Endoscopic papillary balloon dilation: Revival of the old technique

Radiologists first described the removal of bile duct stones using balloon dilation in the early 1980s.Recently,there has been renewed interest in endoscopic balloon dilation with a small balloon to avoid the complications of endoscopic sphincterotomy(EST)in young patients undergoing laparoscopic cholecystectomy.However,there is a disparity in using endoscopic balloon papillary dilation(EPBD)between the East and the West,depending on the origin of the studies.In the early 2000s,EST followed by endoscopic balloon dilation with a large balloon was introduced to treat large or difficult biliary stones.Endoscopic balloon dilation with a large balloon has generally been recognized as an effective and safe method,unlike EPBD.However,fatal complications have occurred in patients with endoscopic papillary large balloon dilation(EPLBD).The safety of endoscopic balloon dilation is still a debatable issue.Moreover,guidelines of indications and techniques have not been established in performing endoscopic balloon dilation with a small balloon or a large balloon.In this article,we discuss the issue of conventional and large balloon endoscopic dilation.We also suggest the indications and optimal techniques of EPBD and EPLBD.     

Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography

Endoscopic ultrasonography （EUS）-guided biliary drainage was performed for treatment of patients who have obstructive jaundice in cases of failed endoscopic retrograde cholangiopancreatography （ERCP）. In the present study, we introduced the feasibility and outcome of EUS-guided choledochoduodenostomy in four patients who failed in ERCR We performed the procedure in 2 papilla of Vater, including one resectable case, and 2 cases of cancer of the head of pancreas. Using a curved linear array echoendoscope, a 19 G needle or a needle knife was punctured transduodenally into the bile duct under EUS visualization. Using a biliary catheter for dilation, or papillary balloon dilator, a 7-Fr plastic stent was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. In 3 （75%） of 4 cases, an indwelling plastic stent was placed, and in one case in which the stent could not be advanced into the bile duct, a naso-biliary drainage tube was placed instead. In all cases, the obstructive jaundice rapidly improved after the procedure. Focal peritonitis and bleeding not requiring blood transfusion was seen in one case. In this case, pancreatoduodenectomy was performed and the surgical findings revealed severe adhesion around the choledochoduodenostomy site. Although further studies and development of devices are mandatory, EUS-guided choledochoduodenostomy appears to be an effective alternative to ERCP in selected cases.     

Role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma

AIM:To study the role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma.METHODS:In this study the authors retrospectively analyzed clinical records of patients with periampullary tumors diagnosed by ampullary biopsy taken after needle knife papillotomy in whom surface ampullary biopsies were non contributory.RESULTS:Between January 2008 and December 2010,38 patients with periampullary tumors were seen by us and initial side viewing endoscopy with surface biopsy from the papilla was positive for malignancy in 25 patients.Thirteen patients with a negative surface biopsy for malignancy underwent a repeat ampullary biopsy following needle knife papillotomy.There were 8(61.5%)males and 5(38.5%)females.The most common presenting symptom was jaundice(100%),followed by fever(46.2%),melena(38.5%),abdominal pain(30.8%)and weight loss(30.8%).All the patients had hyperbilirubinemia with a mean ± SD serum bilirubin of(11.2 ± 1.9)mg/dL(normal value <1 mg%)and the mean ± SD serum alkaline phosphatase was(288.0 ± 94.3)IU/L(normal value < 129 IU/L).Serum CA 19.9 level estimation was done in 11 patients;it was elevated(cut off value > 70.5 IU/L)in all of them with a median of 1200 IU/L(inter quartile range 274-3500).Side viewing endoscopy showed a bulky papilla in all of them.Adequate tissue was obtained in all of the 13 patients for histological evaluation;12 of the 13 patients were reported to have adenocarcinoma while one patient had adenoma.There were no complications from the needle knife papillotomy in any of the patients.CONCLUSION:Needle knife assisted ampullary biopsy appears to be a safe and effective diagnostic modality for periampullary carcinoma.     

