十二指肠乳头旁憩室对内镜十二指肠乳头切开术治疗胆总管结石及其并发症的影响

目的 探讨十二指肠乳头旁憩室（juxtapapillary duodenal diverticulum,JPDD）与胆总管结石的关系,以及对内镜乳头括约肌切开术（EST）治疗胆总管结石和术后并发症的影响.方法 回顾性分析513例ERCP病例,其中行EST治疗胆总管结石253例,合并JPDD的胆总管结石51例.分析JPDD与胆总管结石发生的关系;比较合并JPDD胆总管结石组与未合并JPDD胆总管结石组ERCP插管成功率、EST胆总管取石成功率及其并发症发生率的差异.结果 JPDD组原发性胆总管结石发生率显著高于无JPDD组（18.4％ VS 8.9％,P＜0.01）.与未合并JPDD胆总管结石组比较,合并JPDD胆总管结石组ERCP插管成功率无显著性差异（96.1％ VS 99.5％,P＞0.05）,而EST取石成功率明显降低（91.8％ VS 99.5％,P＜0.05）,EST术后创口出血显著增多（11.1％ VS 1.9％,P＜0.01）,其他近期并发症及远期并发症发生率均无显著性差异（P＞0.05）.结论 JPDD与原发性胆总管结石的发生相关;JPDD对EST治疗胆总管结石有一定影响;EST仍是治疗合并JPDD胆总管结石的一种相对安全、有效的治疗手段.     

单纯十二指肠乳头气囊扩张治疗胆总管结石合并乳头旁憩室的安全性

目的评价内镜下单纯十二指肠乳头气囊扩张(EPBD)治疗胆总管结石合并乳头旁憩室的安全性。方法对65例胆总管结石合并十二指肠乳头旁憩室患者进行内镜下取石治疗,其中35例行单纯EPBD术后取石,30例行十二指肠乳头括约肌小切开(sEST)联合EPBD取石。比较两组取石取净率、术中出血情况及并发症。结果两组取石取净率差异无统计学意义(P0.05);单纯EPBD组术后无出血,明显少于EST+EPBD组(P=0.04)。术后胰腺炎及胆管炎相当,差异无统计学意义,两组均未发生穿孔。结论单纯EPBD术治疗胆总管结石合并十二指肠乳头旁憩室比EST联合EPBD安全,且操作方便,能够减少十二指肠乳头出血的风险。     

十二指肠乳头旁憩室对ERCP手术治疗胆总管结石患者效果的影响*

目的 分析十二指肠乳头旁憩室(PAD)对内镜下逆行胰胆管造影术(ERCP)治疗胆总管结石患者手术的影响。方法 2016年12月～2019年12月我院消化内科诊治的胆总管结石合并PAD患者101例(憩室内乳头37例,非憩室内乳头64例)和胆总管结石患者174例。所有患者在ERCP下插管、取石治疗。结果 憩室组和非憩室组插管成功率分别为95.1%和98.4%,取石成功率分别为91.1%和92.0%,差异无统计学意义(P>0.05);术后,憩室组与非憩室组并发症发生率为19.8%和19.0%,差异无统计学意义(P>0.05);憩室内乳头组插管成功率为86.5%,取石成功率为81.1%,均显著低于非憩室内乳头组的100.0%和96.9%(P<0.05);术后,憩室内乳头组与非憩室内乳头组并发症发生率分别为24.3%和17.2%,差异无统计学意义(P>0.05)。结论 PAD会对ERCP手术治疗胆总管结石患者的效果产生一定的不利影响,尤其是憩室内乳头会增加插管难度,降低取石成功率,需要医生提高手术技巧,才能获得手术的成功。     

十二指肠乳头旁憩室与胆总管结石和胰腺炎发生的相关分析

目的 探讨十二指肠乳头旁憩室(JPD)与胆总管结石、胰腺炎发生的相关性.方法 收集2001年至2006年行ERCP检查的462例患者资料,分析JPD与胆总管结石、胰腺炎发生的关系.结果 总的JPD检出率为27.5%(127例),JPD检出率随着年龄增长而增加,从＜50岁的4.6%(4/87)到＞80岁的56.4%(22/39,P＜0.05).JPD患者中胆总管结石的检出率为74%(94/127);JPD直径＞1.0 cm者,胆总管结石检出率为79.6%(82/103),明显高于JPD直径≤1.0 cm者的50.0%(12/24,P＜0.01),但JPD数量与结石发生无明显相关性.不伴胆总管结石的JPD患者胆总管直径为(1.47±0.54)cm,显著大于不伴胆总管结石的无JPD患者的(1.20±0.54)cm(P＜0.05).JPD患者胰腺炎发生率为8.66%,明显高于无JPD患者的3.58%,但JPD与ERCP术后胰腺炎无相关性.结论 JPD可能是胆总管结石及胰腺炎发生的因素之一.     

