ERCP update: diagnostic and therapeutic applications.

Endoscopic retograde cholangiopancreatography (ERCP) is currently utilized to evaluate jaundice, both intra- and extrahepatic, and can differentiate between these by demonstrating specific anatomic lesions. ERCP is definitive in the evaluation of gallbladder disease when other modalities are indefinite. For the first time outside the operating room, the pancreatic duct can be opacified by ERCP. The newest application of ERCP, endoscopic papillotomy (EP), has revolutionized the treatment of common bile duct gallstones and stenosis of the duct, offering a safe and effective alternative to repeated surgery, especially in those patients at risk. Because of these diverse and effective applications, ERCP has become firmly established in our diagnostic armamentarium.     

ERCP诊治指南（2010版）（三）

胰腺疾病的ERCP诊治指南 一、ERCP对胰腺疾病的诊断作用 1．单纯胰管造影（ERP）对于慢性胰腺炎、自身免疫性胰腺炎、侵及主胰管的肿瘤病变具有较高的诊断价值,但对其他病变,尤其是仅累及胰腺实质或分支胰管的病变则敏感性较低。     

ERCP诊治指南（2010版）（一）

自从1968年内镜下逆行胆胰管造影术（endoscopic retrograde cholangiopancreatography,ERCP）问世以来,尤其是1974年内镜下乳头括约肌切开术（endoscopic sphincterotomy,EST）的临床应用,ERCP已成为临床诊断和治疗胆胰疾病的重要手段。我国ERCP技术起步于1970年代,经过几代内镜工作者的不懈努力,目前已日益成熟和普及。     

诊断性与治疗性ERCP早期并发症与处理

目的 探讨诊断性及治疗性ERCP早期并发症发生情况及处理。方法 回顾总结了我国23年间8579例次诊断性与治疗性ERCP临床资料。分析了早期并发症发生情况。种类、处理及预后。结果 23年间8579例ERCP诊疗中，共发生早期并发症112例（1.31%)，其中诊断性ERCP发生率为1.30%(95/7290)，治疗性ERCP为1.32%(17/1289)，并发水肿型胰腺炎38例（0.44%)，胆道感染30例（0.35%)，消化道大出血26例（0.30%)，药物反应8例（0.09%)，结石及取石篮嵌顿5例（0.06%)，肠穿孔3例（0.03%)，急性出血坏死型胰腺炎1例（0.01%)，后腹膜腔积气1例（0.01%）。112例并发症中，经内科保守治疗痊愈106例（94.6%)，外科手术治疗5例（4.5%(。1例死亡。结论 诊断性ERCP并发症中以急性胰腺炎发生率为高，可能与插管困难，反复显影，注射造影剂压力过大，量过多有关；治疗性ERCP并发症中以出血为常见，与操作技术，伴有黄疸及糖尿病等因素有关。绝大多数并发症可经内科保守治疗而得以痊愈，仅极少数患者需外科手术处理。     

Use of a double-channel duodenoscope for diagnostic and therapeutic ERCP

BACKGROUND: A double-channel duodenoscope has the potential to shorten ERCP procedure time or improve procedure success rates because tasks can be done in parallel through variably situated accessory channels. METHODS: We prospectively evaluated a prototype double-channel duodenoscope in 102 patients, recording findings, procedural success, and potential advantages or problems associated with the instrument. RESULTS: Both channels were used in 79 cases (77%) and a single-channel in the remainder. Ninety-nine percent (101 of 102) of diagnostic and 95% (87 of 92) of therapeutic ERCPs were successful. Instrument advantages included decreased procedure time (23%), cannulation/procedural ease (16%), and miscellaneous (6%). Disadvantages were noted in 15% of the patients and were related to instrument diameter and diameter of the accessory channels. CONCLUSIONS: Additional study of second generation dual-channel duodenoscopes appears warranted.     

胰腺分裂症的ERCP诊断与治疗价值（附10例临床分析）

目的探讨胰腺分裂症(Pancreatic     

Complications of diagnostic and therapeutic ERCP: a prospective multicenter study

OBJECTIVES: Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP/ES) can be associated with unforeseeable complications, especially when involving postprocedural pancreatitis. The aim of the study was to investigate risk factors for complications of ERCP/ES in a prospective multicentric study. METHODS: One hundred fifty variables were prospectively collected at time of ERCP/ES and before hospital discharge over 2 years, in consecutive patients undergoing the procedure in nine endoscopic units in the Lombardy region of Italy. More than 150 ERCPs were performed in each center per year by a single operator or by a team of no more than three endoscopists. RESULTS: Two thousand four hundred sixty-two procedures were performed; 18 patients were discharged because the papilla of Vater was not reached (duodenal obstruction, previous gastrectomy, etc.). Two thousand four hundred forty-four procedures were considered in 2103 patients. Overall complications occurred in 121 patients (4.95% of cases): pancreatitis in 44 patients (1.8%), hemorrhage in 30 (1.13%), cholangitis in 14 (0.57%), perforation during ES in 14 (0.57%), and others in 14 (0.57%); deaths occurred in three patients (0.12%). In multivariate analysis, the following were significant risk factors: a) for pancreatitis, age (< or = 60 yr), use of precutting technique, and failed clearing of biliary stones, and b) for hemorrhage, precut sphincterotomy and obstruction of the orifice of the papilla of Vater. CONCLUSIONS: The results of our study further contribute to the assessment of risk factors for complications related to ERCP/ES. It is crucial to identify high risk patients to reduce complications of the procedures.     

