青少年慢性胰腺炎的内镜诊断与治疗

目的：研究诊断性和治疗性经内镜逆行胰胆管造影术(ERCP)在青少年慢性胰腺炎(CP)诊断及治疗中的价值。方法：回顾分析1997年2月～2002年2月间确诊为青少年CP并行ERCP的13例临床资料。结果：13例中12例存在腹痛症状，10例有“胰腺炎”病史。ERCP见胰管扩张12例，胰管结石7例，胰腺假性囊肿2例，胰腺分裂症3例，胆囊结石l例。内镜下治疗：乳头括约肌切开术7例，胰管取石6例，支架置入5例，胰管狭窄扩张术4例，副乳头切开2例。ERCP后高淀粉酶血症4例，胰腺炎急性发作3例，均为水肿型胰腺炎。经6—68个月随访，ll例未复发，2例复发者经再次ER-CP治疗后腹痛未再出现。结论：ERCP对青少年CP的诊断及治疗有较高的价值。但青少年CP患者ERCP术后具有较高的并发症发生率，对此内镜医师应高度重视。     

内镜超声下胰腺假性囊肿经胃置管引流的临床研究

目的分析探讨内镜超声（EUS）下胰腺假性囊肿经胃置管引流的疗效及并发症情况。方法回顾分析2001年以来经胃置管引流胰腺假性囊肿的24例患者病历及随访资料。引流方法采用EUS引导下穿刺囊肿，插入导丝，用探条或扩张水囊行针道扩张，置入鼻囊肿引流管或1～4根双猪尾型塑料支架引流。术后定期随访，囊肿消失后拔除支架。结果24例患者均完成囊肿穿刺、置管，手术成功率100％，死亡率为0。发生并发症8例（33．3％），其中严重并发症3例（12．5％），分别为出血、感染、支架移位各1例。平均随访21．2个月，2例失访，17例假性囊肿完全消失，2例囊肿明显缩小但持续存在2年以上，腹痛症状消失，1例感染性假性囊肿内镜引流无效转外科手术。内镜引流总的有效率为86．4％（19／22），无一例复发。结论EUS下经胃置管引流治疗胰腺假性囊肿是一种安全、有效的治疗方法，其常见并发症为出血和感染。     

内镜经十二指肠乳头引流治疗胰腺假性囊肿的临床应用疗效分析

目的评估内镜经十二指肠乳头引流治疗巨大胰腺假性囊肿（脓肿）的临床应用疗效。方法2003年6月至2006年6月取沈阳军区总医院消化内镜中心按照统一标准选择入组的胰腺假性囊肿（脓肿）病例10例，其中非感染性8例，感染性1例，胰腺脓肿1例。均采用内镜经乳头引流治疗，通过回顾性总结临床治疗和相关研究指标变化，综合评估此种治疗方法的临床应用疗效。结果内镜治疗失败1例，术后并发假性囊肿感染2例，急性胰腺炎1例。8例随访观察平均16．5个月，其中假性囊肿完全消失4例，假性囊肿残腔形成1例，假性囊肿不断缩小3例。急性重症胰腺炎2例治愈。结论内镜经乳头引流治疗胰腺炎合并巨大胰腺假性囊肿（脓肿）是一种确切有效的治疗方法。     

经乳头内镜胰腺假性囊肿引流术

文章报告了３０例接受经乳头内镜胰腺假性囊肿引流术（ｅｎｄｕｓｃｏｐｉｃｔｒａｎｓｐａｐｉｌｌａｒｙｃｙｓｔｄｒａｉｎａｇｅ，ＥＴＣＤ）治疗的胰腺假性囊肿病人。２例病因为胆源性急性胰腺炎，２８例为慢性胰腺炎引起，平均主胰管最大直径４．２ｍｍ（３～１２ｍｍ），１１例存在胰管狭窄。本方法为通过主或副乳头置入假体管以引流与胰管系统相通的胰腺假性囊肿。施行诊断性ＥＲＣＰ后，进行短距（５ｍｍ）胰管括约肌切开术，可能的话事先行胆管括约肌切开术，扩张胰管狭窄后，置入胰管支架管，将导丝插入胰管并尽可能接近胰腺假性…     