经内镜逆行胰胆管造影治疗十二指肠乳头憩室合并胆总管结石的临床价值

回顾性分析2014年1月至2017年12月在蚌埠市第三人民医院接受ERCP取石治疗的171例十二指肠乳头憩室合并胆总管结石的患者资料。患者均成功完成ERCP取石治疗,平均手术时间（35.6±7.9）min,平均插管时间（6.5±2.1）min,插管成功率100％。167例患者取净结石,一次取石成功率 97.7％（167／171）。7例（4.1％）患者术中出血,1例（0.6％）患者发生迟发性出血;术中及术后无一例患者发生穿孔;3例（1.8％）患者术后发生急性胰腺炎。术后随访时间12～24个月,随访期间,所有患者健康生存,无严重并发症发生。ERCP治疗十二指肠乳头憩室伴胆总管结石安全有效。     

经十二指肠镜治疗合并乳头旁憩室的胆总管结石106例临床分析

目的 总结经十二指肠镜治疗合并乳头旁憩室的胆总管结石的临床效果,经验体会.方法 回顾分析我院2005年2月至2011年4月经十二指肠镜治疗的胆总管结石伴十二指肠乳头旁憩室106例患者资料.结果 106例中行十二指肠乳头括约肌切开（EST）95例,乳头气囊扩张术（EPBD）6例,一次性成功取净胆总管结石101例,5例镜下治疗失败转外科手术治疗,无1例出现憩室穿孔并发症.结论 十二指肠镜对合并乳头旁憩室的胆总管结石进行治疗,相对正常乳头下而言,操作难度有所增大,乳头切开以小切开为宜,十二指肠镜对合并乳头旁憩室的胆总管结石进行镜下治疗依然是一种微创、安全、有效的方法.     

十二指肠乳头旁憩室伴胆管结石的内镜治疗

随着治疗内镜逆行胰胆管造影（ERCP）技术的广泛开展，十二指肠乳头旁憩室（juxtapapillary duodenal diverticulum，JPD）合并胆管结石的治疗逐渐为临床医师所重视。由于憩室的存在，乳头位置及其开口发生了各种变异，以往多采用手术治疗，但创伤大，并发症多，而内镜治疗创伤小，但操作技术要求高，目前基层医院开展受限。     

十二指肠乳头周围憩室与胆总管结石关系的探讨

目的探讨十二指肠乳头周围憩室在胆总管结石发病中的作用。方法回顾分析我院近5年来行逆行胰胆管造影术(ERCP)检查的878例患者,其中发现十二指肠乳头周围憩室者128例(憩室组),未发现憩室者750例(非憩室组)。分析比较2组患者年龄、胆总管结石的发病率、复发率方面的差异。结果ERCP检出十二指肠乳头周围憩室128例,占14.58%。憩室组平均年龄64.8岁,明显高于非憩室组54.2岁(P<0.01)。憩室组胆总管结石检出率为66.4%,非憩室组为41.3%(P<0.001)。憩室组胆总管结石复发率为24.7%,非憩室组为11.9%(P<0.01)。结论十二指肠乳头周围憩室患者胆总管结石的发病率、复发率显著增高,十二指肠乳头周围憩室是胆总管结石形成的病因之一,也是胆总管结石复发的重要因素。     

老年胆总管结石合并十二指肠乳头旁憩室患者清醒镇静下内镜治疗

十二指肠乳头旁憩室常发生于老年人，且易并发胆总管结石口，在内镜诊治过程中，应用镇静麻醉药物，甚至在麻醉状态下操作，对患者、操作者及疾病的诊治均有益处。我们于2002年6月至2004年7月为32例老年胆总管结石合并十二指肠乳头旁憩室患者给予小剂量咪唑安定静脉注射，在患者清醒镇静下行内镜乳头括约肌切开胆总管取石术，疗效满意，报道如下。     

