临时性胰管支架在ERCP胆管插管困难病例中的应用价值

目的 探讨通过留置临时性胰管支架选择性胆管插管对提高胆管插管困难者的造影成功率及并发症发生率.方法 内镜下逆行性胰胆管造影(ERCP)以胆管插管为目的时,因为十二指肠乳头偏位、柔软易移动、胆总管下端过度弯曲、乳头狭窄、憩室旁乳头等存在一些胆管插管困难病例,导丝反复进入胰管,且双导丝技术2～3次后导丝仍不能进入胆管者,我们采用在胰管内临时留置胰管支架,再试行胆管插管造影或预切开.结果 43例留置胰管支架者,42例胆管插管造影成功,1例失败,1例轻症胰腺炎发生结论.结论 ERCP选择性胆管插管困难时采用临时胰管支架能提高成功率,可能降低胰腺炎发生率.     

3种辅助插管技术在ERCP胆管插管困难病例中的临床应用

目的对比双导丝插管技术、针状刀乳头预切开术与经胰管乳头预切开术3种辅助插管技术在ERCP胆管插管困难病例中的成功率和并发症发生率,探讨安全有效的辅助插管技术。方法将104例经内镜逆行胰胆管造影(ERCP)选择性胆管插管困难患者随机分成3组分别行3种不同辅助插管技术,即双导丝插管术组(A组)35例,针状刀乳头预切开组(B组)35例,经胰管乳头预切开组(C组)34例。对比3组患者辅助胆管插管的成功率、获得成功插管的时间与并发症的发生率。结果 A组辅助插管成功率为51.43%(18/35),B组为91.43%(32/35),C组为70.59%(24/34),3组成功率差异均有统计学意义(P<0.05)。3组成功插管时间分别为(7.83±1.08)min,(8.20±0.91)min和(7.91±1.20)min,3组成功插管时间无显著性差异(P>0.05)。3组患者术后胰腺炎发生率分别为:2.86%(1/35),22.86%(8/35)与8.82%(3/34),3组间术后胰腺炎发生率差异有统计学意义(P<0.05)。3组患者均无严重感染、大出血、穿孔等并发症发生。结论 3种辅助插管技术均可提高胆管插管成功率,其中针状刀乳头预切开术与经胰管乳头预切开术有更高的成功率,但术后胰腺炎等并发症发生率亦较高;双导丝插管术成功率较低,但安全性较高。     

经胰管乳头括约肌预切开术在困难胆道插管中的临床应用

目的评价经胰管乳头括约肌预切开术在困难胆道插管中的安全性和疗效。方法回顾性分析2005年7月至2006年7月在我院行ERCP的患者。对常规胆管插管失败且导丝反复进入胰管（〉4次）者行经胰管乳头括约肌预切开，胆管插管成功后，导丝留置胆管内，继续完成胆管括约肌切开及相应的治疗。统计插管的成功率及并发症的发生率。结果在整个研究期间内共行ER—CP1576例次，需胆管深插管879例次，经胰管乳头括约肌预切开者30例。经胰管乳头括约肌预切开后，首次ERCP胆管深插管成功率为93．3％（28／30），2次ERCP插管成功率为96．7％（29／30）。2例（占6．7％）发生并发症，为轻型胰腺炎。无出血、穿孔或操作相关的死亡发生。结论在困难胆道插管中采用经胰管乳头括约肌预切开术是一种安全有效的方法。     

