胆囊切除术后综合征的内镜诊断和治疗

目的 探讨内镜在胆囊切除术后综合征病因诊断和治疗中的应用价值。方法 对326例胆囊切除术后综合征患者ERCP检查明确病因后,对胆管结石行内镜乳头括约肌切开术（EST）和内镜乳头气囊扩张术（EPBD）后取石;对乳头炎必狭窄行EST或EPBD治疗;对乳头旁憩室压迫乳头开口和Oddi括约肌功能紊乱（SOD）行EPBD治疗;对乳头肿瘤和肝门胆管癌行内镜胆管金属内支架治疗（EMBE）;对化脓性胆管炎,继发性胆总管多发结石、结石难以一次取净及术后胆瘘,胆管中段狭窄行内镜鼻胆管引流（ENBD）。结果 315例（96．6％）ERCP成功。未发现异常30例。胆管结石191例,186例经1－3次内镜取石后取净。乳头炎性狭窄39例,经EST或EPBD治疗1次成功。乳头旁憩室压迫乳头开口9例,行EPBD治疗1次成功。胆管中段狭窄16例,11例行ENBD成功。乳头肿瘤6例,肝门胆管癌5例,EMBE治疗后黄疸减退。SOD7例,行EPBD治疗成功。胃十二指肠溃疡6例。胆囊管结石残留4例。胆囊切除术后胆瘘2例,行ENBD治疗成功,避免再次外科手术。总的并发症发生率4．8％,其中急性轻型胰腺炎11例,急性胆管炎3例,上消化道出血1例。结论 ERCP能及早发现胆囊切除术后综合征确切病因并给予相应内镜治疗。熟练掌握ERCP技术可减少并发症的发生。     

经内镜诊治胆囊切除术后综合征96例

[目的]探讨胆囊切除术后综合征（PCS）的最佳治疗方法及微创治疗的临床效果。[方法]经十二指肠镜行逆行胰胆管造影（ERCP）确诊，针对胆管结石、壶腹括约肌功能障碍、胆管狭窄等综合征，分别行乳头括约肌切开术、碎石及取石术、胆道探条扩张术及胆管支架置入术。[结果]诊治的96例PCS患者，治疗后疼痛均有不同程度的缓解，其中以胆管结石及乳头括约肌功能障碍者最为明显。胆红素1周后均下降40．6％～62．5％，发热患者术后1～3d内恢复正常，无大出血及消化道穿孔等并发症发生，术后12例有一过性淀粉酶升高，经用善宁及抗生素等药物治疗后，均在24～48h恢复正常。[结论]经内镜诊治PCS是一种损伤小、快速有效的微创诊治方法。     

内镜下乳头气囊扩张对胆总管结石的治疗价值

经内镜乳头括约肌切开术（EST）是治疗性经内镜逆行胰胆管造影术（ERCP）的基础,尤其在胆总管结石的治疗中EST是运用最广泛最成功的内镜下技术.尽管如此,EST仍然有不少短期、长期并发症,如出血、穿孔、胰腺炎及乳头狭窄、胆管炎等[1].1983年,Staritz等[2]介绍了一项可以替代EST的新技术--内镜下乳头气囊扩张术（EPBD）,与EST相比,EPBD的并发症如出血、穿孔发生率明显降低.     

老年患者ERCP术后十二指肠乳头出血与原发疾病的关系研究

目的探讨老年患者经内镜逆行胰胆管造影(ERCP)术后十二指肠乳头出血与原发疾病的关系。方法回顾性分析成都大学附属医院收治的320例老年胆胰疾病患者的临床资料,分析ERCP术后十二指肠乳头出血与原发疾病的相关性。结果老年患者ERCP术后十二指肠乳头出血总体发生率为6.3%。出血组中壶腹部嵌顿结石、胆管癌、胰头癌及十二指肠乳头癌患者所占比例均明显高于未出血组(P均0.05)。出血组患者合并高血压病及十二指肠乳头旁憩室的比例均明显高于未出血组(P均0.05)。结论老年壶腹部嵌顿结石、恶性肿瘤患者以及合并高血压病、十二指肠乳头旁憩室的患者,ERCP术后十二指肠乳头出血的风险较大。ERCP术后出血治疗首选急诊内镜下止血。     

