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。     

胰管狭窄的内镜下支架置入术发展历史及临床进展

胰管狭窄是胰腺疾病常见的病理生理改变，可导致胰液流出受阻、胰腺实质高压和局部缺血，诱发腹痛和加速胰腺内外分泌功能减退。扩张胰管、通畅引流为胰管狭窄的治疗核心。随着经内镜下逆行胰胆管造影术的不断完善，内镜治疗逐渐成为胰管狭窄的一线治疗方法，常用手段有括约肌切开术、狭窄扩张术和支架置入术。其中，括约肌切开术和狭窄扩张术效果不持久，常作为支架置入术的先导步骤。本文就胰管狭窄的内镜下支架置入术发展历史及临床进展进行了综述。     

超声内镜引导下胰管引流术治疗进展

各种原因引起的胰管梗阻,易诱发腹痛和胰腺炎,需要胰管引流治疗。随着内镜微创介入技术发展,无法手术切除的胰腺肿瘤和良性病变所致的胰管梗阻首选内镜下的引流已形成共识。超声内镜引导下胰管引流术(endoscopic ultrasound-guided pancreatic duct drainage, EUS-PDD)可以较好解决无法行经内镜逆行胰造影术(endoscopic retrograde pancreatography, ERP)或ERP失败的患者,丰富和完善了胰管引流的内镜下治疗手段。本文主要对病例选择、术式和手术器件选择、操作成功率、并发症及长期疗效的新进展进行总结,期望有助于临床医师对EUS-PDD有全面了解。     

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。     

胰管离断综合征内镜诊治1例

本文报道了1例以复发性胰腺假性囊肿为主要表现的胰管离断综合征,经过2次内镜下囊肿胃引流以及4次经内镜逆行胰胆管造影术治疗,最终成功放置胰管支架进行胰管断裂桥接治疗,术后囊肿吸收,患者恢复良好。此病例有助于临床医师认识胰管离断综合征,尤其是对于反复发作的胰腺假性囊肿更应当警惕本病。     

胰管良恶性狭窄的内镜治疗

目的 探讨内镜治疗胰管狭窄的临床疗效。方法 36例影像学检查确诊的胰管狭窄患者,病因包括慢性胰腺炎、胰腺分裂症、胰头癌、胰腺假性囊肿等,分别在内镜逆行胰胆管造影基础上行内镜治疗,包括胰管支架置入、气囊扩张、探条扩张以及经内镜胰管括约肌切开术（EPS）、经内镜乳头括约肌切开术（EST）,同时观察术后症状缓解情况（如腹痛缓解率）、并发症发生率以及近期与远期疗效。结果36例分别进行了胰管支架引流术、气囊扩张、探条扩张、EPS和EST,术后腹痛症状有不同程度的改善,并发症发生率较低。随访1个月～36个月,平均15个月。术后近期（≤3个月）腹痛缓解率为72.2％（26/36）,长期（>3个月）随访显示47.2％（17/36）的患者腹痛缓解无复发,63.9％（23/36）的患者体重增加,生活质量改善。高淀粉酶血症、出血的发生率分别为13.9％（5/36）和5.6％（2/36）,均经一般内科治疗于3日内缓解。支架阻塞、支架脱落的发生率分别为12.5％（3/24）和4.2％（1/24）。结论 经内镜治疗胰管狭窄是安全而有效的方法。     

ERCP治疗胰管结石的临床分析

目的 分析经内镜逆行性胰胆管造影术(endoscopic retrograde cholangiopancreatography, ERCP)治疗胰管结石的适应证、临床效果及并发症。方法 选择2016年1月至2022年1月在郑州大学第一附属医院内镜中心诊治的35例胰管结石患者，分析取石成功率、并发症，随访术后6个月临床症状缓解情况。结果 35例患者共进行ERCP 53例次，取净结石21例，取石成功率60.0%。术中乳头出血1例，术后高淀粉酶血症6例，急性胰腺炎2例，术后6个月随访患者腹痛、脂肪泻等症状缓解，体质量增加。结论 ERCP治疗胰管结石是安全有效的，能减轻患者痛苦，改善临床症状。     

副胰管在ERCP中的应用价值

内镜逆行胰胆管造影术（ERCP）联合内镜下操作,即治疗性ERCP已被广泛应用于临床胆胰疾病的诊治。ERC作为一种微创治疗手段,其术后并发症仍是广大临床医生迫切希望解决的问题之一。本文旨在通过介绍副胰管的解剖结构及其与ERCP术后胰腺炎（post-ERCPpancreatitis,PEP）发生率之间的相关性,提出副胰管（accessorypancreaticduct,APD）介入治疗在ERCP治疗中的潜在可能性。     

内镜超声引导下胰管引流

通常,胰管高压的患者以腹痛为主要症状,常见于慢性胰腺炎、胰管结石、胰空肠吻合口狭窄及胰腺导管内乳头状黏液性肿瘤（IPMN）的患者,主要解决方式为外科手术或内镜下减压,如括约肌切开术、逆行胰管支架置入术、胰管狭窄扩张术等。一项随机试验显示,慢性胰腺炎导致胰管阻塞的治疗中外科介入的有效性优于内镜介入,然而并未考虑患者主观接受程度与创伤大小。一些由于一般条件不允许行外科手术或拒绝行手术治疗的患者会选择内镜介入治疗,但对于有解剖结构改变者,如Whipple术后患者,经典的ERCP术往往不能成功。     