胰腺假性囊肿内镜引流治疗研究进展

胰腺假性囊肿内镜引流是一安全、有效、微创的治疗方法,包括ERCP经乳头引流术、内镜下经胃或十二指肠壁引流术及腹腔镜胃腔内手术。文章就其临床应用及出血和感染等并发症的研究进展作一综述。     

内镜经十二指肠乳头引流治疗胰腺假性囊肿的临床应用疗效分析

目的评估内镜经十二指肠乳头引流治疗巨大胰腺假性囊肿(脓肿)的临床应用疗效。方法2003年6月至2006年6月取沈阳军区总医院消化内镜中心按照统一标准选择入组的胰腺假性囊肿(脓肿)病例10例,其中非感染性8例,感染性1例,胰腺脓肿1例。均采用内镜经乳头引流治疗,通过回顾性总结临床治疗和相关研究指标变化,综合评估此种治疗方法的临床应用疗效。结果内镜治疗失败1例,术后并发假性囊肿感染2例,急性胰腺炎1例。8例随访观察平均16.5个月,其中假性囊肿完全消失4例,假性囊肿残腔形成1例,假性囊肿不断缩小3例。急性重症胰腺炎2例治愈。结论内镜经乳头引流治疗胰腺炎合并巨大胰腺假性囊肿(脓肿)是一种确切有效的治疗方法。     

内镜治疗慢性胰腺炎的探讨

目的 探讨内镜治疗慢性阻塞性胰腺炎疗效及并发症。方法 经内镜治疗２９例慢性胰腺炎中胰管括约肌切开术２７例（１９例为７内镜治疗前处置）,副乳头切开８例,乳头括约肌切开术５例,网篮邓胰石９例,胰管内引流７例,鼻胰管引流３例,辅助探条或球囊扩张共１４例。１３例治疗前、后检测胰腺内分泌功能。结果 ２９例中２６例（８９．７％）治疗后腹痛消失或明显减轻,９例胰腺结石患者中６例取出胰石;７例胰管内引流管未阻塞。     

猪作为胰胆管造影操作模型的实验研究

内镜下逆行性胰胆管造影（endoscopic retrograde cholangiopancreotography．ERCP）是在十二指肠镜直视下经十二指肠乳头注入造影剂作X线胰胆管造影检查，是胰腺、胆道等疾病的重要诊治手段之一。通过ERCP．可以进行乳头括约肌切开术、胆胰管取石、支架植入和狭窄扩张。此项微创技术需要经验丰富的内镜医师操作，初学者操作有一定风险.     

内镜逆行副胰管造影的应用进展

副胰管是胰液的第二流出道, 内镜逆行副胰管造影在胰腺疾病的诊疗中起重要作用。内镜逆行副胰管造影作为主胰管深插管失败的重要补充手段, 可以进行副乳头括约肌切开术和副胰管支架置入术等治疗。内镜逆行副胰管造影最常用于胰腺分裂的诊疗, 也是部分慢性胰腺炎、胰腺假性囊肿等疾病的有效治疗方式。内镜逆行副胰管造影并发症发生率较主胰管造影高, 要预防和关注术后并发症的发生。     

超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术治疗胰腺分裂症1例

1例慢性胰腺炎、胰管结石伴梗阻性黄疸患者,因经内镜逆行胰胆管造影术主乳头胰管反复插管困难,副乳头开口难辨,最后选择在全麻下行超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术+副乳头扩张术+胰管探条扩张术+胰管支架置入术,术中补充诊断：胰腺分裂。本文报道了该疑难病例的内镜治疗过程及护理配合要点。     

EUS-assisted rendezvous stenting of the pancreatic duct for chronic calcifying pancreatitis with multiple pseudocysts.