ERCP在腹腔镜胆囊切除术后胆管并发症诊治中的应用

目的探讨内镜逆行胰胆管造影（ERCP）在腹腔镜胆囊切除术（LC）后胆管并发症诊治中的应用价值。方法对96例LC术后胆管并发症者行ERCP检查,并根据检查结果给予相应处理。结果本组ERCP显示,胆管残余结石70例,45例采用括约肌切开术（EST）,25例采用乳头气囊扩张术（EPBD）,结石排出67例;胆总管部分狭窄17例,行胆管扩张和内镜逆行胆管内引流术（ERBD）,术后随访1a狭窄解除12例;胆总管完全横断5例,2例行ERBD,黄疸减退后均行外科胆管空肠Roux—en—Y吻合;胆瘘4例,3例经EST治疗后症状减轻,避免手术,1例症状无改善接受手术治疗。结论对Lc术后胆管并发症者行ERCP,有助于明确病因,并指导相应的治疗。     

双镜联合序贯治疗胆囊结石合并胆总管结石36例

目的探讨十二指肠镜联合腹腔镜序贯治疗胆囊结石合并胆总管结石的可行性。方法 2013年5月至2014年6月,对36例胆囊结石合并胆总管结石的患者采用双镜序贯治疗。逆行胆胰管造影(ERCP)采用或不采用乳头括约肌切开(EST)、球囊扩张(EPBD)后取石,然后放置鼻胆管引流(ENBD)。术后若无并发胰腺炎,第2~3天在手术室全身麻醉下行腹腔镜胆囊切除术(LC),随后观察疗效和并发症发生情况。结果 34例患者均成功完成ERCP和LC操作,1例结石嵌顿胆总管下端,插管不成功转外科手术治疗。1例乳头处肠穿孔,外科手术修补。4例术中少许渗血,给予球囊压迫止血,无继续出血。1例并发胰腺炎,给予保守治疗胰腺炎控制后行LC治疗。无术后迟发性出血、胆瘘发生。术后第2天流质,第3天出院。平均住院时间短7.8 d。术后随访12个月期间行腹部B超或MRCP检查,均未发现胆总管残留结石、再生结石、胆道狭窄。结论序贯完成ERCP和LC是安全可行的,具有住院时间短、并发症少、创伤小、胃肠功能恢复快等优点。     

内镜治疗胆总管结石的临床研究

目的 探讨内镜在胆总管探查取石中的应用价值。方法 对227例拟诊胆总管结石 的患者采用经内镜治疗,其中14例直径<1.0 cm的结石采用经内镜乳头球囊扩张术治疗,194例直 径1.0-1.5cm的结石采用内镜乳头括约肌切开治疗,19例直径>1.5cm的结石采用内镜下机械碎 石治疗。结果 15％(34例)胆管造影未见结石,经内镜探查阴性。余193例中,187例取石成功,成 功率为96.9％(187／193)。并发症发生率为5.29%(12／227),其中急性胆管炎3例,急性胰腺炎8 例,消化道出血1例。结论 内镜治疗胆总管结石安全有效,并发症少,应当首选。但对ERCP无法 明确的胆总管结石,不主张行乳头括约肌切开及内镜下的胆管探查,以最大限度地减少并发症。     

超声内镜在可疑胆胰疾病ERCP术前的初步应用

目的 超声内镜(EUS)在可疑胆胰病变患者行内镜逆行胰胆管造影(ERCP)术前的临床应用价值.方法 对15例急性胰腺炎、梗阻性黄疸、胆总管扩张或反复腹痛等病史的患者,经腹部B超、CT和/或MRCP检查可疑胆胰病变,术前行EUS检查诊断,并经ERCP确认.结果 15例患者确诊胆总管结石并行EST取石术9例,确诊壶腹部肿瘤2例,胆管内乳头状瘤2例,十二指肠乳头炎性狭窄1例,胰管结石1例.结论 EUS对可疑胆胰病变有很高的诊断价值,特别能提高胆总管结石确诊率,高于MRCP检查,并能指导ERCP,提高治疗效果,减少风险.     

内镜下乳头括约肌小切开联合气囊扩张术治疗胆总管结石临床体会

目的 探讨内镜下乳头括约肌小切开联合乳头气囊扩张术(EPBD)治疗胆总管结石的效果.方法 对121例胆总管结石患者行乳头括约肌小切开联合EPBD后取石治疗.结果 2例结石太大转外科手术治疗,2例乳头插管未成功转外科手术治疗;83例一次完成取石,34例二次取石后取尽,取石成功率98％;并发胰腺炎2例,胆道感染1例,高淀粉酶血症11例.结论 内镜下乳头括约肌小切开联合EPBD术治疗胆总管结石效果确切,无严重并发症发生.     