Comparative analysis of endoscopic precut conventional and needle knife sphincterotomy

AIM:To compare the efficacy,complications and postprocedural hyperamylasemia in endoscopic pre-cut conventional and needle knife sphincterotomie.METHODS:We performed a retrospective analysis of two pre-cut sphincterotomy(PS) techniques,pre-cut conventional sphincterotomy(PCS),and pre-cut needle knife(PNK).The study included 143 patients;the classic technique was used in 59 patients(41.3%),and the needle knife technique was used in 84 patients(58.7%).We analyzed the efficacy of bile duct access,the need for a two-step procedure,the rates of complications and hyperamylasemia 4 h after the procedure,"endoscopic bleeding" and the need for bleeding control.Furthermore,to assess whether the anatomy of the Vater’s papilla,indications for the procedure or the need for additional procedures could inform the choice of the PS method,we evaluated the additive hyperamylasemia risk 4 h after the procedure with respect to the above mentioned variables.RESULTS:The bile duct access efficacy with PNK and PCS was 100% and 96.6%,respectively,and the difference between the two groups was not significant(P = 0.06).However,the needle knife technique required two-step access significantly more often,in 48.8% vs8.5% of cases(P < 0.0001).The only complication noted was post-ercp pancreatitis(PEP),which was observed in 4/84(4.8%) and 2/59(3.4%) patients submitted to PNK and PSC,respectively;the difference between the two procedures was not significant(P = 0.98).An analysis of other consequences of the techniques yielded the following results in the PNK and PCS groups:hyperamylasemia 4 h after the procedure > 80 U/L,41/84 vs 23/59(P = 0.32);hyperamylasemia 4 h after the procedure > 240 U/L,19/84 vs 11/59(P = 0.71);pancreatic pain,13/84 vs 7/59(P = 0.71);endoscopic bleeding,10/84 vs 8/59(P = 0.97);and the need for bleeding control,10/84 vs 7/59(P = 0.79).In the next part of the study,we analyzed the influence of the method chosen on the risk of hyperamylasemia with respect to an indication for endoscopic retrograde cholangiopancr     

Stone extraction balloon-guided repeat self-expanding metal stent placement

Self-expanding metal stent (SEMS) placement offers safe and effective palliation in patients with upper gastrointestinal obstruction due to a malignancy. Well described complications of SEMS placement include tumor growth, obstruction, and stent migration. SEMS occlusions are treated by SEMS redeployment, argon plasma coagulation application, balloon dilation, and surgical bypass. At our center, we usually place the second SEMS into the first SEMS if there is complete occlusion by the tumor. We discovered a...     

Stenosis in gastric bypass: Endoscopic management

Gastric bypass is a treatment option for morbid obesity. Stenosis of the gastrojejunal anastomosis is a recognized complication. The pathophysiological mechanisms involved in the formation of stenosis are not well known. Gastrojejunal strictures can be classified based on time of onset, mechanism of formation, and endoscopic aspect. Diagnosis is usually obtained by endoscopy. The two main treatment alternatives for stomal stricture are: endoscopic dilatation (balloon or bouginage) and surgical revision (open or laparoscopic). Both techniques of dilation [through-the-scope (TTS) balloon dilators, Bougienage dilators] are considered safe, effective, and do not require hospitalization. The optimal technique for dilation of stomal strictures remains to be determined, but many authors prefer the use of TTS balloon catheters. Most patients can be successfully treated with 1 or 2 sessions. The need for reconstructive surgery of a stomal stricture is extremely rare.     

Sphincterotomy by triple lumen needle knife using guide wire in patients with Billroth Ⅱ gastrectomy

AIM:To investigate the usefulness of a guide wire and triple lumen needle knife for removing stones in BillrothⅡ(B-Ⅱ)gastrectomy patients.METHODS:Endoscopic sphincterotomy in patients with B-Ⅱgastrectomy is challenging.We used a new guide wire technique involving sphincterotomy by triple lumen needle knife through a forward-viewing endoscopy.This technique was performed in nine patients between August 2010 and June 2012.Sphincterotomy as described above was performed.Adequate sphincterotomy,successful stone removal,and complications were investigated prospectively.RESULTS:Sphincterotomy by triple lumen needle knife using guide wire was successful in all nine patients.Sphincterotomy started towards the 4-5 o’clock direction and continued to the upper margin of the papillary roof.Complete stone removal in one session was achieved in all patients.There were no procedure related complications,such as bleeding,pancreatitis,or perforation.CONCLUSION:In patients with B-Ⅱgastrectomy,guide wire using sphincterotomy by triple lumen needle knife through a forward-viewing endoscopy seems to be an effective and safe procedure for the removal of common bile duct stones.     

