Primary needle-knife fistulotomy for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: Importance of the endoscopist’s expertise level

BACKGROUNDNeedle-knife fistulotomy (NKF) is used as a rescue technique for difficult cannulation. However, the data are limited regarding the use of NKF for primary biliary cannulation, especially when performed by beginners.AIMTo assess the effectiveness and safety of primary NKF for biliary cannulation, and the role of the endoscopist’s expertise level (beginner vs expert).METHODSWe retrospectively evaluated the records of 542 patients with naïve prominent bulging papilla and no history of pancreatitis, who underwent bile duct cannulation at a tertiary referral center. The patients were categorized according to the endoscopist’s expertise level and the technique used for bile duct cannulation. We assessed the rates of successful cannulation and adverse events.RESULTSThe baseline characteristics did not differ between the experienced and less-experienced endoscopists. The incidence rate of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) was significantly affected by the endoscopist’s expertise level in patients who received conventional cannulation with sphincterotomy (8.9% vs 3.4% for beginner vs expert, P = 0.039), but not in those who received NKF. In the multivariable analysis, a lower expertise level of the biliary endoscopist (P = 0.037) and longer total procedure time (P = 0.026) were significant risk factor of PEP in patients who received conventional cannulation with sphincterotomy but only total procedure time (P = 0.004) was significant risk factor of PEP in those who received NKF.CONCLUSIONPrimary NKF was effective and safe in patients with prominent and bulging ampulla, even when performed by less-experienced endoscopist. We need to confirm which level of endoscopist’s experience is needed for primary NKF through prospective randomized study.     

内镜逆行胰胆管造影术后并发胰腺炎的相关因素分析与对策探讨

目的 探讨内镜逆行胰胆管造影术（ERCP）后并发胰腺炎（PEP）的影响因素。方法 回顾性分析2018年2月－2021年2月该院343例行ERCP患者的临床资料,根据是否发生胰腺炎分为PEP组（n = 51）和非PEP组（n = 292）。采用Logistic回归法分析发生PEP的相关危险因素,并提出预防对策。结果 两组患者在性别、年龄 < 60岁、胆总管结石、胰腺炎病史、Oddi括约肌功能障碍、胰腺显影、行胰管括约肌切开术、行Oddi括约肌测压术、ERCP手术结局、插管困难和导丝多次进胰管等方面比较,差异均有统计学意义（P < 0.05）。Logistic回归分析显示,胆总管结石、胰腺炎病史、Oddi括约肌功能障碍、胰腺显影、行胰管括约肌切开术、行Oddi括约肌测压术、ERCP手术失败、插管困难及导丝多次进胰管是PEP的独立危险因素（P < 0.05）。结论 胆总管结石、胰腺炎病史、Oddi括约肌功能障碍、胰腺显影、行胰管括约肌切开术、行Oddi括约肌测压术、ERCP手术失败、插管困难及导丝多次进胰管是PEP的独立危险因素。     

内镜逆行胰胆管造影术用于老年胆总管结石效果及术后并发症的危险因素分析

目的评价内镜逆行胰胆管造影术(ERCP)用于老年胆总管结石效果及并发胰腺和胆道感染的危险因素。方法收集2019年3月-2020年5月入院行ERCP的300例老年胆总管结石患者的基本情况、临床资料和既往病史等,观察其治疗效果,并分析探讨术后并发症的危险因素。结果 300例老年胆总管结石患者经ERCP治疗后,取石成功率为97.33%,37例(12.33%)患者术后并发胰腺和胆道感染,其中术后胰腺炎(PEP) 20例,胆道感染17例。经Logistic回归分析,肥胖[体重指数(BMI) 28 kg/m~2]、Oddi括约肌功能障碍(SOD)病史、多次插管、插管时间 60 min以及胰管显影为老年胆总管结石患者ERCP术后并发胰腺炎的危险因素;胆管结石病史、胆管治疗史以及胆管中高位梗阻为术后并发胆道感染的危险因素。结论ERCP治疗老年胆总管结石疗效显著,需加强危险因素识别与评估,以减少并发症的发生。     

