Endoscopic papillary balloon dilation for difficult common bile duct stones: Our experience

AIM: To evaluate the efficacy and safety of endoscopic balloon dilation (EBD) performed for common bile duct (CBD) stones.METHODS: From a computer database, we retrospectively analyzed the data relating to EBD performed in patients at the gastrointestinal unit of the Sandro Pertini Hospital of Rome (small center with low case volume) who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CBD from January 1, 2010 to February 29, 2012. All patients had a proven diagnosis of CBD stones studied with echography, RMN-cholangiography and, when necessary, with computed tomography of the abdomen (for example, in cases with pace-makers). Prophylactic therapies, with gabexate mesilate 24 h before the procedure and with an antibiotic (ceftriaxone 2 g) 1 h before, were administered in all patients. The duodenum was intubated with a side-viewing endoscope under deep sedation with intravenous midazolam and propofol. The patients were placed in the supine position in almost all cases. EBD of the ampulla was performed under endoscopic and fluoroscopic guidance with a balloon through the scope (Hercules, wireguided balloon^®, Cook Ireland Ltd. and CRE^®, Microvasive, Boston Scientific Co., Natick, MA, United States).RESULTS: A total of 14 patients (9 female, 5 male; mean age of 73 years; range 57-82 years) were enrolled in the study, in whom a total of 15 EBDs were performed. All patients underwent minor endoscopic sphincterotomy (ES) prior to the EBD. The size of balloon insufflation depended on stone size and CBD dilation and this was performed until it reached 16 mm in diameter. EBD was performed under endoscopic and fluoroscopic guidance. The balloon was gradually filled with diluted contrast agent and was maintained inflated in position for 45 to 60 s before deflation and removal. The need for precutting the major papilla was 21.4%. In one patient (an 81-year-old), EBD was performed in a Billroth II. Periampullary diverticula were found only in a 74-year-old female. The adverse event related to the procedures (ERCP + ES) was only an intra procedural bleeding (6.6%) that occurred after ES and was treated immediately with adrenaline sclerotherapy. No postoperative complications were reported.CONCLUSION: With the current endoscopic techniques, very few patients with choledocholithiasis require surgery. EBD is an efficacious and safe procedure.     

Radiation exposure in patients undergoing endoscopic retrograde cholangiopancreatography and endoscopic papillotomy

Radiation exposure was studied in 327 patients undergoing endoscopic retrograde cholangiopancreatography, or endoscopic papillotomy taking into account fluoroscopy time and incident area exposure. The mean fluoroscopy time was 238±152 seconds and the incident area exposure 3,730±2,790 R×cm².These results were compared with standard exposures in upper GI series and colon examinations as found in the literature.     

治疗性ERCP对胆胰疾病的运用（附32例报告）

目的：对32例接受治疗性经内镜逆行胰胆管造影（ERCP）患者资料进行回顾性分析,以提高对胆胰疾病治疗水平。方法：患者男23例,女9例,中位年龄56岁。全部患者接受了治疗性CRCP,其中胆道引流16例、经内镜乳头肌切开15例（合并取石10例）、取蛔虫1例。重点讨论对胆道疾病的治疗。结果：全部胆总管结石清除。患者临床情况改善,没有严重并发症。结论：治疗性ERCP对胆胰疾病是有效手段,值得推广应用。     

经胸入路腔镜下甲状腺肿块切除术

目的 探讨腔镜下甲状腺切除术的方法优缺点。方法 连续为18例甲状腺肿块患者施行经胸入路的腔镜下甲状腺肿块切除术。结果 全部均成功地施行腔镜下甲状腺肿块切除术，平均手术时间128分钟。平均术后住院时间5天（4—7天）。无喉返神经或甲旁腺损伤及其它并发症。结论 经胸入路腔镜下甲状腺切除术具有更好的美容效果。     

ERCP在胆囊切除术后黄疸诊治中的应用

目的：探讨经内镜逆行胆胰管造影（endoscopicretrogradecholangiopancreatograp11y,ERCP）在胆囊切除术后黄疸患者的诊断和治疗中的应用价值。方法：对53例胆囊切除术后不明原因或考虑为外科原因的黄疸患者行ERCP检查,明确黄疸的原因并在内镜下采取相应的治疗措施。对于胆总管结石的患者行乳头括约肌切开（endoscopicsphincterotomy,EST）或乳头球囊扩张（endoscopicpapillaryballoondilation,EPBD）取石,对胆漏和胆道狭窄患者行内镜引流术,对乳头狭窄或括约肌功能异常的患者行EST或EPBD。结果：53例患者均成功行ERCP检查,结果显示胆总管结石38例、胆道损伤8例、乳头狭窄或括约肌功能异常3例、乳头癌1例、肝门胆管癌1例、未见异常2例。经相应治疗后,所有患者均未出现严重并发症。结论：对于胆囊切除术后出现黄疸的患者,ERCP是理想的诊断方法,同时还可以进行内镜下治疗。     

