Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma

AIM: To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma. METHODS: In total, 118 patients with hilar cholangiocarcinoma underwent endoscopic management [endoscopic nasobiliary drainage (ENBD) or endoscopic biliary stenting] as a temporary drainage in our institution between 2009 and 2014. We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment. The risk factors for biliary reintervention, post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis, and percutaneous transhepatic biliary drainage (PTBD) were also analyzed using patient- and procedure-related characteristics. The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage. RESULTS: In total, 137 complications were observed in 92 (78%) patients. Biliary reintervention was required in 83 (70%) patients. ENBD was significantly associated with a low risk of biliary reintervention [odds ratio (OR) = 0.26, 95%CI: 0.08-0.76, P = 0.012]. Post-ERCP pancreatitis was observed in 19 (16%) patients. An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis (OR = 3.46, 95%CI: 1.19-10.87, P = 0.023). PTBD was required in 16 (14%) patients, and Bismuth type III or IV cholangiocarcinoma was a significant risk factor (OR = 7.88, 95%CI: 1.33-155.0, P = 0.010). Of 102 patients with initial unilateral drainage, 49 (48%) required bilateral drainage. Endoscopic sphincterotomy (OR = 3.24, 95%CI: 1.27-8.78, P = 0.004) and Bismuth II, III, or IV cholangiocarcinoma (OR = 34.69, 95%CI: 4.88-736.7, P < 0.001) were significant risk factors for bilateral drainage. CONCLUSION: The endoscopic management of hilar cholangiocarcinoma is challenging. ENBD should be selected as a temporary drainage method because of its low risk of complications.     

The role of endoscopy in noniatrogenic injuries of the liver

Traumatic noniatrogenic biliary injuries, unlike iatrogenic injuries, are usually complex in nature and are frequently associated with other multiorgan trauma and infection. Bile leaks following these injuries are an important source of short-and long-term morbidity. Repeat surgery for primary repair of complex bile leaks is difficult and can be complicated by anastomotic leakage and biliary stricture formation. Endoscopic retrograde cholangiopancreatography (ERCP) was initially used only as a diagnostic technique to guide surgical repair in this setting. However, with the high success rates observed in treatment of iatrogenic bile leaks, ERCP has emerged as a nonoperative treatment option for noniatrogenic biliary leaks as well. Recent data show that ERCP is effective in managing bile leaks after blunt and sharp liver injuries, using transpapillary stenting, endoscopic sphincterotomy, or both, with greater than 80% healing rates. The evidence is not clear regarding which ERCP maneuver—endoscopic sphincterotomy, transpapillary stenting, or both—should be used.     

肝移植术后胆管并发症的内镜治疗价值

目的评估肝移植术后胆管并发症内镜治疗的临床价值。方法我院从2001年3月至2006年10月进行的45例肝移植中,术后出现胆管并发症16例,其中胆漏1例,胆管狭窄8例,胆管狭窄并胆管结石2例。11例接受了内镜介入治疗计14次,包括内镜下放置鼻胆管外引流4例,放置支架内引流10例,气囊扩张10例,乳头括约肌小切开7例,乳头括约肌切开加取石2例。结果1例因内镜治疗时导丝无法通过狭窄段,改行PTC放置胆管支架,其余胆管并发症经内镜介入治疗有效。结论ERCP有助于肝移植术后胆管并发症诊断,治疗有效、安全,是肝移植术后胆管并发症首选治疗方法。     

Repeat endoscopic retrograde cholangiopancreaticography after failed initial precut sphincterotomy for biliary cannulation

