内镜下十二指肠乳头预切术在恶性胆道梗阻诊治中的应用

目的 探讨内镜下十二指肠乳头预切术在恶性胆道梗阻诊治中的应用价值.方法 对46例插管困难的恶性胆道梗阻患者,根据十二指肠乳头及其周围结构、插管情况等采用不同预切方法对乳头括约肌施行内镜下预切术,观察ERCP诊治的完成情况,以及并发症发生情况.结果 应用弓形刀切开法4例、针状刀切开法24例、经胰管胆管切开法12例、联合方法6例,其中35例预切术后胆管插管成功,成功率达76.1%（35/46）.发生术后黏膜渗血3例、胰腺炎1例、高淀粉酶血症2例、胆管炎1例,未见穿孔发生.结论 内镜下乳头预切术可提高恶性胆道梗阻患者ERCP诊治的成功率,且适时、正确地应用可以降低并发症的发生率.     

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.     

双导丝技术在导丝所致十二指肠乳头穿孔中的应用价值

目的 评价ERCP插管过程中导丝所致十二指肠乳头穿孔时使用双导丝技术胆管插管的效果及安全性。 方法 2008年1月至2016年9月,57例ERCP插管过程中导丝所致十二指肠乳头穿孔病例纳入回顾性研究,其中采用双导丝技术行胆管插管30例（双导丝组）、传统方法继续胆管插管27例（标准组）,总结并比较2组的插管成功率、插管时间及并发症发生率。 结果 双导丝组插管成功率[96.7%（29/30）]明显高于标准组[74.1%（20/27）,χ2=5.545,P=0.019],平均插管时间[（21.8±7.8）min]明显短于标准组[（40.7±8.4）min,t=8.076,P=0.000],并发症发生率[13.3%（4/30）]与标准组[11.1%（3/27）,χ2=0.292,P=0.596]相近,均为术后高淀粉酶血症。 结论 ERCP插管过程中导丝所致十二指肠乳头穿孔时使用双导丝技术胆管插管安全且有效,较之传统方法具有插管成功率更高且省时的优势。     

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。     

内镜下针状刀乳头开窗术在乳头结石嵌顿中的应用

目的探讨内镜下针状刀乳头开窗术,又称内镜下胆管十二指肠造口术(ECDT)治疗乳头结石嵌顿的价值。方法对有乳头结石嵌顿的患者行经内镜逆行胰胆管造影(ERCP)时,应用针状刀行乳头开窗术,取出嵌顿结石。结果 49例行ECDT术,其中45例患者一次性取出嵌顿结石,取石成功率91.8%,1例先放置鼻胆管,后再次行ERCP成功取石,2例转外科手术,1例放置胆管塑料支架。其中结石直径小于12 mm的患者取石成功率高于直径大于13 mm的患者(P<0.05),而乳头开口处结石暴露患者与未见结石患者取石成功率差异无统计学意义(P>0.05)。结论乳头结石嵌顿造成乳头肿大,行ECDT术可取出嵌顿结石,成功率高,并发症少,能有效缓解症状,值得临床广泛应用。     

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．     

针状刀乳头预切开在胆管疾病中的应用体会

[目的]报道采用针状刀行乳头预切开治疗胆管疾病的体会。[方法]入选胆管疾病患者48例,采用针状刀行乳头预切开术。[结果]48例经针状刀切开成功42例,成功率87.5%。[结论]针状刀作为选择性胆管插管失败的最后选项,可使大部分难治性胆管疾病的内镜诊疗得以进一步进行;但对于扁平小乳头、憩室旁小乳头或憩室内乳头、乳头表面明显恶性病变者应慎用。     

双腔前视胃镜治疗毕Ⅱ式胃空肠吻合术后胆胰疾病的临床观察

目的评价使用双腔前视胃镜对毕Ⅱ式胃空肠吻合术后胆胰疾病患者进行经内镜逆行胰胆管造影术（ERCP）治疗的疗效及安全性。方法回顾性总结46例使用双腔前视胃镜进行ERCP治疗的毕Ⅱ式胃空肠吻合术后胆胰疾病患者的临床资料,统计十二指肠乳头插管成功率、并发症发生情况和治疗情况。结果十二指肠乳头插管成功率为82．6％（38／46）,8例失败,其中6例因双腔前视胃镜无法进入输入袢找到十二指肠乳头而失败,2例因乳头插管困难而失败。38例插管成功者中,3l例胆管结石者均成功取出结石,4例胆总管下端恶性梗阻者均成功置入胆管金属支架,3例十二指肠乳头良性狭窄者经气囊扩张后均成功置入鼻胆引流管;所有患者术后恢复良好,无一例发生出血、穿孔和术后胰腺炎等严重并发症。结论使用双腔前视胃镜对毕Ⅱ式胃空肠吻合术后胆胰疾病患者进行ERCP治疗,插管成功率较高,可顺利完成后续ERCP相关治疗,并且不会明显增加并发症发生率,具有较好的临床应用价值。     

