nono sphincter pre-cision yana nufin ƙaddamarwar endoscopic na mucosa na papilla da ƙananan ƙwayar sphincter ta hanyar wuka mai tsinke don nemo buɗewar bile duct, sannan a yi amfani dajagorako catheter don shigar da bile duct.
Wani bincike na cikin gida ya nuna cewa yawan nasarar PST ya kai 89.66%, wanda bai bambanta da DGT da TPS ba. Koyaya, abin da ya faru na PEP a cikin PST yana da girma fiye da na DGT da TPS.
A halin yanzu, shawarar yin amfani da wannan fasaha ya dogara da abubuwa daban-daban. Alal misali, wani rahoto ya bayyana cewa an fi amfani da PST mafi kyau a lokuta inda papilla na duodenal ba shi da kyau ko kuma ya lalace, kamar duodenal stenosis ko malignancy.
Bugu da ƙari, idan aka kwatanta da sauran hanyoyin magancewa, PST yana da matsala mafi girma na rikitarwa irin su PEP, kuma abubuwan da ake bukata na aiki suna da yawa, don haka wannan aikin ya fi dacewa da ƙwararrun endoscopists.
VI.Needle-wuka Papillotomy,NKP
NKP dabara ce ta intubation mai taimakon allura. Lokacin da intubation ke da wuya, za a iya amfani da wuka mai allura don yanka wani ɓangare na papilla ko sphincter daga buɗewar papilla na duodenal zuwa 11-12 na dare, sannan a yi amfani dajagorako catheter zuwa Zaɓin sakawa a cikin bututun bile na gama gari. A matsayin dabarar jure wahalar shigar da bututun bile, NKP na iya inganta yadda ya kamata a inganta ƙimar nasarar shigar da bututun bile. A baya, an yi imani da cewa NKP zai ƙara yawan PEP a cikin 'yan shekarun nan. A cikin 'yan shekarun nan, yawancin rahotanni na nazari na baya-bayan nan sun nuna cewa NKP ba ya ƙara haɗarin rikitarwa bayan aiki. Yana da kyau a lura cewa idan an yi NKP a farkon matakin intubation mai wahala, zai zama babban taimako don haɓaka ƙimar nasarar intubation. Koyaya, a halin yanzu babu yarjejeniya kan lokacin da za a yi amfani da NKP don cimma kyakkyawan sakamako. Ɗaya daga cikin binciken ya ba da rahoton cewa adadin intubation na NKP da aka yi amfani da shi a lokacinERCPkasa da mintuna 20 ya fi na NKP da aka yi amfani da shi a baya fiye da mintuna 20 daga baya.
Marasa lafiya da ke da wuyar ƙwayar bile duct za su amfana da wannan dabarar idan suna da kumburin nonuwa ko mahimmancin dilation na bile duct. Bugu da ƙari, akwai rahotanni cewa lokacin da ake fuskantar matsalolin intubation mai wuyar gaske, haɗuwa da amfani da TPS da NKP yana da babban nasara fiye da yin amfani da shi kadai. Rashin lahani shi ne cewa dabaru da yawa da aka yi amfani da su a kan nono za su ƙara faruwar rikitarwa. Don haka, ana buƙatar ƙarin bincike don tabbatar da ko za a zaɓi farkon ƙaddamarwa don rage abubuwan da ke faruwa na rikice-rikice ko haɗa matakan gyara da yawa don haɓaka ƙimar nasara na intubation mai wahala.
VII.Needle-wuka Fistulotomy,NKE
Dabarar ta NKF tana nufin yin amfani da wukar allura don huda mucosa kamar 5mm sama da kan nono, ta yin amfani da gaurayawan halin yanzu don yanka Layer ta Layer zuwa karfe 11 na rana har sai an sami tsari mai kama da bile, sannan a yi amfani da shi. wayar jagora don gano fitowar bile da tsinkayar nama. An zaɓi shigar da bututun bile a wurin jaundice. NKF tiyata ya yanke sama da buɗewar nono. Saboda kasancewar ƙwayar bile duct sinus, yana da mahimmanci rage lalacewar thermal da lalacewar injiniya ga buɗewar duct na pancreatic, wanda zai iya rage yawan PEP.
