Roux‑en‑Y吻合术后超声内镜引导下经胃肠吻合旁路辅助内镜逆行胰胆管造影术进展（含视频）

Roux‑en‑Y吻合术为消化系统外科手术常用术式,主要包括Roux‑en‑Y胃旁路术与Roux‑en‑Y胆肠吻合术。Roux‑en‑Y吻合术后患者的内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography, ERCP）是内镜医师面临的一项挑战。针对这一临床难点,一项新技术——超声内镜引导下经胃肠吻合旁路辅助ERCP,应运而生。该技术在超声引导下创建胃肠吻合旁路,缩短ERCP行镜距离,与现有的各项辅助ERCP技术相比,在插管成功率、操作成功率、手术时间、术后住院时间、费用等方面都具备优势。本文介绍该项辅助ERCP技术的发展过程、适应证、操作步骤、临床疗效、并发症等方面,以期促进该技术在我国的进一步研究与推广。     

Endoscopic Retrograde Cholangiopancreatography with Single-Balloon Enteroscopy Is Feasible in Patients with a Prior Roux-en-Y Anastomosis

The purpose of this study is to describe the feasibility of using single-balloon enteroscopy (SBE) to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who had a prior Roux-en-Y (RY) anastomosis. This case series describes four patients, one with RY gastric bypass, two with RY due to bile duct injury, and one with RY after liver transplantation, who underwent ERCP with SBE. Cholangiography was successful in three of the four patients. In the procedure that was not successful, the enteroenterostomy site could not be located. The successful procedures ranged from 65–91 min in duration. Medication doses were higher than with typical ERCPs. No procedural complications occurred. SBE for ERCP is a feasible option for endoscopic access to the biliary tree in patients with prior RY anastomoses. Limitations of this technique include the time requirement, delay in identification of the enteroenterostomy site, potential learning curve, and immature technology lacking accessories.     

Large Gallstones Stacked Together in the Common Bile Duct after Choledochojejunostomy

A 65-year-old man had a history of cholecystectomy and treatment for cholelithiasis with a common bile duct incision. Owing to frequent cholangitis, he underwent choledochojejunostomy. Twenty years after the surgery, he was hospitalized for cholangitis and was suspected of having hilar cholangiocarcinoma based on imaging findings. Percutaneous transhepatic cholangioscopy using a SpyGlass™ DS (Boston Scientific, Marlborough, USA) showed gallstones and bile sludge in the bile ducts, but no tumors were noted. Electrohydraulic shockwave lithotripsy with double-balloon enteroscopy enabled complete stone removal; a direct visual biopsy with peroral cholangioscopy showed no malignancy in the bile duct.     

短单气囊小肠镜在Roux-en-Y术后患者经内镜逆行胰胆管造影中的应用

目的:评估短单气囊小肠镜(single balloon enteroscope, SBE )辅助下经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography, ERCP)在Roux-en-Y术后患者中的应用价值。方法:收集鼓楼医院消化内镜中心2019年5月—20...     

Endoscopic papillectomy: Is there room for this procedure in clinical practice?

It has been 20 years since the development of endoscopic papillectomy (snare excision of the papilla of Vater). The accepted indication for this procedure is adenoma of the duodenal papilla. As for the evaluation of tumor extent, there is room for improvement of the diagnostic accuracy. Due to the high incidence of coexistent cancer detected by histological examination of surgically resected specimens in biopsy‐proven adenoma of the papilla of Vater, ablation techniques should essentially be avoided in order to preserve a specimen that is amenable to reliable histological examination. Otherwise, there may be a risk of retained coexistent cancer. It is not always possible to leave a safety margin when removing a tumor of the papilla of Vater by the snare excision technique and careful follow up is mandatory after the treatment. Consensus has not been reached as to the interval and the method of biopsy during follow up. When endoscopic biopsy from the site of the papilla of Vater at follow‐up endoscopy proves malignancy, the remnant needs to be resected surgically. An adequate follow‐up interval should be determined before this technique is established as the treatment of choice for ampullary tumors.     

Cholangiographic appearance of multiseptate gallbladder: Case report and a review of the literature

A case of multiseptate gallbladder is described, with a review of the literature. This is the 24th such case report. The patient complained of right upper quadrant pain, colicky in nature. Abdominal ultrasonography showed multiple fine echoes within the gallbladder. On endoscopic retrograde cholangiography, multiple radiolucent lines crossing the gallbladder in various directions were noted within the gallbladder. The gallbladder was crisscrossed by numerous delicate septations and had a honeycomb appearance. These findings suggested multiseptate gallbladder.     