双导丝技术及经胰管乳头预切开术在困难性ERCP胆管插管中的应用

目的探讨双导丝技术及经胰管乳头预切开术在困难性经内镜逆行胰胆管造影(ERCP)胆管插管中的应用。方法选取2015年1月至2018年1月在我院消化内镜中心收治的困难性ERCP胆管插管患者81例,分三组采用不同插管方法,其中双导丝技术(A组)33例,经胰管乳头预切开术(B组)18例,常规插管法(C组)30例。比较3种方法胆管插管成功率及并发症发生率。结果 A组患者28例插管进入胆总管,成功率84.8%,B组患者17例进入胆总管,成功率94.4%,C组患者16例进入胆总管,成功率53.3%。A、B两组插管成功率比较,差异无统计学意义(P0.05),A、C两组,B、C两组插管成功率比较,差异有统计学意义(P0.05),A组患者术后并发高淀粉酶血症4例,胰腺炎1例,无出血、穿孔,并发症发生率15.2%;B组患者术后并发高淀粉酶血症3例,消化道出血1例,急性胰腺炎1例,无穿孔患者,并发症发生率27.8%;C组患者术后并发高淀粉酶血症5例,胰腺炎1例,无出血、穿孔患者,并发症发生率20.0%。A、B、C三组并发症发生率差异无统计学意义(P0.05)。结论 ERCP选择性胆管插管困难,反复进入胰管,采用双导丝技术或经胰管乳头预切开术可明显提高插管成功率,且并发症无明显增加。     

胰管导丝占据法在困难内镜逆行胰胆管造影中的应用价值

目的评价胰管导丝占据法在内镜逆行胰胆管造影（ERCP）中胆管选择性插管困难时的应用价值。方法2008年6月至2012年6月间共3505例患者符合入选条件。开始均尝试对患者用导丝辅助的括约肌切开刀行选择性胆管插管（标准法）,若导丝反复进入胰管5次仍未插管成功则导丝留置于胰管,退出切开刀另用一根导丝尝试插管（占据法）,尝试失败则行经胰预切开或针状刀乳头开窗术（占据法失败行预切开）,若尝试插管达5次胰管亦未能进入则行针状刀乳头开窗术（胆胰管插管失败行预切开）。比较各组间胆管插管成功率及并发症的发生率。结果标准法插管成功率（93．4％）明显高于占据法（54．8％,P〈0．001）、占据法失败行预切开（81．3％,P〈0．001）及胆胰管插管失败行预切开（84．6％,P=0．011）;占据法失败行预切开及胆胰管插管失败行预切开插管成功率均明显高于占据法（P值均〈0．001）;各组间术后胰腺炎发生率差异无统计学意义。标准法插管成功后行括约肌切开有2例出血,行预切开插管患者中有5例出血、1例穿孔,无死亡病例。结论胰管导丝占据法胆管插管成功率虽不高,但当标准插管法困难时应首先尝试,以尽量避免预切开的风．呤．     

十二指肠乳头插管困难时的操作策略

目的提高ERCP十二指肠乳头插管困难时的操作成功率。方法在常规插管方法失败时,采用超细导丝配合尖头导管插管技术、乳头预切开技术、导丝胰管占据技术、经皮经肝与ERCP对接技术等,来提高十二指肠乳头插管成功率。结果5年间内镜下行乳头插管5743例,插管成功5664例（98．6％）;其中发生乳头插管困难396例,分别采用以下技术：超细导管插管20例,胰管占据67例,预切开294例,对接法15例,共成功317例,成功率80．0％。结论根据乳头形态特点,合理运用各类特殊插管技术,注重操作配合技巧,可有效提高乳头插管困难者的操作成功率。     

内镜逆行胰胆管造影术中选择性胆管插管失败的影响因素及辅助插管价值探讨

目的研究经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)中选择性胆管插管失败的影响因素,并对辅助插管的方式及并发症的发生进行探讨。方法选取汕头市中心医院2014年1月至2017年1月接受ERCP的患者122例,分析选择性胆管插管失败的原因及影响因素;对选择性胆管插管失败的患者进行不同辅助插管并记录其成功率,对术后急性胰腺炎(postoperative acute pancreatitis,PEP)的发生进行对比分析。结果常规选择性胆管插管成功率为81. 1%(99/122),导致选择性胆管插管失败的危险因素为十二指肠乳头长且松弛、胆总管弯曲成角。常规选择性胆管插管失败者分别采用经胰管预切术辅助插管(11例)和双导丝插管术进行辅助插管(12例),总插管成功率提升至92. 6%(113/122),且经胰管预切术辅助成功率明显高于双导丝插管术,差异有统计学意义(P 0. 05)。113例插管成功者中,发生PEP 11例,其中单纯常规插管者5例(5. 1%),发生率明显低于联合经胰管预切术(4例,50. 0%)及双导丝辅助插管术(2例,33. 3%),且双导丝辅助插管者PEP发生率低于经胰管预切开法,差异均有统计学意义(P 0. 05)。结论应在行ERCP前评估患者的十二指肠乳头及胆总管的情况,选择合适的插管方式,减少PEP的发生。     

