内镜逆行副胰管造影的应用进展

副胰管是胰液的第二流出道, 内镜逆行副胰管造影在胰腺疾病的诊疗中起重要作用。内镜逆行副胰管造影作为主胰管深插管失败的重要补充手段, 可以进行副乳头括约肌切开术和副胰管支架置入术等治疗。内镜逆行副胰管造影最常用于胰腺分裂的诊疗, 也是部分慢性胰腺炎、胰腺假性囊肿等疾病的有效治疗方式。内镜逆行副胰管造影并发症发生率较主胰管造影高, 要预防和关注术后并发症的发生。     

2007′上海胰腺疾病与内镜技术临床应用研讨会主要内容

◆主题报告1.急性胆源性胰腺炎内镜治疗现状2.慢性胰腺炎内镜治疗价值3.胰腺疾病的EUS、EUS-FNA诊断价值4.中晚期胰腺癌EUS下放射粒子种植治疗5.壶腹癌、胆管癌放射粒子支架治疗6.重症胰腺炎内镜介入治疗价值◆内镜演示内容胰管塑料、金属支架胰腺假性囊肿内镜引流术EUS、EUS-F     

儿童慢性胰腺炎内镜治疗的研究进展

儿童慢性胰腺炎是一种慢性、不可逆性炎症性疾病,可出现顽固性腹痛和胰腺内外分泌功能异常,严重影响儿童生长发育和生活质量。经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography, ERCP）于20世纪70年代末开始用于儿童患者,主要用于治疗胰管结石、胰管狭窄、胰腺假性囊肿等,常见方法有胰管括约肌切开术、结石取出术、胰管支架置入术。ERCP治疗慢性胰腺炎因疗效好、创伤小等优点已逐渐替代传统外科手术,成为首选治疗方案。     

内镜逆行胰胆管造影术联合超声内镜引导下胰管支架引流治疗重症胰腺炎后胰管离断综合征1例

本文报道一例患者急性坏死性胰腺炎后出现胰瘘、胰管离断, 曾放置腹腔引流管引流胰腺远端胰液, 第1次ERCP造影证实胰腺体部胰管不完全断裂, 放置双猪尾胰管支架以引流胰腺远端胰液, 后胰管支架移位, 再次ERCP, 导丝及造影剂无法逆行越过胰体部胰管断裂处, 后通过超声内镜引导下胰管穿刺引流术经胃壁穿刺胰管, 内镜下放置7 Fr×150 mm塑料支架至胰管断裂处。患者术后恢复良好, 定期随访腹部CT提示胰管支架位置良好, 胰腺体尾部积液逐渐吸收。     

胰管支架在胰腺疾病中的应用

1983年Seigal等率先经内镜引导下胰管内放置塑料支架治疗慢性胰腺炎胰管狭窄,此后胰管支架因其良好的引流效果、微创以及并发症少而逐渐应用于多种胰腺疾病的治疗. 一、慢性胰腺炎 慢性胰腺炎(CP)是指各种原因造成的胰腺局部的、节段性的或弥漫性的慢性进行性炎症,使胰腺组织的功能长期损伤,胰腺呈部分或广泛纤维化,主要的病理生理改变是胰管压力升高.胰管狭窄和胰管结石可以导致胰管内的压力增高,并引起腹痛等相关临床症状.正常胰管内压力在16～18 mmHg(1 mmHg=0.133kPa),CP伴有胰管扩张的患者咦管压力在18～48 mmHg[1].     

超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术治疗胰腺分裂症1例

1例慢性胰腺炎、胰管结石伴梗阻性黄疸患者,因经内镜逆行胰胆管造影术主乳头胰管反复插管困难,副乳头开口难辨,最后选择在全麻下行超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术+副乳头扩张术+胰管探条扩张术+胰管支架置入术,术中补充诊断：胰腺分裂。本文报道了该疑难病例的内镜治疗过程及护理配合要点。     

