逆行胰胆管造影、乳头括约肌切开配合腹腔镜胆囊切除术治疗胆石症

为治疗伴有或可疑伴有胆总管结石的胆囊结石病人，在对胆囊结石病人行腹腔镜胆囊切除术（ＬＣ）时，对ＬＣ术前可疑伴有胆总管继发性结石的１４２例病人（术前组）和ＬＣ术后可疑胆总管残留结石的３９例病人（术后组）选择性地行逆行性胰胆管造影（ＥＲＣＰ）检查和乳头括约肌切开术（ＥＳＴ）治疗。结果：术前组ＥＲＣＰ发现胆总管继发结石６５例，ＥＳＴ清除结石６０例，清除率９１．５％；术后组ＥＲＣＰ发现胆总管残留结石６例，ＥＳＴ清除结石５例。结果提示ＥＲＣＰ、ＥＳＴ配合ＬＣ治疗伴有胆总管结石的胆囊结石病人是一种安全有效的好方法，明显减少了ＬＣ的并发症和胆总管结石开腹手术的比例。     

逆行胰胆管造影,乳头括约肌切开配合腹腔镜胆囊切除术治…

为治疗伴有或可疑伴有胆总管结石的胆囊结石病人，在对胆囊结石病人行腹腔镜胆囊切除术（ＬＣ）时，对ＬＣ术前可疑伴有胆总管继发性结石的１４２例病人（术前组）和ＬＣ术后可疑胆总管残留结石的３９例病人（术后组）选择性地行逆行性胰胆管造影（ＥＲＣＰ）检查和乳头括约肌切开术（ＥＳＴ）治疗。结果：术前组ＥＲＣＰ发现胆总管继发结石６５例，ＥＳＴ清除结石６０例，清除率９１．５％；术后组ＥＲＣＰ发现胆总管残留结石６例，     

经内镜治疗胆总管结石及Oddi括约肌狭窄

自１９９７年５月至１９９８年９月,我们选择经Ｂ超及经内镜逆行性胰胆管造影（ＥＲＣＰ）诊断的３４例胆总管结石和６例Ｏｄｄｉ括约肌狭窄者,行经内镜乳头括约肌切开术（ＥＳＴ）或经内镜乳头括约肌气囊扩张术（ＥＰＢＤ）后,采用网篮及机械碎石后取石或自然排石等方...     

十二指肠内镜术在胆胰疾病诊疗中的地位

内镜逆行胰胆管造影（ＥＲＣＰ）可以在内镜下经造影将胰胆管显示清楚,从而使胆胰疾病的诊治提高到了一个新的水平,被誉为医学史上的一次革命。１９７４年Ｋａｗａｉ等首次采用内镜下乳头括约肌切开（ＥＳＴ）治疗胆总管结石,开创非外科手术治疗胆总管结石的先河,加上后来的经内镜胆管引流ＥＲＢＤ、经内镜鼻胆管引流术ＥＮＢＤ、经内镜胰管引流术（ＥＲＰＤ）、经内镜乳头气囊扩张术ＥＰＢＤ、内镜内引流管置入术（ｅｎｄｏｐｒｏｔｈｅｓｉｓｓｔｅｎｔ）及子母镜技术（ＰＣＳ）,使内镜的介入技术在胆胰疾病的诊疗方面进入一个诊断和…     

结合EPCP与螺旋CT三维成像对阻塞性黄疸的诊断价值

目的：探讨对阻塞性黄疸更精确的影像学诊断方法。方法：对４５名怀疑有阻塞性黄疸的病人,行常规ＥＲＣＰ检查,退镜后立即进行螺旋ＣＴ扫描。将螺旋ＣＴ三维成像显示胆管阻塞的原因、位置和程度与ＥＲＣＰ的检查结果相比较。结果：４５名病人中,螺旋ＣＴ胆管造影显示了３０名病人有胆管阻塞,没有假阳性或假阴性病例。胆管阻塞的原因有：胆管结石２４例、胆管癌３例、胆管狭窄３例。ＥＲＣＰ与螺旋ＣＴ胆管造影均能对２４例胆管结     

ERCP对肝外胆管癌的诊断价值

肝外胆管癌临床表现多不典型 ,易误诊漏诊 ,术前诊断主要靠逆行胰胆管造影 (ＥＲＣＰ)、经皮肝穿胆道造影 (ＰＴＣ)、Ｂ超和ＣＴ检查[1] 。本文对经手术病理证实的 33例肝外胆管癌的ＥＲＣＰ资料进行回顾性的分析 ,以探讨ＥＲＣＰ对肝外胆管癌的诊断价值。1　资料和方法1.1　一般资料　本组 33例肝外胆管癌中男 2 7例 ,女6例 ,年龄 4 6～ 6 8岁 ,平均 5 6 72岁。临床表现黄疸2 9例 ,腹痛腹胀 2 5例 ,皮肤瘙痒 2 5例 ,乏力 2 1例 ,食欲不振 2 5例 ,发热寒战 4例。病理分型腺癌 32例 ,鳞癌 1例。1.2　方法　 33例肝外胆管癌术前均行ＥＲＣＰ …     