Nazarin Jin et al. ya nuna cewa nasarar nasarar NK tube intubation zai iya kaiwa 96.3%, kuma babu wani PEP na baya-bayan nan. Bugu da ƙari, nasarar nasarar NKF a cikin cire dutse ya kai 92.7%. Saboda haka, wannan binciken yana ba da shawarar NKF a matsayin zaɓi na farko don kawar da dutsen bile na kowa. . Idan aka kwatanta da papillomyotomy na al'ada, haɗarin aiki na NKF har yanzu yana da girma, kuma yana da haɗari ga rikice-rikice irin su perforation da zubar jini, kuma yana buƙatar babban matakin aiki na endoscopists. Madaidaicin wurin buɗe taga, zurfin da ya dace, da madaidaicin dabara duk suna buƙatar koya a hankali. maigida.
Idan aka kwatanta da sauran hanyoyin riga-kafi, NKF hanya ce mafi dacewa tare da ƙimar nasara mafi girma. Koyaya, wannan hanyar tana buƙatar yin aiki na dogon lokaci da ci gaba da tarawa ta mai aiki don zama mai cancanta, don haka wannan hanyar ba ta dace da masu farawa ba.
VIII.Maimaita-ERCP
Kamar yadda aka ambata a sama, akwai hanyoyi da yawa don magance matsalolin intubation. Duk da haka, babu tabbacin samun nasara 100%. Littattafan da suka dace sun nuna cewa lokacin da intubation na bile yana da wahala a wasu lokuta, dogon lokaci da intubation mai yawa ko tasirin zafin jiki na pre-yanke zai iya haifar da duodenal papilla edema. Idan aikin ya ci gaba, ba kawai intubation na bile ba zai yi nasara ba, amma damar da za a iya samun rikitarwa kuma zai karu. Idan yanayin da ke sama ya faru, zaku iya la'akari da ƙarewar halin yanzuERCPfara fara aiki kuma yi ERCP na biyu a lokacin zaɓin zaɓi. Bayan papilloedema ya ɓace, aikin ERCP zai yi sauƙi don samun nasarar shigar da ciki.
Donnellan et al. yayi dakika dayaERCPaiki a kan marasa lafiya 51 waɗanda ERCP ya gaza bayan ƙaddamar da allura-wuka, kuma lokuta 35 sun yi nasara, kuma abubuwan da ke faruwa ba su karu ba.
Kim et al. ya yi aikin ERCP na biyu akan marasa lafiya 69 da suka kasaERCPbayan riga-kafin allura, kuma 53 sun yi nasara, tare da nasarar kashi 76.8%. Sauran shari'o'in da ba su yi nasara ba kuma sun yi aiki na ERCP na uku, tare da nasarar nasarar 79.7%. , da kuma ayyuka da yawa ba su ƙara faruwar rikitarwa ba.
Yu Li et al. ya yi zaɓe na sakandareERCPakan marasa lafiya 70 da suka kasa ERCP bayan an riga an yi wa allura wuka, kuma lokuta 50 sun yi nasara. Yawan nasarar gaba ɗaya (ERCP na farko + ERCP na biyu) ya karu zuwa 90.6%, kuma abubuwan da suka faru na rikice-rikice ba su ƙaru sosai ba. . Kodayake rahotanni sun tabbatar da ingancin ERCP na biyu, tazara tsakanin ayyukan ERCP guda biyu bai kamata ya yi tsayi da yawa ba, kuma a wasu lokuta na musamman, jinkirin magudanar ruwan biliary na iya tsananta yanayin.
IX.Endoscopicultrasound-shiryarwar biliary magudanar ruwa,EUS-BD
EUS-BD hanya ce mai ban tsoro da ke amfani da allurar huda don huda gallbladder daga ciki ko duodenum lumen karkashin jagorancin duban dan tayi, shigar da duodenum ta cikin papilla duodenal, sannan a yi intubation na biliary. Wannan dabarar ta ƙunshi duka hanyoyin intrahepatic da na waje.
