良性胆管狭窄的内镜诊疗现状

原文聪; 何桥; 王志鑫; 樊海宁; 王海久; 任宾; 任利

doi:10.3969/j.issn.1001-5256.2021.11.055

良性胆管狭窄的内镜诊疗现状

DOI: 10.3969/j.issn.1001-5256.2021.11.055

原文聪^{1, 2},
何桥^{1, 2},
王志鑫^{1, 2},
樊海宁^{1, 2},
王海久^{1, 2},
任宾^{1, 2},
任利^{1, 2, ,}

1.
青海大学附属医院肝胆胰外科，西宁 810001
2.
青海省包虫病研究重点实验室，西宁 810001

基金项目:

国家重点研发计划项目 (2017YFC0909900);

青海省科技厅项目 (2020-ZJ-Y01)

详细信息

通信作者:
任利，renliweimin_xn@126.com

原文聪，何桥对本文贡献相同，同为第一作者

中图分类号: R657.46
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出版历程
- 收稿日期: 2021-03-31
- 录用日期: 2021-04-12
- 出版日期: 2021-11-20

Current status of endoscopic diagnosis and treatment of benign biliary stricture

Wencong YUAN^{1, 2},
Qiao HE^{1, 2},
Zhixin WANG^{1, 2},
Haining FAN^{1, 2},
Haijiu WANG^{1, 2},
Bin REN^{1, 2},
Li REN^{1, 2
, ,}

1.
Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Xining 810001, China
2.
Qinghai Province Key Laboratory of Hydatid Disease Research, Qinghai 810001, China

Research funding:

National Key R&D Program Project (2017YFC0909900);

Qinghai Province Science and Technology Department Project (2020-ZJ-Y01)

摘要

摘要: 良性胆管狭窄(BBS)指由一系列非恶性肿瘤疾病引起的胆管完全性或不完全性狭窄。其病因复杂多样，未充分治疗的BBS甚至会出现严重并发症。目前临床上使用的诊断方法有影像学、内镜逆行胰胆管造影、超声内镜、胆道镜等，治疗上有球囊扩张、支架置入、经皮经肝胆管引流术、手术治疗等措施。目前通过内镜下诊疗BBS成为首选方法, 然而目前BBS尚无明确分型，需进一步探究。通过查阅国内外相关文献资料，重点对BBS内镜下诊断及按分型治疗相关问题作一综述。
- 胆管疾病 /
- 内窥镜检查 /
- 超声检查 /
- 诊断 /
- 治疗学
Abstract: Benign biliary stricture (BBS) refers to complete or incomplete stricture of the biliary tract caused by a series of non-malignant diseases. BBS often has complex and diverse etiologies, and severe complications may occur if it is not adequately treated. Diagnostic methods currently used in clinical practice include imaging, endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and choledochoscopy, and treatment methods include balloon dilatation, stent implantation, percutaneous transhepatic biliary drainage, and surgical treatment. At present, endoscopic diagnosis and treatment of BBS has become the preferred method. However, there is still no clear classification of BBS, which needs further investigation. By consulting related literature in China and globally, this article summarizes the issues associated with the endoscopic diagnosis and treatment of BBS.
- Bile Duct Diseases /
- Endoscopy /
- Ultrasonography /
- Diagnosis /
- Therapeutics

HTML全文

表 1 各内镜诊断方法操作方式的特点及用途

操作方式	特点	用途
导管内超声(intraductal ultrasonography，IDUS)	鉴别MBS与BBS敏感度、特异度、准确度高；联合ERCP对鉴别BBS敏感度及准确度高^[21]	鉴别良恶性胆管狭窄^[21]
探头式共聚焦显微内镜(probe based confocal laser endomicroscopy, PCLE)	预测恶性病变敏感度、特异度、准确度均高于ERCP组织活检^[22]	评估良恶性胆管狭窄^[23]
光学相干层析成像(optical coherence tomography，OCT)	对ERCP细胞刷检/组织活检有补充作用^[24]	为恶性肿瘤的预测提供标准化的标准^[24]