两种指引导丝操作技术治疗冠状动脉慢性闭塞性病变患者的疗效及安全性

目的 观察应用以球囊做支撑用普通指引导丝(中等硬度3～6 g)(球囊支撑组)及单独使用指引导丝(普通组)治疗冠状动脉(冠脉)慢性闭塞性病变(CTO)的可行性、安全性和效果.方法 经冠脉造影检查发现有CTO病变并行经皮冠脉介入(PCI)治疗的患者108例(陈旧性心肌梗死59例,不稳定型心绞痛22例,稳定型心绞痛27例).普组组65例,球囊支撑组43例,比较两组患者手术成功率、并发症发生率等.结果 108例CTO病变88例(81.5%)获得成功,20例(18.5%)未成功,普通组与球囊支撑组分别成功52例(80.0%)与36例(83.7%),两组比较差异无统计学意义 (P＞0.05).并发症普通组7例(10.8%)高于球囊支撑组的1例(2.3%)(P＜0.05).术中无死亡病例,术后住院期间无主要不良心脏事件(MACE)发生.结论 以球囊支撑普通指引导丝做CTO 安全方便.

Abstract：

Objective To observe the feasibility, safety and efficacy of percutaneous coronary intervention (PCI) for treatment of chronic total occlusions (CTO)by only the guidewire versus by the guidewire dependent on balloon. Methods The 108 patients with CTO confirmed by coronary angiography and treated with PCI from March 2009 to March 2011 were enrolled in this study, including 59 cases with old myocardial infarction, 22 unstable angina cases and 27 stable angina cases. The clinical data, outcomes of PCI, perioperative complications and incidence of major adverse cardiac events (MACEs) during follow-up were retrospectively analyzed between group A (only by the guide wire) and group B (by guide wire dependent on balloon). Results The 88 of 108 patients (81.5%) got successful operations. The success rate of CTO was a little higher in group B than in group A [80.0%(52/65) vs. 83.7%(36/43), P＞0.05]. The rate of total complications was more in group A than in group B [10.8%(7/65) vs. 2.3%(1/43), P＜0.05]. No death occurred during operation, no MACE occurred after operation in hospital and no patients underwent emergency coronary artery bypass graft (CABG) in the two groups. Conclusions The PCI for treatment of CTO used by the guidewire dependent on balloon shows a safety and effecary.     

Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy

AIM： TO introduce a new method： small endoscopic sphincterotomy （ES） combined with endoscopic papillary large balloon dilation （SES ＋ EPLBD） to treat patients with large biliary stones.
METHODS： Retrieval of large biliary stones was performed in 88 patients. Mean stone size was 14 ± 3 mm and mean number of stones was 2.5 ± 3.5. Firstly, ES with a small incision was performed. Next, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket.
RESULTS： Stone retrieval was successful in all cases except one cystic duct stone case without the need to crush large stones. Mean procedure time was 30 ± 5 min. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations. One instance of post-procedural pancreatitis （1%） occurred.
CONCLUSION： SES ＋ EPLBD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy.     

Endoscopic papillary large balloon dilation for removal of bile duct stones

AIM:To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation(EPLBD)for bile duct stones in a multicenter prospective study.METHODS:Lithotomy by EPLBD was conducted in 124patients with bile duct stones≥13 mm in size or with three or more bile duct stones≥10 mm.After endoscopic sphincterotomy,the papilla was dilated using balloons 12-20 mm in diameter fitting the bile duct diameter.RESULTS:The success rate of first-time lithotomy was 86.3%(107/124)and the final lithotomy success rate was 100%(124/124).Lithotripsy was needed in10 of the 124(13.6%)patients.Adverse events due to the treatment procedure occurred in 6(4.8%)patients,all of which were mild.Performing large balloon dilation after endoscopic sphincterotomy in patients with large stones or multiple stones in the bile duct is considered to ensure the safety of treatment and to reduce the need for lithotripsy.CONCLUSION:It is suggested that treatment by EPLBD for large bile duct stones may be safe and useful.     

球囊扩张疗法治疗良性气道狭窄临床应用

临床研究显示,电凝治疗气道瘢痕病变时可导致对气道更严重、更大范围的损伤,从而引起再狭窄并最终导致治疗失败。根据良性气道瘢痕狭窄的不同情况,采用单纯球囊扩张治疗,或采用针形电刀和(或)冷冻对瘢痕组织进行先期松解,然后在辅以球囊扩张,是目前治疗良性瘢痕增生性气道狭窄疗效相对可靠且并发症相对较少的方法。经合理恰当的球囊扩张治疗,其疗效在80%以上,值得在临床中加以推广。     