Wani bincike na baya-bayan nan ya ba da rahoton cewa nasarar nasarar EUS-BD ya kai 82%, kuma abin da ya faru na rikice-rikicen bayan tiyata shine kawai 13%. A cikin kwatankwacin binciken, EUS-BD idan aka kwatanta da fasahar riga-kafi, yawan nasarar shigarsa ya yi girma, ya kai kashi 98.3%, wanda ya fi na 90.3% na riga-kafi. Koyaya, ya zuwa yanzu, idan aka kwatanta da sauran fasahohin, har yanzu akwai ƙarancin bincike akan aikace-aikacen EUS don wahalaERCPintubation. Babu isassun bayanai don tabbatar da ingancin fasahar huda bile duct da EUS ke jagoranta don wahalaERCPintubation. Wasu nazarin sun nuna cewa ya rage Matsayin PEP na baya-bayan nan ba mai gamsarwa ba ne.
X.Percutaneous transhepatic cholangial magudanar ruwa,PTCD
PTCD wata dabara ce ta gwaji da za a iya amfani da ita tare da itaERCPdon matsananciyar bututun bile, musamman a lokuta na toshewar biliary m. Wannan dabarar tana amfani da allura mai huda don shiga cikin bile duct, ta huda bile duct ta cikin papilla, sannan a sake shigar da bile duct ta hanyar da aka tanada.jagora. Ɗaya daga cikin binciken ya bincika marasa lafiya 47 da ke da wuyar ƙwayar bile ducts waɗanda suka yi amfani da fasaha na PTCD, kuma yawan nasarar ya kai 94%.
Nazarin Yang et al. ya nuna cewa aikace-aikacen EUS-BD a fili yana iyakance idan ya zo ga hilar stenosis da buƙatar huda madaidaicin bile duct na intrahepatic, yayin da PTCD yana da fa'idodin daidaitawa da axis na bile duct kuma kasancewa mafi sassauƙa a cikin na'urori masu jagora. Ya kamata a yi amfani da intubation na bile a cikin irin waɗannan marasa lafiya.
PTCD aiki ne mai wahala wanda ke buƙatar horon tsari na dogon lokaci da kuma kammala isassun adadin lokuta. Yana da wahala ga novice don kammala wannan aikin. PTCD ba kawai wuyar aiki ba, amma dajagoraHakanan na iya lalata bututun bile yayin ci gaba.
Kodayake hanyoyin da ke sama na iya inganta ƙimar nasara mai wahala na intubation na bile duct, zaɓin yana buƙatar yin la'akari sosai. Lokacin yin aikiERCP, SGT, DGT, WGC-PS da sauran dabaru za a iya la'akari; Idan fasahohin da ke sama sun kasa, manya da goguwa da masu haɓaka su na iya haifar da dabarun da aka riga aka riga su, kamar TPS, NKP, NkF, da sauransu.; in har yanzu Idan ba a iya kammala intubation na bile duct ba, zaɓi na sakandareERCPza a iya zaba; idan babu daya daga cikin dabarun da ke sama da zai iya magance matsalar intubation mai wuya, ana iya ƙoƙarin yin ɓarna kamar EUS-BD da PTCD don magance matsalar, kuma za a iya zaɓar maganin tiyata idan ya cancanta.
Mu, Jiangxi Zhuoruihua Medical Instrument Co., Ltd., wani manufacturer ne a kasar Sin ƙware a endoscopic consumables, kamar biopsy forceps, hemoclip, polyp tarko, sclerotherapy allura, fesa catheter, cytology goge,jagora, kwandon dawo da dutse, hanci biliary drainage catheterda dai sauransu waɗanda ake amfani da su sosai a cikin EMR, ESD,ERCP. Samfuran mu suna da takardar shedar CE, kuma tsire-tsire namu suna da takaddun ISO. An fitar da kayanmu zuwa Turai, Arewacin Amurka, Gabas ta Tsakiya da wani yanki na Asiya, kuma suna samun abokin ciniki yabo da yabo!
Lokacin aikawa: Janairu-31-2024