内镜综合治疗慢性胰腺炎

目的探讨内镜在慢性胰腺炎治疗中的临床应用价值方法回顾性分析经内镜治疗的37例慢性胰腺炎患者的临床资料,总结治疗的体会。结果37例均经内镜下胰胆管造影明确诊断,患者均有不同程度的胰管扩张,其中胰管狭窄21例,伴有钙化9例,行乳头括约肌切开术37例,胰管括约肌切开术18例,网篮、球囊取胰石6例,胰管内支架引流17例,鼻胰管引流5例。37例中34例治疗后腹痛消失。结论内镜治疗慢性胰腺炎是较安全、有效的,而内镜下多种治疗方法的综合应用明显改善了传统慢性胰腺炎治疗的现状,提高了治疗水平。     

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…     

经内镜治疗急性胰腺炎临床探讨

目的探讨内镜治疗急性胰腺炎（ＡＰ）的临床效果。方法采用经内镜鼻胆（胰）管引流（ＥＮＢ（Ｐ）Ｄ）及经内镜乳头括约肌切开术（ＥＳＴ）等内镜技术治疗ＡＰ５６例,其中重症急性胰腺炎（ＳＡＰ）３６例。结果治愈５３例,死亡２例,因胰腺出血致导管堵塞改行手术１例。结论内镜治疗以微小创伤达到满意外科引流效果,能够有效地降低胆胰管内压,缓解胰腺病变,起到治疗作用,不失为ＡＰ治疗手段和方法上的一个补充,具有一定的临床使用价值。     

内镜超声引导下胰管引流

通常,胰管高压的患者以腹痛为主要症状,常见于慢性胰腺炎、胰管结石、胰空肠吻合口狭窄及胰腺导管内乳头状黏液性肿瘤（IPMN）的患者,主要解决方式为外科手术或内镜下减压,如括约肌切开术、逆行胰管支架置入术、胰管狭窄扩张术等。一项随机试验显示,慢性胰腺炎导致胰管阻塞的治疗中外科介入的有效性优于内镜介入,然而并未考虑患者主观接受程度与创伤大小。一些由于一般条件不允许行外科手术或拒绝行手术治疗的患者会选择内镜介入治疗,但对于有解剖结构改变者,如Whipple术后患者,经典的ERCP术往往不能成功。     

胰腺疾病的内镜处理

内镜治疗胰腺炎的方法分为两类:急性胰腺炎的治疗和慢性胰腺炎的治疗。急性胰腺炎的介入性治疗方法通常有两种:即胆道括约肌切开术和胆道取石术(包括泥砂状沉积物);慢性胰腺炎的介入性治疗包括沿用至今治疗胆道疾病的各种方法,包括胰管括约肌切开术、取石术、经鼻胰腺引流术和治疗胰管疾病、假性囊肿、胸腔积液及胰性腹水等。     

十二指肠乳头括约肌小切开联合气囊扩张术治疗胆总管结石

经内镜乳头括约肌切开术（EST）取石用于治疗胆总管结石已得到广泛认可,但并发症发生率仍较高,经内镜乳头气囊扩张术（EPBD）取石具有与EST取石相近的成功率,出血、穿孔并发症相对较少,且保护了十二指肠乳头括约肌功能,但因球囊压迫胰管开口,术后胰腺炎的发生率相对较高。我们采用内镜下乳头括约肌小切开联合EPBD治疗了38例胆总管结石,现总结资料,探讨其有效性、安全性和在减少近期、远期并发症方面的作用。     

内镜下诊治伴发胰管结石慢性胰腺炎的价值

目的探讨ERCP在胰管结石诊断和治疗中的临床价值及其安全性评估。方法分析2008年2月～2008年10月期间共20例接受ERCP诊断和治疗的伴发胰腺结石慢性胰腺炎患者的临床资料。结果20例病例中,16例（80％）胰管结石位于胰头处,3例（15％）位于胰头及胰体处,1例（5％）累及全程胰管。14例（70％）患者一次性取石完全,5例患者术后接受体外震波碎石（ESWL）,1例患者未能完成取石,建议其外科手术治疗．18例表现为腹痛的病例,在接受内镜下治疗结石后,腹痛症状均消失,在接受治疗后2～10d内出院,平均（5．3±2．43）d。术后2例（10％）出现一过性的血淀粉酶升高。结论对于伴有胰管结石的慢性胰腺炎病例而青,内镜下取石是安全有效的方法,同时应川支架及鼻胰管引流,不仅对胰管结石的治疗有效,而且充分的胰液引流对于缓解腹痛症状、减少术后的胰腺炎、高淀粉酶m症的发乍有着重要的作用。     