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表 2 根据狭窄部位和病因选择治疗方式

狭窄部位	常见病因	内镜治疗
远端胆总管	慢性胰腺炎	MPS、FCSEMS
肝外中段胆管(据肝门＞1 cm)	肝移植、胆囊切除术	MPS、FCSEMS
肝门、肝内胆管	PSC、IgG4-SC	球囊扩张、塑料支架(多/单)
手术胆肠吻合口	Roux-en-Y吻合，肝结肠吻合和Whipple手术后的吻合口狭窄	球囊扩张
注：MPS，多根塑料支架；FCSEMS，全覆盖自膨胀金属支架；PSC，原发性硬化性胆管炎；IgG4-SC，IgG4相关性硬化性胆管炎。

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参考文献(46)

[1]	BOWLUS CL, OLSON KA, GERSHWIN ME. Evaluation of indeterminate biliary strictures[J]. Nat Rev Gastroenterol Hepatol, 2017, 14(12): 749. DOI: 10.1038/nrgastro.2017.154.
[2]	NESBIT GM, JOHNSON CD, JAMES EM, et al. Cholangiocarcinoma: Diagnosis and evaluation of resectability by CT and sonography as procedures complementary to cholangiography[J]. AJR Am J Roentgenol, 1988, 151(5): 933-938. DOI: 10.2214/ajr.151.5.933.
[3]	LIU HZ, ZHAO QX, ZHANG YD, et al. Value of magnetic resonance cholangiopancreatography combined with DCE-CT in the diagnosis of biliary stricture[J]. Mod Prevent Med, 2019, 46(12): 2292-2296. https://www.cnki.com.cn/Article/CJFDTOTAL-XDYF201912042.htm 刘焕珍, 赵青修, 张艳东, 等. 磁共振胰胆管成像联合CT动态增强诊断胆道狭窄性质的价值[J]. 现代预防医学, 2019, 46(12): 2292-2296. https://www.cnki.com.cn/Article/CJFDTOTAL-XDYF201912042.htm
[4]	HE C. Meta analysis of ERCP and MRCP in the diagnosis of malignant biliary stricture[J]. Shandong Med J, 2020, 60(14): 74-77. DOI: 10.3969/j.issn.1002-266X.2020.14.022. 何婵. ERCP与MRCP诊断恶性胆管狭窄价值的Meta分析[J]. 山东医药, 2020, 60(14): 74-77. DOI: 10.3969/j.issn.1002-266X.2020.14.022.
[5]	NAVANEETHAN U, NJEI B, LOURDUSAMY V, et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: A systematic review and meta-analysis[J]. Gastrointest Endosc, 2015, 81(1): 168-176. DOI: 10.1016/j.gie.2014.09.017.
[6]	KUSHNIR VM, MULLADY DK, DAS K, et al. The diagnostic yield of malignancy comparing cytology, fish, and molecular analysis of cell free cytology brush supernatant in patients with biliary strictures undergoing endoscopic retrograde cholangiography (ERC): A prospective study[J]. J Clin Gastroenterol, 2019, 53(9): 686-692. DOI: 10.1097/MCG.0000000000001118.
[7]	AL-TAEE A, GHOULAM E, BURTON S, et al. Su1570 utility of the 3-chromosome fish test in the evaluation of indeterminate biliary stricturES: A single tertiary center experience[J]. Gastrointestinal Endoscopy, 2020, 91(6): 383-384. DOI: 10.1016/j.gie.2020.03.2416.
[8]	LIEW ZH, LOH TJ, LIM T, et al. Role of fluorescence in situ hybridization in diagnosing cholangiocarcinoma in indeterminate biliary strictures[J]. J Gastroenterol Hepatol, 2018, 33(1): 315-319. DOI: 10.1111/jgh.13824.
[9]	BEYNA T, GERGES C. Clinical management of bile duct diseases: Role of endoscopic ultrasound in a personalized approach[J]. J Pers Med, 2020, 11(1): 1. DOI: 10.3390/jpm11010001.
[10]	JIN ZD, SUN LQ. Application of endoscopic ultrasound in diagnosis and therapy for biliary tract diseases[J]. Chin J Pract Surg, 2017, 37(8): 845-850. DOI: 10.19538/j.cjps.issn1005-2208.2017.08.05. 金震东, 孙力祺. 超声内镜在胆道疾病诊治中的应用[J]. 中国实用外科杂志, 2017, 37(8): 845-850. DOI: 10.19538/j.cjps.issn1005-2208.2017.08.05.
[11]	de MOURA D, MOURA E, BERNARDO WM, et al. Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis[J]. Endosc Ultrasound, 2018, 7(1): 10-19. DOI: 10.4103/2303-9027.193597.
[12]	VIKAS S, ARORA A, GUPTA A. Endoscopic ultrasound-guided fine needle aspiration as a primary diagnostic modsality in patients with unresectable proximal biliary strictures: A large single-center study[J]. Endosc Ultrasound, 2017, 6(7): 18-18. DOI: 10.4103/2303-9027.212301.
[13]	OPPONG KW, BEKKALI N, LEEDS JS, et al. Fork-tip needle biopsy versus fine-needle aspiration in endoscopic ultrasound-guided sampling of solid pancreatic masses: A randomized crossover study[J]. Endoscopy, 2020, 52(6): 454-461. DOI: 10.1055/a-1114-5903.
[14]	NAVANEETHAN U, MOON JH, ITOI T. Biliary interventions using single-operator cholangioscopy[J]. Dig Endosc, 2019, 31(5): 517-526. DOI: 10.1111/den.13361.
[15]	NAVANEETHAN U, HASAN MK, KOMMARAJU K, et al. Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: A multicenter clinical experience (with video)[J]. Gastrointest Endosc, 2016, 84(4): 649-655. DOI: 10.1016/j.gie.2016.03.789.
[16]	JANG S, STEVENS T, KOU L, et al. Efficacy of digital single-operator cholangioscopy and factors affecting its accuracy in the evaluation of indeterminate biliary stricture[J]. Gastrointest Endosc, 2020, 91(2): 385-393. e1. DOI: 10.1016/j.gie.2019.09.015.
[17]	XIA MX, WU J, YE X, et al. The diagnostic value of the novel SpyGlass peroral choledochoscopy for indeterminate biliary strictures[J]. Chin J Dig Endosc, 2020, 37(10): 722-726. DOI: 10.3760/cma.j.cn321463-20190731-00534. 夏明星, 吴军, 叶馨, 等. 新型SpyGlass经口胆道镜对性质不明胆管狭窄的诊断价值[J]. 中华消化内镜杂志, 2020, 37(10): 722-726. DOI: 10.3760/cma.j.cn321463-20190731-00534.
[18]	KARAGYOZOV P, BOEVA I, TISHKOV I. Role of digital single-operator cholangioscopy in the diagnosis and treatment of biliary disorders[J]. World J Gastrointest Endosc, 2019, 11(1): 31-40. DOI: 10.4253/wjge.v11.i1.31.
[19]	SO H, PARK DH. Digital single-operator cholangioscopy for indeterminate biliary stricture: Enthusiasm or still evolving for unmet need?[J]. Gastrointest Endosc, 2020, 91(2): 394-395. DOI: 10.1016/j.gie.2019.10.009.
[20]	YAN S, TEJASWI S. Clinical impact of digital cholangioscopy in management of indeterminate biliary strictures and complex biliary stones: A single-center study[J]. Ther Adv Gastrointest Endosc, 2019, 12: 2631774519853160. DOI: 10.1177/2631774519853160.
[21]	CHEN J, LU Y, KULKARNI P. Tu1008 a meta-analysis of the value of intraductal ultrasound (IDUS) in differentiating malignant from benign biliary strictures[J]. Gastroenterology, 2020, 158(6): 1003-1004. DOI: 10.1016/S0016-5085(20)33183-8.
[22]	YANG J, JI R, REN HB, et al. Value of probe-based confocal laser endomicroscopy for differential diagnosis of biliary stricture[J]. Chin J Dig Endosc, 2017, 34(10): 713-718. DOI: 10.3760/cma.j.issn.1007-5232.2017.10.006. 杨静, 季锐, 任洪波, 等. 探头式共聚焦激光显微内镜应用于胆管狭窄鉴别诊断的研究[J]. 中华消化内镜杂志, 2017, 34(10): 713-718. DOI: 10.3760/cma.j.issn.1007-5232.2017.10.006.
[23]	DUBOW M, TATMAN PD, SHAH RJ. Individual probe based confocal laser endomicroscopy criteria in the analysis of indeterminate biliary strictures[J]. Scand J Gastroenterol, 2018, 53(10-11): 1358-1363. DOI: 10.1080/00365521.2018.1512151.
[24]	TYBERG A, RAIJMAN I, NOVIKOV AA, et al. Optical coherence tomography of the pancreatic and bile ducts: Are we ready for prime time?[J]. Endosc Int Open, 2020, 8(5): e644-e649. DOI: 10.1055/a-1119-6248.
[25]	KAFFES AJ. Management of benign biliary strictures: Current status and perspective[J]. J Hepatobiliary Pancreat Sci, 2015, 22(9): 657-663. DOI: 10.1002/jhbp.272.
[26]	OHYAMA H, MIKATA R, ISHIHARA T, et al. Efficacy of multiple biliary stenting for refractory benign biliary strictures due to chronic calcifying pancreatitis[J]. World J Gastrointest Endosc, 2017, 9(1): 12-18. DOI: 10.4253/wjge.v9.i1.12.
[27]	SⅡKI A, HELMINEN M, SAND J, et al. Covered self-expanding metal stents may be preferable to plastic stents in the treatment of chronic pancreatitis-related biliary strictures: A systematic review comparing 2 methods of stent therapy in benign biliary strictures[J]. J Clin Gastroenterol, 2014, 48(7): 635-643. DOI: 10.1097/MCG.0000000000000020.
[28]	LAKHTAKIA S, REDDY N, DOLAK W, et al. Long-term outcomes after temporary placement of a self-expanding fully covered metal stent for benign biliary strictures secondary to chronic pancreatitis[J]. Gastrointest Endosc, 2020, 91(2): 361-369. e3. DOI: 10.1016/j.gie.2019.08.037.
[29]	COSTAMAGNA G, TRINGALI A, PERRI V, et al. Endotherapy of postcholecystectomy biliary strictures with multiple plastic stents: Long-term results in a large cohort of patients[J]. Gastrointest Endosc, 2020, 91(1): 81-89. DOI: 10.1016/j.gie.2019.05.042.
[30]	LI JS, LIU F, LI ZS. An excerpt of endoscopic biliary stenting: Indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline-updated 2018[J]. J Clin Hepatol, 2018, 34(11): 2311-2315. DOI: 10.3969/j.issn.1001-5256.2018.11.009. 李家速, 刘枫, 李兆申. 《2018年欧洲胃肠内镜学会指南更新: 内镜下胆管支架置入的指征、支架选择和疗效》摘译[J]. 临床肝胆病杂志, 2018, 34(11): 2311-2315. DOI: 10.3969/j.issn.1001-5256.2018.11.009.
[31]	TRINGALI A, REDDY DN, PONCHON T, et al. Treatment of post-cholecystectomy biliary strictures with fully-covered self-expanding metal stents - results after 5 years of follow-up[J]. BMC Gastroenterol, 2019, 19(1): 214. DOI: 10.1186/s12876-019-1129-3.
[32]	JANG S, STEVENS T, LOPEZ R, et al. Self-expandable metallic stent is more cost efficient than plastic stent in treating anastomotic biliary stricture[J]. Dig Dis Sci, 2020, 65(2): 600-608. DOI: 10.1007/s10620-019-05665-9.
[33]	POLEY JW, PONCHON T, PUESPOEK A, et al. Fully covered self-expanding metal stents for benign biliary stricture after orthotopic liver transplant: 5-year outcomes[J]. Gastrointest Endosc, 2020, 92(6): 1216-1224. DOI: 10.1016/j.gie.2020.04.078.
[34]	TRINGALI A, TARANTINO I, BARRESI L, et al. Multiple plastic versus fully covered metal stents for managing post-liver transplantation anastomotic biliary strictures: A meta-analysis of randomized controlled trials[J]. Ann Gastroenterol, 2019, 32(4): 407-415. DOI: 10.20524/aog.2019.0376.