胰腺分裂的内镜诊断

为了认识胰腺分裂及其临床意义，对２５００例经内镜逆行胰胆管造影（ＥＲＣＰ）检查中检出的３７例胰腺分裂患者资料进行回顾分析。３７例均经主、副乳头插管显示出腹胰管及背胰管，胆管显影１４例，显影率３７．８％。体会到胰腺分裂者ＥＲＣＰ时插胆管困难，并对胰腺分裂的ＥＲＣＰ诊断及临床意义进行了讨论     

如何提高内镜治疗胆管结石的成功率

近年来，胆管结石的内镜治疗有了很大发展和普及，国外已广泛应用于临床，在很大程度上取代了外科剖腹手术治疗，本文就内镜治疗胆道结石方面有关的几个问题作一介绍，以促进国内治疗性ＥＲＣＰ的普及开展。一、正确的胆管造影、准确判断结石是先决条件一般情况下，按常规行ＥＲＣＰ是不困难的。经胆管造影发现结石后，并不是所有的结石都能经内镜取出，其中最重要的因素为：结石的大小及形状。判断结石的大小，可用内镜镜身外径来判断，一般Ｘ线片上内镜为１５ｍｍ（略有放大），当结石大于内镜外径时，取石就增加了难度，结石直径≥２５ｍ…     

胆管镜临床应用进展

胆管镜临床应用进展黑龙江省临床消化病研究所（哈尔滨，１５００３８）朱雅琪陶铸胆管镜应用于临床已有２５年多的历史，主要用于肝内、外胆石的治疗，本文也仅就此方面加以介绍。由于十二指肠纤维内镜做逆行胰胆管造影（ＥＲＣＰ）和乳头切开（ＥＳＴ）后能使胆管结石（...     

核磁共振胰胆管造影与内镜下逆行胰胆管造影在胰胆疾病诊断方面的对比研究

目的：探索核磁共振胰胆管造影（ＭＲＣＰ）检查在临床应用中的价值。方法：对１１０例胰胆管疾病患者选择性地行ＭＲＣＰ检查,并与内镜下逆行胰胆管造影（ＥＲＣＰ）检查作比较,结合内镜下治疗以及外科手术,以明确两者之间的相关性。ＥＲＣＰ和手术结果作为金标准。结果：１１０例患者ＭＲＣＰ图像质量均较高,对胆管扩张诊断的敏感性为８５．０６％（７８／８７）,对胆管下段狭窄伴扩张诊断的敏感性为９０％（１８／２０）。Ｍ     

经内镜逆行胰胆管造影术中不同取石器械对胆总管结石的疗效及安全性分析

目的 比较经内镜逆行胰胆管造影术（ERCP）中不同取石器械取石的效果及安全性。方法 回顾性分析2015年1月—2018年8月在南京市江宁医院及池州市人民医院行ERCP取石治疗的178例胆总管结石患者资料。患者先使用扩张气囊充分扩张乳头口，再行取石。根据取石器械不同，分为单纯气囊组（54例），单纯网篮组（60例）及网篮联合气囊组（64例），比较各组一次性结石清除率、术后24 h血淀粉酶水平及并发症发生率。结果 单纯气囊组、单纯网篮组及网篮联合气囊组一次性结石清除率分别为96.3%（52/54）、95.0%（57/60）、95.3%（61/64），3组比较差异无统计学意义（χ2=0.120,P=0.942）。3组术后24 h血淀粉酶水平分别为180.5（85.2,410.5）U/L、129.0（59.0,287.0）U/L、100.0（58.2,166.2）U/L，差异有统计学意义（H=9.655，P=0.008）。ERCP术后高淀粉酶血症、出血、术后胰腺炎发生率3组比较差异均无统计学意义（P均＞0.05）。3组均无穿孔发生，但网篮组发生结石嵌顿1例。结论 在使用扩张气囊充分扩张乳头口的情况下，ERCP取石可优先选用气囊取石，其具有较高的取石成功率，并发症发生率无显著升高，且不会发生取石器械嵌顿。     