十二指肠乳头气囊扩张术与十二指肠乳头括约肌切开术治疗肝外胆管结石的近期疗效观察

目的:探讨内镜下十二指肠乳头气囊扩张术(EPBD)与十二指肠乳头括约肌切开术(EST)在治疗肝外胆管结石时的安全性和疗效。方法:(1)实施EPBD68例,应用气囊将十二指肠乳头开口扩张至8-10mm,直接用取石网篮或取石气囊取石。其中63例在EPBD后当即清除结石(9例在EPBD后再行EST取石);3例7-10d后在十二指肠镜下再次行EPBD取尽残余结石;2例改行外科手术取石。(2)实施。KST63例,应用拉式切开刀对乳头作12-15mm切开后取石。其中59例用取石网篮及取石气囊当即清除结石(其中7例附加碎石网篮碎石后取石);2例7-10d后在十二指肠镜下再次取尽残余结石;2例改行外科手术取石。结果:68例完成EPBD的病例中,无出血、穿孔、胆管炎及重症胰腺炎发生。63例完成EST的病例中,无穿孔发生;胆管炎2例,出血2例,重症胰腺炎1例。9例在EPBD后再行EST取石的病例,无出血、穿孔、胆管炎及重症胰腺炎发生。结论:EPBD联合EST取石可提高取石的成功率,且胰腺炎的发生率较单纯EST显著降低,发生出血、穿孔的风险也明显降低;EPBD联合EST取石,出血风险及胰腺炎的发生率与单纯EPBD比较无明显差异。     

Sequential therapy with combined trans-papillary endoscopic naso-pancreatic and endoscopic retrograde pancreatic drainage for pancreatic pseudocysts

BACKGROUNDEndoscopic retrograde pancreatic drainage (ERPD) and stent implantation has become the major treatment method for pancreatic pseudocysts. However, it is associated with a high recurrence rate and infection.AIMTo manage pancreatic pseudocysts by sequential therapy with endoscopic naso-pancreatic drainage (ENPD) combined with ERPD and evaluate the treatment outcome.METHODSOne hundred and sixty-two cases of pancreatic pseudocyst confirmed by endoscopic examination at our hospital between January 2014 and January 2020 were retrospectively analyzed. There were 152 cases of intubation via the duodenal papilla, of which 92 involved pancreatic duct stent implantation and 60 involved sequential therapy with combined ENPD and ERPD (two-step procedure). The success rate of the procedure, incidence of complications (infection, bleeding, etc.), recurrence, and length and cost of hospitalization were compared between the two groups.RESULTSThe incidence of infection was significantly higher in the ERPD group (12 cases) than in the two-step procedure group (2 cases). Twelve patients developed infection in the ERPD group, and anti-infection therapy was effective in five cases but not in the remaining seven cases. Infection presented as fever and chills in the two-step procedure group. The reoperation rate was significantly higher in the ERPD group with seven cases compared with zero cases in the two-step procedure group (P < 0.05). Similarly, the recurrence rate was significantly higher in the ERPD group (19 cases) than in the two-step procedure group (0 cases).CONCLUSIONSequential therapy with combined ENPD and ERPD is safe and effective in patients with pancreatic pseudocysts.     

内镜下针形刀乳头括约肌切开术的临床应用

目的：探讨在十二指肠乳头梗阻性病变的内镜处理。方法：从1999年3月-2001年3月，对于24例病人，其中男性15例，女性9例，平均年龄52岁。在临床上出现黄疸，化脓性胆管炎、胆道蛔虫症、胆囊切除术后综合征、所致的oddis括约肌开口处的梗阻性病变，包括胰头部肿瘤4例，壶腹部肿瘤1例，胆总管结石嵌顿13例，蛔虫嵌顿2例，oddis括约肌严重狭窄3例，十二指肠乳头扭曲1例。这些病变在常规内镜诊断治疗时，乳头插管往往困难。利用针型切开刀，在十二指肠乳头开口处近端，即胆管隆起部作开窗并置管插入胆道，再进行一系列相应的内镜治疗。结果：乳头开窗术在24例病人中均获得成功。经乳头开窗术置管作内镜治疗包括乳头括约肌切开，网篮取石，取蛔虫，置入胆道内置管、鼻胆管引流，均获得满意的效果。在乳头开窗时有2例出现少量渗血，经电凝、喷洒止血药物后缓解。无十二指肠穿孔发生。结论：对于常规十二指肠乳头插管困难时，利用针型切开刀可获得满意的效果，提高了内镜诊断治疗的成功率。特别对于乳头处的嵌顿病变，更可达到事半功倍的疗效。     

Treatment strategy for gallstone pancreatitis and the timing of cholecystectomy

AIM:To reviewed the literature and evaluated the scope and timing of the application of endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(ES)and cholecystectomy.METHODS:A pooled odds ratio(OR)and a pooled mean difference with the 95%CI were used to assess the enumeration data of included studies.A pooled weighted mean difference(WMD)and a pooled mean difference with the 95%CI were used to assess the measurement data of included studies.Statistical heterogeneity was tested with theχ2 test.According to forest plots,heterogeneity was not significant,so the fixed effect model was adopted.The significance of the pooled OR was determined by the Z test and statistical significance was considered at P0.05.RESULTS:Data were collected from two studies(353patients,142 in the early cholecystectomy group and211 in the delayed cholecystectomy group)regarding the length of hospital stay[The WMD was-2.87(95%CI:-3.36--2.39,P0.01).Data were collected from four studies(618 patients,211 in the early cholecystectomygroup and 408 in the delayed cholecystectomy group)regarding perioperative complications(OR=0.94,95%CI:0.41-2.12,P0.05).Data were collected from four studies(618 patients,211 in the early cholecystectomy group and 408 in the delayed cholecystectomy group)on the number of patients who underwent ERCP±ES postoperatively(OR=0.80,95%CI:0.45-1.41,P0.05).CONCLUSION:Cholecystectomy offers better protection than ES against further bouts of pancreatitis in patients with gallstone pancreatitis,although ES is an acceptable alternative.