乳头扩约肌预切开术在困难插管内镜逆行胰胆管造影术中的疗效分析

目的 探讨十二指肠乳头预切开术在内镜逆行胰胆管造影术( ERCP)中的应用,并评价其在ERCP中的作用和安全性.方法 自2008年1月至2011年6月我院肝胆胰外科共完成内镜下逆行胰胆管造影术930例,其中选择性插管困难者采用常规方法不能完成而采用乳头预切开术108例,占11.6％.纳入标准为常规插管失败或反复进入胰管4次判定为选择性插管困难,术中改行乳头预切开术,根据病情完成ERCP检查和内镜下治疗.观察终点为治疗成功率和并发症发生率,并与同期常规ERCP插管病例资料对比分析.统计学处理采用SPSS 13.0统计软件,率的比较采用x2检验,P＜0.05为差异有统计学意义.结果 本组乳头预切开术108例,ERCP成功103例,成功率95.4％.术后并发症7例,发生率6.5％,无十二指肠穿孔及死亡病例.同期822例常规ERCP诊治成功率97.7％,术后并发症63例,发生率7.7％.乳头预切开与常规选择性胆管插管两组患者的并发症发生率(x2=0.141,P=0.707)及成功率(x2=2.041,P=0.153)差异无统计学意义.结论 乳头预切开术与常规ERCP相比不增加发生并发症的风险,可提高困难ERCP的成功率,但要严格掌握适应证,由经验丰富的医师进行.     

High-dose versus low-dose intravenous proton pump inhibitor treatment for bleeding peptic ulcers

Evaluation of: Liu N, Liu L, Zhang H et al. Effect of intravenous proton pump inhibitor regimens and timing of endoscopy on clinical outcomes of peptic ulcer bleeding. J. Gastroenterol. Hepatol. 27(9), 1473–1479 (2012).

Peptic ulcer bleeding is a common medical emergency associated with significant mortality and healthcare costs. All recent guidelines agree on the beneficial role of proton pump inhibitor treatment, but there is still controversy regarding the optimal dose and route of administration of proton pump inhibitors. The evaluated article reports on a large, single-center randomized controlled trial that compared the clinical efficacy of a low-dose twice-daily intravenous bolus regimen with a high-dose continuous intravenous infusion regimen in 875 patients with acute bleeding from peptic ulcers. The high-dose regimen was associated with significant reductions in rebleeding, blood transfusion requirements and length of hospital stay. There was no demonstrable difference in mortality or the need for endoscopic hemostatic treatment or surgery. We discuss the strengths and limitations of the evaluated article, as well as the implications for clinical practice.     

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.     

Alternative sedation for the higher risk endoscopy: a randomized controlled trial of ketamine use in endoscopic retrograde cholangiopancreatography

Abstract

Objective. Sedation for endoscopy carries an element of cardiorespiratory risk, more significant for certain procedures and in certain patient groups. Ketamine has features which make it an attractive agent for sedation during the higher risk endoscopy; the objectives of this pilot trial were to assess the effectiveness and tolerability of ketamine as a primary agent for sedation during endoscopy. Methods. The study was a prospective randomized controlled trial, in which American Society of Anesthesiologists’ (ASA) class 1–3 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) received either conventional sedation with midazolam and pethidine or a combination of midazolam and ketamine. Patients were monitored physiologically and in respect to depth of sedation (Modified Observer’s Assessment of Alertness/Sedation score) and were observed post procedure for evidence of emergence reactions or other complications. After full recovery, patients completed a questionnaire on their experiences, with particular emphasis on vivid dreaming or other complications attributable to ketamine. Results. Demographically, control (n = 18) and study (n = 19) groups were similar in makeup. Median midazolam dose was 2 mg (interquartile range [IQR] = 1–3) and 2 mg (IQR = 2–3), respectively (p = 0.98); median procedure duration was 25.5 min (IQR = 17–30) and 21.0 min (IQR = 15–34) (p = 0.92). Median satisfaction with sedation (scored from 0 to 4) was 3.5 (range 1–4) and 4 (range 2–4) respectively (p = 0.88). No patient in either group experienced emergence reactions, dysphoria, or vivid dreaming. Conclusion. In this pilot study, sedation for endoscopy with ketamine and midazolam was as effective as conventional sedation, as acceptable to patients, and was not associated with dysphoric events. Ketamine may have potential as an agent for sedation in higher risk patients.     

Sedation during endoscopic retrograde cholangiopancreatography: a randomized controlled study of patient-controlled propofol sedation and that given by a nurse anesthetist

Abstract

Objective. Different regimens are used for sedation during endoscopic retrograde cholangiopancreatography (ERCP). Our objectives were to compare safety, ease of treatment, recovery, and patients’ experiences using patient-controlled sedation (PCS) with propofol, nurse anesthetist-controlled sedation (ACS), or the department’s standard of care, midazolam given by the procedure team (control group). Material and methods. The study included 281 adults in 301 procedures. The PCS group (n = 101) delivered bolus doses of 5 mg of propofol according to their need for sedation. The ACS group (n = 100) had 2–8 mg/kg/h of propofol infused, with the target for sedation being level 3 of the Observer’s Assessment of Alertness/Sedation (OAA/S) scale. The control group was given 2–3 mg of midazolam for induction and additional 1 mg if required. Results. PCS and ACS increased the ease of the procedure and reduced the number of sedation failures compared to midazolam sedation (ACS n = 0; PCS n = 4; midazolam n = 20). The ACS group had more deeply sedated patients (OAA/S level 2), desaturation, and obstructed airways than the PCS and midazolam groups. Time to full recovery (Aldrete score ≥9) was shortest following PCS. PCS resulted in the least fatigue and pain after the procedure. Patients’ preference for PCS and ACS was the same. Conclusion. PCS with propofol is superior to midazolam and comparable to ACS. PCS resulted in a rapid recovery, fewer respiratory events, and was almost as effective as ACS in ensuring a successful examination.     

Comparison between ulinastatin and gabexate mesylate for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective,randomized trial

Background It has been reported that the administration of ulinastatin, gabexate mesylate, or somatostatin may be effective in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, few randomized trials of ulinastatin and gabexate mesylate for the prevention of post-ERCP pancreatitis have been reported. The aim of this study was to compare the efficacy of ulinastatin and gabexate mesylate for the prevention of post-ERCP pancreatitis. Methods Sixty-eight patients who underwent diagnostic ERCP at our hospital were divided at random by computer-generated randomization into an ulinastatin group (n = 34) and a gabexate group (n = 34). Each patient received a continuous intravenous infusion of ulinastatin (150 000 units) or gabexate mesylate (600 mg), beginning 60–90 min before the ERCP and continuing until 22 h after the ERCP. The primary endpoint was the incidence of post-ERCP pancreatitis, and the secondary endpoints were the incidences of hyperenzymemia and pain. Results The overall incidence of post-ERCP pancreatitis was 2.9% (two patients), comprising one patient in the ulinastatin group and one patient in the gabexate group (2.9% vs 2.9%, respectively). Neither of these two patients developed severe pancreatitis. There were no significant differences in the serum levels of pancreatic enzymes or in the levels of pain between the two groups. Conclusions There was no clinical difference between the effect of preventive administration of ulinastatin and that of gabexate mesylate on the incidence of post-ERCP pancreatitis. Ulinastatin may be equivalent in efficacy to gabexate for reducing the incidence of post-ERCP pancreatitis.