青少年慢性胰腺炎的内镜诊断与治疗

目的：研究诊断性和治疗性经内镜逆行胰胆管造影术(ERCP)在青少年慢性胰腺炎(CP)诊断及治疗中的价值。方法：回顾分析1997年2月～2002年2月间确诊为青少年CP并行ERCP的13例临床资料。结果：13例中12例存在腹痛症状，10例有“胰腺炎”病史。ERCP见胰管扩张12例，胰管结石7例，胰腺假性囊肿2例，胰腺分裂症3例，胆囊结石l例。内镜下治疗：乳头括约肌切开术7例，胰管取石6例，支架置入5例，胰管狭窄扩张术4例，副乳头切开2例。ERCP后高淀粉酶血症4例，胰腺炎急性发作3例，均为水肿型胰腺炎。经6—68个月随访，ll例未复发，2例复发者经再次ER-CP治疗后腹痛未再出现。结论：ERCP对青少年CP的诊断及治疗有较高的价值。但青少年CP患者ERCP术后具有较高的并发症发生率，对此内镜医师应高度重视。     

Effects of acute pancreatic duct obstruction on pancreatic perfusion: implication of acute pancreatic duct decompression

BACKGROUND: Acute pancreatitis can result in pancreatic ischaemia and necrosis. Pancreatic duct (PD) obstruction may be the first step causing ischaemia in acute pancreatitis. Nitric oxide donors can attenuate acute pancreatitis through improvement in compromised pancreatic perfusion (PP). In this study, we determined if (1) PD obstruction altered PP and (2) PD decompression or L-arginine administration reversed this change. METHODS: Fifteen Australian possums were randomly assigned to two groups: Animals in group A (n = 6) were subjected to 30 min of PD obstruction and 60 min of PD decompression. Animals in group B (n = 9) were subjected to 120 min PD ligation and 60 min PD decompression. A subset group B (n = 6) were subjected to intravenous L-arginine (100 microg/kg) at the end of 120 min of ligation and at the end of PD decompression. The PP (Laser Doppler fluxmetry), PD pressure and blood pressure were continuously monitored. RESULTS: PD pressure increased from 2.9 +/- 2.5 to 18.1 +/- 4.9 mmHg following PD ligation. PP was reduced to 67.1% +/- 4.5% (P<0.01) and 46.2% +/- 7.5% (P<0.001) of baseline following 30 and 120 min of PD ligation, respectively. Following 60 min of PD decompression, PP was restored to 89.1% +/- 13.4% (P<0.02) of the baseline in the 30-min group. However, following 120 min PD ligation, PP remained depressed. L-arginine administration after 120 min of PD ligation transiently increased PP from 46.2% +/- 7.5% to 81.1% +/- 8.6% (P<0.03) of baseline. This effect was reproduced if L-arginine was administered at the end of decompression (P<0.05). CONCLUSION: In patients with acute pancreatitis due to obstructive causes, early decompression of the PD may prevent early pancreatic ischaemia.     

Cystic duct directly joining the main pancreatic duct

A unique anomaly of the direct union between the cystic duct and the main pancreatic duct is presented. A 19-year-old man with a history of repeated epigastralgia underwent endoscopic retrograde cholangiopancreaticography that showed a direct union between the cystic duct and the main pancreatic duct. No pancreaticobiliary maljunction was noticed. Cholecystectomy accompanied by resection of the long cystic duct was performed. The excised gallbladder showed cholesterolosis, chronic cholecystitis, and hyperplasia of the pseudopyloric glands microscopically. The patient has been well for 3 years since surgery.     

Endoscopic pancreatic duct stenting to treat pancreatic ascites

BACKGROUND: Management of pancreatic ascites with conservative medical therapy or surgery has met with limited success. Decompression of the pancreatic ductal system through transpapillary stent placement, an alternative strategy, has been reported in only a handful of cases of pancreatic ascites. METHODS: We reviewed all cases from 1994 to 1997 in which patients with pancreatic ascites underwent an endoscopic retrograde pancreatogram documenting pancreatic duct disruption with subsequent placement of a transpapillary pancreatic duct stent. Clinical end points were resolution of ascites and need for surgery. RESULTS: There were 8 cases of pancreatic ascites in which a 5F or 7F transpapillary pancreatic duct stent was placed as the initial drainage procedure. Pancreatic ascites resolved in 7 of 8 patients (88%) within 6 weeks. Ascites resolved in the eighth patient, a poor candidate for surgery, following placement of a 5 mm expandable metallic pancreatic stent. No infections, alterations in ductal morphology, or other complications related to stent placement were noted. There was no recurrence of pancreatic ascites or duct disruption at a mean follow-up of 14 months. CONCLUSIONS: Our experience doubles the number of reported cases in which transpapillary pancreatic stent placement safely obviated the need for surgical intervention in the setting of pancreatic ascites. This therapeutic endoscopic intervention should be seriously considered in the initial management of patients with pancreatic ascites.     

The pancreatic duct cell.

A conference entitled "The Pancreatic Duct Cell: Physiology and Pathophysiology" was held September 26-29, 1991, at the Engineering Society Club of Baltimore. The conference was organized by a committee consisting of John Williams of the University of Michigan (Co-Chair), Daniel Longnecker of Dartmouth Medical School (Co-Chair), Barry Agent of Newcastle Upon Tyne, Raymond Frizzell of the University of Alabama at Birmingham, Sherwood Githens of the University of New Orleans, and Sarah Kalser of the NIDDK. The meeting was sponsored by the NIDDK with contributions from NCI, NIDR, ADAMHA, and the American Gastroenterological Association. About 100 investigators from the United States, England, Canada, Germany, Norway, and Israel attended the conference. The participants were based in a number of distinct disciplines including both basic and clinical sciences. While the main focus was on pancreatic ducts, comparison of salivary and bile ducts was also included.