AIM: To investigate the outcome of repeating endoscopic retrograde cholangiopancreaticography (ERCP) after initially failed precut sphincterotomy to achieve biliary cannulation.METHODS: In this retrospective study, consecutive ERCPs performed between January 2009 and September 2012 were included. Data from our endoscopy and radiology reporting databases were analysed for use of precut sphincterotomy, biliary access rate, repeat ERCP rate and complications. Patients with initially failed precut sphincterotomy were identified.RESULTS: From 1839 consecutive ERCPs, 187 (10%) patients underwent a precut sphincterotomy during the initial ERCP in attempts to cannulate a native papilla. The initial precut was successful in 79/187 (42%). ERCP was repeated in 89/108 (82%) of patients with failed initial precut sphincterotomy after a median interval of 4 d, leading to successful biliary cannulation in 69/89 (78%). In 5 patients a third ERCP was attempted (successful in 4 cases). Overall, repeat ERCP after failed precut at the index ERCP was successful in 73/89 patients (82%). Complications after precut-sphincterotomy were observed in 32/187 (17%) patients including pancreatitis (13%), retroperitoneal perforations (1%), biliary sepsis (0.5%) and haemorrhage (3%).CONCLUSION: The high success rate of biliary cannulation in a second attempt ERCP justifies repeating ERCP within 2-7 d after unsuccessful precut sphincterotomy before more invasive approaches should be considered.     

How do we manage post-OLT redundant bile duct?

AIM: To address endoscopic outcomes of post-Orthotopic liver transplantation (OLT) patients diagnosed with a "redundant bile duct" (RBD). METHODS: Medical records of patients who underwent OLT at the Liver Transplant Center, University Texas Health Science Center at San Antonio Texas were retrospectively analyzed. Patients with suspected biliary tract complications (BTC) underwent endoscopic retrograde cholangiopancreatography (ERCP). All ERCP were performed by experienced biliary endoscopist. RBD was defined as a looped, sigmoid-shaped bile duct on cholangiogram with associated cholestatic liver biomarkers. Patients with biliary T-tube placement, biliary anastomotic strictures, bile leaks, bile-duct stonessludge and suspected sphincter of oddi dysfunction were excluded. Therapy included single or multiple biliary stents with or without sphincterotomy. The incidence of RBD, the number of ERCP corrective sessions, and the type of endoscopic interventions were recorded. Successful response to endoscopic therapy was defined as resolution of RBD with normalization of associated cholestasis. Laboratory data and pertinent radiographic imaging noted included the pre-ERCP period and a follow up period of 6-12 mo after the last ERCP intervention. RESULTS: One thousand two hundred and eighty-two patient records who received OLT from 1992 through 2011 were reviewed. Two hundred and twenty-four patients underwent ERCP for suspected BTC. RBD was reported in each of the initial cholangiograms. Twentyone out of 1282 (1.6%) were identified as having RBD. There were 12 men and 9 women, average age of 59.6 years. Primary indication for ERCP was cholestatic pattern of liver associated biomarkers. Nineteen out of 21 patients underwent endoscopic therapy and 2/21 required immediate surgical intervention. In the endoscopically managed group: 65 ERCP procedures were performed with an average of 3.4 per patient and 1.1 stent per session. Fifteen out of 19 (78.9%) patients were successfully managed with biliary stenting. All stents were     

Long-term outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction and normal pancreatogram