ENDOSCOPIC SNARE PAPILLECTOMY FOR TUMORS OF THE MAJOR DUODENAL PAPILLA

Safer procedures for performing endoscopic papillectomy on papillary tumors should be established. Fourteen patients underwent endoscopic papillectomy between January 2000 and February 2007. Before papillectomy, tumors were slightly elevated by submucosal injection of glycerol, followed by semi‐circular mucosal incision of the anal border of the lesion in five cases. In nine cases, balloon‐catheter‐assisted endoscopic snare papillectomy was performed. All patients routinely underwent endoscopic nasobiliary drainage tube placement in the bile duct. A pancreatic stent was inserted only in patients with non‐patent minor papilla. The rate of positive margins was lower in patients who received balloon‐catheter‐assisted papillectomy than in patients who received papillectomy without a balloon catheter. Of three patients with local recurrence, only one patient required surgery. Post‐procedural complications included hemorrhage in eight patients, pancreatitis in one patient, and perforation in one patient. No perforation occurred after submucosal injection and mucosal incision. In three of four patients with early hemorrhage, bleeding was noticed as hemobilia through the nasobiliary drainage tube; this appears to be useful for early diagnosis of bleeding. No pancreatitis occurred in patients with patent minor papilla, suggesting that pancreatic stent placement is unnecessary in patients with patent minor papilla.     

Efficacy and Safety of Percutaneous Transhepatic Cholangioscopy with the Spyglass DS Direct Visualization System in Patients with Surgically Altered Anatomy: A Pilot Study

Background/AimsPercutaneous transhepatic cholangioscopy (PTCS) is used for the diagnosis and treatment of biliary diseases in patients with failed endoscopic retrograde cholangiopancreatography, particularly those with surgically altered anatomy. However, few studies are available on the clinical use of Spyglass DS direct visualization system (SpyDS)-assisted PTCS. This study aimed to assess the efficacy and safety of SpyDS-assisted PTCS in patients with surgically altered anatomy, particularly those with a Roux-en-Y reconstruction.MethodsThirteen patients (six women, median age 71.4 years [range, 53 to 83 years]) with surgically altered anatomy (four Roux-en-Y choledochojejunostomies, seven Roux-en-Y hepaticojejunostomies, and two Roux-en-Y esophagojejunostomies) who underwent SpyDS-assisted PTCS between January 2019 and August 2020 were included and the data was acquired by retrospectively reviewing electronic medical record.ResultsA total of 19 SpyDS-assisted PTCS procedures were performed in the 13 patients eight had bile-duct stones, and five had biliary strictures. All SpyDS-assisted PTCS procedures were successfully performed. The total procedure time was 42.42±18.0 minutes (mean±standard deviation). Bile duct clearance was achieved in all bile duct stone cases after a median of 2 (range, 1 to 3) procedures. In the five biliary stricture cases, the results of SpyBite forceps-guided targeted biopsy were consistent with adenocarcinoma (100% accuracy). The median hospitalization duration was 20 days (range, 14 to 30 days). No procedure-related morbidity or mortality occurred.ConclusionsSpyDS-assisted PTCS may be a safe, feasible, and effective procedure for the diagnosis and treatment of biliary diseases in patients with surgically altered anatomy, particularly in those with the Roux-en-Y reconstruction requiring a percutaneous approach. However, our findings need to be validated in further studies.     

Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method

Background—Magneticresonance cholangiography (MRC) is a new technique for non-invasiveimaging of the biliary tract.
Aim—To assess theresults of MRC in patients with suspected bile duct stones as comparedwith those obtained with reference imaging methods.
Patients/Methods—70patients (34 men and 36 women, mean (SD) age 71 (15.5) years; median75) with suspected bile duct stones were included (cholangitis, 33;pancreatitis, three; suspected post-cholecystectomycholedocholithiasis, nine; cholestasis, six; stones suspected onultrasound or computed tomography scan, 19). MR cholangiograms with twodimensional turbo spin echo sequences were acquired. Endoscopicretrograde cholangiography with or without sphincterotomy (n = 63),endosonography (n = 5), or intraoperative cho- langiography (n = 2)were the reference imaging techniques used for the study and wereperformed within 12 hours of MRC. Radiologists were blinded to theresults of endoscopic retrograde cholangiography and previous investigations.
Results—49patients (70%) had bile duct stones on reference imaging (common bileduct, 44, six of which impacted in the papilla; intrahepatic, four;cystic duct stump, one). Stone size ranged from 1 to 20 mm (mean 6.1, median 5.5). Twenty seven patients (55%) had bile duct stones smallerthan 6 mm. MRC diagnostic accuracy for bile duct lithiasis was:sensitivity, 57.1%; specificity, 100%; positive predictive value,100%; negative predictive value, 50%.
Conclusions—Stonessmaller than 6 mm are still often missed by MRC when standard equipmentis used. The general introduction of new technical improvements isneeded before this method can be considered reliable for the diagnosisof bile duct stones.

Keywords:bile duct calculi; endoscopic retrogradecholangiography; magnetic resonance cholangiography

     

EXPERIENCES OF BILIARY INTERVENTIONS USING SHORT DOUBLE‐BALLOON ENTEROSCOPY IN PATIENTS WITH ROUX‐EN‐Y ANASTOMOSIS OR HEPATICOJEJUNOSTOMY

Background: The efficacy of double‐balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux‐en‐Y gastrectomy or hepaticojejunostomy (HJ). Patients and Methods: Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux‐en‐Y reconstruction or HJ anastomosis. Results: A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively. Conclusions: Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy.