Endoscopic biliary drainage

Endoscopic biliary drainage (EBD) has become an established method of relieving posthepatic jaundice. This study comprises 399 patients in whom 472 EBD procedures were performed during a 5 year period; 272 patients had malignant obstruction, 36 had a benign stricture, 79 had common duct stones and 12 patients had other benign conditions requiring drainage. A 7F double pigtail endoprosthesis was used in the majority of patients and was inserted with an Olympus JF-1T duodenoscope. Ninety-two per cent of the prostheses were correctly positioned, and 88 per cent of these functioned well with relief of symptoms. The 30-day mortality was 22 per cent and one-third of these deaths were due to the procedure, septicaemia being the dominant hazard. This was more marked if the obstruction was not relieved satisfactorily. Antibiotic cover was not used routinely and had not been prescribed in any of the fatal cases. This omission probably made a significant contribution to the septicaemia. Acute pancreatitis and haemorrhage were rare complications and both were probably related to the coincidental sphincterotomy. Prostheses intended for permanent relief of malignant obstruction remained patent for 2-3 months (median) with a wide range of 1-618 days. Survival among these patients is so short, that one or two EBD procedures will keep the majority of patients free from symptoms related to biliary obstruction, and only two patients needed more than three procedures. Fifty-one patients with pancreatic head carcinoma had EBD as a bypass before an intended operation. Only 16 patients actually had a resection. The median survival among the 51 patients was 106 days (compared with 59 days among 100 patients with a permanent prosthetic bypass). Only one patient with a very small periampullary carcinoma has survived for more than 3 years. Forty-seven patients are dead. Among the 51 patients in whom radical resection was intended two-thirds were actually treated by permanent surgical or prosthetic bypass.     

胆道梗阻经内镜引流术的体会

目的探讨经内镜胆道引流治疗胆道梗阻的可行性和疗效。方法回顾性分析我院2003年3月~2004年10月对96例胆道梗阻病例进行103例次内镜下胆道引流的诊治经过,分析其黄疸改善情况、支架通畅率及生存期。结果操作成功率为93.6%。良性胆道梗阻者总有效率为86.7%,恶性梗阻者为88.0%。ERBD组3、6、12月生存率分别为45.8%、33.3%、0;EMBE组分别为100%、76.9%、30.7%。EMBE支架通畅率与平均引流时间均优于ERBD者(P<0.01)。结论经内镜胆道引流治疗老年人良、恶性胆道梗阻疗效确切,可达到减黄、减压、延长生存期的目的。     

Endoscopic drainage of pancreatic pseudocysts

Summary Seventeen patients with pancreatic pseudocysts were treated by endoscopic drainage. In nine cases we performed endoscopic retrograde pancreatic drainage (ERPD) by inserting 7-Fr pigtail catheters via the papilla into the cyst or into the main pancreatic duct. In two cases transduodenal cystotomy (ECD) and in eight cases transgastral cystotomy (ECG) are performed by using coagulator and papillotome. In five cases of ECG an endoprosthesis was inserted into the cyst. In two cases combination therapy of ERPD and ECG was performed. All patients reported reduction of continuous pain and postprandial epigastralgia after placement of endoprosthesis. After disappearance of symptoms and abnormal endoscopic findings within a period of 2–12 months the drainage tubes were removed. In one case postoperative dislocation of the prosthesis was observed; no serious complication was not encountered. The period of observation varied from 5 to 40 months. Two patients are presently under treatment with endoprostheses. Endoscopic drainage yielded good results in the treatment of pancreatic pseudocysts.     