BACKGROUND: For patients with sphincter of Oddi dysfunction and abnormal pancreatic basal sphincter pressure, additional pancreatic sphincterotomy has been recommended. The outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction was evaluated. METHODS: An ERCP database was searched for data entered from January 1995 to November 2000 on patients with sphincter of Oddi dysfunction who met the following parameters: sphincter of Oddi manometry of both ducts, abnormal pressure for at least 1 sphincter (> or =40 mm Hg), no evidence of chronic pancreatitis, and endoscopic dual pancreatobiliary sphincterotomy. Patients were offered reintervention by repeat ERCP if clinical symptoms were not improved. The frequency of reintervention was analyzed according to ducts with abnormal basal sphincter pressure, previous cholecystectomy, sphincter of Oddi dysfunction type, and endoscopic dual pancreatobiliary sphincterotomy method. RESULTS: A total of 313 patients were followed for a mean of 43.1 months (median, 41.0 months; interquartile range: 29.8-60.0 months). Immediate postendoscopic dual pancreatobiliary sphincterotomy complications occurred in 15% of patients. Reintervention was required in 24.6% of patients at a median follow-up (interquartile range) of 8.0 (5.5-22.5) months. The frequency of reintervention was similar irrespective of ducts with abnormal basal sphincter pressure, previous cholecystectomy, or endoscopic dual pancreatobiliary sphincterotomy method. Of patients with type III sphincter of Oddi dysfunction, 28.3% underwent reintervention compared with 20.4% with combined types I and II sphincter of Oddi dysfunction (p = 0.105). When compared with endoscopic biliary sphincterotomy alone in historical control patients from our unit, endoscopic dual pancreatobiliary sphincterotomy had a lower reintervention rate in patients with pancreatic sphincter of Oddi dysfuntion alone and a comparable outcome in those with sphincter of Oddi dysfunction of both ducts. CONCLUSION: Endoscopic dual pancreatobiliary sphincterotomy is useful in patients with pancreatic sphincter of Oddi dysfunction. Prospective randomized trials of endoscopic biliary sphincterotomy alone versus endoscopic dual pancreatobiliary sphincterotomy based on sphincter of Oddi manometry findings are in progress.     

Endoscopic balloon dilatation is a safe method in the management of common bile duct stones

BACKGROUNDS AND AIMS: Endoscopic sphincterotomy is a widely accepted treatment for patients with common bile duct stones. Despite improvement in this technique, endoscopic sphincterotomy is still associated with some biliary complications. Endoscopic balloon dilatation is a less traumatic and sphincter preserving method for removal of common bile duct stones. However, the results of controlled studies in comparison with these two methods are contradictory. The aim of this study is to compare the safety and efficacy of endoscopic balloon dilatation and endoscopic sphincterotomy in Chinese patients. PATIENTS AND METHODS: A total of 104 patients with common bile duct stones on endoscopic retrograde cholangiopancreatography were enrolled. They were randomly assigned to endoscopic balloon dilatation or endoscopic sphincterotomy. Endoscopic balloon dilatation was performed by using a balloon dilator to dilate the sphincter for 5 min. The common bile duct stones were then removed by a Dormia basket after endoscopic balloon dilatation or endoscopic sphincterotomy. Mechanical lithotripsy was performed if the stones were difficult to remove by Dormia basket. After discharge, patients were regularly followed up for biliary complications. RESULTS: The successful bile duct stone clearance rate was 94.1% in endoscopic balloon dilatation group and 100% in endoscopic sphincterotomy group. Post-procedural significant haemorrhage was higher in endoscopic sphincterotomy group than in endoscopic balloon dilatation group (14/53 versus 1/48, P < 0.001). The bleeding patient from endoscopic balloon dilatation group was a case of uremia and bleeding occurred 48 h after endoscopic balloon dilatation. All the patients with post-procedural haemorrhage were controlled endoscopically. The post-procedural serum amylase level showed no significant difference in both groups and none of them developed clinical pancreatitis. After a mean 16 months follow-up, three patients (6.3%) in endoscopic balloon dilatation group and four patients (7.5%) in endoscopic sphincterotomy group developed recurrent common bile duct stones. The recurrent common bile duct stones were multiple and muddy in consistency. They were successfully removed endoscopically. CONCLUSION: Both endoscopic balloon dilatation and endoscopic sphincterotomy are safe and effective techniques for the treatment of common bile duct stones. Endoscopic balloon dilatation can be safely applied in patients with coagulopathy and does not increase the incidence of pancreatitis or bleeding.     