胆囊切除术后残留胆总管结石的内镜诊治

目的：探讨经内镜逆行胰胆管造影（ERCP）在胆囊切除术后残留胆总管结石诊治中的应用价值。方法：对胆囊切除术后腹痛、发热、黄疸或肝功能异常而经B超、CT或磁共振胰胆管造影（MRCP）证实或怀疑残留胆总管结石的患者进行ERCP检查，对发现胆总管结石的患者行EST或EPBD后取石。结果：ERCP检查的成功率为96．4％（108／112）。85例证实胆总管结石的患者行EST或EPBD后取石，79例（92．9％）取石治疗成功；6例因合并肝内胆管多发结石而行外科手术治疗。并发症发生率为4．5％，其中消化道出血2例，急性胰腺炎3例。结论；对于胆囊切除术后残留胆总管结石的患者，ERCP是理想的诊断方法，而且还可以同时进行治疗。     

Postendoscopic sphincterotomy stenosis

We report on two patients. The first patient is a 62-year-old female patient who had cholecystectomy in 1970, and in whom two small bile duct stones were removed after endoscopic sphincterotomy in 1987. Within two months of this procedure, she developed three episodes of documented acute pancreatitis. The other patient, a 58-year-old female, developed acute pancreatitis three months after an endoscopic sphincterotomy for stones in the common bile duct. In both patients, ERCP revealed a cicatricial stenosis of the common bile duct and the pancreatic duct. The condition was resolved by repeat sphincterotomy. The first patient needed repeated endoscopic insertion of bilioduodenal endoprostheses and an endoprosthesis in the pancreatic duct. It is interesting to note that, in contrast to surgical reports, very few postpapillotomy stenoses are reported by endoscopists.     

内镜下十二指肠乳头括约肌切开取石术后胰腺炎影响因素分析

目的探讨胆总管结石内镜下十二指肠乳头切开取石术相关内镜逆行胰胆管造影术(ERCP)术后胰腺炎(PEP)的影响因素。方法回顾分析327例经内镜乳头切开取石术患者的临床资料,就患者的临床表现、伴随疾病、血生化、困难插管、胆总管扩张程度、胆总管结石大小及数量、乳头括约肌切开大小、鼻胆引流(ENBD)及术前用药等20余项指标进行统计学处理,寻找影响PEP的相关因素。结果 327例患者共发生PEP 23例(7.0%),单因素统计处理发现患者伴有胆囊结石、入院时血清总胆红素(TBIL)、直接胆红素(DBIL)、谷丙转氨酶(ALT)、谷草转氨酶(AST)、谷氨酰转肽酶(GGT)、胆总管扩张程度PEP组和非PEP组比较P值小于或接近0.05,将这7项有可能影响PEP的指标纳入多因素分析,结果示胆囊结石和胆总管扩张程度是影响PEP发生的独立因素。结论伴有胆囊结石和胆总管不扩张或轻度扩张的胆总管结石患者,行内镜下乳头切开取石术较易并发PEP。     

Cystic duct entry--another cause of pseudocalculus

Certain pitfalls face the endoscopist during ERC in the diagnosis of common bile duct stones. False-positive filling defects for calculi may be caused by air bubbles, blood clot, tumor, and the pseudocalculus sign of the lower common bile duct (CBD) due to sphincter spasm. Another false positive may be encountered by the presence of a filling defect at the confluence of the cystic duct and common bile duct, and we report on three such cases. The cause of this pseudocalculus sign of the mid-CBD is not clear. We speculate that it may arise as a result of an unopacified jet of bile flowing from the cystic duct displacing contrast in the CBD.     

导丝进入胰管的困难性胆管插管策略在内镜逆行胰胆管造影术中的应用

目的 探讨导丝进入胰管的困难性胆管插管策略应用于内镜逆行胰胆管造影术（ERCP）中的临床效果。方法 回顾性分析该院63例导丝进入胰管的困难性胆管插管患者的临床资料。依次采用双导丝法、胰管预切开法和胰管支架法选择性胆管插管,根据不同胆管插管方法分为双导丝组、胰管预切开组和胰管支架组。分析各组的插管成功率、插管时间及ERCP术后并发症之间的差异。结果 3组总体插管成功率为96.8%。双导丝组、胰管预切开组及胰管支架组的插管时间分别为（70.7±28.6）、（116.6±43.2）和（129.1±88.2）s,组间比较,差异有统计学意义（P < 0.05）。ERCP术后高淀粉酶血症总体发生率为39.3%,胰管预切开组明显高于其他两组（P < 0.05）。ERCP术后胰腺炎（PEP）总发生率为21.3%,胰管预切开组明显高于其他两组（P < 0.05）。ERCP出血发生率为6.6%。未发生重症胰腺炎和十二指肠穿孔病例。结论 导丝进入胰管后依次采用双导丝法、胰管预切开法和胰管支架法选择性胆管插管,上述方法插管成功率高,手术安全可行。     

腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石

目的:探讨腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石的临床疗效.方法:回顾分析2009年1月-2010年12月腹腔镜胆囊切除术(LC)联合十二指肠镜治疗35例胆囊结石合并胆总管结石患者的临床资料.所有患者均采取经十二指肠镜逆行胰胆管造影(ERCP),内镜下十二指肠乳头括约肌切开术(EST),取出胆总管结石,放置胆道塑料支架引流(ERBD).ERCP后3d内行LC,术后4d出院.出院后1～2周内再次行十二指肠镜取出胆道支架并行ERCP了解胆管有无残余结石.结果:35例患者均1次取净胆总管结石,1例EST术中出血,34例成功行LC,1例中转开腹行胆囊切除术.术后并发急性胰腺炎2例,所有患者均无胆漏、十二指肠穿孔、黄疸等并发症.结论:腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石具有疗效确切、创伤小、恢复快等优点.     

Choledochoduodenal fistulas

In 2,012 ERCP studies reviewed in the period between 1976 and 1989, we observed 14 choledochoduodenal fistulas found in the upper portion of the papilla of Vater. Two fistulas occurred spontaneously due to necrosis of the duodenal wall caused by stones located in the distal common bile duct above the sphincter of the papilla. In these two cases the stones were removed endoscopically. The twelve remaining cases were iatrogenic, caused during surgical papillotomy which resulted in a false tract. All patients showed raised AP and gamma GT. Eight had acute cholangitis, 7 were jaundiced, there was one case each of acute pancreatitis and chronic recurrent pancreatitis. Nine patients had stones located in the distal common bile duct. In eight cases it was possible to cannulate the papillary opening and do a papillotomy thereby connecting the fistulous orifice with the opening of the papilla. The other patient was treated surgically. Two patients had papillary stenosis. One was successfully treated with papillotomy through the papillary opening. In the other, the fistulous orifice was joined with the papillary opening using a diathermy scalpel. This patient suffered a posterior duodenal wall perforation. One patient with acute pancreatitis and common bile duct stones distal to the fistula improved with papillotomy and stone removal. The patient with chronic recurrent pancreatitis without lithiasis refused any form of treatment.     

Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Pancreaticobiliary maljunction(PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct(CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum(PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition.Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct.CASE SUMMARY A boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography(ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain.CONCLUSION We consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases,especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.     

急性胆源性胰腺炎急诊内镜治疗

目的探讨急性胆源性胰腺炎的急诊内镜治疗的疗效和安全性。方法回顾性分析本院1998年4月至2006年6月间41例急性胆源性胰腺炎患者接受急诊内镜治疗结果。结果于入院72h内41例均接受了EST、胆总管取石治疗,20例同时接受了ENBD治疗,其中38例得到治愈,1例因治疗后并发胰腺脓肿接受开腹手术,1例治疗未成功转外科手术,1例出现呼吸衰竭死亡。结论早期内镜治疗急性胆源性胰腺炎疗效显著,无明显内镜操作相关的并发症,值得临床推广应用。     

急性胆源性胰腺炎的急诊内镜治疗

目的：探讨急性胆源性胰腺炎的急诊内镜治疗的方法。方法：36例急性胆源性胰腺炎患者接受急诊经内镜逆行胆道造影和乳头括约肌切开并取石，35例治疗成功。结果：24例轻型胰腺炎经内镜治疗后均得到治愈，11例重症胰腺炎中8例缓解，2例因胰腺脓肿接受开腹手术，1例死于呼吸衰竭。结论：内镜治疗急性胆源性胰腺炎具有操作简单、安全、有效等优点，是胆源性胰腺炎较为理想的治疗方法。     

ERCP: current uses and less-invasive options

Endoscopic retrograde cholangiopancreatography (ERCP) is well suited for the evaluation and treatment of diseases of the bile ducts and pancreas, but it carries the risk of inducing pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography have exceptional value in imaging the gallbladder, common hepatic duct, common bile duct, and pancreas. These imaging studies have replaced ERCP for diagnostic purposes in patients with a low pretest probability of finding lesions amenable to endoscopic therapy, such as bile duct stones.     