胰管支架在内镜逆行胆胰管造影中的应用价值

[目的]探讨胰管支架在选择性胆管插管的内镜逆行胆胰管造影术(ERCP)中的应用价值。[方法]将114例选择性胆管插管的ERCP患者随机分为支架组(51例)和非支架组(63例),支架组在插入胰管后行经胰管胆胰管隔膜切开术后常规置入胰管支架之后继续下一步治疗,非支架组在进入胰管后行经胰管胆胰管隔膜切开术后再行选择性胆管插管及下一步治疗,观察2组患者ERCP后胰腺炎(PEP)的发生率及插管成功率。[结果]支架组PEP发生率1.96%(1/51)、插管成功率98.04%(50/51),非支架组PEP发生率14.28%(9/63)、插管成功率84.13%(53/63),2组患者PEP发生率及插管成功率差异均有统计学意义(P0.05)。[结论]选择性胆管插管的ERCP患者在插入胰管后置入胰管支架可降低其PEP的发生率,提高插管成功率。     

合并十二指肠乳头旁憩室的胆胰疾病患者行经内镜逆行胰胆管造影的操作技巧

目的探讨合并十二指肠乳头旁憩室行经内镜逆行胰胆管造影术(ERCP)的操作技巧。方法回顾性分析2013年3月-2015年2月于山东省交通医院肝胆内镜科行ERCP合并十二指肠乳头旁憩室患者867例的临床资料,分析插管成功率、治疗效果及并发症发生情况。结果插管成功率99.8%,使用切开刀直接插管成功793例,采用双导丝及胰管支架占据44例,止血夹固定乳头法3例,预切开25例,2例未能成功插管。治疗过程中出现胰腺炎5例,穿孔1例,延迟性出血1例,经保守治疗后均治愈。结论 ERCP治疗合并十二指肠乳头旁憩室的胆胰疾病,应明确ERCP、内镜下乳头括约肌切开术适应证,根据乳头特点采用针对性的操作技巧,有助于提高成功率,减少并发症,是一种安全的微创治疗方法。     

经胰管弓式隔膜乳头预切开术和针式乳头预切开术在困难胆管插管中的应用研究

目的评价经胰管弓式隔膜乳头预切开术处理ERCP困难胆管插管的应用价值。方法回顾2006年1月至2008年7月109例ERCP胆总管插管困难患者进行经胰管弓式隔膜乳头预切开术（下称经胰管组,56例）和常规针式乳头预切开术（下称常规针刀组,53例）的临床资料,比较两种方法插管成功率及并发症发生率。结果109例患者中的97例在乳头预切开术后可成功插入胆管,经胰管组成功率96．4％（54／56）,常规针刀组成功率81．1％（43／53）,两者差异具统计学意义（P〈0．05）。109例中11例出现并发症,包括急性胰腺炎5例、出血4例、胆道感染2例。其中,经胰管组急性胰腺炎2例,常规针刀组急性胰腺炎3例,出血4例,胆道感染2例。两组比较,经胰管组总的并发症发生率低于常规针刀组（3．6％比17．0％,P〈0．05）,术后胰腺炎、出血、感染发生率也分别低于后者,但均无统计学意义。结论内镜经胰管弓式隔膜乳头预切开术超选胆总管成功率高于针式乳头预切开术,而且并发症较低,是处理选择性胆总管插管较困难患者的安全和有效的办法。     

Endoscopic transpancreatic septotomy as a precutting technique for difficult bile duct cannulation