Endoscopic biliary drainage in malignant bile duct obstruction

During a four-year period endoscopic biliary drainage (EBD)--preoperative in 25 and permanent in 45 patients--was successfully established without sphincterotomy in 70 out of 89 referred patients (79%) with malignant bile duct obstruction. 51 of the patients had internal stents and 19 external naso-biliary tubes. There was no procedure-related mortality or severe complications such as perforation or bleeding. One patient, however, got a moderate pancreatitis after stent drainage (1%). In the early drainage period (before operation or discharge) the cholangitis rate was 10%, and during the late period (after discharge) it rose to 27% of the patients. 68 of all 70 patients (94%) had a reduction in S-bilirubin concomitant with clinical improvement and 27 of the 45 patients (59%) with permanent drainage became unjaundiced. Recurrent or increasing jaundice occurred, however, in half the number of these patients (23/45) after an average of 89 days; twelve of them had a temporary regression of jaundice after exchange of stents in spite of advanced disease. The use of multiple stents did not reduce the risk of recurrent jaundice or of cholangitis. It is concluded that EBD inserted without sphincterotomy is a safe and efficient non-surgical alternative in the treatment of malignant bile duct obstruction.     

Endoscopic drainage of pancreatic pseudocysts in children

Background/Purpose

Symptomatic pancreatic pseudocysts have traditionally been managed with surgical, percutaneous, and, more recently, endoscopic drainage. Although the role of the latter is well defined in the adult population, its utility in children needs to be clarified. The authors reviewed their experience with endoscopic drainage of pancreatic pseudocyst (EDPP).

Methods

A retrospective chart review was conducted, and relevant demographic and clinical data were obtained for all patients with pancreatic pseudocysts managed with endoscopic drainage in the period from 1997 through 2001, inclusive.

Results

Three children had successful endoscopic drainage of pancreatic pseudocysts. They were 9, 13, and 14 years old, and were all boys. The etiology of the pancreatitis was idiopathic related to anomalous pancreatic divisum ducts in the first 2 and azathioprine induced in the latter. The first 2 patients had endoscopic transpapillary drainage, whereas the third had an endoscopic cystduodenostomy. All patients had complete resolution of the pseudocyst clinically and radiologically after follow-up periods of 3, 31, and 21 months, respectively. The first needed a subsequent pancreaticojejunostomy for persistent symptoms related to chronic pancreatitis. A successful endoscopic drainage of a posttraumatic pancreatic pseudocyst has previously been reported from our institution.

Conclusions

This experience would indicate that endoscopic drainage of pancreatic pseudocyst is an effective and relatively safe option of managing this problem in children.     

Endoscopic drainage for pancreatic pseudocyst in children

The authors report here the results of endoscopic cystogastrostomy performed on 3 children aged 11, 3, and 2.5 years with nonresolving pancreatic pseudocyst (PP) of 12, 9.5, and 7 cm in diameter. The etiology of PP was abdominal trauma in 2 and idiopathic acute pancreatitis in 1 case. Ultrasound and computed tomography scans confirmed the diagnosis and suitability for gastric drainage. After the puncture of cyst, a double pig-tail stent was placed for the permanent drainage of cystogastrostomy. Complete regression was confirmed by follow-up ultrasonography at 8, 6, and 7 weeks, respectively. There were no procedure-related complications, nor was there a recurrence of cyst during the 2 years of follow-up. This report suggests that children with nonresolving PP, that are anatomically accessible, can be treated successfully and safely by endoscopic drainage.     

Endoscopic drainage of postnecrotic pancreatic cysts

Results of endoscopic drainage of postnecrotic pancreatic cysts in 12 patients were analyzed. Possibilities of the method are limited by location of the cysts in pancreatic head and corpus. Clear visualization of the cysts on the gastric or duodenal wall is the main condition for this procedures feasibility. Surgery must be started with point burning in the wall that is safe and permits the surgeon to stop procedure when cyst is not found. When the cyst is drained through the duodenal lumen, it is necessary to visualize Veter's papilla and perform the procedure below it to prevent lesion of a distal part of the common bile duct. Section of the cyst with wall thickness to 3-4 mm from the duodenal lumen and the ikness to 6-7 mm from the stomach is safe enough. Endoscopic procedures are not indicated in hypertension in the bile ducts.     