支气管镜介入技术治疗结核性瘢痕性中心气道狭窄的对照研究

目的 探讨当前我国常用的支气管镜介入技术治疗结核性瘢痕性中心气道狭窄的安全性和有效性,探索针对该类患者的最佳治疗方法.方法 结核性瘢痕性中心气道狭窄患者85例,根据采用的不同介入治疗方法将患者分为4组:A组给予单纯球囊扩张;B组给予.球囊扩张联合冷冻;C组给予球囊扩张联合针形电刀;D组给予球囊扩张联合局部应用丝裂霉素.每例患者给予每周1次的介入治疗,连续4周,初次治疗后于第5、9、13、21、25、29周进行疗效评价.评价指标:气促评分、KPS评分、狭窄程度、狭窄长度以及治疗有效率和临床受益率.结果 各组患者治疗后气促评分、KPS评分、狭窄程度均显著改善,组间差异无统计学意义.除球囊扩张联合冷冻组治疗有效率较低(82.4％)外,其余3组患者有效率和临床受益率均在90％以上,4组间比较差异无统计学意义.结论 上述方法均能有效治疗结核性瘢痕性气道狭窄,组间差异无统计学意义.出于减少治疗程序,减轻费用,在上述4种方法中,我们推荐单独球囊扩张治疗结核性瘢痕性中心气道狭窄.     

难治性中心气道狭窄的综合介入治疗

目的 评价5种介入技术联合应用在难治性中心气道狭窄治疗中的价值.方法 2001年1月至2008年6月第四军医大学唐都医院呼吸科收住的138例难治性中心气道狭窄患者,经临床、肺功能评价后,根据狭窄的病因、类型、部位、程度、长度以及狭窄远端肺组织和气道功能的不同,选择高频电力、氩等离子体凝固(APC)、冷冻、支架置入和高压球囊扩张等5种技术中的2种(包括2种)以上方法.138例中高频电刀+APC治疗42例,高频电刀+冷冻+APC治疗54例,高频电刀+冷冻+APC+支架置入治疗29例,冷冻+APC+高压球囊扩张治疗13例.达到理想效果1个月后评价气道开放、近期疗效和肺功能改善情况.结果 138例患者近期总有效率为100%,气道直径术前为(2.6±1.5)mm,术后为(6.2±1.7)mm;气促评分由术前的(2.4±0.8)减少到术后的(0.7 4±0.6).FEV_1由术前的(1.8±0.6)%上升到术后的(3.1±0.7)%.23例良性病变(包括4例良性肿瘤,15例结核性狭窄和4例其他肉芽肿狭窄)的患者,3个月随访有5例发生再狭窄需要介入治疗,有效率为78.3%(18/23),6个月随访有3例再狭窄需要介入治疗,有效率为86.9%(20/23),12个月随访23例患者均未见明显狭窄.恶性肿瘤狭窄患者未进行远期随访.结论 高频电刀、APC、冷冻、支架置入和高压球囊扩张等5种介入技术联合应用,对难治性中心气道狭窄有较好的效果,该方法并发症少,安令可行,值得临床推广应用.     

40例主气道狭窄患者诊治体会

目的 探讨主气道狭窄患者的病因及选择适当的治疗方式.方法 收集吉林大学第二医院40例主气道狭窄患者的病因,并观察其选择不同治疗方式的效果.结果 40例主气道狭窄患者中,总气管肿物15例(37.5％),气管内膜结核11例(27.5％),气管插管及切开后9例(22 5％),气管黏膜炎症3例(7.5％),气管淀粉样变1例(2.5％),食管癌术后放疗1例(2.5％).在治疗方式的选择上,除外保守治疗(19例),选择气管切开9例,球囊扩张6例,T管置入5例,冷冻治疗7例,氩气刀治疗6例.接受气管切开、球囊扩张、T管置入、冷冻治疗及氩气刀治疗的患者呼吸困难等症状均得到明显减轻.结论 气管插管及切开造成主气道狭窄的发病率有所上升.患者通过气管切开可迅速缓解症状,联合介入技术及T管置入术已成为除外外科手术治疗的有效方式.     

良性气道狭窄的处理方法

良性气道狭窄种类繁多,当病变累及范围过大或患者心肺功能差时,不能通过外科手术方式解除梗阻.内镜技术的进展为气道阻塞性疾病患者提供了大量的姑息性甚至治愈的方法,包括球囊扩张、电灼烧、激光消融、氩等离子体凝固技术、冷冻、腔内放疗、光动力治疗、支架植入等.但是没有随机试验比较不同治疗方法的效果,本文主要介绍几种良性气道狭窄性疾病及其处理方法.     

