Interventional Sialendoscopy by Oded Nahlieli

题目：Interventional Sialoendoscopy
作者：Oded Nahlieli, DMD

选自Maria Troulis 和 Leonard Kaban主编的Minimally Invasive MAXILLOFACIAL SURGERY

Nahlieli 是涎腺内窥镜的先驱之一。这一章节主要是介绍他们团队在内窥镜诊断、治疗、疗效和操作并发症方面的经验，但是实际上并没有对技术的细节方面进行详细描述。

适应症选择

• Inspection of salivary ducts to identify and localize stones.
• Inspection of salivary ducts for diagnostic purposes in patients with recurrent episodes of salivary gland swelling without an obvious cause of obstruction.
• Removal of deeply located small to medium (<5 mm) stones in the middle and posterior portion of Wharton’s or Stenson’s ducts.
• Exploration of the duct system for secondary stones, stone particles, or debris after removal or mechanical fragmen- tation of calculi or lithotripsy.
• Identification and treatment of strictures and kinks in the submandibular and parotid ducts.
• Treatment of recurrent nonobstructive submandibular and parotid sialadenitis by endoscopic inspection, dilata- tion and copious irrigation.

（本文作者注：在大多数文献中，认为比较适合直接通过取物篮或取石钳整块取出的结石直径应小于5mm，再大的结石则需要通过各种碎石的技术。）

内窥镜进入导管的四种方法

• Dilatation of the duct orifice with dilators and lacrimal probes.
• Papillotomy of the duct orifice (commonly required) performed with a CO2 laser, a fine scissors or a number 11 scalpel blade.
• Incision of the floor of mouth mucosa to identify and enter the anterior portion of the submandibular duct. The submandibular duct can be opened safely anywhere along its length. The parotid duct is prone to stricture and the duct should not be opened over more than 1 mm or 2 mm.
• Direct insertion after sialolithotomy.The endoscope can be inserted through the opening made for intraoral stone extraction.

（本文作者注：这四种属于比较常见的方法，其他还有通过导丝引导或者使用Salivary duct introducer等。）

操作过程中的冲洗

内镜操作过程需要持续的等渗液体冲洗以打开管腔提供视野。Nahlieli认为 ：The duct system is sensitive to lumenal pressure (much like the kidney) and may constrict in response to high-pressure irrigation. Before irrigating, therefore, 5 mL to 10 mL of 2% lidocaine without epinephrine should be injected into the duct. Irrigation can be accomplished by means of a 500 mL bag of normal saline on a self-filling syringe or simply a 20 mL syringe connected by a short (60 cm) tube to the endoscope. The syringe should not be connected directly to the endoscope because pressing the plunger moves the endoscope and distorts the image.

取石操作

（本文作者注：包括内镜取石、内镜结合手术取石或者采用碎石技术等，缺乏具体操作细节介绍。）

腺管狭窄和扭曲(kinks)的处理

对腺管狭窄的扩张方法一般有如下几种：通过生理盐水灌注同时使用内镜扩张；球囊扩张。作者认为使用球囊扩张时，“The duct is allowed to remain dilated for 5 minutes and the maneuver is repeated 3 times. This is sufficient to dilate most strictures. ”

另外还介绍了一种使用取石钳进行扩张的方法：

Grasping forceps can be used to dilate strictures. The forceps is inserted to just beyond the stricture and then opened and slowly withdrawn along the walls of the stricture.

扩张治疗后，作者常使用 100 mg of hydrocortisone solution 灌注导管。

对于腺管扭曲的处理，仍然使用的是外科的方法牵拉导管减轻扭曲程度，并且可能的话在术后放置支架2-4周。同时使用amoxicillin 1.5 g per day for 7 days.

在治疗效果方面：

Nahieli et al. have treated 111 strictures endoscopically: Parotid gland (n = 71, 64%); and submandibular gland (n = 40, 36%). The success rate for the treatment was 81%. In 15% of the cases, more than 1 procedure was required and in 4%, the dilatation procedure failed.

非阻塞性涎腺炎症

对于未发现明显阻塞因素的涎腺炎症的处理:

thorough sialoendoscopic-guided lavage of the main and secondary ducts with at least 60 cc of normal saline is a very effective strategy to prevent recurrences. Adhesions may be responsible for stasis and poor flow which then result in recurrent submandibular sialadenitis.

治疗数据汇总

During the past 13 years, sialoendoscopy has been performed on 1078 glands with symptoms of obstructive disease at Barzilai Medical Center. There were 545 males and 533 females, with an age range of 2 to 96 years. There were 722 submandibular, 347 parotid, and 9 sublingual glands examined. All patients underwent preoperative and postoperative screening including routine radiography, sialography, and ultrasound. Postoperative examination was routinely performed 1 month following the procedure. The longest follow-up was 40 months postendoscopy. The majority of procedures were performed under local anesthesia on an outpatient basis. The duration of the procedures ranged from 30 to 90 minutes.

The success rate for parotid sialolithotomy was 86% and for submandibular gland sialolithotomy 89%. Immediate failures (introduction of the miniature endoscope failed or proved not feasible) occurred in 1.1%; intraoperative failures (inability to accomplish any of the endoscopic stone retrieval techniques) in 4.4%; and late failures in 4.7% of patients. Complications in- cluded: temporary lingual nerve paresthesia in 0.4%, postopera- tive infection in 1.6%, postoperative bleeding in 0.5%, traumatic ranula in 0.7%, and ductal strictures in 2.5% of patients.

同时的他们在使用内镜的过程中发现了一些micro-anatomic and pathophysiologic phe- nomena：

• Sphincter-likemechanisms.
• Sublingual duct opening (Bartholin’sduct).This opening was noted in the anterior portion of Wharton’s duct, between 0 mm and 5 mm posterior to the papilla.
• Changes in the ductal system: a matted appearance, ecchymosis and hypovascularity in chronic sialadenitis or in the presence of long-standing calculi; a shiny appear- ance of the ductal lining visible mucosal vascularity healthy glands or in patients with short-term obstruction.
• Peculiar connections between calculi and the ductal wall were observed in the submandibular and parotid glands.
• Intraparenchymal stones.
• Foreign bodies: ten foreign bodies in the ductal system were identified—four in the parotid duct and six in the submandibular duct. Of the ten foreign bodies, four were hair shafts and three were parts of a plant that were washed out by irrigation. Five of the ten foreign bodies were associated with calculi, three were found in children. Formation of a sialolith around a hair shaft was observed in two cases.
• Ductal strictures and kinks: malformations of salivary ducts were detected in 148 cases—37 kinks (29 sub- mandibular and 8 parotid) and 111 strictures (40 sub- mandibular and 71 parotid).
• Pelvis-like formation: an anatomic malformation in the submandibular hilum was identified to be a pelvis-like configuration of the duct (a basin-like structure) instead of a bifurcation or trifurcation. This pelvis-like formation may have caused an obstructive phenomena.
• Intraductal evagination: an evagination of the duct was identified in a 10-year-old child who had two sialoliths. The sialoliths were identified in Wharton’s duct. During stone extraction, the evagination was noted. It obstructed the ductal lumen and, was probably the cause for the for- mation of calculi.

涎腺导管结石治疗方式选择

文中推荐了一个2006形成的导管结石治疗方法选择共识（未找到原文）：

1. Seleting submandibular sialoendoscopy techniques:

2. Selecting parotid sialoendoscopy techniques