Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: A nationwide analysis

AIM To assess the effect of early vs late endoscopic retrograde cholangiopancreatography(ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.METHODS We used the 2014 National Readmissions Database to identify adult patients hospitalized with acute cholangitis who underwent therapeutic ERCP within one week of admission. Early ERCP was defined as ERCP performed on the same day of admission or the next day(days 0 or 1, 48 h), and late ERCP was performed on days 2 to 7 of admission. Patients with severe cholangitis had any of the following additional diagnoses: Severe sepsis, septic shock, acute renal failure,acute respiratory failure, or thrombocytopenia. Multivariate logistic regression was used to calculate the adjusted odds of association of ERCP timing with inhospital mortality, 30-d mortality, and 30-d readmissions, controlling for age, sex,severe disease and comorbidities.RESULTS Four thousand five hundred and seventy patients satisfied the inclusion criteria;with a mean age of 64.1 years. Of these, 66.6% had early ERCP, while 33.4% had late ERCP. Early ERCP was associated with lower in-hospital mortality [1.2% vs2.4%, adjusted odds ratio(aOR) = 0.50, 95%CI: 0.76-0.83, P = 0.001] and lower 30-d mortality(1.5% vs 3.3%, aOR = 0.48, 95%CI: 0.33-0.69, P 0.0001) compared to the late ERCP group. Similarly, early ERCP was associated with lower 30-d readmissions(9.7% vs 15.1%, aOR = 0.58, 95%CI: 0.49-0.7, P 0.0001). When stratified by severity of cholangitis, there was a similar benefit of early ERCP on all outcomes in those with and without severe cholangitis. The mean length of stay was higher in the late ERCP group compared to the early ERCP group(6.9 d vs 4.5 d, P 0.0001). The mean hospitalization cost was higher in the late ERCP group($21459 vs $16939, P 0.0001).CONCLUSION Early ERCP is associated with lower in-hospital and 30-d mortality in those with or without severe cholangitis. Regardless of severity, we suggest performing early ERCP.     

Efficacy and safety of emergency endoscopic retrograde cholangiopancreatography for acute cholangitis in the elderly

AIM To investigate the efficacy and safety of emergency endoscopic retrograde cholangiopancreatography(ERCP) in elderly patients with acute cholangitis. METHODS From June 2008 to May 2016, emergency ERCPs were performed in 207 cases of acute cholangitis at our institution. Patients were classified as elderly if they were aged 80 years and older(n = 102); controls were under the age of 80 years(n = 105). The patients' medical records were retrospectively reviewed for comorbidities, laboratory data, etiology of cholangitis(presence of biliary stones, biliary stricture and malignancy), details of the ERCP(therapeutic approaches, technical success rates, procedure duration), ERCP-related complications and mortality. RESULTS The frequency of comorbidities was higher in the elderly group than the control group(91.2% vs 67.6%). Periampullary diverticulum was observed in the elderly group at a higher frequency than the control group(24.5% vs 13.3%). Between the groups, there was no significant difference in the technical success rates(95.1% vs 95.2%) or endoscopicprocedure durations. With regard to the frequency of ERCP-related complications, there was no significant difference between the two groups(6.9% vs 6.7%), except for a lower rate of post-ERCP pancreatitis in the elderly group than in the control group(1.0% vs 3.8%). Neither angiographic nor surgical intervention was required in any of the cases with ERCP-related complications. There was no mortality during the observational periods. CONCLUSION Emergency ERCP for acute cholangitis can be performed safely even in elderly patients aged 80 years and older.     