针形刀预切开术在老年患者胆道远端恶性狭窄支架置入中的应用

目的 研究针形刀预切开术在老年胆管远端恶性狭窄患者中行内镜逆行胰胆管造影术(ERCP)支架置入的应用效果.方法 选取常州市第一人民医院2018年1月-2021年1月47例明确诊断为胆管远端恶性狭窄且常规插管失败而行针形刀预切开术的老年患者(年龄>70岁).其中,男29例,女18例;年龄71～93岁,平均81.04岁;十...     

Selective endoscopic cholangiography for the detection of common bile duct stones in patients with cholelithiasis

BACKGROUND AND STUDY AIMS: The detection and management of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy continues to be controversial. Several diagnostic and therapeutic strategies have been suggested. These include intraoperative cholangiography, selective endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, and endoscopic ultrasonography. The aim of this study was to evaluate the efficacy of selective ERCP in detecting CBD stones in patients with cholelithiasis before laparoscopic cholecystectomy. PATIENTS AND METHODS: In a prospective study, patients with cholelithiasis who presented during a 6-year period were assessed on a selective basis with ERCP for suspected CBD stones before laparoscopic cholecystectomy. ERCP was carried out if the patient had any of the following criteria: a dilated CBD on ultrasound, gallstone pancreatitis, or abnormal liver function tests. Intraoperative cholangiography was not performed in any of the patients. Long-term follow-up was undertaken. RESULTS: The study included 427 patients. On the basis of selective criteria, ERCP was carried out in 41 patients (9.6 %), with confirmed CBD stones in 22 cases (53.7 %). The most useful predictor of CBD stones on ERCP was the presence of a dilated CBD in association with abnormal liver function tests. In this situation, CBD stones were identified in 14 of 17 cases (82 %). Abnormal liver function tests alone had a sensitivity of 50 % (four of eight). All other parameters used in isolation had a lower detection rate. During a median follow-up period of 6 years (range 1-10 years), six of 386 patients (1.6 %) with initially normal imaging and biochemical tests presented again with retained stones. All were successfully managed by ERCP and sphincterotomy. There were no major complications. CONCLUSIONS: Preoperative selective ERCP is effective in detecting clinically significant CBD stones. However, there is a high false-negative rate when a single criterion is used to guide therapy. Multivariate analysis of preoperative parameters for risk stratification, in conjunction with other imaging modalities, may make it possible to minimize unnecessary ERCPs.     

腹腔镜胆总管探查取石与内镜ERCP/EST联合LC治疗胆囊疾病合并胆总管结石的临床对比研究

【目的】评价腹腔镜胆总管探查取石术(LCBDE)与内镜逆行胆管造影、括约肌切开取石术(ER CP/EST)联合腹腔镜胆囊切除术(LC)治疗胆囊疾病合并胆总管结石的临床效果,探讨胆石症的微创外科治疗策略。【方法】回顾性分析152例胆囊疾病合并胆总管结石病人分别采用LC LCBDE术(68例)、内镜EST联合LC术(84例)治疗的临床资料, 进行胆总管内径、结石大小、手术时间、手术费用、并发症发生率、术后住院日等方面的统计学对比分析。【结果】两种术式的术后住院日差异无显著性(P>0. 05),手术时间、手术费用、并发症发生率等方面比较差异有显著性(P<0. 01 ), 且两者的胆总管内径、结石大小相比较有差别。【结论】胆总管直径小于1. 0cm,尤其胆总管下端结石嵌顿时宜采用内镜、腹腔镜联合手术治疗;胆总管直径大于1. 0cm或多发结石,尤其并存二级支肝管结石者(无胆管狭窄),腹腔镜下一期手术LC LCBDE是治疗胆囊疾病合并胆总管结石的最佳选择。     