The needle knife: a valuable tool in diagnostic and therapeutic ERCP

Using monopolar electrocautery technique, we have used both an electrified guide wire and a needle-tipped sphincterotome to successfully enter the common bile duct, subsequently image it, and perform therapeutic procedures when by virtue of the patient's anatomy, or because of tumor, this had not been possible using conventional ERCP catheters. In an initial group of 45 patients using the needle-tipped sphincterotome, clinically significant complications occurred in 3 patients but were not of a serious nature. The technique was an effective method for achieving both diagnostic ERCP and therapeutic maneuvers in 43 of 45 patients. We stress that this technique should only be attempted by those with long experience in ERCP and related procedures.     

Bacteremia and meningitis following fiberoptic bronchoscopy.

Bacteremia and meningitis due to Streptococcus pneumoniae developed in a 52-year-old man 28 hours after an otherwise uncomplicated fiberoptic bronchoscopy. The patient responded to antimicrobial therapy and supportive care and later underwent pneumonectomy for carcinoma. This report reinforces previous observations that bacteremia may occasionally be associated with the performance of fiberoptic bronchoscopy.     

Features that may predict hospital admission following outpatient therapeutic ERCP

BACKGROUND: Some patients are admitted following outpatient therapeutic ERCP because of adverse events. This study aimed to identify factors that may predict such admissions. METHODS: We prospectively studied admissions for post-ERCP adverse events in 415 consecutive patients undergoing outpatient therapeutic ERCP. Potentially relevant predictors of admission were assessed by univariate analysis and in case of significance included in a multivariate analysis. RESULTS: Admission was necessary in 41 patients (9.9%) because of complications and in 63 (15.2%) for observation of adverse events that did not progress to definable complications. Potential predictors of admission were evaluated comparing patients who required more than an overnight admission (n = 63) with those who did not (n = 352). Multivariate analysis identified three factors that were significant: pain during the procedure (odds ratio 3.8: 95% CI [1.8, 7.9]), history of pancreatitis (odds ratio 2.3: 95% CI [1.1, 4.7]) and performance of sphincterotomy (odds ratio 2.2: 95% CI [1.1, 4.3]). The presence of all these features was associated with a 66.7% likelihood of admission, whereas the absence of pain during the procedure, history of pancreatitis and performance of sphincterotomy made admission likely in only 11.0%, 9.8% and 10.7%, respectively, of the cases. CONCLUSIONS: The occurrence of pain during the procedure, a history of pancreatitis and the performance of sphincterotomy were independent predictors of admission following outpatient therapeutic ERCP.     

Postcholecystectomy syndrome in northern India--study on the diagnostic and therapeutic role of ERCP

One hundred and twenty two patients with postcholecystectomy syndrome were studied by endoscopic retrograde cholangiopancreatography (ERCP). The procedure was successful in 105 patients (85.3%) and it accurately detected abnormality of the pancreatico-biliary system in 71 patients (67.6%). ERCP results were abnormal in 82.6% of patients with biliary symptoms, with or without jaundice, compared with 34.7% of patients with non-biliary symptoms (P less than 0.001). Though ERCP showed abnormality in all patients with biliary symptoms and jaundice, as many as 70.4% of patients without jaundice had abnormal ERCP. The commonest abnormality was retained/recurrent stones (37/105 patients). Patients with biliary strictures presented significantly more often with jaundice compared with patients with biliary stones (74.3% vs 22.3%). In 19 of the 37 patients with retained biliary stones endoscopic sphincterotomy was performed and it was successful in 16 patients (84.2%). Our data indicates that ERCP detects the anatomical level as well as the nature of lesion accurately, and is essential and safe in the diagnosis and management of patients with postcholecystectomy syndrome.     

诊断性ERCP研究进展

内镜下逆行胰胆管造影术(ERCP)仍是目前诊断胰胆疾病的金标准.但ERCP术后胰腺炎不可避免.自从出现磁共振胰胆管造影(MRCP)以来,MRCP已被广泛应用于临床,具有代替诊断性ERCP的潜在可能性.但目前MRCP设备尚不普及.和ERCP相比,MRCP图象不十分理想.随着技术进步,诊断性ERCP应用有可能逐渐减少,成为取得组织学、细胞学标本和功能研究的方法.