内視鏡的胆管造影―胆管腫瘍の診断を中心に

Endoscopic Cholangiography: centering around the diagnosis of biliary neoplasms

内視鏡的胆管造影の歩み

　十二指腸ファイバースコープを用いて十二指腸乳頭から逆行性に膵管や胆管を造影する内視鏡的膵・胆管造影は，十二指腸フィイバースコープの開発当初から考えられていたことである．1969年2月に町田製作所でFDS-Lbが試作されるや，同年4月には内視鏡的膵管造影¹⁾が，そして6月には胆管の造影²⁾が行われたことがそのことを如実に物語っている．

　しかし，はじめは膵管は造影されても胆管は造影されず，膵管に多量に注入した造影剤が胆管に逆流することによって胆管造影が得られた，だが，この方法では膵に過度の負荷をかけることになり，直接胆管へ挿管する方法が望まれた．胆管を造影するためにまず一度膵管に挿管した造影用カテーテルの方向を上方に向けていくことによって直接胆管に造影剤を注入することが成功し，一応，内視鏡的膵・胆管造影法の基本的手技が確立した³⁾．

　From Sept. 1969 to Aug. 1972, 220 cases have been studied with retrograde cholangiography by means of fiberduodenoscope. In recent selective cholangiography the bile duct was visualized in 74 per cent.

　The merits of endoscopic cholangiography are: (1) Not only the bile duct is visualized, but also the pancreatic duct is simultaneously opacified in addition to the study of the duodenum, so that the bile duct can be studied in a comprehensive way; (2) discomfort to the examinee is slight, and so also is the risk of the procedure; and (3) sufficient visualization is achieved. On the other hand, its drawbacks include the difficulty in the visualization of the intra hepatic bile ducts, a procedure requiring proficiency in the technics of examination. When an obstructive lesion exists within the bile duct, the duct can be visualized up to the occulusion, and so far it is an advantage, while it can be a demerit because the duct oral from the obstructed part can not be seen radiographically.

　Twelve cases of cancer in the bile duct and 8 cases of gallbladder cancer account for all the tumors in the biliary tract we have encountered. Not a case of benign tumor was experienced. Of 8 cases of cancer in the bile duct, 6 were well visualized, and so were all 4 cases of gallbladder cancer. In cancer of the bile duct, its obstruction was seen in 3 cases, constriction in 2 and shadow defect in 1. In cancer of the gallbladder, occulusion, narrowing, shadow defect and partial portrayal of the bile duct were seen in each of cases. Unlike cancer of the pancreatic head, no abnormality was seen in the pancreatic duct in our series.

　Except for 2 cases, icterus was invariably seen at admission in cancer of the biliary tract. Carcinomas that were resectable were 3 including 2 cases without icterus.

　Although endoscopic cholangiography is an important examination technic along with percutaneous transhepatic cholangiography, it is still an insufficient procedure when we aim at accurate diagnosis especially from the viewpoint of treatment.