内镜治疗胆总管结石146例

[目的]探讨内镜下乳头括约肌切开术(EST)治疗胆总管结石的疗效和安全性.[方法]对2003年1月～2007年12月采用内镜治疗的146例胆总管结石病例进行分析研究.[结果]146例中,EST成功142例,取石成功138例,成功率为97.18%(138/142).其中1次取净结石者108例,2次或2次以上取净结石者30例,8例未成功者转外科手术治疗.取石成功者中10例出现并发症,占7.25%(10/138).[结论]内镜治疗胆总管结石安全、有效.     

Suturing techniques with endoscopic clips and special devices after endoscopic resection

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.     

Evolving endoscopic surgery

Since the days of Albukasim in medieval Spain, natural orifices have been regarded not only as a rather repugnant source of bodily odors, fluids and excreta, but also as a convenient invitation to explore and treat the inner passages of the organism. However, surgical ingenuity needed to be matched by appropriate tools and devices. Lack of technologically advanced instrumentation was a strong deterrent during almost a millennium until recent decades when a quantum jump materialized. Endoscopic surgery is currently a vibrant and growing subspecialty, which successfully handles millions of patients every year. Additional opportunities lie ahead which might benefit millions more, however, requiring even more sophisticated apparatuses, particularly in the field of robotics, artificial intelligence, and tissue repair (surgical suturing). This is a particularly exciting and worthwhile challenge, namely of larger and safer endoscopic interventions, followed by seamless and scarless recovery. In synthesis, the future is widely open for those who use together intelligence and creativity to develop new prototypes, new accessories and new techniques. Yet there are many challenges in the path of endoscopic surgery. In this new era of robotic endoscopy, one will likely need a virtual simulator to train and assess the performance of younger doctors. More evidence will be essential in multiple evolving fields, particularly to elucidate whether more ambitious and complex pathways, such as intrathoracic and intraperitoneal surgery via natural orifice transluminal endoscopic surgery (NOTES), are superior or not to conventional techniques.     

CURRENT STATUS AND FUTURE EXPECTATIONS FOR ENDOSCOPIC BILIARY DRAINAGE IN 16 HOSPITALS

The authors examined the performance of endoscopic biliary drainage (EBD) in 16 hospitals. The examination was in the form of a questionnaire given between 1 June and 20 July 2005 to clarify the status of 369 patients who had undergone EBD. A total of 124 patients underwent endoscopic nasobiliary drainage (ENBD), 224 patients underwent endoscopic biliary drainage (EBS), and one patient underwent simultaneous ENBD and EBS. With regard to the underlying diseases, 227 patients had malignant disease and 142 had benign disease. A total of 244 patients underwent EBS. Plastic stent (PS) was used in 200 cases, and metal stent (MS) in 44 cases. One stent was used in 89% of cases, two stents in 10%, three or more stents in 1%. Metal stent was used in 44 patients (23 were covered and 21 uncovered) with unresectable biliary stenosis. One stent was used in 33 patients, two stents in 10 patients, and three stents in one patient. For treating middle and inferior common bile duct stenosis, PS having a caliber of 10 Fr is too soft; newer tubes should be developed utilizing materials that provide longer stent patency. Longer patency can be achieved now by applying EBS using a covered MS. Improving the materials will also improve stent flexibility and the smoothness of the coating film. When treating superior common bile duct and porta hepatic bile duct stenosis, the stent is placed in both lobes of the liver.     

Endoscopic ultrasonography-guided biliary drainage

Background and purpose

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage method in patients with obstructive jaundice. EUS-BD is divided into EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided gallbladder drainage (EUS-GBD). The aim of this review is to focus on the current status and limitations of EUS-BD.

Methods

A systematic review was performed to evaluate EUS-BD. MEDLINE, EMBASE and manual searches were performed to identify the pertinent English language full articles.

Results

The high success rate without fatal adverse events for EUS-CDS (93%; 28/30) and EUS-HGS (97%; 28/29) suggest the feasibility and safety of the procedures in high-volume endoscopic centers adopting various procedural techniques. Although the number of reported cases was very small, the success rate of EUS-GBD was high (100%; 14/14), without serious adverse events.

Conclusions

Although all procedures require further assessment in a larger cohort of patients, including comparative studies between EUS-CDS or EUS-HGS versus PTBD, and EUS-GBD versus PTGBD, EUS-BD may be a promising procedure for the treatment of obstructive jaundice. However, dedicated devices for EUS-guided drainage are needed for reliable procedures.     

Endoscopic closure after intraluminal surgery

Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full‐thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full‐thickness resection. Several closure techniques, including over‐the‐scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.     

THE TECHNICAL FUNDAMENTALS OF ENDOSCOPIC MUCOSAL RESECTION IN THE COLON: OUR METHOD

Endoscopic mucosal resection (EMR) is the technique used to resect flat or depressed tumors or larger tumors such as laterally spreading tumors with marginal normal mucosa. Recently, endoscopic mucosal dissection technique has been rapidly accepted, mainly in early gastric cancer in Japan. We need to have firm knowledge of EMR technique in the colon for recovery as we advance this new technique. We describe our conventional EMR method practically. EMR should be performed to locate the target lesion at down side to perform sure EMR. The ideal shape of upheaval by saline injection is hemisphere. The needle sheath and snare should be taken out a little of the endoscopy to manipulate firmly. Another technique of secure EMR is the snare manipulation. We prefer that the shape of the snare is circular and the snare is hard. It is important while trapping to press the target lesion with both the whole snare circle and the end of the sheath. With these fundamental procedures we could resect the target lesions at will.     

ENDOSCOPIC MANAGEMENT OF BILIARY and PANCREATIC DUCTS STRICTURES

Endoscopic treatment is applied to a relatively large number of biliary and pancreatic duct strictures, and is a practical matter. It is essential to select the most appropriate treatment for each lesion. For instance, when treating malignant biliary stricture, accurate diagnosis of whether surgical treatment is required or not is vital; and in choosing a stent for an inoperable case, location of the stricture, with or without anticancer treatment, prognosis, and management of possible post‐stenting re‐stricture must be taken into consideration. For benign strictures, not only short‐term results in mobility and motality, but also decades of long‐term results must be cautiously questioned. Bearing these in mind, we need to accumulate the worldwide data of the treatments and establish a proper treatment guideline.     

Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra‐abdominal diseases

Clinical research on natural orifice transluminal endoscopic surgery (NOTES) has been increasingly reported over the past 5 years and more than 1200 patients have received various NOTES procedures. The present article reviews the clinical practice of NOTES for the treatment of intra‐abdominal diseases, and was carried out through systematic search with specific keywords in major databases for NOTES‐related clinical literature. The last date of the search was 15 August, 2012. Transvaginal cholecystectomy is the commonest NOTES procedure reported, and its clinical feasibility and safety was established through prospective case series and randomized trials. There is a regional difference in NOTES development with the majority of NOTES fromCaucasian countries being transvaginal cholecystectomy and most reports from Asian countries being NOTES‐related procedures. Safe closure of gastrointestinal access remains challenging, and novel endoscopic instruments are essential to enhance future development of NOTES.     

ANALYSIS OF PLASTIC STENTS IN THE TREATMENT OF LARGE COMMON BILE DUCT STONES IN 45 PATIENTS

Background: Although endoscopic plastic biliary stenting is a clinical procedure routinely carried out in patients with common bile duct stones, the effects of stenting on the sizes or fragmentation of large common bile duct stones have not been formally established and the mechanism of this condition is controversial. We compared the stone sizes of common bile duct stones after biliary stenting in order to develop the mechanism. Patients and Methods: Endoscopic plastic biliary stenting was performed in 45 patients with large common bile duct stones or those difficult to extract with conventional endoscopic therapy, including mechanical lithotripsy. The stone diameter was ≥16 mm in all patients. Bile duct drainage and endoscopic placement of 7–8.5 Fr plastic biliary stents were established in all patients. Differences of stone sizes and fragmentations after biliary stenting were compared. The complete stone clearance rate after treatment was obtained. Results: After biliary stenting for 3–6 months, the bile stones disappeared or changed to sludge in 10 (10/45) patients, and fragmentation of the stones or decreased stone sizes were seen in 33 patients, whose stone median size was significantly decreased from 23.1 mm to 15.4 mm in 33 patients (P < 0.05). The stones were removed successfully with basket, balloon, mechanical lithotripsy or a combination in 43 (43/45) patients. The remaining two patients (2/45) demonstrated no significant changes in stone sizes. Conclusion: Plastic biliary stenting may fragment common bile duct stones and decrease stone sizes. This is an effective and feasible method to clear large or difficult common bile duct stones.