内镜下胆管引流术治疗恶性胆道梗阻

目的 探讨经内镜逆行胰胆管造影术（ERCP）加鼻胆管引流（ENBD）、塑料支架置入引流（ERBD）或金属支架置入引流（EMBE）治疗恶性胆道梗阻的疗效比较。方法 136例恶性胆道梗阻患者,分为：ENBD组、ERBD组和EMBE组,观察各组疗效、支架通畅时间及生存时间。结果 三组总体置管成功率95.4%;治疗1周内肝功能及临床症状较术前明显好转,引流总体有效率为91.0%;并发症发生率为5.4%。ERBD组平均通畅时间（88.0±21.9）d,EMBE组平均通畅时间（200.6±46.6）d,两组差异有统计学意义（P＜0.0 1）;ERBD组平均生存时间（215.4±111.3）d,EMBE组平均生存时间（271.8±100.8）d,两组差异无统计学意义（P＞0.05）。结论 经ERCP对恶性胆道梗阻患者给予鼻胆管引流及支架置入是一种安全有效的姑息性治疗方法。     

经内镜胆道引流术在老年良恶性胆道梗阻中的应用价值

我院自2003年3月至2004年6月对68例住院的老年良恶性胆道梗阻病人成功地进行了8l例次的胆道引流,现报告如下。     

Endoscopic retrograde biliary drainage for posttraumatic intrapancreatic biliary stenosis in a child

Bile duct injury caused by blunt abdominal trauma is rare and usually associated with liver parenchymal injury. The authors report the case of a 15-year-old boy with jaundice caused by a posttraumatic isolated common bile duct stricture without associated liver injury. Endoscopic retrograde biliary drainage (ERBD) was performed and the jaundice disappeared 2 months after drainage commenced. Although restenosis and mild jaundice was revealed 2 years after injury, ERBD can be a first-line minimally invasive treatment of pediatric posttraumatic biliary stricture.     

Endoscopic ultrasound-guided transduodenal placement of a fully covered metal stent for palliative biliary drainage in patients with malignant biliary obstruction

Background  

Endoscopic ultrasound (EUS)-guided biliary drainage (EUSBD) has been described as a viable alternative to percutaneous transhepatic cholangiography (PTC) in patients in whom ERCP has been unsuccessful. The purpose of our study was to assess the utility of EUSBD using a newly released, fully covered, self-expanding, biliary metal stent (SEMS) for palliation in patients with an obstructing malignant biliary stricture.     

超声内镜引导下穿刺引流治疗胰腺假性囊肿

目的探讨超声内镜引导下经胃肠壁穿刺置管引流治疗胰腺假性囊肿的疗效及并发症。方法选择2004年8月至2011年3月胰腺假性囊肿患者28例,首先使用线阵型超声内镜扫查,明确病变部位后选择合适穿刺点,导丝沿穿刺针道进入囊肿,沿导丝放置双猪尾硅胶支架1～3支。术后定期随访,囊肿消失后拔除支架。结果本组28例患者,穿刺引流成功25例,成功率为89．3％,其中经胃19例,经十二指肠6例。发生并发症3例,支架移位、出血、感染各1例。随访8—34个月,19例假性囊肿完全消失,6例腹痛症状消失、囊肿明显缩小、但持续存在2年以上,所有患者均未见假性囊肿复发。结论超声内镜引导下经胃肠壁穿刺置管引流术是治疗胰腺假性囊肿的较好方法之一,其疗效确切,并发症少。     

内镜下胆道支架置入术在高位胆管恶性梗阻中的临床总结

［摘要］ 目的 探讨经内镜放置胆道支架治疗高位胆管恶性梗阻的疗效及影响因素。方法 回顾性分析2008年8月～2014年4月168例高位胆管恶性梗阻行内镜胆道支架置入术的成功率、有效引流率、并发症发生率与30天死亡率、支架通畅时间及生存时间。结果 168例患者中148例成功通过ERCP置入塑料或金属支架,其中13例联合PTCD途径反向导丝与ERCP对接的会师技术置入,成功率88.1%;另外20例行两种处理方法仍未能成功,改行PTCD外引流;有效引流率为91.9%,早期并发症发生率为23.0%,总的支架有效时间59天,总的中位生存时间248天。结论 高位胆管恶性梗阻的内镜治疗应根据个体化原则选择不同的治疗方案;内镜治疗过程中进行有效的操作,减少并发症,是临床内镜医生应重视的问题。     