十二指肠副乳头的诊断及其治疗应用

十二指肠副乳头为胚胎时期副胰管进入十二指肠的开口,成年后发生退化,但部分人群的十二指肠副乳头退化不明显,表现为解剖变异。超声内镜、内镜下逆行胰胆管造影、磁共振胰胆管成像对其有较高的诊断价值。十二指肠副乳头通常只需随访,对于并发肿瘤的患者,则可根据情况选择内镜下治疗或外科手术治疗。在主胰管中断或狭窄变形导致插管困难的患者中,十二指肠副乳头可用于插管造影进行胰腺分裂症、胰腺炎、胰腺结石等疾病的诊断。此外,通过十二指肠副乳头括约肌切开后进行插管、球囊扩张、副胰管支架置入等方法,可以缓解胰腺分裂症及慢性胰腺炎患者的临床症状。通过十二指肠副乳头进行插管取石,对胰腺结石患者也有较好疗效。该文对其临床特征、病理特点、诊断及相关治疗作一综述。     

超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术治疗胰腺分裂症1例

1例慢性胰腺炎、胰管结石伴梗阻性黄疸患者, 因经内镜逆行胰胆管造影术主乳头胰管反复插管困难, 副乳头开口难辨, 最后选择在全麻下行超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术+副乳头扩张术+胰管探条扩张术+胰管支架置入术, 术中补充诊断:胰腺分裂。本文报道了该疑难病例的内镜治疗过程及护理配合要点。     

胰腺分裂内镜治疗价值

目的探讨内镜下治疗胰腺分裂的疗效和安全性。方法收集2006年6月至2013年6月在南京大学医学院附属鼓楼医院消化科就诊的8例胰腺分裂患者的临床资料,对术中及术后情况进行回顾性分析。结果8例胰腺分裂患者共行经内镜逆行胰胆管造影术28例次,均置入胰管支架,其中7例同时行副乳头括约肌切开术,6例行内镜下扩张术,1例行胰管取石术。术后出现1例次轻度胰腺炎。随访2～47个月,1例死于胰腺癌,3例已拔出支架,3例定期复查,1例失访。患者术后慢性胰腺炎急性发作频率及腹痛程度均较术前明显降低。结论内镜下治疗胰腺分裂安全有效,可减少胰腺炎发作频率,减轻术后腹痛程度,术后并发症发生率低。     

急性胰腺炎的内镜治疗

30多年前经内镜逆行胰胆管造影及乳头肌切开取石术已用于急性胆源性胰腺炎的病因去除。近10余年来,内镜微创技术迅速发展,更广泛地用于治疗急性胰腺炎的后期并发症,如感染性胰腺坏死、胰腺假性囊肿、胰管中断综合征以及消化道瘘等。重点介绍了内镜在急性胰腺炎治疗中的应用及进展。     

Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study

BACKGROUND: Pancreatitis is the most frequent complication of ERCP. Injury to the papilla during ERCP could obstruct pancreatic duct outflow and initiate pancreatitis. A randomized prospective study was performed to evaluate the effect of pancreatic duct stent placement on the frequency and severity of post-ERCP pancreatitis in a selected group of patients. METHODS: The study group consisted of patients over 18 years of age at high risk for post-ERCP pancreatitis because of a difficult cannulation, sphincter of Oddi manometry, and/or the performance of endoscopic sphincterotomy. Patients were prospectively randomized to have a pancreatic duct stent placed or no stent upon completion of the ERCP. The endoprosthesis used was either a 5F nasopancreatic catheter or 5F, 2-cm long pancreatic stent. Study endpoints were the frequency and severity of post-ERCP pancreatitis. RESULTS: Patients undergoing pancreatic duct stent placement had a lower frequency of post-ERCP pancreatitis as compared with those in the control group (28% vs. 5%; p < 0.05). Pancreatitis tended to be less severe in patients who had pancreatic duct drainage. CONCLUSIONS: Pancreatic duct stent insertion after ERCP reduces the frequency of post-ERCP pancreatitis in patients at high risk for this complication.     