Oldest biliary endoprosthesis in situ

The advantages of endoscopic retrograde cholangiopancreatography over open surgery have made it the predominant method of treating patients with choledocholithiasis. After sphincterotomy, however, 10%-15% of common bile duct stones cannot be removed with a basket or balloon. The methods for managing “irretrievable stones” include surgery, mechanical lithotripsy, intraductal or extracorporeal shock wave lithotripsy and biliary stenting. The case presented was a referred 82-year-old Caucasian woman with a 7-year-old plastic biliary endoprosthesis in situ. To the best of our knowledge the examined endoprosthesis is the oldest endoprosthesis in situ reported in the literature. Endoscopic biliary endoprosthesis placement remains a simple and safe procedure for patients with stones that are difficult to manage by conventional endoscopic methods and for patients who are unfit for surgery or who are high surgical risks. To date no consensus has been reached regarding how long a biliary prosthesis should remain in situ. Long-term biliary stenting may have a role in selected elderly patients if stones extraction has failed because the procedure may prevent stones impaction and cholangitis.     

ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis

BACKGROUND: Surgery for liver hydatidosis can result in serious morbidity and mortality. The role and efficacy of ERCP in the management of these complications was reviewed. METHODS: Retrospective analysis of 79 patients with liver hydatidosis who underwent ERCP for postoperative complications. RESULTS: All patients with biliary fistulas (n = 50) were managed by endoscopic sphincterotomy, although 9 (18%) also required a biliary endoprosthesis. Surgical reintervention was avoided in 46 (92%) patients with subsequent surgery required in only in 4 (8%). The mean time to fistula closure was 13.3 days. Patients with daughter cysts in the bile ducts (n = 7) were also treated by endoscopic sphincterotomy and evacuation of obstructing cyst material. Seven patients with elevated liver enzymes or biliopancreatic symptoms but normal ERCP findings also underwent endoscopic sphincterotomy with normalization of biochemical tests. CONCLUSIONS: ERCP is valuable for detecting and treating postoperative biliary complications after surgery for hepatic echinococcal disease. In the majority of patients, endoscopic sphincterotomy allows healing of postoperative external biliary fistulas, and should be performed as early as possible. In some cases, a biliary prosthesis may be required. Endoscopic sphincterotomy also enables clearing of the bile ducts of hydatid remnants.     

Conservative management of duodenal perforation following endoscopic sphincterotomy

Overall endoscopic retrograde cholangiopancreatography (ERCP) complication rates of 4–10% and mortality rates of 1.5% have been reported. For those patients who fail conservative therapy, a mortality rate of almost 50% has been reported. This has led some authors to recommended early operation in all duodenal perforations. We report two cases of duodenal perforations following endoscopic sphincterotomy. Perforation was suspected immediately post‐ERCP in one case and, in the second case, perforation was evident during ERCP and a biliary stent was inserted. Both of the patients were managed conservatively with bowel rest, nasogastric suction, analgesia and intravenous antibiotics. Although abdominal XR and CT showed extensive intraperitoneal and retroperitoneal gas, both of the patients made an uneventful recovery without surgical management. Based on our experience and literature review, routine surgery is not required in patients with duodenal perforations following endoscopic sphincterotomy. Surgery should be considered in any patients with clinical signs of sepsis, abscess or fluid collection in the retroperitoneum or peritoneum, documented ERCP perforation with cholelithiasis, choledocholithiasis or retained hardware. There are currently no strong data to support the benefits of early routine surgery and management should be tailored individually according to the patient's clinical condition and response to therapy.     

ERCP for the treatment of bile leak after partial hepatectomy and fenestration for symptomatic polycystic liver disease

AIM: To describe endoscopic treatment of bile leaks in these patients and to identify risk factors in these patients which can predict the development of bile leaks.METHODS: Retrospective case-control study examining consecutive patients who underwent partial hepatectomy for polycystic liver disease (PLD) and developed a postoperative bile leak managed endoscopically over a ten year period. Each case was matched with two controls with PLD who did not develop a postoperative bile leak.RESULTS: Ten cases underwent partial hepatectomy with fenestration for symptoms including abdominal distention, pain and nausea. Endoscopic retrograde cholangiopancreatography (ERCP) showed anatomic abnormalities in 1 case. A biliary sphincterotomy was performed in 4 cases. A plastic biliary stent was placed with the proximal end at the site of the leak in 9 cases; in 1 case two stents were placed. The overall success rate of ERCP to manage the leak was 90%. There were no significant differences in age, gender, comorbidities, duration of symptoms, history of previous surgery or type of surgery performed between cases and controls.CONCLUSION: ERCP with stent placement is safe and effective for management of post-hepatectomy bile leak in patients with PLD.     

Endoscopic ultrasound-guided vs endoscopic retrograde cholangiopancreatography biliary drainage for obstructed distal malignant biliary strictures: A systematic review and meta-analysis

BACKGROUND For palliation of malignant biliary obstruction(MBO), the gold-standard method of biliary drainage is endoscopic retrograde cholangiopancreatography(ERCP)with the placement of metallic stents. Endoscopic ultrasound(EUS)-guided drainage is an alternative that is typically reserved for cases of ERCP failure.Recently, however, there have been robust randomized clinical trials(RCTs)comparing EUS-guided drainage and ERCP as primary approaches to MBO.AIM To compare EUS guidance and ERCP in terms of their effectiveness and safety in palliative biliary drainage for MBO.METHODS This was a systematic review and meta-analysis, in which we searched the MEDLINE, Excerpta Medica, and Cochrane Central Register of Controlled Trials databases. Only RCTs comparing EUS and ERCP for primary drainage of MBO were eligible. All of the studies selected provided data regarding the rates of technical and clinical success, as well as the duration of the procedure, adverse events, and stent patency. We assessed the risk of biases using the Jadad score and the quality of evidence using the Grading of Recommendations Assessment,Development and Evaluation criteria.RESULTS The database searches yielded 5920 records, from which we selected 3 RCTs involving a total of 222 patients(112 submitted to EUS and 110 submitted to ERCP). In the EUS and ERCP groups, the rate of technical success was 91.96%n and 91.81%, respectively, with a risk difference(RD) of 0.00%(95%CI:-0.07, 0.07;P = 0.97; I~2 = 0%). The clinical success was 84.81% and 85.53% in the EUS and ERCP groups, respectively, with an RD of-0.01%(95%CI:-0.12, 0.10; P = 0.90; I~2 =0%). The mean difference(MD) for the duration of the procedure was-0.12%(95%CI:-8.20, 7.97; P = 0.98; I~2 = 84%). In the EUS and ERCP groups, there were14 and 25 adverse events, respectively, with an RD of-0.06%(95%CI:-0.23, 0.12; P= 0.54; I~2 = 77%). The MD for stent patency was 9.32%(95%CI:-4.53, 23.18; P =0.19; I~2 = 44%). The stent dysfunction rate was significantly lower in the EUS t group(MD =-0.22%; 95 CI:-0.35,-0.08; P = 0.001; I~2 = 0%).CONCLUSION EUS represents an interesting alternative to ERCP for MBO drainage,demonstrating lower stent dysfunction rates compared with ERCP. Technical and clinical success, duration, adverse events and patency rates were similar.     