经口直接胆道进镜对ERCP残留结石的诊疗价值

目的探讨经口直接胆道进镜方法及其对ERCP残留结石的诊疗价值。方法用3-0丝线将0．533mm（0．021in）斑马导丝软头连结于取石球囊前部的导管外面上,成为引导超细胃镜进镜的球囊．导丝“引导装置”,ERCP取石后的十二指肠镜将“引导装置”的取石球囊（连同导丝并行）送至肝内胆管充气锚定,退出十二指肠镜,沿导丝经口插入超细胃镜直至胆道,观察ERCP取石后结石残留情况,如发现残留结石可直接用超细胃镜网篮取出,结石较大则液电击碎再取出。结果46例患者中42例超细胃镜成功进镜至肝门区胆管,4例失败,自口插镜到达肝门区胆管平均时间为11．3min。成功进镜的42例中发现直径i〉4mm结石6例,残留率为14．3％,最大结石直径为10mm×12mm;27例ERCP单纯取石者发现结石2例,15例ERCP网篮碎石后再取石者发现结石4例。6例残留结石中5例直接用取石网篮取出,1例液电击碎后再网篮取出。术后未见严重并发症。结论应用本方法进行经口直接胆道镜诊疗是可行的,能及时诊断ERCP残留结石并予取除,避免再次取石治疗。     

Clinical usefulness of transpapillary removal of common bile duct stones by frequency doubled double pulse Nd：YAG laser

AIM： To study the efficacy and the safety of laser lithotripsy without direct visual control by using a balloon catheter in patients with bile duct stones that could not be extracted by standard technique.
METHODS： The seventeen patients （7 male and 10 female; mean age 67.8 years） with difficult common bile duct （CBD） stones were not amenable for conventional endoscopic maneuvers such as sphincterotomy and mechanical lithotripsy were included in this study. Laser wavelengths of 532 nm and 1064 nm as a double pulse were applied with pulse energy of 120 mJ. The laser fiber was advanced under fluoroscopic control through the ERCP balloon catheter. Laser lithotripsy was continued until the fragment size seemed to be less than 10 mm. Endoscopic extraction of the stones and fragments was performed with the use of the Dormia basket and balloon catheter.
RESULTS： Bile duct clearance was achieved in 15 of 17 patients （88%）. The mean number of treatment sessions was 1.7 ± 0.6. Endoscopic stone removal could not be achieved in 2 patients （7%）. Adverse effects were noted in three patients （hemobilia, pancreatitis, and cholangitis）.
CONCLUSION： The Frequency Doubled Double Pulse Nd：YAG （FREDDY） laser may be an effective and safe technique in treatment of difficult bile duct stones.     

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

AIM： To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography （ERCP） without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. METHODS： Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCI and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. RESULTS： The mean age of the patients was 28 years （range, 21-33 years）. The mean gestational age for the fetus was 23 wk （range, 14-34 wk）. Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. CONCLUSION： Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.     

The role of percutaneous transhepatic papillary balloon dilation in percutaneous choledochoscopic lithotomy

BACKGROUND: When choledochoscopic lithotomy with basket and electrohydraulic lithotripsy is used to remove intrahepatic duct stones, fragments or small stones usually remain in the bile duct that are too small to be captured with a basket. METHODS: An attempt was made to remove stone fragments in 16 patients with intrahepatic duct stones by antegrade balloon dilation of the sphincter of Oddi with a conventional balloon catheter. After balloon dilation, remnant stones and sludge were pushed through the papilla with the choledochoscope. RESULTS: Bile duct stones were completely removed in 12 of 16 patients (75%); stones were removed in 1 session. There was no clinical evidence of procedure-related pancreatitis or fatal complications. CONCLUSIONS: Percutaneous transhepatic papillary balloon dilation of the sphincter of Oddi and clearance of remnant bile duct stones and stone fragments with the tip of choledochoscope is simple and effective in patients undergoing percutaneous transhepatic choledochoscopic lithotomy.     

Transnasal extraction of residual biliary stones by Seldinger technique and nasobiliary drain

BACKGROUND: Complete endoscopic clearance of bile duct stones is unsuccessful in up to 30% of patients at the first attempt, necessitating further endoscopic procedures. A novel transnasal approach for extraction of these residual stones using Seldinger technique and a nasobiliary drain was evaluated. METHODS: Twenty-one patients with residual biliary stones after ERCP underwent transnasal extraction under fluoroscopy without sedation. A 0.035-inch guidewire was inserted though the previously placed nasobiliary drain into the intrahepatic ducts. The nasobiliary drain was removed, leaving the guidewire in place. A double-lumen extraction balloon was inserted over the guidewire. Multiple withdrawal maneuvers of the inflated balloon were performed to clear the bile duct. RESULTS: Residual stones were present in the extrahepatic and intrahepatic ducts in, respectively, 18 and 3 patients. The mean largest stone diameter was 5.9 mm (range, 3-12 mm). Seventeen patients had a single stone. Complete duct clearance was achieved in 17 patients (81%). The procedure was unsuccessful because of guidewire dislodgement in 3 patients and inability to pass the guidewire through the nasobiliary drain in 1 patient. There was no procedure-related complication. CONCLUSIONS: Transnasal extraction of residual biliary stones after ERCP with the Seldinger technique is safe and feasible with reasonable success and can avoid the inconvenience and cost of a repeat ERCP.     