经内镜乳头括约肌切开术后的肠胆反流和胰胆反流

经内镜乳头括约肌切开术（ endoscopic sphincterotomy,EST）是在ERCP诊断性技术的基础上发展起来的,是一种内镜下高频电切开十二指肠乳头及胆总管末端括约肌的治疗技术。EST经过近40年的临床应用和发展,已经成为胆总管结石、胆源性胰腺炎、急性梗阻性化脓性胆管炎及乳头括约肌功能障碍（sphincter of Oddi dysfunction,SOD）等胆胰疾病的内镜下标准治疗方式。但EST需部分或全部切开胆管或胰管括约肌,势必会带来Oddi括约肌结构和功能的损伤。     

内镜逆行胰胆管造影在胰管结石诊治中的临床价值

目的：探讨内镜逆行胰胆管造影（ERCP）在胰管结石（PDS）诊断与治疗中的价值。方法：回顾分析1998年1月－2000年12月本院经ERCP诊治的18例PDS患者的治疗方式和结果。结果：18例PDS患者临床上均以上腹痛为主要首发症状且合并慢性胰腺炎,其中1例合并胰腺癌。经B超检查,10例患者检出有PDS或胰管扩张;全部病例经ERCP检查后均明确显著有PDS和胰管扩张。经ERCP＋乳头括约肌切开术（EST）／胰管括约肌切开术（EPST）成功取石4例;行EPST＋体外震波碎石（ESWL）及ESWL＋胰管内支架引流（ERPD）者各1例,半年后复查时胰石消失：行ERPD者12例。3例患者置管后3个月内因伴主胰管多发、巨大结石和胰腺癌而接受手术治疗。18例患者经1－11个月的随访,腹痛近期（＜3个月）缓解率为88．9％,远期（＞3个月）缓解率为75．0％,体重、脂肪泻、胰腺内、外分泌功能不足表现有不同程度的改善。ERCP术后早期并发症主要为一过性高淀粉酶血症,支架阻塞是其晚期并发症。结论：ERCP能清晰显示结石的位置、大小、形态及数量,是诊断PDS的主要手段。经ERCP取石具有安全可靠、创伤小、疗效满意及患者易于接受等优点,在PDS的治疗中亦具有较大临床应用价值。     

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。     

Pancreatic ductal morphological pattern and dilatation in postoperative abdominal pain in patients with congenital choledochal cyst: an analysis of postoperative pancreatograms

BACKGROUND: Postoperative abdominal pain associated with pancreatitis has been reported as a pancreas-associated complication after total biliary excision. The aim of the present study was to determine pancreatic ductal patterns in the head of the pancreas and evaluate pancreatic ductal dilatation in patients presenting with postoperative abdominal pain after radical biliary excision for congenital choledochal cyst. METHODS: Postoperative endoscopic retrograde pancreatography (ERP) was performed in a total of 38 patients (27 female and 11 male) with a history of postoperative abdominal pain or an increase in serum and urinary amylase on laboratory analysis. Pancreatic ductal configuration and ductal dilatation were determined. RESULTS: Pancreatic configurations included the usual type (n = 20), ansa pancreatica type (n = 11), loop type (n = 5), and divisum type (n = 2). Dilatation of the pancreatic duct was observed in 34 patients. The common channel was dilated in 29 patients. Mild postoperative pancreatitis occurred in 4 patients in the long term. Protein plugs were observed in the dilated pancreatic duct. CONCLUSIONS: Pancreatic ductal morphological pattern and ductal dilatation, possibly caused by long-standing stagnation of the pancreatic juice, may be associated with postoperative abdominal pain and pancreatitis in congenital choledochal cyst.     

胰管内支架治疗慢性胰腺炎18例临床分析

目的　探讨慢性胰腺炎胰管内支架治疗的临床疗效。方法　取沈阳军区总医院 2 0 0 2 - 0 7～ 2 0 0 4 -17经临床、化验及检查明确诊断为慢性胰腺炎的 18例患者 ,分别接受胰管内支架治疗 ,术后观察随访临床症状及化验检查等指标变化情况。结果　所有患者胰管内支架置放成功 ,腹痛症状在术后 1个月内均基本缓解 ,腹痛缓解率 10 0 % ,消瘦、脂肪泻等症状得到改善 ,除 1例因有胰腺外分泌障碍血清淀粉酶下降慢外 ,其他患者血清淀粉酶均于术后 1～ 14d内降至正常 ,1例患者术后第 10天因支架阻塞更换支架。结论　慢性胰腺炎内镜下置放胰管内支架治疗是一种较安全、低创伤、低费用、见效快的首选方法 ,极具临床应用价值。     

An endoscopic pancreatic function test with synthetic porcine secretin for the evaluation of chronic abdominal pain and suspected chronic pancreatitis

