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。     

ERCP困难胆管插管时早期预切开术的应用

目的探讨预切开技术在常规ERCP插管失败病例中应用的有效性和安全性。方法回顾性分析在常规ERCP插管失败的98例病例中,应用包括电针切开术和经胰管乳头切开术在内的预切开技术完成插管,观察插管的成功率和并发症的发生率。结果常规插管失败并行预切开术的98例患者中,插管成功率为93.9%(92/98),其中行电针切开术76例,经胰管乳头切开术22例,术后胰腺炎发生率为5.1%(5/98),都为轻型胰腺炎,未发生出血、穿孔等其它严重并发症。结论预切开技术在困难ERCP中应用是安全、有效的,在常规插管失败的病例中预切开术可以显著提高插管成功率,其并发症的发生率与常规插管的发生率没有显著差异。     

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。     

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.     

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。     

经胰管乳头预切开术后胰腺炎风险的回顾性分析

目的 探讨经胰管乳头预切开术是否会增加ERCP术后胰腺炎的风险.方法 比较经胰管预切开+EST组与我院同期未经胰管预切开直接行EST组术后胰腺炎的发生率.结果 经胰管乳头预切开术+EST组术后胰腺炎的发生率5.71%(2/35),EST组术后胰腺炎的发生率4.0%(19/475).两组比较无统计学差异,P＞0.05.结...     

乳头预切开术在内窥镜逆行胰胆管造影术中的应用

目的　对乳头括约肌预切开术在内窥镜逆行胰胆管造影术（ＥＲＣＰ） 诊断和治疗中的作用及其安全性作回顾性评价．方法　７３ 例患者在行ＥＲＣＰ 诊疗时,当常规操作不能使胆系显影或胆道深部插管困难时,即用犁状拉式刀行乳头预切开,观察预切开的效果和近期并发症．结果　全组胆道造影成功率９５－９ ％ , 胆管深部插管成功率７２－９ ％ ,其中第一次操作胆道显影率９３－２ ％ , 深部插管率６２－９ ％ ． 术后并发症５ 例（６－８ ％ ） ,包括轻度胰腺炎２ 例,发热３ 例．结论　乳头括约肌预切开术是ＥＲＣＰ 诊疗中成功进入胆道的一项极有效的方法,但需熟练的内镜医师操作． 采用犁状刀进行预切开安全性高,并发症少．     

不同方式十二指肠乳头括约肌切开术在经内镜逆行胰胆管造影术中的应用

目的 观察经胰管和针状刀十二指肠乳头括约肌切开术(EST)在行内镜逆行胰胆管造影术(ERCP)解决胆管插管困难中的应用效果.方法 对在ERCP过程中出现胆管插管困难而行EST术的患者64例,32例采用经胰管EST,另32例采用针状刀EST,比较两种术式在ERCP中插管成功率和并发症的发生情况.结果 本组32例患者经针状刀EST成功实施ERCP30例(93.8％);另32例患者经胰管EST成功实施ERCP 24例(75.0％,c2=4.267,P=0.042).经胰管EST失败的8例患者,有5例改为针状刀EST后,成功插管并完成了ERCP检查;两组患者术后胰腺炎、穿孔、术中出血发生率差异均无统计学意义(P＞0.05).结论 在行ERCP过程中插管困难时可通过EST手术扩大切口,以提高插管成功率.     

内镜下胰管括约肌切开术后早期并发症的前瞻性研究

目的评价内镜下胰管括约肌切开术后早期并发症的发生率及相关危险因素。方法前瞻性观察2006年5月至2007年4月行ERCP的住院患者,将ERCP下行胰管括约肌切开术的患者纳入研究。在ERCP术前及术中分别将患者和操作相关情况记录在统一的观察表上;术后随访并发症的发生情况直至出院;有关数据进行统计学分析。结果在纳入观察的165例行胰管括约肌切开术的患者中,25例发生并发症（15．2％）,其中急性胰腺炎22例（13．3％,轻度15例、中度6例、重度1例）,出血1例（0．6％）,急性胆管炎2例（1．2％）,无穿孔或操作相关的死亡发生。多变量分析提示术后急性胰腺炎危险因素是：女性（OR=3．8,95％CI1．4～10．8）、复发性胰腺炎（OR=3．1,95％CI1．0-9．9）、副乳头切开术（OR=5．9,95％CI1．2—28．8）。结论与常规ERCP操作比较,内镜下胰管括约肌切开术后急性胰腺炎的发生率较高。特别是女性、复发性胰腺炎、行副乳头切开术的患者,术后更易发生急性胰腺炎。     

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。     

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.     

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.     