[35]	AEPLI P, ST JOHN A, GUPTA S, et al. Success and complications of an intra-ductal fully covered self-expanding metal stent (ID-FCSEMS) to treat anastomotic biliary strictures (AS) after orthotopic liver transplantation (OLT)[J]. Surg Endosc, 2017, 31(4): 1558-1563. DOI: 10.1007/s00464-016-5138-9.
[36]	CHAPMAN R, FEVERY J, KALLOO A, et al. Diagnosis and management of primary sclerosing cholangitis[J]. Hepatology, 2010, 51(2): 660-678. DOI: 10.1002/hep.23294.
[37]	European Association for the Study of the Liver. EASL clinical practice guidelines: Management of cholestatic liver diseases[J]. J Hepatol, 2009, 51(2): 237-267. DOI: 10.1016/j.jhep.2009.04.009.
[38]	WANG L, HAN Y. An excerpt of British Society of Gastroenterology and UK-PSC guidelines for the diagnosis and management of pri-mary sclerosing cholangitis (2019)[J]. J Clin Hepatol, 2019, 35(9): 1937-1941. DOI: 10.3969/j.issn.1001-5256.2019.09.010. 王璐, 韩英. 《2019年英国胃肠病学会和英国原发性硬化性胆管炎协作组指南: 原发性硬化性胆管炎的诊断和治疗》摘译[J]. 临床肝胆病杂志, 2019, 35(9): 1937-1941. DOI: 10.3969/j.issn.1001-5256.2019.09.010.
[39]	PONSIOEN CY, ARNELO U, BERGQUIST A, et al. No superiority of stents vs balloon dilatation for dominant strictures in patients with primary sclerosing cholangitis[J]. Gastroenterology, 2018, 155(3): 752-759. DOI: 10.1053/j.gastro.
[40]	LIU W, CHEN W, HE X, et al. Poor response of initial steroid therapy for IgG4-related sclerosing cholangitis with multiple organs affected[J]. Medicine (Baltimore), 2017, 96(12): e6400. DOI: 10.1097/MD.0000000000006400.
[41]	MIYAZAWA M, TAKATORI H, KAWAGUCHI K, et al. Management of biliary stricture in patients with IgG4-related sclerosing cholangitis[J]. PLoS One, 2020, 15(4): e0232089. DOI: 10.1371/journal.pone.0232089.
[42]	TANG F, REN JZ, HAN XW, et al. Efficacy of percutaneous transhepatic biliary drainage combined with balloon dilatation in the treatment of benign biliary-enteric anastomosis stricture[J]. Chin J Hepatobiliary Surg, 2020, 26(4): 265-269. DOI: 10.3760/cma.j.cn113884-20191126-00385. 唐凡, 任建庄, 韩新巍, 等. 经皮肝穿胆道引流联合球囊扩张治疗胆肠吻合口良性狭窄的疗效[J]. 中华肝胆外科杂志, 2020, 26(4): 265-269. DOI: 10.3760/cma.j.cn113884-20191126-00385.
[43]	SATO T, KOGURE H, NAKAI Y, et al. Double-balloon endoscopy-assisted treatment of hepaticojejunostomy anastomotic strictures and predictive factors for treatment success[J]. Surg Endosc, 2020, 34(4): 1612-1620. DOI: 10.1007/s00464-019-06924-6.
[44]	YANG YL, ZHANG C, WU P, et al. Choledochoscopic high-frequency needle-knife electrotomy for treatment of anastomotic strictures after Roux-en-Y hepaticojejunostomy[J]. BMC Gastroenterol, 2016, 16(1): 54. DOI: 10.1186/s12876-016-0465-9.
[45]	LI Y, ZHU HY, SUN H, et al. Clinical efficacy of endoscopic magnetic compression bilio-enteric anastomosis for the treatment of biliary obstruction after complex abdominal surgery[J]. Chin J Dig Surg, 2020, 19(5): 544-551. DOI: 10.3760/cma.j.cn115610-20200325-00196. 李宇, 朱浩阳, 孙昊, 等. 内镜下磁压榨胆肠吻合术治疗腹部复杂手术后胆道梗阻的临床疗效[J]. 中华消化外科杂志, 2020, 19(5): 544-551. DOI: 10.3760/cma.j.cn115610-20200325-00196.
[46]	LI Y, SUN H, YAN X, et al. Magnetic compression anastomosis for the treatment of benign biliary strictures: A clinical study from China[J]. Surg Endosc, 2020, 34(6): 2541-2550. DOI: 10.1007/s00464-019-07063-8.