针状刀乳头括约肌切开术在困难ERCP病例中的应用体会

目的总结针状刀乳头括约肌切开术在难插性ERCP操作中应用的经验体会,分析其价值。方法回顾性分析我院自2008年1月～2010年12月,常规插管不能完成采用针状刀乳头括约肌切开41例临床资料。结果 41例行针状刀乳头切开,成功37例,成功率为90.2%,使ERCP成功率由86%提升到96.9%,术中出现乳头部出血10例,2例出血自行停止,8例给予局部喷洒1：10000肾上腺素、氩气烧灼或钛夹止血,出血停止。术后并发急性胰腺炎3例,胆管炎2例,穿孔1例行手术治疗;无死亡病例。结论在ERCP操作中由于各种生理及病理原因造成的常规插管困难使用针状刀进行乳头切开,可提高ERCP操作成功率,在严格把握适应症的前提下,仔细耐心操作,便可最大限度的控制减少并发症,值得临床推广。     

选择性胆管插管困难患者弓形刀胰管预切开和针状刀切开的联合应用

目的 探讨弓形刀胰管预切开联合针状刀补切开在经内镜逆行选择性胆管插管困难患者应用的价值及安全性.方法 对38例选择性胆管插管困难患者,创新性运用双刀联合进行插管,即先行弓形刀胰管预切开再行针状刀联合补切开.结果 双刀联合切开后38例患者插管成功33例,成功率86.8％;术后并发症9例,其中高淀粉酶血症4例,胰腺炎4例,胆管炎1例,保守治疗2～5d后痊愈,未发生出血和穿孔并发症.结论 应用弓形刀胰管括约肌预切开联合针状刀乳头切开,能够提高胆管插管困难者操作的成功率,也较安全,是一种行之有效的操作技法.     

内镜下逆行胰胆管造影术在完全性内脏反位中的临床应用价值

目的评价在完全性内脏反位(SIT)患者中进行经内镜逆行胰胆管造影术(ERCP)的有效性和安全性。方法回顾性分析2008年12月至2018年12月在杭州市第一人民医院消化内镜中心行ERCP治疗的SIT患者的资料,评估插镜成功率、插管成功率、治疗成功率和并发症发生情况。结果共有10例SIT患者进行了11例次ERCP,其中胆总管结石7例,胆总管结石合并胆总管下端狭窄1例,胆总管下端恶性狭窄1例,胆总管下端良性狭窄1例。所有患者采用常规左侧卧位,插镜成功率为100%,胆道插管的成功率为100%,总体治疗成功率为100%,有2例放置金属支架的患者术后出现腹痛,给予保守治疗后好转。结论在SIT患者中施行ERCP安全有效。     

Comparison of efficacy and safety of transpancreatic septotomy,needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology

Background

Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography (ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy (TPS), needle-knife fistulotomy (NKF) or both based on the presence of unintentional pancreatic access and papillary morphology.

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。     

Double guide-wire technique versus transpancreatic biliary sphincterotomy for difficult biliary cannulation: Real life experience from a referral center

BackgroundDuring ERCP for biliary indication, when a difficult bile duct (BD) cannulation occurs, with unintended access to the main pancreatic duct (PD), both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed. We aimed to compare the technical success and adverse events (AEs) rate of these techniques.MethodsA retrospective analysis of patients with naïve papillae referred to the Pancreas Institute of Verona from January 2016 and July 2021 to undergo ERCP for biliary indications was performed.ResultsOverall, 202 patients (53.5% males, mean age 67.2 years) were evaluated (96 DGW, 106 TPBS). Malignant biliary stricture was the most common ERCP indication (78.2%). The rate of success in deep biliary cannulation was significantly higher in the DGW group (94.8%) compared to TPBS (79.2%) at the first attempt (p = 0.001). This result was also confirmed in the subgroup of patients with malignant distal stricture (72/77, 93.5% vs 63/80, 78.8%, p = 0.01). No significant difference in AEs rate, particularly in PEP incidence was found between the two groups.ConclusionsDGW demonstrated a higher success rate and similar safety profile compared with TPBS in difficult biliary cannulation. Based on this retrospective study, DGW should be preferred over TPBS in case of unintended PD cannulation. Further prospective studies are needed to confirm our results.     

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.     

Guidewire cannulation increases the success rate of needle‐knife fistulotomy for difficult bile duct access

Background and Aim: Selective bile duct cannulation is a prerequisite for performing therapeutic endoscopic biliary intervention. This study aimed to evaluate if using a soft‐tipped guidewire to cannulate the bile duct would increase the success rate of needle‐knife fistulotomy for difficult bile duct access. Methods: We reviewed sixty 60 patients with difficult bile duct access who underwent conventional cannulation with radiocontrast dye (29) or guidewire cannulation (31) after needle‐knife fistulotomy. Results: There were no significant differences in the demographic data between the two groups. The initial success rate of selective bile duct cannulation was significantly higher in the guidewire cannulation group compared with the conventional cannulation group: 100% versus 79.3%, P = 0.009. The success rate of selective biliary cannulation in the patients with non‐dilated common bile duct (< 8 mm) was significantly higher in the guidewire cannulation group compared with the conventional cannulation group: 100% versus 68.4%, P = 0.003. The incidence of post‐endoscopic retrograde cholangiopancreatography pancreatitis was not significantly different between the two groups. No serious complications occurred in either group. Conclusions: In this retrospective and small case series, guidewire cannulation after needle‐knife fistulotomy increased the success rate of selective bile duct cannulation in patients with difficult bile duct access.     

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.     

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.     

Application of needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is widely used in the diagnosis and treatment of biliary disorders. Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic endoscopy. The cannulation success rate depends on patient selection, the utilization of specialized catheters, and the skill and experience of the endoscopist. This improved significantly when the clever-cut knife with guidewire was introduced. However, i…