Diagnostic and therapeutic ERCP in hepatic hydatid disease

BACKGROUND: This retrospective study evaluated the use of diagnostic and therapeutic ERCP in pre- and postoperative patients with hepatic hydatid disease. METHODS: For 8 years, ERCP was performed in 39 patients with hepatic echinococcal disease. Indications in the preoperative group of patients (n = 19) included a cholestatic enzyme profile in all cases; jaundice or acute cholangitis also was present in, respectively, 14 and 7 cases. In the postoperative group (n = 20), indications for ERCP included persistent external biliary fistula after surgery in 10 patients, jaundice in 8, acute cholangitis in 7, and right upper quadrant pain in 2 patients. RESULTS: ERCP findings in the preoperative group included cystobiliary fistula (9 patients), external compression of the hepatic biliary system (5), hydatid vesicles and/or membranes within the biliary tract (3), intrahepatic duct stricture (1), and a normal cholangiogram (4). The most common ERCP finding in the postoperative group was external biliary fistula (10 patients); other findings consisted of hydatid cyst material within the bile duct (4), bile duct stenosis (2), cystobiliary fistula and hydatid cyst material in the bile duct (1), cystobiliary fistula (1), hydatid membranes in the gallbladder (1), extrinsic compression to bile ducts (1), and a normal cholangiogram (1). In the preoperative group, endoscopic sphincterotomy was performed in 11 patients, with balloon catheter extraction in 2; complete resolution of findings was achieved in 10 cases. In the postoperative group, sphincterotomy (with balloon or basket extraction as needed) was performed in 19 patients, stents were placed in 2 patients, 1 patient underwent balloon dilatation, and 1 had nasobiliary drainage; there was complete resolution of the findings in 14 of the 20 patients. CONCLUSIONS: ERCP and related therapeutic maneuvers are safe and valuable in the pre- and postoperative management of patients with hepatic hydatid disease.     

Difficult bile duct stones

Opinion statement Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary.     

Cholangiography of intrahepatic bile ducts in hepatolithiasis by endoscopic placement of an indwelling balloon catheter

To improve the diagnostic yield and safety of endoscopic retrograde balloon catheter cholangiography, two technical refinements were added: (1) intraductal retention of a balloon catheter allowing injection of a contrast medium in the supine position; and (2) slow, constant injection of the contrast medium with a heavy-duty infusion pump. Maximum filling of intrahepatic branches was attempted by both the original balloon method and the new method in seven hepatolithiasis patients. The new method was superior for visualization of the right intrahepatic ducts. Although there were no significant differences in the amount of filling of the left intrahepatic ducts, the new method provided an unobstructed view since the endoscope was out of the way. Harmful rapid increase of intraductal pressure and excessive injection of contrast medium were avoided by fluoroscopically controlled infusion. No serious complications were encountered.     

治疗性经内镜逆行胰胆管造影在高龄人群胆总管结石中的应用(附91例临床分析)

目的评价内镜治疗70岁以上胆总管结石患者的安全性及有效性。方法回顾性分析2004年1月～2010年12月我院内镜中心91例70岁以上胆总管结石患者的内镜诊治资料及随访情况。结果 91例患者经内镜逆行胰胆管造影(ERCP)全部成功,其中18例因插管困难行十二指肠乳头括约肌预切开术。所有患者均有胆总管结石,其中1枚结石者48例,2枚结石者19例,3枚或3枚以上结石者24例;取石方法:网篮直接取石13例,机械碎石后取石52例,球囊扩张后取石11例;胆总管放置塑料支架而未能一次取石15例。胆总管结石直径1.4～4.5 cm,平均(1.9±0.7)cm。7例出现出血并发症,应用局部喷洒或黏膜下注射1∶10 000肾上腺素、局部电凝方法止血;11例患者术后出现一过性淀粉酶升高,2例患者发生ERCP相关胰腺炎,上述患者行禁食、抑制胰液分泌、抑制胰酶活性、抗炎补液等治疗。入组患者无ERCP相关性死亡,89例患者随访6～12个月,2例失访,5例出现结石再发。结论内镜下治疗高龄胆总管结石患者疗效确切,安全性较好。