经内镜鼻胆管引流术治疗术后胆漏

目的　总结经内镜鼻胆管引流术治疗术后胆漏的经验。 方法　对６ 例经内镜鼻胆管引流术治疗的术后胆漏病人进行回顾性分析。 结果　６ 例术后胆漏病人中５ 例愈合,占８３ ％ 。胆漏愈合时间为１８ ～２９ 天,平均２３ 天。 结论　经内镜鼻胆管引流术是治疗术后胆漏的安全有效的非手术疗法。     

胆胰疾病的内镜超声治疗

在过去的20年中,内镜超声(EUS)已从一种单纯的临床诊断方法发展为集诊断与介入治疗于一身的临床手段。EUS对胆胰疾病具有较高的诊断价值,其所具有的高分辨率图像,可以清晰地显示胆总管和胰腺的疾病,并可以在EUS的引导下,通过胃肠道对相应的病变以最短的距离进行精确的定位穿刺。正是EUS的这些独特优势,使其在胆胰疾病的治疗中起着重要作用。在EUS的引导下细针穿刺已广泛应用于胆胰疾病的引流治疗和注射治疗[1]。1引流治疗1.1EUS引导下胰胆管造影和引流EUS引导下胰胆管造影技术(endosonography guidedcholangiopancreatography,EGC…     

Endoscopic diagnosis and management of biliary and pancreatic disease

The diagnosis and management of pancreatic and biliary tract disease require the closely coordinated efforts of the surgeon, radiologist, gastroenterologist, endoscopist and pathologist. Modern surgery needs a precise data base to meet the demands for speed, accuracy and a successful outcome. The sequential approach to the differential diagnosis of jaundice, with its emphasis on “noninvasive” diagnostic tests⁶² and lengthy evaluation⁶³ has been preempted by precise positive diagnostic studies. Our approach to the patient suspected of pancreatic or biliary tract disease has been revolutionized by developments in fiberoptic endoscopy and radiology, culminating in the techniques of ERCP, endoscopic biliary surgery, PTC and the removal of common duct stones through the T-tube tract. The therapeutic value of endoscopic biliary surgery and T-tube tract extraction of retained common duct stones as alternatives to secondary biliary tract surgery is clearly established. We are aware of the potential for dissolving cholesterol gallstones with oral medication or direct injection of solvents into the biliary tree. These advances will be clinically available shortly.Preoperative diagnosis of periampullary cancer permits the patient's referral to a specialized center that promises a lower operative mortality and the best chance for cure.⁶⁴ The frustrations and disappointments of operations for pancreatic cancer can be reduced by accurate preoperative diagnosis and palliative bypass surgery.^{[65.] and [66.]}The influence on surgical options of endoscopic biliary surgery and extraction or dissolution of stones through the T-tube tract is not yet clear. The pressure on the surgeon to clear the biliary tree at operation is lessened, since the mortality increase caused by adding common duct exploration (2.4%)⁶⁷ to elective cholecystectomy (0.6%) in the difficult case is greater than the hazard of endoscopic biliary surgery for choledocholithiasis (1.1%).⁶⁶ In patients with acute cholecystitis, preoperative definition of cystic duct patency and anatomy may reduce the hazard of cholecystectomy alone (2.4%) and allow the surgeon to exercise options that reduce the risk of the added common duct exploration (8%).⁶⁷ Cholangiographic studies performed by PTC or ERCP techniques may obviate the need for some common duct explorations. Initial endoscopic surgery can be used to control cholangitis by removing common duct stones and establishing biliary drainage or to facilitate clearing the biliary tree at operation. Alternatively, in the difficult operation, biliary drainage may be established by placing a T-tube in the common bile duct and extraction or dissolution techniques may be used postoperatively, when the patient is stable.^{[68.] and [69.]}These new concepts, therapies and techniques force us to reevaluate the indications for “exploratory laparotomy”, particularly in the elderly.^{[68.] and [72.]} More important, they herald a new era in surgery of the biliary tract and pancreas, when preoperative appreciation of pathologic anatomy and normal variants, with use of endoscopic and radiologic techniques, will produce the consistent yield of excellence desired by all.