胆道微结石在急性胆管炎中的临床意义

目的:探讨胆道微结石在急性胆管炎中的临床意义。方法:收集54例急性胆管炎患者,通过经内镜逆行胰胆管造影(ERCP)或内镜鼻胆管引流术(ENBD)收集胆汁,通过普通和偏振光显微镜查找微结石。结果:54例急性胆管炎患者中,3例ERCP失败,其余均插管成功。其中35例胆总管结石或扩张,4例胆总管下端炎性狭窄,12例未见明显异常。在35例胆总管结石中,29例发现胆道微结石,4例胆总管炎性狭窄的患者中,3例发现胆道微结石。在12例ERCP阴性胆管炎患者中,9例发现了胆道微结石(大多为胆固醇单水结晶),3组之间两两比较,差异无显著性(P>0.05)。结论:(1)在急性胆管炎中,ERCP联合微结石检测可以提高胆道结石的诊断率。(2)胆道微结石与急性胆管炎的发病密切相关。     

Managing concomitant gallbladder stones and common bile duct stones in the laparoscopic era: a systematic review

Background: There is still no consensus on the ideal management of common bile duct (CBD) stones. This article aims to review the management of concomitant gallbladder stones and CBD stones in the laparoscopic era. Method: A PubMed database search was performed to identify MEDLINE articles from 1986 to 2010 using the key terms “common bile duct stones,”“cholecystectomy,”“bile duct exploration,”“ERCP” (endoscopic retrograde cholangiography), and “endoscopic sphincterotomy.” Results: There were five randomized comparative trials (RCT) comparing sequential preoperative ERCP and laparoscopic cholecystectomy (LC) to laparoscopic common bile duct exploration (LCBDE). Two RCTs showed similar stone clearance rates and shorter hospital stays in the LCBDE group, while three RCTs showed similar stone clearance rates and hospital stays in sequential preoperative ERCP, LC and LCBDE groups. There were two RCTs comparing LCBDE to sequential LC and postoperative ERCP. One showed similar stone clearance rate and shorter hospital stay in LCBDE group, while the other showed similar stone clearance rate and hospital stay. There were three RCTs comparing sequential preoperative ERCP and LC against LC with intraoperative ERCP. All three studies showed similar stone clearance rates and shorter hospital stays in the intraoperative ERCP group. There was only one RCT comparing sequential preoperative ERCP and LC against sequential LC and postoperative ERCP. This showed a similar stone clearance rate and shorter hospital stay in the postoperative ERCP group. Conclusion: Different management approaches of concomitant gallbladder stones and CBD stones were equivalent in efficacy. However, one‐stage management had the advantage of providing a shorter hospital stay.     

经内镜逆行胰胆管造影术后并发症的影响因素探讨

目的 探讨经内镜逆行胰胆管造影术(ERCP)后并发症的高危因素.方法 回顾性分析解放军总医院消化内镜中心2005年8月至2007年6月行ERCP诊断与治疗的全部住院患者的临床资料;统计并发症的发生情况,对数据进行单因素变量分析.结果 864例患者完成ERCP检查和治疗,ERCP操作成功率为96.8%(836/864).影响ERCP成功的主要因素有:肿瘤完全阻塞乳头致使导丝无法通过;肿瘤、溃疡或其他原因致肠腔狭窄使内镜不能进入十二指肠降部.出现并发症105例,发生率为12.2%,其中胰腺炎49例(5.7%),胆道感染37例(4.3%),上消化道出血15例(1.7%),穿孔4例(0.5%).经单变量分析显示,ERCP术后并发胰腺炎的相关因素主要有插管时间过长(>60 min,χ~2=5.22,P=0.022)、行胰管造影(χ~2=6.83,P=0.009)、奥迪括约肌功能障碍(χ~2=19.89,P=0.000)、血清胆红素正常(χ~2=4.02,P=0.045);ERCP术后并发胆道感染的相关因素主要有患有恶性胰胆系统肿瘤(χ~2=16.39,P=0.001)及胆道结石病史(χ~2=7.48,P=0.006)、胆道高位梗阻(χ~2=67.13,P=0.000)、胆管治疗性ERCP(χ~2=6.39,P=0.012).结论 ERCP术后并发症的发生与患者自身因素及医师操作技术有关,认识患者高危因素并提高医师操作水平是减少或避免ERCP术后并发症的关键.