The role of endoscopic retrograde cholangiopancreatography in patients with pancreatic disease

Given the significant risk of pancreatitis and the advent of high-fidelity diagnostic techniques, ERCP is now reserved as a therapeutic procedure for those with pancreatic disease. Early ERCP benefits those with gallstone pancreatitis who present with or develop cholangitis or biliary obstruction. Among those with idiopathic pancreatitis, ERCP may be used to confirm and treat SOD, microlithiasis, and structural anomalies, including pancreas divisum. Pancreatic endotherapy is a consideration to decrease pain in those with pancreatic duct obstruction, although surgical decompression may be more durable, particularly in those with severe disease. Pancreatic duct leaks may respond to endoscopic drainage, but optimal therapy is achieved if a bridging stent can be placed. Finally, using a wire-guided technique and pancreatic duct stents in high-risk patients, particularly in cases of suspected SOD, may minimize the risk of post-ERCP pancreatitis.     

Stenting in chronic pancreatitis--the mistakes and limitations

Endoscopic treatment of chronic pancreatitis using pancreatic duct stents was first described 15 years ago. Considering our own experience and the data of the literature we describe indications, contraindications, risks and limitations of the procedure and on the other hand its therapeutic effects. According to the actual experience an indication for pancreatic duct stenting can be seen in patients with a solitary prepapillary stenosis without stenosis of side branches or as success control for a planned surgical intervention. Contraindications are suspected malignancy, multiple pancreatic duct stenosis in the main duct or stenosis in small ducts and chronic calcifying pancreatitis with pancreatic duct stones. From 6/92 until 5/97 189 patients were operated for chronic pancreatitis in the Ulm University Hospital. Of these patients 35 (18.7%) were unsuccessfully treated preoperatively in other hospitals by pancreatic duct stent. Because of frequent complications like stent dislocation and stent occlusion repeated ERCPs (4.5/patient) and stent exchanges (3.7/patient) were performed. A therapeutical long-term benefit of pancreatic duct stenting is questionable, a definitive therapy can only be achieved in a small group of patients. However stent-induced changes of the pancreatic duct similar to chronic pancreatitis can be observed in up to 80% of all patients. Long-term observations of the reversibility of these stent-induced changes are missing, persisting chronic pancreatitis in the stented region is reported in animal models and in humans. The rates in the literature for stent dislocation and stent occlusion rate are 10-18% and 39-100% respectively. Induction of acute pancreatitis (up to 10%), duodenal reflux into the pancreatic duct, and bacterial infection with abscess formation are further severe and frequent complications of pancreatic duct stenting (1, 2). Lethal courses are reported (3, 4). Endoscopic pancreatic duct stenting in chronic pancreatitis at present is not indicated because of low success rate and a substantial risk of complications.     

Placement of a fully covered self-expandable metal stent in a young patient with chronic pancreatitis

Plastic stent insertion is a treatment option for pancreatic duct stricture with chronic pancreatitis. However, recurrent stricture is a limitation after removing the plastic stent. Self-expandable metal stents have long diameters and patency. A metal stent has become an established management option for pancreatic duct stricture caused by malignancy but its use in benign stricture is still controversial. We introduce a young patient who had chronic pancreatitis and underwent several plastic stent insertions due to recurrent pancreatic duct stricture. His symptoms improved after using a fully covered self-expandable metal covered stent and there was no recurrence found at follow-up at the outpatient department.     

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.     

Stent placement in the pancreatic duct prevents pancreatitis after endoscopic sphincter dilation for removal of bile duct stones

BACKGROUND: Pancreatitis is the most serious complication of endoscopic sphincter dilation. The aim of this study was to determine whether temporary stent placement in the main pancreatic duct decreases the frequency of pancreatitis and level of hyperamylasemia. METHODS: Stents were placed in the pancreatic duct after endoscopic sphincter dilation in 40 consecutive patients with bile duct stones. Stents were removed endoscopically 3 days later. Changes in serum amylase and the frequency of pancreatitis for this group were compared with those in 92 patients who underwent sphincter dilation without pancreatic duct stent placement. RESULTS: Stent placement was successful in 38 of 40 patients. Although the difference in the frequency of pancreatitis was not significantly different between stent and control groups, there was a trend toward a decrease in pancreatitis in the stent group. The level of postprocedure hyperamylasemia was significantly less in the stent group (p < 0.05). There were no procedure-related complications. CONCLUSIONS: Temporary placement of a stent in the pancreatic duct after sphincter dilation for removal of bile duct stones has a beneficial effect in terms of postprocedure hyperamylasemia and appears to reduce the frequency of postprocedure pancreatitis.     