New role of the dual knife for precut papillotomy in difficult bile duct cannulation

The dual knife is usually used for endoscopic submucosal dissection (ESD). To date, however, there have been no clinical trials of the safety and effectiveness of precut papillotomy using the dual knife for biliary access in patients failing conventional endoscopic retrograde cholangiopancreatography (ERCP) cannulation. We herein report 18 patients who underwent precut papillotomy with the dual knife. All had intact papilla, and had failed deep cannulation of the bile ducts. After successful biliary cannulation and standard endoscopic sphincterotomy, if necessary, stone removal or plastic or metal stent insertion was attempted. Selective bile‐duct cannulation was achieved in all 18 patients (100%), at an average time of 4.2 min (range, 3–6 min). Of these 18 patients, six had malignant bile duct obstruction and 12 had common bile duct stones. One patient developed post‐ERCP pancreatitis, which resolved after conservative management. There were no deaths related to the procedure.     

经胰管预切开联合胰管支架置入法在困难胆管插管中的应用

目的 探讨经胰管预切开联合胰管支架置入法在经内镜逆行性胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)乳头困难插管中的应用价值。方法 纳入2017年1月—2019年12月在海军医科大学第三附属医院行ERCP治疗的169例乳头插管困难病例,其中137例采用双导丝法,32例患者采用经胰管预切开联合胰管支架置入法,观察两组的插管成功率、插管时间以及术后并发症等。结果 双导丝组和经胰管预切开联合胰管支架置入组的插管成功率分别为98.54％(135／137)和100.00％(32／32)(P>0.05);两组的插管时间分别为(15.69±9.07)min 和(17.06±5.79)min(P>0.05);术后并发症发生率分别是25.55％(35／137)和 9.38％(3／32)(P<0.05),其中胰腺炎发生率分别是5.8％(8／137)和0。结论 ERCP乳头插管困难时采用经胰预切开联合胰管支架置入法,具有与双导丝技术相似的成功率,同时更加安全,值得临床推广应用。     

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.     

Precut papillotomy using needle knife fashioned from discarded standard papillotomes.

AIM: To evaluate the results of precut papillotomy using needle-knife papillotomes fashioned from discarded standard sphincterotomes. METHODS: Case records of 50 patients undergoing precut papillotomy for access to either common bile duct or pancreatic duct during endoscopic retrograde cholangiopancreatography were reviewed. Precut was performed using needle-knife papillotomes fashioned from standard pull-type sphicterotomes that were discarded because of broken cutting wires. A diagnostic procedure was planned in all 50 patients (bile duct = 39, pancreatic duct = 9, both ducts = 2) and therapeutic procedure in 36 patients (bile duct = 31, pancreatic duct = 5). RESULTS: Of the 47 patients who needed precut prior to diagnostic ERCP, 44 (93.6%) underwent successful cannulation of the duct of choice. Therapeutic procedures were planned in 36 patients; these were successful in 24 (67%; bile duct = 22, pancreatic duct = 2). The complications included cholangitis in 8 patients (16%) and pancreatitis in 2 (4%). None had bleeding or perforation. CONCLUSIONS: Precut needle-knife papillotomes fashioned from discarded standard sphincterotomes can be used effectively and can help in cost containment in endoscopic retrograde cholangiopancreatography.     

Proximally migrated pancreatic stent successfully removed using needle-knife and forceps: complication after precut papillotomy assisted by pancreatic stenting

Pancreatic stent-assisted ampullary precut papillotomy is a rescue method for cases with difficult bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP). We describe a case in which post-ERCP pancreatitis (PEP) developed due to the proximal migration of pancreatic stent, after precut papillotomy. Removal of the migrated pancreatic stent was achieved after needle-knife incision of the pancreatic duct's orifice followed by retrieval of the stent using rat-tooth forceps, which resulted in rapid resolution of the PEP. Caution is needed when pancreatic stent is placed after papillary incision. Needle-knife incision of the pancreatic duct orifice followed by forceps removal is an effective technique for rescuing pancreatic stent migration.     

Accidental cannulation of the hepatic artery following needle-knife sphincterotomy

The use of needle-knife sphincterotomy has become an established technique for precut sphincterotomy to achieve am otherwise inaccessible bile duct. The present case report describes an accidental cannulation of the proper hepatic artery following needle-knife sphincterotomy. The endoscopic retrograde cholangiopancreaticography (ERCP) was performed for diagnosis and treatment of a pancreatitis presumably caused by cholelithiasis. After guide-wire placement and angiography of the artery through the papilla, there were no further complications. The distance between the catheter and the hepatic hilus was seen under X-ray control.