BACKGROUND: Pancreatic function tests are the most reliable methods for the diagnosis or exclusion of chronic pancreatitis in patients without obvious radiologic changes, but they are cumbersome, time consuming, and unavailable in clinical practice. Synthetic porcine secretin, a 27 amino acid peptide identical to the biologic form, is available for exocrine function testing. This study examined the utility of a simple, newly developed, purely endoscopic pancreatic function test with synthetic porcine secretin. METHODS: Three groups of patients were studied: patients with chronic abdominal pain with and without risk factors for chronic pancreatitis, and patients with advanced chronic pancreatitis. All patients with abdominal pain had "pancreatic type" pain for greater than 6 months and negative radiographic imaging studies. All patients with chronic pancreatitis had advanced disease based on retrograde pancreatography and/or CT findings. Participants underwent the following protocol: (1) standard endoscopy to the descending duodenum with the patient under conscious sedation; (2) intravenous administration of secretin (0.2 microgram/kg); (3) endoscopic duodenal fluid collection at 0, 15, 30, 45, and 60 minutes after secretin injection; and (4) fluid analysis for bicarbonate concentration. RESULTS: Eighteen patients were studied (5 abdominal pain without risk factors, 7 abdominal pain with risk factors, and 6 advanced chronic pancreatitis). Median peak (interquartile range) bicarbonate concentrations in meq/L for each group were, respectively, 87 (6, range 84-108), 72 (10, range 68-90), and 35 (27, range 18-88). Median peak bicarbonate concentration values for the 3 groups are significantly different (p = 0.010; Kruskal-Wallis test). Bicarbonate secretion in patients with chronic pancreatitis was markedly reduced compared with that in patients with abdominal pain without risk factors (p = 0.038; the Fisher exact test). The secretory function curve for patients with abdominal pain with risk factors was markedly abnormal, resembling the attenuated secretory curve seen in patients with chronic pancreatitis. The test was safe and well tolerated. CONCLUSIONS: A simple endoscopic pancreatic function test with synthetic porcine secretin appears to distinguish patients with known chronic pancreatitis from those with chronic abdominal pain without chronic pancreatitis. This simple, practical endoscopic test can be performed during upper endoscopy and may decrease the need for invasive procedures in patients with abdominal pain and normal radiographic imaging studies.     

ENDOSCOPIC PANCREATIC SPHINCTEROTOMY PLUS LARGE‐BALLOON DILATION FOR REMOVAL OF A LARGE IMPACTED PANCREATIC DUCT STONE (WITH VIDEO)

Pancreatic duct stones are a common complication of chronic pancreatitis. We describe successful endoscopic removal of a large pancreatic duct stone using large‐balloon dilation in combination with pancreatic sphincterotomy. A 63‐year‐old woman was admitted for endoscopic treatment of acute on chronic pancreatitis with diabetes and epigastric pain with liver dysfunction due to a large impacted stone within the distal main pancreatic duct. Endoscopic pancreatic sphincterotomy was carried out using a wire‐guided pull‐type sphincterotome. Although we could carry out a relatively large incision, the stone could not be extracted. We therefore carried out papillary dilation using a large balloon (diameter 12 to 15 mm) to make room alongside the stone. A 10 × 20‐mm white pancreatic duct stone was extracted during the process of pulling a dilating balloon into the working channel of the endoscope. Eventually, the second stone was removed without any procedure‐related complication.     

Update on endoscopic management of main pancreatic duct stones in chronic calcific pancreatitis

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed.     

Pancreatic Ductal Morphological Pattern and Dilatation in Postoperative Abdominal Pain in Patients with Congenital Choledochal Cyst: An Analysis of Postoperative Pancreatograms

Background: Postoperative abdominal pain associated with pancreatitis has been reported as a pancreasassociated complication after total biliary excision. The aim of the present study was to determine pancreatic ductal patterns in the head of the pancreas and evaluate pancreatic ductal dilatation in patients presenting with postoperative abdominal pain after radical biliary excision for congenital choledochal cyst. Methods: Postoperative endoscopic retrograde pancreatography (ERP) was performed in a total of 38 patients (27 female and 11 male) with a history of postoperative abdominal pain or an increase in serum and urinary amylase on laboratory analysis. Pancreatic ductal configuration and ductal dilatation were determined. Results: Pancreatic configurations included the usual type (n = 20), ansa pancreatica type (n = 11), loop type (n = 5), and divisum type (n = 2). Dilatation of the pancreatic duct was observed in 34 patients. The common channel was dilated in 29 patients. Mild postoperative pancreatitis occurred in 4 patients in the long term. Protein plugs were observed in the dilated pancreatic duct. Conclusions: Pancreatic ductal morphological pattern and ductal dilatation, possibly caused by long-standing stagnation of the pancreatic juice, may be associated with postoperative abdominal pain and pancreatitis in congenital choledochal cyst.     