An analysis of the relationship between bile duct stones and periampullary duodenal diverticula

Previous studies have suggested a relationship between bile duct stones and periampullary duodenal diverticula. The aim of the present study was to examine this association in more detail, including step-wise logistic regression to identify independent predictors for the presence of diverticula. Clinical, endoscopic and radiological data were analysed from 794 consecutive subjects with bile duct stones; 44 with primary duct stones (without gall-bladder stones) and 750 with bile duct stones associated with current or previous gall-bladder stones. Frequencies of diverticula in subjects with bile duct stones were compared with those in age-matched controls who had undergone upper gastrointestinal endoscopy using a side-viewing endoscope (n = 100) or who had undergone endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic cancer (n = 100). The frequencies of diverticula in subjects with primary duct stones (70%) and bile duct stones with current or previous gall-bladder stones (25%) were significantly higher than in both control groups (7 and 8%, respectively). When subjects with bile duct stones were analysed by step-wise logistic regression, age and bile duct diameter were independent predictors of the presence of diverticula, but diverticula were unrelated to gender, mode of presentation, number of bile duct stones and outcome after endoscopic sphincterotomy. A significant association exists between duodenal diverticula and bile duct stones, perhaps because diverticula predispose to stone formation through the combined effects of bile stasis and bacterial contamination of bile.     

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM: To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS: Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores.RESULTS: Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management.CONCLUSION: Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patient’s condition, operator’s expertise and local resources should be taken into account in making treatment decisions.     

Ampulla dilation with different sized balloons to remove common bile duct stones

AIM:To assess the outcomes of ampulla dilation with different sized balloons to remove common bile duct (CBD) stones.METHODS:Patients (n=208) were divided into five groups based on the largest CBD stone size of < 5,6-8,8-12,12-14,and > 14 mm.Patients underwent limited endoscopic sphincterotomy (EST) alone or limited EST followed by endoscopic papillary balloon dilation with 8,10,12 and 14 mm balloons,such that the size of each balloon did not exceed the size of the CBD.Short-and long-term outcomes,such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis,perforation,bleeding,and pneumobilia were compared among the five groups.RESULTS:The overall rate of successful stone removal in all groups was 100%,and all patients were cured.Eight (3.85%) patients had post-ERCP pancreatitis,none had perforations,and 6 (2.9%) had bleeding re-quiring transfusion.There were no significant differences in early complication rates among the five groups.We observed significant correlations between increased balloon size and the short-and long-term rates of postERCP pneumobilia.Post-ERCP pancreatitis and bleeding correlated significantly with age,with post-ERCP pancreatitis occurring more frequently in patients aged < 60 years,and bleeding occurring more frequently in patients aged > 70 years.We observed a significant correlation between patient age and the diameter of the largest CBD stone,with stones > 12 mm occurring more frequently in patients > 60 years old.CONCLUSION:Choosing a balloon size based on the largest stone diameter is safe and effective for removing CBD stones.Balloon size should not exceed 15 mm.     

Endoscopic treatment of difficult extrahepatic bile duct stones,EPBD or EST: An anatomic view

Large bile duct stone( 10 mm) or multiple stones(≥ 3) are challenging for endoscopists. Endoscopic sphincterotomy(EST) is a routine therapeutic endoscopic retrograde cholangiopancreatography(ERCP) procedure usually used. It is safe and effective, but severe perforation or massive bleeding are the main causes of mortality. Because of the permanent destroy ofOddi sphincter, the use of EST is still controversial. Endoscopic papillary balloon dilation(EPBD) gives another way to open the sphincter. Less incidence of bleeding, perforation and partly preserving the Oddi sphincter's function are the main advantages. But high incidence of post-ERCP pancreatitis becomes a predominant problem. According to the anatomical feature of Oddi sphincter, limited EST + EPBD seems a more reasonable procedure. Compared to the former two procedures, it makes the stone extraction process much easier with lower incidences of short-term and long-term complications.     

Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones

AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones. METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed. RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P=0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P=0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P=0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P=0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P=0.00). CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.     