Endoscopic management of traumatic hepatobiliary injuries

BACKGROUND: Non-surgical treatment has become the therapeutic method of choice in hemodynamically stable patients with liver trauma. There are a few reports of endoscopic management of traumatic hepatobiliary injuries in such patients; however, the optimal intervention is not known. METHODS: Twenty patients with traumatic hepatobiliary injuries from May 1997 to November 2005 were retrospectively evaluated. RESULTS: There were 18 male and two female patients with a mean age of 21.45 +/- 10.17 years (range 7-42 years). Seven patients were children. Patients presented 19.4 +/- 17.04 days following trauma. Computed tomography (CT) revealed hepatic laceration in right lobe in 14 (70%) and in left lobe in six (30%) patients. Endoscopic retrograde cholangiopancreatography (ERCP) revealed biliary leak in right duct in 14 (70%) and in left duct in six (30%) patients. Five patients also had bilhemia and one had hemobilia. Thirteen patients (65%) were treated by endoscopic sphincterotomy with nasobiliary drainage and seven (35%) were treated by nasobiliary drainage alone, which enabled fistula closure in 15.76 +/- 4.22 days and 12.14 +/- 3.93 days, respectively (P > 0.05). One patient in sphincterotomy group died due to multiple bony injuries and fat embolism. Two patients developed fever following ERCP, which responded to antibiotic treatment. CONCLUSIONS: Endoscopic treatment with nasobiliary drainage without sphincterotomy is the optimal method of management of traumatic hepatobiliary injuries in hemodynamically stable patients.     

A National Survey on the Environment and Basic Techniques of Endoscopic Retrograde Cholangiopancreatography in Korea

Background/AimsThe work environment in which endoscopic retrograde cholangiopancreatography (ERCP) is conducted has influence on its efficacy and safety. We aimed to assess the current status of ERCP work environments and to investigate the trends associated with the basic techniques of ERCP in Korea.MethodsThe work environment and information on the basic techniques of ERCP were acquired by the Korean Pancreatobiliary Association (KPBA) through a national survey in 2019. The survey was performed at the KPBA conference in 2019. The contents of survey comprised of the current environment of ERCP, preparation before ERCP, and the preferred basic techniques used in ERCP.ResultsCompleted questionnaires were returned from 84 KPBA members. The mean ERCP volume per year was approximately 500. About 60% (50/84) reported that they worked with a dedicated ERCP team with experienced nurses. Two-thirds (57/84, 68%) answered that they had a fluoroscopy room used solely for ERCP procedures. All respondents intravenously hydrated the patient to prevent post-ERCP pancreatitis (84/84, 100%). The preferred procedural sedations were balanced propofol sedation (50%) and midazolam-only sedation (47%). Wire-guided cannulation was most commonly used for selective cannulation (81%). Endoscopic retrograde biliary drainage was preferred over endoscopic nasobiliary drainage (60% vs 22%). The initial method of ampullary intervention was endoscopic sphincterotomy in 60%.ConclusionsData from the survey involving a large number of Korean ERCP doctors revealed considerable variabilities with regard to the work environment and basic techniques of ERCP in Korea. The study provides information regarding the current trends of ERCP that can be used to establish ERCP standards in Korea.     

Endoscopic ultrasound-guided biliary drainage as an alternative to percutaneous drainage and surgical bypass

Endoscopic retrograde cholangiopancreatography had been a treatment modality of choice for both benign and malignant biliary tract obstruction for more than half century, with a very high clinical success rate and low complications. But in certain circumstances, such as advanced and locally advanced pancreatobiliary malignancies(pancreatic cancer, cholangiocarcinoma, ampullary tumor) and tight benign strictures, endoscopic retrograde cholangiopancreatography(ERCP) fails. Up to this point, the only alternative interventions for these conditions were percutaneous transhepatic biliary drainage or surgery. Endoscopic ultrasound guided interventions was introduced for a couple decades with the better visualization and achievement of the pancreatobiliary tract. And it’s still in the process of ongoing development. The inventions of new techniques and accessories lead to more feasibility of high-ended procedures. Endoscopic ultrasound guided biliary drainage was a novel treatment modality for the patient who failed ERCP with the less invasive technique comparing to surgical bypass. The technical and clinical success was high with acceptable complications. Regarded the ability to drain the biliary tract internally without an exploratory laparotomy, this treatment modality became a very interesting procedures for many endosonographers, worldwide, in a short period. We have reviewed the literature and suggest that endoscopic ultrasoundguided biliary drainage is also an option, and one with a high probability of success, for biliary drainage in the patients who failed conventional endoscopic drainage.     