Transmural endoscopy drainage of pancreatic pseudocyst: long-term outcome

BACKGROUND: Pancreatic pseudocysts are relatively common complications of pancreatitis in adults. OBJECTIVE: To evaluate the long-term results from transmural endoscopic drainage and thus to establish its role in managing pancreatic pseudocyst. METHODS: Fourteen patients with pancreatic pseudocyst were studied. Their main complaint was pain in the upper levels of the abdomen. They presented palpable abdominal mass and underwent cystogastrostomy (n = 12) and cystoduodenostomy (n = 2), with clinical follow-up using abdominal computed tomography for up to 51 months. Retrograde endoscopic cholangiopancreatography was attempted in all cases to study the pancreatic duct and classify the cysts. RESULTS: There were 10 cases (71.5%) of chronic pancreatitis that had become acute through alcohol abuse and 4 (28.5%) that had become acute through biliary disorders. Both types of endoscopic drainage (cystogastrostomy and cystoduodenostomy) were effective. There was no change in the therapeutic management proposed. Migration of the orthesis into the pseudocyst at the time of insertion (two cases) was the principal complication, and these could be removed during the same operation, by means of a Dormia basket, with the aid of fluoroscopy. There has so far not been any mortality or relapse. The mean hospital stay was 3 days. CONCLUSION: Transmural endoscopic drainage was an efficacious form of therapy, presenting a low complication rate and no mortality, and only requiring a short stay in hospital.     

Chronic pancreatitis progressing from segmental lesions

BACKGROUND/AIMS: Chronic pancreatitis is histologically and functionally a progressive disease. To examine the natural history of chronic pancreatitis, we evaluated serial pancreatography in cases of chronic pancreatitis, focusing on the progression of diffuse-type chronic pancreatitis from the segmental type. METHODOLOGY: We reviewed 57 patients with chronic pancreatitis who had undergone endoscopic retrograde pancreatography on more than 2 occasions at intervals of at least 1 year. Cases of chronic pancreatitis were categorized as diffuse (n=37) and segmental (n=20) on the findings of initial endoscopic retrograde pancreatography. RESULTS: Twenty-three cases of diffuse-type chronic pancreatitis showed progression of pancreatic duct abnormalities. Segmental abnormalities of the main pancreatic duct at the body or tail of the pancreas spread to the head of the pancreas in 8 cases. Etiologies of these cases of chronic pancreatitis were alcoholic, in which patients continued drinking after initial endoscopic retrograde pancreatography. In 2 patients who underwent distal pancreatectomy, although segmental lesions showed typical histological findings of alcoholic chronic pancreatitis, appearances near the margin of these lesions were almost normal or indicated slight interlobular fibrosis. CONCLUSIONS: The pancreatic tail might represent the site of the initial lesion in some cases of alcoholic pancreatitis.     

La pancréatite chronique tropicale: une entité rare, à propos d’un cas et revue de la littérature

Tropical chronic pancreatitis (TCP) is a juvenile type of non alcoholic chronic pancreatitis. It is found mostly in developing countries, predominantly in India with a prevalence estimated at 0.02% of the general population but rarely in Africa. We are hereby reporting a case of tropical chronic pancreatitis in an 11 year old girl. The etiopathogenic factors are essentially malnutrition and genetic predispositions with the mutation of the N34S gene encoding for serine protease (SPINK1) in the homozygote or heterozygote state. Abdominal pain is the main symptom. Pancreatic calcifications are the constant morphological findings. The most feared complication is the occurrence of pancreatic cancer. Treatment consists of management of pain and eventual complications.     

Pancreatic Sphincterotomy and Pure Pancreatic Juice Collection for Treatment of Chronic Pancreatitis

Abstract: After our introduction of endoscopic pancreatic sphincterotomy for treatment of chronic pancreatitis in 1985, our interest has been focused to the value of pure pancreatic juice collection with or without pancreatic sphincterotomy for management of chronic pancreatitis. Through pancreatic sphincterotomy, pain relief was obtained in 13 out of 16 cases with moderate and marked chronic pancreatitis. After pancreatic sphincterotomy extraction of pancreatic calculi using basket forceps was done successfully in 2 of these cases, Spontaneous stone passage occured in the other 2. In pure pancreatic juice collection without pancreatic sphincterotomy, pain relief was seen in 6 out of 13 cases with mild and moderate chronic pancreatitis. The protein plug was simultaneously aspirated during the procedure in 3 cases. Recently, we have indicated in these patients both pancreatic sphincterotomy and pure pancreatic juice collection and noted pain relief was obtained in all of the 8 cases with this approach. With an improvement in the technology of pancreatic drainage, these endoscopic treatment modalities may be possibly useful to stop the progression of chronic pancreatitis.