ERCP与EST并发出血的相关临床研究

目的 分析胆总管结石ERCP与EST并发出血的相关危险因素,并探讨有效防治措施。方法 回顾性分析皖南医学院弋矶山医院消化内镜中心2012年1月至2012年12月299例胆总管结石患者行ERCP与EST取石术的临床资料。结果 299例患者,术中少量出血52例,明显出血50例,其成功插入乳头时间经方差分析（F=3.713）差异有统计学意义（P=0.026,P〈0.05）;出血病例中,存在憩室21例,出血量与憩室的关系经卡方检验（x2=5.314）差异有统计学意义（P=0.021,P〈0.05）;术中出血患者分别采用内镜下电凝止血与钛夹止血处理,经Fisher精确概率检验法,提示内镜下钛夹止血治疗的止血有效率高于电凝止血治疗（P=0.464,P〈0.05）,并发术后出血8例,其中3例行内科保守治疗有效,1例无效,3例行内镜下止血治疗有效,1例行介入止血治疗并发重症急性胰腺炎。结论 胆总管结石ERCP与EST并发出血与成功插入乳头时间,有无憩室等因素相关,内镜下干预治疗是防治术中术后出血的有效措施。     

CA199联合ERCP对胰胆管恶性肿瘤的诊断价值研究

目的研究CA19—9对胆道和胰腺恶性肿瘤的诊断价值,以及胆总管梗阻对CA19—9值的影响。方法首先回顾性分析168例胆道和胰腺疾病的患者血清CA199对胆道和胰腺恶性肿瘤的诊断价值。然后前瞻性地对54例因胆总管梗阻而行ERCP＋胆总管支架植入术的患者进行研究。结果胆道和胰腺恶性肿瘤组CA199水平明显高于良性疾病组,差异具有统计学意义（P〈0.01）。血清CA199对胰腺和胆道恶性肿瘤诊断的敏感性分别为100%和84%,特异性分别为87.27%和53.16%。在ERCP术前CA199对胆总管恶性梗阻的诊断的特异性只有43.48%,而在ERCP术后上升到86.96%。结论 CA199对胰腺和胆道恶性肿瘤具有较高的诊断价值,尤其是解除胆道梗阻以后其诊断恶性肿瘤的特异性显著升高。     

Biliary, Pancreatic, and Sphincter of Oddi Electrical and Mechanical Signals Recorded During ERCP

Measurements of biliary tract motility havefocused on radiologic and pressure measurements toquantify biliary motility rather than measurements ofelectrical activity of the biliary tract. We previously reported the recording of biliary electricalsignals during ERCP and now report on the continueddevelopment and validation of a system to measurebiliary tract electrical activity as well as biliarymechanical activity. In 26 patients presenting with avariety of clinical indications, we recordedmeasurements of electrical activity from the common bileduct sphincter (16 patients), pancreatic duct sphincter(eight patients), and/or sphincter of Oddi (eightpatients). Electrical recordings were performed with aspecially modified ERCP catheter, using two circularelectrodes as well as a custom catheter that measured both electrical and mechanical activity.Electrical activity of the biliary tract wassuccessfully recorded in 25 of 26 patients (96%),including the common bile duct sphincter (16 patients,62%), pancreatic duct sphincter (eight patients, 31%) andsphincter of Oddi (eight patients, 31%). Along with theelectrical recordings, common bile duct sphinctermechanical activity was recorded in 12 patients (67%), pancreatic duct sphincter mechanical activityin six patients (33%), and sphincter of Oddi mechanicalactivity in six patients (33%). Frequency analysis ofelectrical signals revealed a mean frequency(cycles/min) of 4.7 ± 0.5 in the common bile ductsphincter, 4.1 ± 0.6 in the pancreatic ductsphincter, and 4.9 ± 0.7 in the sphincter ofOddi. Phasic mechanical frequency in cycles per minutewas recorded at a frequency of 4.8 ± 0.5 in common bileduct sphincter, 4.0 ± 0.6 in pancreatic ductsphincter, and 5.3 ± 0.9 in sphincter of Oddi.Tonic pressure (averaged 12.1 ± 1.5 mm Hg) incommon bile duct sphincter, 12.4 ± 1.4 mm Hg inpancreatic duct sphincter, and 15.0 ± 5.1 mm Hgin sphincter of Oddi. Analysis of wave form propagations(noted as percentage antegrade, retrograde, orindeterminant) revealed 50% antegrade, 23% retrograde, and 27%indeterminant). One patient was recorded on twooccasions via ERCP; the same patient had anintraoperative recording. All three recordings showedsimilarities. We conclude that measurements of biliary,pancreatic, and sphincter of Oddi electrical andmechanical activity are feasible and can be done as partof ERCP. There was good correlation between biliarytract electrical and mechanical events and differentwave form characteristics were noted for different partsof the biliary tree. Further studies are warranted toevaluate the potential usefulness of measurement of biliary tract electrical activity, and toconfirm its correlation with mechanical events in thepancreato-biliary tree.     

Endoscopic papillary large balloon dilation in patients with large biliary stones and periampullary diverticula: Results of a multicentric series

IntroductionStone extraction represents the most frequent indication for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic papillary large balloon dilation (EPLBD) is a recent introduced approach consisting of an endoscopic papillary large balloon dilation following limited endoscopic sphyncterotomy (ES), which has been proven to be safe and effective for extraction of large common bile duct (CBD) stones. Peri-ampullary diverticula (PAD) are described in 10–20% of patients undergoing ERCP. Aim of our study is to evaluate efficacy and safety of EPLBD for the extraction of large biliary stones in patients with PAD.MethodsThe prospectively collected endoscopy databases of 4 Italian ERCP high-volume centers were reviewed retrospectively, and all consecutive patients with an instrumental diagnosis of large biliary stones and PAD, between September 2014 and October 2016, were included in this study.ResultsEighty-one patients (36 males, median age 75 years) were treated between September 2014 and October 2016. Deep biliary cannulation was reached in 78/80 patients. Successful extraction was achieved in 74/78 patients at the first attempt. AEs occurred in 8 patients (1 severe). Younger age, stone size and incomplete stone extraction were significantly associated with AEs.ConclusionsEPLBD is an effective and safe technique in patients with PAD and large biliary stones, which avoids the need of other techniques, thereby reducing the risks of adverse events.     

Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction

Background & Aims: Patients with sphincter of Oddi dysfunction are at high risk of developing pancreatitis after endoscopic biliary sphincterotomy. Impaired pancreatic drainage caused by pancreatic sphincter hypertension is the likely explanation for this increased risk. A prospective, randomized controlled trial was conducted to determine if ductal drainage with pancreatic stenting protects against pancreatitis after biliary sphincterotomy in patients with pancreatic sphincter hypertension. Methods: Eligible patients with pancreatic sphincter hypertension were randomized to groups with pancreatic duct stents (n = 41) or no stents (n = 39) after biliary sphincterotomy. The primary measured outcome was pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). Results: Pancreatic stenting significantly decreased the risk of pancreatitis from 26% to 7% (10 of 39 in the no stent group and 3 of 41 in the stent group; P = 0.03). Only 1 patient in the stent group developed pancreatitis after sphincterotomy, and 2 others developed pancreatitis at the time of stent extraction. Patients in the no stent group were 10 times more likely to develop pancreatitis immediately after sphincterotomy than those in the stent group (relative risk, 10.5; 95% confidence interval, 1.4–78.3). Conclusions: Pancreatic duct stenting protects significantly against post-ERCP pancreatitis in patients with pancreatic sphincter hypertension undergoing biliary sphincterotomy. Stenting of the pancreatic duct should be strongly considered after biliary sphincterotomy for sphincter of Oddi dysfunction; pancreatic sphincter of Oddi manometry identifies which high-risk patients may benefit from pancreatic stenting.GASTROENTEROLOGY 1998;115:1518-1524     

ERCP对原发性肝外胆管癌的诊断价值

ＥＲＣＰ检查梗阻性黄疸２８７例中原发性肝外胆管癌４８例，其中胆囊癌４例（８％），肝总管癌１１例（２３％），胆总管癌１２例（２５％），壶腹癌１７例（３６％），胆管多部位癌４例（８％）。另外胰头癌浸润胆总管５例。本文探讨了原发性肝外胆管癌的Ｘ线特征、鉴别诊断；对比分析了ＥＲＣＰ与Ｂ超的诊断价值。     

Placement of a biliary metal stent to expand a choledochus stenosis after Frey''s surgery

A 47-year-old patient presented with jaundice. Laboratory examinations confirmed cholestasis. The patient had a long history of chronic pancreatitis. Subsequently, cholecystectomy and a duodenumpreserving resection of the pancreatic head (Frey's surgery) had been performed. Endoscopic retrograd holangiography was done. The endoscope was inserted the normal way to the untouched papilla vateri. After injection of contrast medium, only the side-to-side choledocho-jejunal anastomosis but not the common bile duct could be visualized because the catheter spontaneously slipped into the jejunum via the side-to-side choledocho-jejunal anastomosis.

After introducing a catheter percutaneously into the intrahepatic bile duct system, a long stenosis of the common bile duct could be visualized. It was possible to overcome the stenosis with a wire, but the wire also dislocated into the jejunum via the side-to-side choledocho-jejunal anastomosis and could not be placed through the papilla into the duodenum.

The problem was solved in a tricky way: A wire was introduced into the common bile duct via the papilla and placed into the duodenum. A loop was brought in percutaneously and was also placed in the jejunum. With the loop, the wire was grabbed and taken out percutaneously. Now a biliary metal stent could be positioned correctly over the wire to expand the stenosis.

After the procedure jaundice was cured quickly. The further course was uneventful with complete recovery.     

长托宁在老年ERCP麻醉前用药的临床观察

目的：探讨长托宁作为老年患者ERCP麻醉前用药的可行性,临床效果及安全性。方法：选取2009年5月-2013年2月本院90例在静脉麻醉下行ERCP手术老年患者,随机数字表法分为三组,长托宁组30例,阿托品组30例,生理盐水组30例,三组分别以长托宁,阿托品,生理盐水作为麻醉前用药。比较三组患者在麻醉给药后不同时间点SBP、DBP、HR以及唾液分泌量的变化,并比较三组患者在术中术后出现的不良反应情况。结果：三组患者血压变化均平稳,长托宁组患者心率变化较阿托品组平稳,和生理盐水组比较变化无统计学差异,长托宁组患者唾液分泌量明显少于阿托品及生理盐水组。阿托品组患者在给药前后心率变化差异有统计学意义（P〈0.05）。结论：长托宁在应用于老年ERCP术前麻醉时,对老年患者的循环血流动力学影响小,在抗胆碱作用时比阿托品效果更持续,并能够有效的控制围术期间呼吸道分泌物,是一种更为理想的老年患者麻醉前用药。     

高龄患者行ERCP的护理体会

目的探讨≥70岁患者治疗性逆行胰胆管造影术（ERCP）的护理。方法对我科2年来行治疗性ERCP的27例高龄患者的护理进行回顾分析和总结。结果 27例患者中,成功完成25例,成功率92.6%。发生并发症7例,急性胰腺炎7例,经积极的对症处理后均治愈,无1例因护理不当发生并发症。结论术前用心准备、术中细心监护、术后精心护理,配合积极有效的处理是减少并发症、保证治疗成功的关键。     

胆道不同梗阻部位ERCP术后感染率发生情况比较分析

目的为了探讨和比较胆道不同梗阻部位ERCP术后感染率发生情况,从而为预防ERCP术后感染发生的相关研究提供依据和参考。方法选取该院2010年1月—2013年6月期间收治并实施ERCP术治疗的胆道梗阻患者122例为研究对象,按照患者梗阻发生部位不同进行分组,分为高位组和低位组,每组患者均为61例。观察并比较两组患者实施ERCP术后感染率发生情况。结果高位组患者术后感染发生率为27.87%,低位组患者术后感染发生率为8.20%,高位组患者的ERCP术后感染率显著高于低位组患者,且组间数据比较差异具有显著的统计学意义（χ^2=7.9855,P=0.0047）。结论胆道不同梗阻部位ERCP术后感染率水平存在差异,高位胆道梗阻患者术后感染发生率水平显著的高于低位胆道梗阻患者,在手术实施的过程中应根据患者具体情况采取有针对性的预防措施,以降低术后感染发生率。