Introduction: The best choice of endoscopic drainage of pancreatic pseudocysts complicating chronic pancreatitis is currently unknown, with EUS-guided transmural drainage competing with ERCP transpapillary techniques. However, recent studies currently recommend the use of both techniques in complex cases. Case Presentation: We present the case of a 60-year-old male patient with chronic calcifying pancreatitis, with severe ductal obstruction and multiple communicating pancreatic pseudocysts. The patient presented in the emergency department with weight loss, jaundice, steatorrhea and diabetes. Initial imaging evaluation (by transabdominal US, EUS and MRCP) depicted a dilated common bile duct, intrahepatic bile ducts and dilated main pancreatic duct (up to 1 cm) with multiple stones, as well as three pseudocysts at the level of the pancreatic head and one pseudocyst at the level of the pancreatic tail. ERCP with direct cannulation and transpapillary drainage of the bile duct or pancreatic duct was unsuccessful. Consequently, a EUS-assisted rendezvous stenting of the pancreatic duct was done, with the transpapillary placement of a 5-cm stent. Biliary cannulation was also possible with the placement of a double pigtail 9-cm stent in the common bile duct. Subsequent evolution was rapidly favorable with the disappearance of the pancreatic pseudocysts on the control CT after 24 h. Conclusion: Our case clearly showed the benefit of combined draining procedures even in cases of chronic pancreatitis with multiple pseudocysts where surgical drainage was previously deemed necessary.     

十二指肠乳头囊肿引流术治疗胰腺假性囊肿

目的 探讨内镜下经十二指肠乳头囊肿引流术(ETCD)治疗胰腺假性囊肿(PPC)的疗效。方法 26例ETCD治疗患者囊肿大小为1.5-15 cm,23例为直接行ETCD引流,1例因并发黄疸同时行胆管内置管,2例因囊肿外压胃窦及十二指肠而致乳头无法显示,其中1例先行经皮囊肿穿刺术,囊肿缩小后找见乳头,再行ETCD引流。观察术后囊肿消退及临床症状改善情况。结果 治疗后23例患者囊肿消退,腹痛、胃纳、脂肪泻及体重情况均明显改善,1例改善不明显,2例无改善。随访60-850 d,1例囊肿复发,1例并发胰腺脓肿,3例引流术后需行手术治疗。结论 ETCD治疗交通性似性囊肿是安全、有效的首选治疗方法,对于不交通PPC无效。     

Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess

Background/Purpose

Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated.

Methods

After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct.

Results

ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far.

Conclusions

ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.     

Endosonographic drainage of pancreatic fluid collections and walled-off necrosis

Endosonographic drainage of pseudocysts and walled-off necrosis (WON) has not been standardized. Drainage of pseudocysts via endosonographic guidance has high rates of technical success via the transmural approach. Alternative modalities including transpapillary endoscopic retrograde pancreatography with pancreatic duct sphincterotomy and pancreatic duct stent placement are options for patients with small pseudocysts and in the presence of pancreatic duct disruption. Drainage of WON has a variety of approaches and may require a combination of endoscopic or percutaneous techniques to achieve the optimal outcome. Endosonographic drainage of WON has lower rates of mortality and morbidity compared to surgical intervention. Several options regarding stent placement exist including the use of fully covered self-expandable metal stents and lumen-apposing metal stents. Depending upon their properties, each type of stent carries its own risk including the risk of migration. The endoscopist performing drainage of these fluid collections must take into account the number and size of these collections as well as the presence and amount of necrotic debris in order to choose the most appropriate technique and equipment in order to achieve optimal outcomes.     

Intracystic wire exchange facilitating insertion of multiple stents during endoscopic drainage of pancreatic pseudocysts

BACKGROUND: Endoscopic drainage of pancreatic pseudocysts and abscesses has been shown to be an effective treatment modality. A major determinant for successful cyst resolution is the insertion of multiple endoprostheses and/or placement of a nasocystic drain, which require repeated entries of a catheter into the pseudocyst to reintroduce the guidewire. OBJECTIVE: We describe a novel and easy technique to prevent the need for repeated access into the pseudocyst, thereby facilitating the placement of multiple endoprostheses by using a commercially available guiding system for stent introduction. DESIGN: Case series. SETTING: Academic Medical Center, The Netherlands. PATIENTS: Eight consecutive patients with symptomatic pancreatic pseudocysts after acute pancreatitis. INTERVENTIONS: Intracystic wire exchange for the insertion of multiple stents in endoscopic treatment of pancreatic pseudocysts by using an echoendoscope. MAIN OUTCOME MEASUREMENTS: Feasibility of intracystic wire exchange and complications. RESULTS: No guidewire access to the pseudocyst was lost. The procedure was well tolerated by the patients. Complete pseudocyst resolution was established in all patients. CONCLUSIONS: The endoscopic appliance of multiple stents becomes easier when using intracystic wire exchange for transgastric pancreatic pseudocyst drainage.     

