内視鏡的乳頭括約筋切開術と胆管結石除去の方法とその成績

Endoscopic Sphincterotomy and Extraction of Gallstones

　近年，内視鏡的膵胆管造影手技の習熟につれて胆石の内視鏡的除去が試みられ，生検鉗子での乳頭部嵌頓結石の除去¹⁾²⁾や採石具による傍乳頭痩孔を介しての結石除去³などが報告された．しかし，通常の乳頭を介しての結石の機械的除去は極めて困難であり，われわれの経験³⁾からも方法論の展開が必要であろうと思われた．一方，内視鏡下に高周波電気メスを用いて乳頭括約筋を切開する方法，すなわち内視鏡的乳頭括約筋切開術が1973年Kawai, K. et al^4)～6)，Classen, M. et al⁷⁾の，相馬ら⁹⁾により胆管結石の除去を主目的に開発されるや，急速に報告例^10)～18)が増加し，現在では西独，ベルギー，フランスおよび本邦などで各施設の集計報告¹⁹⁾²⁰⁾がなされるまでに至っている．

　われわれは1974年まずサルを用いて本法の基礎実験²¹⁾を行い安全性を確認した上で，同年11月臨床応用に踏み切った．本稿ではわれわれの方法と現在までの成績を中心に報告し本法の問題点と臨床的意義につき述べたい．

　We report the results of endoscopic sphincter0tomy with a long tip cutting wire and basket catheter extraction of gallstones. From November 1974 till March 1979, sphincterotomy was attempted in 104 patients: 63 with retained or recurrent common bile duct stones after cholecystectomy, 10 with hepatocl'1oledocholithiasis after cholecystectomy, 27 with choledocholithiasis of poor operative risk with a gallbladder in place, and 4 with other miscellaneous diseases involving the ampullary region. Half of the 100 patients with common duct stones (49 patients) in this series had at least one operative risk factor. The procedure was successful in 101 patients (97%) in total, and in 97 of 100 patients with gallstones. Of these 97 patients, common duct stones were eliminated in 94 (97 %). The success rate of stone removal was high when compared with other series previously reported. It seemed to be attributable to our aggressive attitude towards extraction of even large stones. Complications of sphincterotomy included three cases of bleeding, two of cholangitis, two of pancreatitis and one of stone impaction which led to the only fatality in the present series. Thus morbidity was 7.7 per cent and mortality 1.0 per cent.

　Although long-term consequences especially in terms of restenosis and reflux cholangitis remain to be defined to make a conclusive assessment of the value of this procedure, it would currently be of great value to remove recurrent or retained common duct stones after previous surgery, or to obtain a biliary drainage in urgent cases of cholangitis.

　We have also stressed the clinical significance of removal of common duct stones by endoscopic sphincterotomy preceding cholecystectorny to reduce an operative burden imposed upon aged or high-risk patients with stones in both of the gallbladder and common duct.