315例瘢痕狭窄型支气管结核的临床分析

目的通过对瘢痕狭窄型支气管结核的临床资料分析,提高临床医生对该类型支气管结核的认识。方法回顾2013年4月至2015年10月在我科呼吸内镜中心进行诊治的315例瘢痕狭窄型支气管结核患者的临床资料,分析其形成因素、病变特点、治疗方法以及愈后。结果 315例患者共进行镜下治疗923例次,涉及的介入治疗方法包括氩气刀、电刀、冷冻、高压球囊扩张等;61.0%患者进行2次及以上治疗,行5次以上治疗的患者病变多为混合型狭窄;多部位狭窄例数占总例数的49.8%,位置以左主支气管最多,段及段以下支气管以左上叶固有支最多;瘢痕狭窄形成后介入治疗方法以球囊扩张为主,扩张比例最高的为左肺下叶;狭窄形成因素主要为结核本身造成的支气管破坏,而非介入干预;早期介入治疗干预患者总体愈后良好。结论瘢痕狭窄型支气管结核为支气管结核常见的类型,常发生于其他类型支气管结核治疗修复过程中,高压球囊扩张为主要的治疗方法,早期治疗有利于患者的长期愈后。     

球囊扩张术治疗结核性气道狭窄的疗效评价

目的探讨球囊扩张术治疗结核性气道狭窄的价值。方法15例结核性气管和支气管狭窄病人,经临床、肺功能评价后,在透视下经纤维支气管镜进行气道球囊扩张术,每周扩张1次,连续3次,多叶狭窄病例采用分段扩张法,评价气道开放、近期疗效和肺功能改善情况。结果15例病人共扩张50次,平均3．3次,气道开放为90．6％,气道直径在扩张前后有显著性差异(t=6．783 0,P＜0．05),扩张后肺功能有明显的改善(t=5．152 7,P＜0．05);6个月内再狭窄率为18％,4例支气管狭窄合用支架。结论球囊扩张术对以纤维疤痕为主的气道狭窄疗效好,以肉芽增生为主的气道狭窄应多次扩张,必要时并用其他手段。球囊扩张术治疗结核性气道狭窄是气道开放、改善肺功能的较好介入手段。     

经支气管镜氩气刀治疗气道狭窄临床观察

目的 探讨经支气管镜氩气刀治疗在气道狭窄的作用及安全性评价.方法 对140 例确诊为中心气道狭窄的患者,在积极治疗原发病的同时,经支气管镜引导进行氩离子凝固术APC.根据狭窄再通和气促评分情况评价疗效.结果 经支气管镜介入治疗1 个月后评价疗效.完全有效62 例(44.3%),部分有效55例(39.3 %),轻度有效2...     

经支气管镜球囊扩张术治疗良性中心气道狭窄临床分析

目的探讨经支气管镜球囊扩张技术治疗良性中心气道狭窄的操作方法、安全性及有效性。 方法选择2014年6月至2018年6月达州市中心医院呼吸内科收治的良性中心气道狭窄患者67例,其中结核性狭窄61例,气管损伤性狭窄6例,对不同原因导致的气道良性狭窄患者进行球囊扩张治疗,并必要时联合其他介入治疗措施如冷冻治疗等。治疗结束后对气促评分、KPS评分、肺功能(FEV₁)、气管狭窄程度和并发症发生情况进行评价。 结果所有患者均在气管镜直视下进行球囊扩张治疗,同时进行冷冻治疗。67例患者中,共进行球囊扩张治疗324次。经过球囊扩张治疗后,短期观察狭窄段支气管均有内径增大,气促评分增加,症状缓解。对球囊扩张后气道扩宽的瘢痕狭窄患者随访观察,有18例气道扩宽后再次发生瘢痕挛缩,发生再次狭窄。所有患者中,扩张治疗出现胸痛12例,黏膜少许撕裂2例,无严重不良反应发生。 结论良性中心气道狭窄支气管球囊扩张治疗,近期疗效良好,远期疗效有待进一步评估。     

小儿食道化学性碱烧伤狭窄的内镜下气囊扩张治疗分析

目的探讨新疆地区小儿食道化学性烧伤狭窄的特点和内窥镜下气囊扩张治疗的安全性及临床价值。 方法收集2009年1月至2017年10月,新疆维吾尔自治区人民医院20例食道化学碱烧伤狭窄的患儿术前通过消化道造影及胃镜检查诊断的临床资料,本组患者均采用胃镜下气囊扩张食道术。 结果本组患者均胃镜下气囊扩张手术成功,食道穿孔0例,死亡0例,17例（85%）扩张术后再次出现进食困难及呕吐等食道狭窄症状,扩张治疗2~12次,平均3.7次／例,3例（15%）第1次扩张术后治愈。 结论化学腐蚀剂灼伤粘膜及肌层,碱性液可渗透食道全层,肌层受损,出现瘢痕狭窄,严重者出现完全梗阻。本组食道狭窄的患儿均选用胃镜下气囊扩张术,直视下进行操作是安全,无辐射性,治疗有效满意。