经内镜下逆行胰胆管造影术治疗急性梗阻性化脓性胆管炎患者疗效及感染病原菌调查*

目的 研究经内镜逆行胰胆管造影术（ERCP）治疗急性梗阻性化脓性胆管炎（AOSC）患者的疗效及感染病原菌特征。方法 2016年11月~2018年11月我院收治的160例AOSC患者均接受ERCP治疗。在ERCP治疗过程中抽取胆汁行细菌培养,采用纸片扩散法检测细菌对各种抗菌药物的敏感性。结果 在160例AOSC患者中,插管成功148例（92.5%）;术后3 d,有效引流者血清总胆红素为（60.2±43.3） μmol/L,显著低于术前[（110.1±53.0） μmol/L,P<0.05）],中性粒细胞百分比为（60.2±5.6） %,显著低于术前[（78.4±12.4） %,P<0.05];13例患者症状缓解不明显,经再次内镜或药物或介入治疗后痊愈,未出现穿孔、出血等并发症或死亡;148例完成手术治疗的患者胆汁细菌培养阳性98例（66.2%）,检出病原菌130株,其中革兰阴性杆菌占66.2%,革兰阳性球菌占33.8%,以屎肠球菌、粪肠球菌、肺炎克雷伯菌、铜绿假单胞菌为主,其中大肠埃希菌所占比例最高,占33.1%;除革兰阳性球菌对万古霉素和亚胺培南100.0%敏感、革兰阴性杆菌对亚胺培南100.0%敏感外,其他病原菌对抗菌药物均呈不同程度的耐药性。结论 采取ERCP治疗AOSC患者临床疗效确切,参照胆汁细菌培养结果合理使用抗菌药物能提高抗菌效率,减少耐药性,提高临床治疗疗效。     

细胞因子与内镜逆行胰胆管造影术后胰腺炎关系的研究进展

内镜逆行胰胆管造影术(enoscopiC retrograde cholangiopancreatography,ERCP)是当前诊治肝、胆、胰疾病的重要手段之一.急性胰腺炎是ERCP术后最常见、最严重的并发症,目前其发病机制仍未完全阐明.近年来研究的普遍共识是炎性细胞因子在轻症胰腺炎向重症胰腺炎演进过程中发挥了重要作...     

急性梗阻化脓性胆管炎的早期内镜介入与外科手术治疗的比较

目的:探讨急诊内镜微创介入与外科手术对急性梗阻化脓性胆管炎(acute obstructive suppurative cholangitis,AOSC)的治疗效果.方法:回顾性分析中国人民解放军总医院消化内科、肝胆外科2008-01/2011-06收治的72例AOSC患者的临床资料,分为内镜组54例:急诊内镜下逆行胰胆管造影术(endoscopic retrograde cholangiopancreatogahpy,ERCP)微创介入治疗;手术组18例:手术开腹胆总管切开、留置T管引流.结果:72例患者平均年龄68.3岁±14.2岁,病因为胆道结石占88.9%、恶性肿瘤占11.1%.内镜组与手术组比较在平均年龄、性别构成、病因构成方面的差异均无统计学意义(P>0.05);在治愈率方面比较内镜组(94.4%)高于手术组(72.2%)(P<0.05);并发症(3.7%vs27.8%)及死亡率(0vs16.7%)内镜组均显著低于手术组(P<0.05),而术后住院时间(9.1d±8.0dvs16.2d±9.9d)和住院费用(3.64万元±1.52万元vs9.33万元±6.86万元),内镜组也均显著低于手术组(P<0.05).内镜组并发症:胰腺炎1例、乳头切开出血1例;手术组并发症:多脏器功能衰竭3例(均死亡)、胆漏1例、肝脓肿1例.结论:AOSC患者的外科手术并发症多、死亡率高,早期内镜微创介入治疗可显著减少并发症并降低死亡率,应成为治疗AOSC的首选方法.     

Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis

Endoscopic retrograde cholangiopancreatography （ERCP） is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound （EUS） and magnetic retrograde cholangiopancreatography （MRCP）, ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.     

Timing of biliary decompression for acute cholangitis

Severe acute cholangitis (AC) exacerbates the risk of death because of the rapid progression of the disease. The optimal timing of biliary decompression (BD) as a necessary intervention in patients with severe AC is controversial. A recently report titled “Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity” in the World Journal of Gastroenterology that the optimal time of endoscopic retrograde cholangiopancreatography for treating patients with severe AC is ≤ 48 but not ≤ 24 h, providing clinical evidence for selecting the optimal time for implementation of BD. Here, we discuss the controversy over the optimal timing of BD for AC based on guidelines and clinical evidence, and consider that more high-level clinical researches are urgent needed to benefit the management of patients with different severity of AC.     