Endoscopic Management of Postoperative Bile Duct Injuries: A Single Center Experience

Background/Aim:

Biliary endoscopic procedures may be less invasive than surgery for management of postoperative bile duct injuries (POBDI). This retrospective work presents the experience of a single referral center during a period of 14 years in endoscopic management of POBDI.

Patients and Methods:

Between 1994 (March) and 2008 (May), ERCP had been performed on 277 patients suspected to have POBDI. Patients shown to have complete transaction of bile duct were prepared for definitive surgery. For patients with simple biliary leak, sphincterotomy was performed with stenting. Pneumatic dilatation and stenting were done on patients with biliary stricture and preserved ductal continuity. ERCP was repeated every 3 months till the site of narrowing disappeared.

Results:

The mean age was 45.3 years, 162 (58.5%) were females. The most common previous surgery was cholecystectomy (open, [N=119] 44%, and laparoscopic, [N=77] 28%). ERCP failed in 17 patients (6.1%). For successfully cannulated cases (N=260, 93.9%), the type of bile duct injury diagnosed at ERCP was completely ligated CBD (N=31/260 , 11.9%). Bile leakage was detected in (N=167/260, 64.2%) all patients with endoscopic sphincterotomy and stent insertion, the leak stopped in all of them. Biliary stricture was diagnosed in 33/260 patients (12.7%) and 17 of them had repeated balloon dilatation with stenting while the remaining had surgical correction. The success rate of endoscopic therapy for biliary strictures was 82%. Cholangiogram was normal in 29 patients (11.2%).

Conclusions:

Endoscopic therapy is safe and effective in the management of postoperative bile duct leak. For postoperative bile ductal strictures, ERCP is a less favorable option.     

经内镜微创治疗胆胰疾病的应用价值

目的　探讨经内镜微创治疗胆胰疾病的应用价值。方法　回顾性分析 1995年 7月至 2 0 0 2年 3月经内镜微创治疗胆胰疾病 42 2例次的效果及并发症 ,探讨各种方法的应用价值及优缺点。结果　 42 2例患者分别采取了乳头切开、气囊扩张、机械碎石、取石、鼻胆引流术、胆道放置内支架等治疗 ,其成功率为 94 5 5 %,并发症3 79%。结论　内镜微创治疗胆胰疾病有效、安全且对病人损伤小、可代替部分胆胰疾病的外科手术治疗。     

Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis

Endoscopic retrograde cholangiopancreatography （ERCP） is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound （EUS） and magnetic retrograde cholangiopancreatography （MRCP）, ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.     

Gallstone Ileus Following Endoscopic Retrograde Cholangiopancreatography and Endoscopic Sphincterotomy

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) is the treatment of choice for common bile duct (CBD) stones. Complication rates of 5-15%, and mortality rates of 1.0% have been reported. We report a case of gallstone ileus presenting 12 days after ERCP and ES.     

Subcapsular hepatic haematoma of the right lobe following endoscopic retrograde cholangiopancreatography: Case report and literature review

Sub capsular hepatic haematoma is a rare complication after endoscopic retrograde cholangiopancreatography(ERCP). Exact pathological mechanism is still unclear and few reports are nowadays available in literature. We report the case of a 58-year-old woman with recurrent episodes of upper abdominal pain, nausea and vomiting. On the basis of laboratory exams, abdomen ultrasound and magnetic resonance imaging she was diagnosed with a common bile duct stone. Endoscopic biliary sphincterotomy was performed. On the following day the patient complaint severe abdominal pain with rebound and hemodynamic instability. A computed tomography scan reveal a 14 cm × 6 cm × 19 cm subcapsular hepatic haematoma on the right lobe that was successfully managed via percutaneous embolization. Sub capsular liver haematoma is a rare life threatening complication after ERCP that should be managed according to patients' haemodynamic and clinic.