AIM: To evaluate the technique of transpancreatic septotomy(TS) for cannulating inaccessible common bile ducts in endoscopic retrograde cholangiopancreatography(ERCP).METHODS: Between May 2012 and April 2013, 1074 patients were referred to our department for ERCP. We excluded 15 patients with previous Billroth Ⅱ gastrectomy, Roux-en-Y anastomosis, duodenal stenosis, or duodenal papilla tumor. Among 1059 patients who underwent ERCP, there were 163 patients with difficult bile duct cannulation. Pancreatic guidewire or pancreatic duct plastic stent assistance allowed for successful ERCP completion in 94 patients. We retrospectively analyzed clinical data from 69 failed patients(36 transpancreatic septotomies and 33 needle-knife sphincterotomies). RESULTS: Of the 69 patients who underwent precut papillotomy, common bile duct cannulation was successfully achieved in 67. The success rates in the TS and needle knife sphincterotomy(NKS) groups were 97.2%(35/36) and 96.9%(32/33), respectively, which were not significantly different(P 0.05). Complications occurred in 11 cases, including acute pancreatitis(n = 6), bleeding(n = 2), and cholangitis(n = 3). The total frequency of complications in the TS group was lower than that in the NKS group(8.3% vs 24.2%, P 0.05).CONCLUSION: Pancreatic guidewire or pancreatic duct plastic stent assistance improves the success rate of selective bile duct cannulation in ERCP. TS and NKS markedly improve the success rate of selective bile duct cannulation in ERCP. TS precut is safer as compared with NKS.     

Endoscopic transpancreatic papillary septotomy for inaccessible obstructed bile ducts: Comparison with standard pre-cut papillotomy

BACKGROUND: Access to the pancreatic or the bile duct is paramount to the success of diagnostic and therapeutic ERCP. Selective cannulation may be difficult because of the small size of the papilla and anatomic factors such as peripapillary diverticulum and gastrectomy with Billroth-II anastomosis. Currently, one of the techniques for gaining access in such cases is the pre-cut technique with a catheter that has a thin wire at the tip (needle knife). A less well-described pre-cut technique involves initial cannulation of the pancreatic duct with a "traction-type" papillotome and then incision through the "septum" toward the bile duct. The aim of this randomized trial was to compare the success and the complication rates of needle-knife sphincterotomy and transpancreatic sphincterotomy in achieving cannulation of an otherwise inaccessible bile duct. METHODS: Sixty-three consecutive patients with inaccessible bile ducts underwent pre-cut sphincterotomy either by needle-knife sphincterotomy (n = 34) or transpancreatic septotomy (n = 29). In patients with an accessible pancreatic duct who undergo needle-knife sphincterotomy, a short (2-3 cm) stent (5F-7F) was placed in the pancreatic duct to act as a guide and to reduce the risk of post-procedure pancreatitis. All patients were hospitalized overnight for observation after pre-cut sphincterotomy. The outcomes measured were success rate and complications. Indications for pre-cut sphincterotomy were the following: suspected choledocholithiasis, 11 patients (17.5%); obstructive jaundice with negative CT findings, 19 patients (29.2%), or with positive CT findings, 13 patients (20.6%); abdominal pain with elevated biochemical tests of liver function, 15 patients (23.8%); and miscellaneous, 5 patients (7.9%). RESULTS: In 55 of 63 (87%) patients, the bile duct was selectively cannulated after pre-cut sphincterotomy. On a pre-protocol basis, the bile duct was cannulated in 29 of 29 (100%) patients randomized to transpancreatic septotomy sphincterotomy and 26 of 34 (77%) patients who underwent needle-knife sphincterotomy (p = 0.01). There were 7 complications, including bleeding (n = 2) and acute pancreatitis (n = 5). Complications were less frequent in the transpancreatic septotomy sphincterotomy group (1/29; 3.5%) compared with the needle-knife sphincterotomy group (6/34; 17.7%). CONCLUSIONS: Transpancreatic pre-cut sphincterotomy can be performed with a high degree of success in patients with inaccessible obstructed bile ducts. Compared with standard needle-knife sphincterotomy, transpancreatic septotomy sphincterotomy has a significantly higher rate of bile duct cannulation and a lower complication rate.     