Endoscopic papillary large balloon dilation for removal of bile duct stones

AIM:To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation(EPLBD)for bile duct stones in a multicenter prospective study.METHODS:Lithotomy by EPLBD was conducted in 124patients with bile duct stones≥13 mm in size or with three or more bile duct stones≥10 mm.After endoscopic sphincterotomy,the papilla was dilated using balloons 12-20 mm in diameter fitting the bile duct diameter.RESULTS:The success rate of first-time lithotomy was 86.3%(107/124)and the final lithotomy success rate was 100%(124/124).Lithotripsy was needed in10 of the 124(13.6%)patients.Adverse events due to the treatment procedure occurred in 6(4.8%)patients,all of which were mild.Performing large balloon dilation after endoscopic sphincterotomy in patients with large stones or multiple stones in the bile duct is considered to ensure the safety of treatment and to reduce the need for lithotripsy.CONCLUSION:It is suggested that treatment by EPLBD for large bile duct stones may be safe and useful.     

Using cholecystokinin to facilitate endoscopic clearance of large common bile duct stones

AIM:To evaluate the effect of cholecystokinin(CCK)during extracorporeal shockwave lithotripsy(ESWL)in the clearance of common bile duct(CBD)stones in endoscopic retrograde cholangiopancreatography(ERCP).METHODS:Between January 2007 and September2012,patients with large CBD stones who were treated with ESWL and ERCP were identified retrospectively.Patients were randomized in equal numbers to cholecystokinin(CCK)and no CCK groups.For each CCK case,a dose(3 ng/kg per min for 10 min)of sulfated octapeptide of CCK-8 was administered intravenously near the beginning of ESWL.ERCP was performed 4 h after a session of ESWL.The clearance rate of the CBD was assessed between the two groups.RESULTS:A total of 148 consecutive cases(CCK group:74,no CCK group:74)were tallied.Overall there were 234 ESWLs and 228 ERCPs in the 148 cases.The use of CCK showed a significantly higher rate of successful stone removal in the first ESWL/ERCP procedure(71.6%vs 55.4%,P=0.035),but resulted in similar outcomes in the second(42.8%vs 39.4%)and third(41.7%vs 40.0%)sessions,as well as total stone clearance(90.5%vs 83.8%).The use of mechanical lithotripsy was reduced in the CCK group(6.8%vs17.6%,P=0.023),and extremely large stone(≥30mm)removal was higher in the CCK group(72.7%vs41.7%,P=0.038).CONCLUSION:CCK during ESWL can aid with the clearance of CBD stones in the first ESWL/ERCP session.Mechanical lithotripsy usage was reduced and the extremely large stone(≥30 mm)clearance rate can be raised.     

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.     

一步法和分步法治疗胆囊结石合并胆总管结石患者疗效及并发症分析

目的 探讨一步法与分步法手术治疗胆囊结石合并胆总管结石患者的疗效.方法 2016年1月～2019年6月我院诊治的胆囊结石合并胆总管结石患者152例,其中87例接受一步法手术,即行腹腔镜胆囊切除(LC)和胆总管探查取石(LCBDE)术,65例接受分步法手术,即行内镜逆行胰胆管造影/乳头括约肌切开(ERCP/EST)和LC...     

内镜下十二指肠乳头小切开后球囊扩张术治疗胆总管结石的临床研究

目的探讨内镜下十二指肠乳头括约肌小切开后球囊扩张术在胆总管结石治疗中的有效性和安全性。方法将150例临床确诊为胆总管结石的患者随机分为乳头括约肌切开组(EST组)和乳头括约肌小切开后球囊扩张术组(SEST+EPBD组),比较两组疗效及并发症的发生率。结果 EST组和SEST+EPBD组取石成功率分别为92%和97%(χ2=1.19,P0.05)。EST组术后出现急性胰腺炎2例,出血4例,结石复发11例,逆行性胆道感染15例。SEST+EPBD组术后出现急性胰腺炎1例,出血1例,结石复发2例,逆行性胆道感染6例。两组取石成功率及近期并发症比较差异无统计学意义(P0.05),远期并发症比较差异有统计学意义(P0.05)。结论内镜下乳头括约肌小切开后球囊扩张术治疗胆总管结石安全、有效,并发症少,并且尽可能的保留了十二指肠乳头括约肌的功能,值得临床推广。