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography(ERCP)in patients with surgically altered anatomy must be performed by a highly experienced endoscopist.The challenges are accessing the afferent limb in different types of reconstruction,cannulating a papilla with a reverse orientation,and performing therapeutic interventions with uncommon endoscopic accessories.The development of endoscopic techniques has led to higher success rates in this group of patients.Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction;however,these success rate is lower in long-limb reconstruction.ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length;however,it must be performed by a highly experienced and skilled endoscopist.Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography,but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy.Laparoscopic-assisted ERCP has an almost 100%success rate in longlimb reconstruction because of the use of a conventional side-view duodenoscope,which is compatible with standard accessories.This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy.This review focuses on the advantages,disadvantages,and outcomes of various procedures that are suitable in different situations and reconstruction types.Emerging new techniques and their outcomes are also discussed.     

治疗性ERCP在85岁以上高龄患者中的应用价值评价

目的 评价治疗性ERCP在85岁以上高龄老年人的安全性和有效性.方法 回顾性分析2004年至2009年间85岁以上ERCP患者（A组,52例）的临床资料,并与同期70～84岁ERCP患者（B组,329例）做比较.结果 A组患者伴发症（52/52）明显高于B组（255/329）,P〈0.05;对于胆总管结石者,需要多次取清结石者A组（19/52）明显多于B组（65/329）,P〈0.05;并发症发生率分别为（4/52）和（16/329）,P〉0.05;术后死亡率分别为（1/52）和（2/329）,P〉0.05.结论 治疗性ERCP对于85岁以上高龄老年人是安全有效的,但需严格掌握手术适应证.     

ERCP结合EPT对胆囊切除术后患者诊治价值的探讨

目的 回顾性研究逆行性胰胆管造影（ERCP）结合乳头肌切开术（EPT）对胆囊切除术后患者的诊治价值。方法 170例胆囊切除术后症状再发或反复发作患者,接受ERCP检查和EPT等治疗,诊断结果与B超作对照。同时动态观察内镜下介入诊治术后临床表现的改变。不良反应及血清淀粉酶的变化及高淀粉酶血症的分布情况。结果 经ERCP结合EPT等术后患者临床症状显著改善;与B超对照ERCP对胆囊切除术后胆总管残余结石的诊断率显著提高（P＜0．001）,对胆总管扩张程度的诊断价值显著优于B超（P＜0．05）,并能发现许多B超检查不能发现的胆胰病变;术后主要不良反应表现为出血、高淀粉酶血症,ERCP结合EPT等治疗组高淀粉酶的发生率显著高于单纯ERCP操作组（P＜0．01）。经积极地处理后短期内出血控制,血清淀粉酶多在3日内转为正常。结论 对胆囊切除术后患者,ECRP结合EPT不失为一项非常有价值、安全的诊治措施。     