乳头预切开术在内镜逆行胰胆管造影术中的应用

目的探讨乳头预切开术在内镜逆行胰胆管造影术中的应用价值。方法对标准乳头切开法不能应用的病例分别采用针状刀预切开法、犁状刀乳头预切开法和经胰管乳头预切开法。结果58例乳头预切开术中,成功53例(91.3%);出现乳头出血3例,经电凝和喷洒副肾止血,2例轻度胰腺炎经内科保守治疗后好转。结论乳头预切开术作为常规逆行胰胆管造影术和内镜下乳头括约肌切开术的补充方法,提高了ERCP的成功率,值得临床推广应用。     

Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study

BACKGROUND: Pancreatitis is the most frequent complication of ERCP. Injury to the papilla during ERCP could obstruct pancreatic duct outflow and initiate pancreatitis. A randomized prospective study was performed to evaluate the effect of pancreatic duct stent placement on the frequency and severity of post-ERCP pancreatitis in a selected group of patients. METHODS: The study group consisted of patients over 18 years of age at high risk for post-ERCP pancreatitis because of a difficult cannulation, sphincter of Oddi manometry, and/or the performance of endoscopic sphincterotomy. Patients were prospectively randomized to have a pancreatic duct stent placed or no stent upon completion of the ERCP. The endoprosthesis used was either a 5F nasopancreatic catheter or 5F, 2-cm long pancreatic stent. Study endpoints were the frequency and severity of post-ERCP pancreatitis. RESULTS: Patients undergoing pancreatic duct stent placement had a lower frequency of post-ERCP pancreatitis as compared with those in the control group (28% vs. 5%; p < 0.05). Pancreatitis tended to be less severe in patients who had pancreatic duct drainage. CONCLUSIONS: Pancreatic duct stent insertion after ERCP reduces the frequency of post-ERCP pancreatitis in patients at high risk for this complication.     

ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla

BACKGROUND: ERCP by means of long-limb Roux-en-Y surgical anastomoses has been reported primarily in patients with biliary or pancreatic anastamoses, but rarely in patients with an intact papilla. METHODS: All ERCP procedures attempted over a 6-year interval in patients with Roux-en-Y gastrojejunostomies and an intact papilla were reviewed. Patients with a prior Billroth II operation or alteration of the major papilla were excluded. Cannulation and therapy were primarily performed with a duodenoscope after exploration and placement of a guidewire in the afferent limb with a forward-viewing colonoscope. In some cases the duodenoscope was pulled into the afferent limb with a wire-guided balloon passed retrograde into the afferent limb. A follow-up of 30 days was obtained for all patients as part of a prospective ERCP outcome study. RESULTS: Of 15 patients in whom ERCP was attempted, the papilla was reached in 10 patients (67%), the bile duct being accessed in all 10. Needle-knife precut papillotomy after placement of a pancreatic duct stent was performed in 3 patients. Biliary sphincterotomy with a variety of techniques was successful in all 9 patients in whom it was attempted. Other maneuvers included stone extraction, sphincter of Oddi manometry, and biliary stent placement. Final diagnoses were sphincter of Oddi dysfunction (6), malignant biliary stricture (2), choledocholithiasis plus tumor (1), and choledocholithiasis (1). Complications occurred after 3 (12%) of 25 ERCP procedures including pancreatitis (1 mild, 1 moderate) and bleeding (1 mild), all in patients with sphincter of Oddi dysfunction. CONCLUSIONS: Diagnostic and therapeutic ERCP was ultimately successful in two thirds of patients with long-limb gastrojejunostomies and an intact papilla. The success of the ERCP is determined primarily by ability to advance a duodenoscope through the afferent limb. Once the major papilla was accessed with a duodenoscope, advanced biliary and pancreatic therapeutic techniques were feasible.     