Endoscopic technique for the management of pancreatitis and its complications

Therapeutic endoscopy is now increasingly used to treat gallstone pancreatitis, acute pancreatitis of other aetiologies, chronic pancreatitis and complications associated with acute or chronic pancreatitis. This chapter is a brief review of the endoscopic interventions currently performed in patients with acute or chronic pancreatitis. These interventions include biliary and pancreatic endoscopic sphincterotomy at the major or minor papilla, stricture dilatation on the common bile duct or main pancreatic duct, stent placement in the biliary or pancreatic ducts, stone extraction with or without extracorporeal shock wave lithotripsy, and transmural or transpapillary drainage of pancreatic fluid collections. As most of the studies reported were uncontrolled and retrospective, uncertainties persist with regard to the best approaches for treating the patients concerned. Appropriate patient selection, adequate expertise, and a supporting multidisciplinary infrastructure are essential prerequisites of a high success rate in improving the clinical condition of these patients.     

MERITS and DEMERITS OF METALLIC STENT FOR TREATMENT OF PANCREATIC DUCT STRICTURES IN PATIENTS WITH CHRONIC PANCREATITIS

We inserted a metallic stent into the strictures of the main pancreatic duct in two patients with calcified chronic pancreatitis and severe abdominal pain not to be relieved using narcotics. One patient was a 39‐year‐ old male, and the other was 49‐year‐old male. Their etiology of chronic pancreatitis was alcoholism. We inserted a Strecker stent, 7 mm in diameter and 6 cm in length, for achieving long‐term patency than plastic stent. In one patient, the stent was obstructed half a year after the first treatment and pancreatic calculi recurred with abdominal pain. After endoscopic extraction of pancreatic stone and balloon dilatation of the stent was performed three times, a plastic stent was inserted in the metallic stent twice. Even if he was performed nerve block twice, he was administered narcotics for treatment of continuous abdominal pain. In the other patient, the stent was obstructed 1.5 years after insertion and pancreatic calculi recurred with abdominal pain. He was treated with extracorporeal shock‐wave lithotripsy for pancreatic stone, abdominal pain continued. He underwent pylorus preserving pancreato‐duodenectomy 6 years after the first stenting, because the obstructed metallic stent could not be removed. Metallic stent should not be chosen for treatment of pancreatic duct stricture.     

Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

AIM： To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement （P-GW） in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography （ERCP）.
METHODS： P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated.
RESULTS： Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% （14 patients： mild, 13; moderate, 1）. Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis （4.7%）. Of the 49 patients without stent placement, 11 developed pancreatitis （22%： mild, 10; moderate, 1）. Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.
CONCLUSION： P-GW is useful for achieving selective biliary cannulation, Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials,     

EFFICACY AND SAFETY OF PROPHYLACTIC PANCREATIC DUCT STENT (PIT‐STENT) PLACEMENT IN PATIENTS AT HIGH RISK OF POST‐ERCP PANCREATITIS

Background: The usefulness of prophylactic pancreatic stent placement for preventing post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis has been reported. We developed a new pancreatic duct stent, which was a 5 Fr, 4 cm‐long stent with a single duodenal pigtail (Pit‐stent). Patients and Methods: Pancreatic duct stenting using a Pit‐stent was attempted in 76 patients (40 men, 36 women; mean age, 65 years; age range, 42–91 years) at high risk of post‐ERCP pancreatitis. The frequency of post‐ERCP pancreatitis and spontaneous passage of the stent were investigated. Results: Pancreatic duct stent placement was successfully performed in 93% of the patients. One patient developed mild pancreatitis after ERCP (1.4%). Spontaneous passage of the stent was observed in 92%. There were no other complications or procedure‐related deaths in this group. Conclusions: Pancreatic duct stent insertion may reduce the incidence of post‐ERCP pancreatitis in patients at high risk of post‐ERCP pancreatitis. Spontaneous migration of a pancreatic stent that contributes to a lessening of the need for additional ERCP can be expected with the use of a Pit‐stent.