经内镜胆道内支架放置术在老年急性梗阻性化脓性胆管炎中的应用价值

目的　评估经内镜胆道内支架放置术（endoscopic retrograde biliary drainage,ERBD）治疗老年急性梗阻性化脓性胆管炎（acute obstructive suppurative cholangitis,AOSC）的安全性和有效性。方法　回顾性分析新疆医科大学第一附属医院2018年1月—2020年1月期间收治的AOSC患者的临床资料。年龄在75岁及以上的患者设为老年组（n=49）,75岁以下的患者设为对照组（n=63）,比较两组患者一般资料、美国麻醉医师协会（American Society of Anesthesiologists, ASA）分级、基础疾病伴随情况、手术相关情况、术后并发症发生率及死亡率等指标。结果　老年组和对照组患者在年龄［（82.6±5.1）岁比 （64.6±4.5）岁,t=19.98, P<0.001］、白蛋白水平［（29.1±5.9）g/L 比 （34.6±8.8）g/L,t=-3.94,P<0.001］、ASA分级（χ²=8.37,P=0.015）方面差异有统计学意义。老年组伴随更多的基础疾病,尤其在高血压［57.1%（28/49）比34.9%（22/63）,χ²=5.51,P=0.019］、冠心病［（55.1%（27/49）比27.0%（17/63）,χ²=9.14,P=0.003］、慢性阻塞性肺疾病/哮喘方面［24.5%（12/49） 比6.3%（4/63）,χ²=7.41,P=0.006］差异有统计学意义。在手术相关指标方面,老年组与对照组手术时间［（31.4±8.1）min 比 （30.4±8.0）min,t=-0.61,P=0.543］、住院时间［（6.1±1.7）d 比（5.7±1.4） d,t=1.35, P=0.182］差异无统计学意义。老年组和对照组并发症发生率分别为14.3％（7/49）和12.7％（8/63）,差异无统计学意义（χ²=0.06,P=0.807）。在院期间,两组均无手术相关死亡病例。结论　对于75岁及以上的老年AOSC患者,急诊ERBD可迅速缓解病情,是一种安全有效的治疗措施,高龄不是急诊ERBD的绝对禁忌证。     

内镜逆行胰胆管造影对Mirizzi综合征的诊断价值

目的 探讨内镜逆行胰胆管造影（ＥＲＣＰ）对Ｍｉｒｉｚｚｉ综合征的诊断价值,提高对该病的术前诊断率。方法 对３０例Ｍｉｒｉｚｚｉ综合征的临床特征,实验室检查、十二指肠镜下特点及ＥＲＣＰ的Ｘ线表现进行分析,并与Ｂ超、ＣＴ检查棹比较。结果 Ｍｉｒｉｚｚｉ综合征病史较长,ＥＲＣＰ的典型表现为肝总管可风级完整的充盈缺损,缺损以上的肝总管及肝内胆管轻至重度扩张。并胆囊萎缩及胆囊结石。ＥＲＣＰ确诊率为８６．６７     

磁共振胰胆管造影术与内镜逆行胰胆管造影术的对照研究

目的 通过磁共振胰胆管造影术（ＭＲＣＰ）与内镜逆行胰胆管造影术（ＥＲＣＰ）的对照研究,评价ＭＲＣＰ对胰胆系疾病的诊断价值。方法 ４０例疑有胰胆系疾病的患者进行了ＭＲＣＰ及ＥＲＣＰ检查,两者结果作对照研究。结果 本组资料中ＭＲＣＰ对胰胆系疾病总的诊断价值为敏感度８９．１％、特异度１００％、准确度９０％,ＥＲＣＰ总的诊断价值为敏感度８４．２％、特异度１００％、准确度８５％,两者统计学上无显著性差异。结     

Crowned dens syndrome developed after an endoscopic retrograde cholangiopancreatography procedure

We present a unique case of crowned dens syndrome(CDS) that developed after endoscopic retrograde cholangiopancreatography(ERCP) in a patient who presented with fever and neck pain. Administration of non-steroidal anti-inflammatory drugs was extremely effective for relieving fever and neck pain, and in the improvement of inflammatory markers. To the best of our knowledge, this is the first case report of CDS caused by an ERCP procedure. In a patient with fever and neck pain after an ERCP procedure, CDS should be considered in the differential diagnosis.     