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.     

Unique usage of a partially covered metal stent for drainage of a pancreatic pseudocyst via endosonography-guided transcystgastrostomy

Pancreatic pseudocysts are frequent complications of pancreatitis episodes. The current therapeutic modalities for drainage of pancreatic pseudocysts include surgical, percutaneous, and endoscopic drainage modalities. Endosonography-assisted endoscopic drainage of these pseudocysts with the placement of multiple plastic or fully covered self-expanding biliary metal stents is becoming more commonly carried out. The present case report discusses the unique and successful drainage of a pancreatic pseudocyst with the placement of a partially covered self-expanding metal stent.     

Endoscopic treatment of chronic pancreatitis

OBJECTIVES: Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. PATIENTS AND METHODS: Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. RESULTS: Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. CONCLUSIONS: Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.     

Pancreatic pseudocyst

Pancreatic pseudocysts are complications of acute or chronic pancreatitis. Initial diagnosis is accomplished most often by cross-sectional imaging. Endoscopic ultrasound with fine needle aspiration has become the preferred test to help distinguish pseudocyst from other cystic lesions of the pancreas. Most pseudocysts resolve spontaneously with supportive care. The size of the pseudocyst and the length of time the cyst has been present are poor predictors for the potential of pseudocyst resolution or complications, but in general, larger cysts are more likely to be symptomatic or cause complications. The main two indications for some type of invasive drainage procedure are persistent patient symptoms or the presence of complications （infection, gastric outlet or biliary obstruction, bleeding）. Three different strategies for pancreatic pseudocysts drainage are available： endoscopic （transpapillary or transmural） drainage, percutaneous catheter drainage, or open surgery. To date, no prospective controlled studies have compared directly these approaches. As a result, the management varies based on local expertise, but in general, endoscopic drainage is becoming the preferred approach because it is less invasive than surgery, avoids the need for external drain, and has a high long-term success rate. A tailored therapeutic approach taking into consideration patient preferences and involving multidisciplinary team of therapeutic endoscopist, interventional radiologist and pancreatic surgeon should be considered in all cases.     

Endoscopic management of pancreatic pseudocysts or abscesses after an EUS-guided 1-step procedure for initial access

BACKGROUND: In this prospective case series, endoscopic management of pancreatic pseudocysts and abscesses was investigated following an EUS-guided 1-step procedure for initial transmural access. METHODS: Endoscopic drainage of pancreatic pseudocysts and abscesses was performed in 35 patients (mean age, 51 years; range, 21-81 years) by using interventional echoendoscopes (FG38UX and EG3830UT; Pentax-Hitachi, Lübbecke, Germany). Interventions were performed by using a 1-step device consisting of a needle-wire suitable for cutting current, a 5.5F dilator, and an 8.5F plastic endoprosthesis (Giovannini Needle Wire Oasis, Cook Endoscopy, Winston-Salem, NC). RESULTS: Endoscopic stent placement was successful in 33 of 35 patients (94%), whereas repeated needle passages were unsuccessful in 2 cases (pancreatic pseudocyst wall, 7 mm). No procedure-related complications, such as bleeding, perforation, or pneumoperitoneum, were observed. All subsequent complications, such as ineffective drainage (9%), stent occlusion (12%), or cyst infection (12%), were managed endoscopically. Fourteen patients (43%) demonstrated sustained clinical improvement and cyst resolution upon placement of the initial 8.5F transmural drain. Ten patients (30%) did not reveal a 50% reduction in cyst size on day 3, but cyst resolution was achieved by additional endoscopic cyst irrigation. Nine patients (27%) with primary or secondary cyst infection underwent endoscopic balloon dilation and prolonged endoscopic drainage procedures to achieve cyst resolution. The overall resolution rate was 88%, with a recurrence rate of 12%, based on a mean follow-up period of 24 months. CONCLUSION: This 1-step EUS-guided technique with a needle-wire device provides safe transmural access and allows subsequent effective endoscopic management of pancreatic pseudocysts and abscesses.