乳头扩约肌预切开术在困难插管内镜逆行胰胆管造影术中的疗效分析

目的 探讨十二指肠乳头预切开术在内镜逆行胰胆管造影术( ERCP)中的应用,并评价其在ERCP中的作用和安全性.方法 自2008年1月至2011年6月我院肝胆胰外科共完成内镜下逆行胰胆管造影术930例,其中选择性插管困难者采用常规方法不能完成而采用乳头预切开术108例,占11.6％.纳入标准为常规插管失败或反复进入胰管4次判定为选择性插管困难,术中改行乳头预切开术,根据病情完成ERCP检查和内镜下治疗.观察终点为治疗成功率和并发症发生率,并与同期常规ERCP插管病例资料对比分析.统计学处理采用SPSS 13.0统计软件,率的比较采用x2检验,P＜0.05为差异有统计学意义.结果 本组乳头预切开术108例,ERCP成功103例,成功率95.4％.术后并发症7例,发生率6.5％,无十二指肠穿孔及死亡病例.同期822例常规ERCP诊治成功率97.7％,术后并发症63例,发生率7.7％.乳头预切开与常规选择性胆管插管两组患者的并发症发生率(x2=0.141,P=0.707)及成功率(x2=2.041,P=0.153)差异无统计学意义.结论 乳头预切开术与常规ERCP相比不增加发生并发症的风险,可提高困难ERCP的成功率,但要严格掌握适应证,由经验丰富的医师进行.     

Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) begins with successful biliary cannulation. However, it is not always be successful. The failure of the initial ERCP is attributed to two main aspects: the papilla/biliary orifice is endoscopically accessible, or it is inaccessible. When the papilla/biliary orifice is accessible, bile duct cannulation failure can occur even with advanced cannulation techniques, including double guidewire techniques, transpancreatic sphincterotomy, needle-knife precut papillotomy, or fistulotomy. There is currently no consensus on the next steps of treatment in this setting. Therefore, this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation. These options include interval ERCP, percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RV), and endoscopic ultrasound-assisted rendezvous procedures (EUS-RV). The overall success rate for interval ERCP was 76.3% (68%-79% between studies), and the overall adverse event rate was 7.5% (0-15.9% between studies). The overall success rate for PTE-RV was 88.7% (80.4%-100% between studies), and the overall adverse event rate was 13.2% (4.9%-19.2% between studies). For EUS-RV, the overall success rate was 82%-86.1%, and the overall adverse event rate was 13%-15.6%. Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise, facilities, or other specialists, it can be considered the first choice for salvage therapy. EUS-RV can also be considered if local experts are available. For patients in urgent need of biliary drainage, PTE-RV should be considered.     

Repeat endoscopic retrograde cholangiopancreaticography after failed initial precut sphincterotomy for biliary cannulation

AIM: To investigate the outcome of repeating endoscopic retrograde cholangiopancreaticography (ERCP) after initially failed precut sphincterotomy to achieve biliary cannulation.METHODS: In this retrospective study, consecutive ERCPs performed between January 2009 and September 2012 were included. Data from our endoscopy and radiology reporting databases were analysed for use of precut sphincterotomy, biliary access rate, repeat ERCP rate and complications. Patients with initially failed precut sphincterotomy were identified.RESULTS: From 1839 consecutive ERCPs, 187 (10%) patients underwent a precut sphincterotomy during the initial ERCP in attempts to cannulate a native papilla. The initial precut was successful in 79/187 (42%). ERCP was repeated in 89/108 (82%) of patients with failed initial precut sphincterotomy after a median interval of 4 d, leading to successful biliary cannulation in 69/89 (78%). In 5 patients a third ERCP was attempted (successful in 4 cases). Overall, repeat ERCP after failed precut at the index ERCP was successful in 73/89 patients (82%). Complications after precut-sphincterotomy were observed in 32/187 (17%) patients including pancreatitis (13%), retroperitoneal perforations (1%), biliary sepsis (0.5%) and haemorrhage (3%).CONCLUSION: The high success rate of biliary cannulation in a second attempt ERCP justifies repeating ERCP within 2-7 d after unsuccessful precut sphincterotomy before more invasive approaches should be considered.