经内镜胆道内支架放置术和鼻胆管引流术治疗各级急性胆管炎的效果比较

目的 比较经内镜胆道内支架放置术（ERBD）和经内镜鼻胆管引流术（ENBD）对各级急性胆管炎的治疗效果。方法 回顾性分析2009年1月至2017年6月在北京朝阳医院接受急诊经内镜逆行胰胆管造影术（ERCP）治疗的272例急性胆管炎患者资料,其中ERBD组143例,包括Ⅰ级（轻度）急性胆管炎63例,Ⅱ级（中度）51例,Ⅲ级（重度）29例;ENBD组129例,包括Ⅰ级（轻度）54例,Ⅱ级（中度）37例,Ⅲ级（重度）38例。分别比较两组总体患者和各级急性胆管炎患者的炎症缓解率、ERCP相关并发症发生率和引流干预率。结果 ERBD组和ENBD组总体炎症缓解率[89.5%（128/143）比94.6%（122/129）,χ2=2.399,P=0.126]及Ⅰ级[93.7%（59/63）比98.1%（53/54）,χ2=0.548,P=0.459]、Ⅱ级[90.2%（46/51）比94.6%（35/37）,χ2=0.125,P=0.724]、Ⅲ级患者炎症缓解率[79.3%（23/29）比89.5%（34/38）,χ2=0.657,P=0.418]比较,差异均无统计学意义。ERBD组和ENBD组总体并发症发生率[11.9%（17/143）比7.8%（10/129）,χ2=1.298,P=0.255]及Ⅰ级[9.5%（6/63）比7.4%（4/54）,χ2=0.006,P=0.939]、Ⅱ级[13.7%（7/51）比8.1%（3/37）,χ2=0.230,P=0.632]、Ⅲ级患者并发症发生率[13.8%（4/29）比7.9%（3/38）,χ2=0.144,P=0.705]比较,差异均无统计学意义。ERBD组和ENBD组总体引流干预率比较差异有统计学意义[10.5%（15/143）比3.1%（4/129）,χ2=5.699,P=0.017],Ⅰ级[6.3%（4/63）比1.9%（1/54）,χ2=0.548,P=0.459]、Ⅱ级患者引流干预率[9.8%（5/51）比5.4%（2/37）,χ2=0.125,P=0.724] 比较差异无统计学意义,但Ⅲ级患者比较差异有统计学意义[20.7%（6/29）比2.6%（1/38）,χ2=3.965,P=0.046]。结论 ENBD与ERBD对各级急性胆管炎的治疗具有相同的效果,但ENBD能够降低术后引流干预率。     

Retrieval-balloon-assisted enterography in post-pancreaticoduodenectomy endoscopic retrograde cholangiopancreatography

This case reports an application of conventional duodenoscope in a post pancreaticoduodenectomy patient with the help of retrieval balloon assisted enterography. The 56-year-old woman had pancreaticoduodenectomy with Child reconstruction 9 mo ago because of pancreatic adenocarcinoma and now there are recurrent enlarged lymph nodes in the anastomotic stoma of hepaticojejunostomy. Considering the patient’s late-stage cancer, a plastic stent was then successfully placed there to drainage. The main challenge in this case was the extremely long afferent loop and blind cannulation through the anastomotic stoma of hepaticojejunostomy. Retrieval balloon assisted enterography is very helpful for duodenoscope going through the reconstructed intestinal tract and for the cannulation. After two weeks, the patient remained free of painful symptoms and free of fever. Liver function improved well. Four months after the placement of stent, the patient died of cachexia without jaundice, fever and abdominal pain according to her daughter’s statement.     

Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study

BACKGROUNDBiliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.AIMTo investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.METHODSIn this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)]. RESULTSBiliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).CONCLUSIONBiliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.     

Propofol use in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

Compared to standard endoscopy,endoscopic retrograde cholangiopancreatography(ERCP)and endoscopic ultrasound(EUS)are often lengthier and more complex,thus requiring higher doses of sedatives for patient comfort and compliance.The aim of this review is to provide the reader with information regarding the use,safety profile,and merits of propofol for sedation in advanced endoscopic procedures like ERCP and EUS,based on the current literature.     

Risk factors of recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography

Background: The risk factors for the recurrent choledocholithiasis after endoscopic retrograde cholangiopancreatography(ERCP) have not been well studied. The aim of this study was to explore the risk factors of recurrent choledocholithiasis. Methods: We carried out a retrospective analysis of data collected between January 1, 2010 and January 1, 2020. Univariate analysis and multivariate analysis were used to explore the independent risk factors of recurrent choledocholithiasis following therape...