The Clinical Study Of Different Pre-cuts In The Treatment Of ERCP Difficult Intubation

Objective:To investigate the application of Precut sphincterotomy(PST)in Endoscopic retrograde cholangiopancreatography(ERCP)during the Difficult selective biliary cannulation(DSBC).Analyze and compare the success rate of different PST intubation,total complications and the incidence of classification complications and influencing factors,etc.To summarize the safety and advantages and disadvantages of different PST,in order to improve the success rate of ERCP difficult intubation and reduce the incidence of complicationsMethod:Were retrospectively analyzed in May 2015-December 2018 in the second affiliated hospital of kunming medical university PST treatment of the clinical data of 185 patients.According to different surgical methods,there were 73 cases in the Needle knife precut papilotomy(NKP)group,24 cases in the Needle knife fistulotomy(NKF)group,and 30 cases in the Transpancreatic septotomy(TPS)group Fifty-eight patients were treated with erlangen-type precut sphincterotomy(Erlangen).The advantages and disadvantages of the four surgical methods,the success rate of intubation,the incidence of complications and the factors that may affect the success of intubation and lithotomy were analyzed.The measurement data of accord with normal distribution with mean±standard deviation,according to comparison between multiple sets of data set using analysis of variance,non-normal distribution of measurement data to the median(interquartile range),said the Kruskal-Wallis test is compared between multiple sets of data set,both two comparison within the groups using the Bonferroni method.Counting data was expressed as rate(%),and 2x2 or RxC chi-square test was used for comparison.Spearman correlation analysis was adopted to analyze the correlation among measurement indexes.Risk factor analysis was conducted by Logistic regression analysis,and variables with univariate analysis P<0.2 were included in the model for multivariate Logistic regression analysis.Results:1.General information:A total of 185 patients were included,including 86 males(46.5%)and 99 females(53.5%),with an average age of(56.09±13.76)years,an average hospitalization time of(16.10±7.58)days,an average hospitalization cost of(28255.42±20086.87)yuan,an average surgery time of(45.93±18.56)minutes,an average contrast dose of(46.79±17.84)ml,and an average stone diameter of(5.77±4.23)mm.The total intubation success rate was 71.89%,the total complication rate was 28.10%,and the duodenal papilla or the juxtapapiilary diverticulum(JAD)was 45 cases.Common bile duct stones and/or gallbladder stones,cholecystitis.common bile duct,ampullary abdomen or periampullary Ca and constrictive papillitis were more commonly diagnosed postoperatively,and the differences between the four groups were not statistically significant(all P>0.05)There were 73 cases in NKP group,24 cases in NKF group,30 cases in TPS group and 58 cases in Erlangen group.The average operation time of NKF group was significantly lower than that of NKP group,and the difference was statistically significant(P<0.05).The average age of the TPS group was higher than that of the other three groups,and the difference was statistically significant(P<0.05).The mean contrast agent dose and mean stone diameter in TPS group were significantly lower than those in NKP and NKF groups,and the differences were statistically significant(all P<0.05).The mean hospital stay,average hospitalization cost and average operation time in Erlangen group were significantly lower than those in NKP group,and the differences were statistically significant(all P<0.05)2.Postoperative outcome:The success rate of intubation in the NKF and TPS groups was higher than that in the NKP group,and the difference was statistically significant(P<0.05).The total complication rate of NKF group was higher than that of NKP group,and the difference was statistically significant(P<0.05).The total complication rate in TPS group was lower than that in NKF group,and the difference was statistically significant(P<0.05).The total complication rate of Erlangen group was higher than that of NKP group and TPS group,and the difference was statistically significant(P<0.05).3.Comparison of PST with other operations:operated by four combinations and operated mostly by Endoscopic papillary balloon dilation(EPBD),but the difference has no statistical significance(P>0.05).NKP and NKF groups had more Endoscopic mechanical lithotripsy(EML),but the differences were not statistically significant(P>0.05).The analysis showed that there was a significant correlation between NKF and TPS and the success of intubation,OR value and 95%confidence interval were respectively(OR=2.060,95%CI:0.235?0.828,P=0.036)and(OR=1.254,95%CI:0.238?0.594,P=0.029).4.Comparison of postoperative inflammatory factors,obstructase,amylase and lipase:Postoperative CRP of Erlangen group was higher than that of other groups,and the difference was statistically significant(all P<0.05),while there was no statistically significant difference among the other four groups(all P>0.05)5.Correlation analysis of stone diameter,contrast dose and operation time,and logistic regression analysis of stone diameter and complications after PST:The relationship between the stone diameter and the contrast dose was analyzed with the operation time as the variable,and the r values were-0.006 and-0.165,respectively,without correlation(all P>0.05).The calculus diameter was taken as the independent variable,and univariate logistic regression analysis of the occurrence of complications showed that there was no correlation between the occurrence of various complications and the calculus diameter(all P>0.05).6.Comparison of EPBD and EML utilization rates:There was a correlation between the utilization rate of EPBD and EML(P<0.05)7.Univariate logistic analysis of PEP:The age of>57years and the total duration of surgery were the influencing factors of PEP,and the OR value and 95%confidence interval were(OR=0.094,95%CI:0.028?0.316.P<0.001)and(OR=1.029,95%CI:1.002?1.057,P=0.036),respectively.There was no significant correlation between other factors and PEP(all P>0.05).8.With PEP as the dependent variable,variables with univariate analysis P<0.2(age,total operative time,EPBD)were included in the model for multivariate stepwise logistic regression analysis.The results showed that advanced>57 years old and EPBD were protective factors for the risk of PEP,and their OR values and 95%confidence intervals were(OR=0.065,95%CI:0.017-0.256,P<0.001)and(OR=0.287,95%CI:0.085-0.969,P=0.044).The total duration of surgery was an independent risk factor for the occurrence of PEP,and the OR value and 95%confidence interval were(OR=1.040,95%CI:1.007?1.074,P=0.016),respectively.Conclusion:1.Different surgical methods are adopted to solve DSBC,and the success rate of intubation and the incidence of complications are different.TPS catheterization has a high success rate and the lowest incidence of complications.2.Compared with NKP,NKF is more effective but less safe.TPS is more effective and safe than NKF.Erlangen is relatively less safe than the other three surgical methods.3.Age,EPBD and total operation time are the factors that affect the incidence of complications,but the specific time amount and when to perform PST still need to be confirmed by further multi-center clinical studies.There was no significant correlation between stone diameter and complication rate.