Radiation dose to patients during endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool for the diagnosis and treatment of the hepatobiliary system. The use of fluoroscopy to aid ERCP places both the patient and the endoscopy staff at risk of radiation-induced injury. Radiation dose to patients during ERCP depends on many factors, and the endoscopist cannot control some variables, such as patient size, procedure type, or fluoroscopic equipment used. Previous reports have demonstrated a linear relationship between radiation dose and fluoroscopy duration. When fluoroscopy is used to assist ERCP, the shortest fluoroscopy time possible is recommended. Pulsed fluoroscopy and monitoring the length of fluoroscopy have been suggested for an overall reduction in both radiation exposure and fluoroscopy times. Fluoroscopy time is shorter when ERCP is performed by an endoscopist who has many years experience of performing ERCP and carried out a large number of ERCPs in the preceding year. In general, radiation exposure is greater during therapeutic ERCP than during diagnostic ERCP. Factors associated with prolonged fluoroscopy have been delineated recently, but these have not been validated.     

细胞因子与内镜逆行胰胆管造影术后胰腺炎关系的研究进展

内镜逆行胰胆管造影术(enoscopiC retrograde cholangiopancreatography,ERCP)是当前诊治肝、胆、胰疾病的重要手段之一.急性胰腺炎是ERCP术后最常见、最严重的并发症,目前其发病机制仍未完全阐明.近年来研究的普遍共识是炎性细胞因子在轻症胰腺炎向重症胰腺炎演进过程中发挥了重要作...     

Oral allopurinol to prevent hyperamylasemia and acute pancreatitis after endoscopic retrograde cholangiopancreatography

AIM： To assess the efficacy of allopurinol to prevent hyperamylasemia and pancreatitis after endoscopic retrograde cholangiopancreatography （PEP）.
METHODS： One hundred and seventy patients were enrolled and randomized to two groups： a study group （n = 85） who received 300 mg of oral allopurinol at 15 h and 3 h before endoscopic retrograde cholangiopancreatography （ERCP） and a control group （n = 85） receiving an oral placebo at the same times. Main Outcome Measurements included serum amylase levels and the number severity of the episodes of pancreatitis. Serum amylase levels were classified as normal （〈 150 IU/L） or hyperamylasemia （〉 151 IU/L）. Episodes of PEP were classified following Ranson＇s criteria and CT severity index.
RESULTS： Gender distribution was similar between groups. Mean age was 53.5 ±18.9 years for study group and 52.8 ± 19.8 years for controls. Also, the distribution of benign pathology was similar between groups. Hyperamylasemia was more common in the control group （P = 0.003）. Mild PEP developed in two patients from the study group （2.3%） and eight （9.4%） from control group （P = 0.04）, seven episodes were observed in high-risk patients of the control group （25%） and one in the allopurinol group （3.3%, P = 0.02）. Risk factors for PEP were precut sphincterotomy （P = 0.02）, pancreatic duct manipulation （P = 0.002） and multiple procedures （P = 0.000）. There were no deaths or side effects.
CONCLUSION： Oral allopurinol before ERCP decreased the incidences of hyperamylasemia and pancreatitis in patients submitted to high-risk procedures.     

Role of endoscopic ultrasound during hospitalization for acute pancreatitis

Endoscopic ultrasound(EUS)is often used to detect the cause of acute pancreatitis(AP)after the acute attack has subsided.The limited data on its role during hospitalization for AP are reviewed here.The ability of EUS to visualize the pancreas and bile duct,the sonographic appearance of the pancreas,correlation of such appearance to clinical outcomes and the impact on AP management are analyzed from studies.The most important indication for EUS appears to be for detection of suspected common bile duct and/or gall bladder stones and microlithiasis.Such an approach might avoid diagnostic endoscopic retrograde cholangio-pancreatography with its known complications.The use of EUS during hospitalization for AP still appears to be infrequent but may become more frequent in future.     

New precut sphincterotomy for endoscopic retrograde cholangiopancreatography in difficult biliary duct cannulation

AIM:To retrospectively investigate the effect and safety of various new type precut sphincterotomy techniques (VNTPST) in endoscopic retrograde cholangiopancreato-graphy (ERCP) due to difficult biliary duct cannulation (DBC). METHODS:A plough-like pull-type sphincterotome (PLPTS) or improved short nose sphincterotome or improved needle knife was applied. VNTPST was carried out in 30 of 280 patients,whose biliary tract could not be exposed well or deep cannulation was difficult to perform during ERCP with traditional methods. Patients were followed up for short-term complications and the therapeutic effect of VNTPS was observed and compared with that of traditional endoscopic sphincterotomy (EST). RESULTS:A total 280 patients underwent ERCP,of which 3 failed in operation because of pathological features in stomch or duodenum,247 successfully underwent traditional ERCP (89.1%,247/277),30 failed (10.8%,30/277). VNTPS technique succeeded in 24 (80%,24/30) of 30 cases. The successful rate of deep biliary duct cannulation increased 8.6% (24/277),the total cannulation successful rate following precut was 97.7%. There was a significant difference between the two groups (97.7% vs 89.1%,χ2 = 17.1,P < 0.01). The incidence of complications was 9.3% (26/277) for traditional ERCP group and 13.3% (4/30) for VNTPS technique group. Guideline tip was broken in pancreatic duct (KPDGP) of one patient,and there was no pancreatitis,slight or moderate bleeding postoperatively occurred in 2 patients,1 patient had bleeding during operation (PDWN). There were no differences between VNTPS technique group and traditional ERCP (TRERCP)group (13.3% vs 9.3%,χ2 = 0.478,P > 0.05). CONCLUSION:VNTPS procedure and Deng's precut are highly effective methods to get biliary access during ERCP with DBC. With skillful techniques,it can increase the successful rate for deep cannulation of biliary duct and decrease complications. VNTPS technique,especially Deng's precut is as effective and safe as EST. This technique can be well performed in hospitals without particular equipments.     

儿童胰腺炎ERCP术后并发症研究

目的 分析儿童胰腺炎患者经内镜逆行胰胆管造影(endoscopic retrograde cholangiop-ancreatography,ERCP)术后高淀粉酶血症、胰腺炎及出血等并发症的发生率,探讨其安全性。方法 回顾分析1997年2月～2002年2月间入住我科确诊为儿童胰腺炎并行ERCP术的27例患者的临床资料,其中急性胰腺炎(acute pancreatitis,AP)14例,慢性胰腺炎(chronic pancreatitis,CP)13例;诊断性ERCP 9例,治疗性ERCP18例。结果 27例患者ERCP术后总体并发症发生率为51.85％(l4/27),其中,高淀粉酶血症发生率22.22％(6/27),术后4、24h血清淀粉酶水平分别为(410.75±230.31)U/L、(367.25±233.90)U/L,48～72h后均恢复正常;胰腺炎发生率22.22％(6/27),均为轻型胰腺炎;乳头切开处出血、黑便发生率7.41％(2/27),均发生于胆总管结石行十二指肠乳头括约肌切开(endoscopicsphincterotomy,EST)+取石术后;诊断性ERCP组并发症的发生率低于治疗性ERCP组,但无统计学意义。结论 儿童胰腺炎患者ERCP术后具有较高的并发症发生率,内镜医师于ERCP术中应高度重视,采取必要的预防措施以减少并发症的发生。     

治疗性内镜下逆行胰胆管造影术后急性胰腺炎高危因素分析

[目的]探索治疗性内镜下逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)术后急性胰腺炎(PEP)的高危因素与防治策略。[方法]运用单因素分析方法分析592例治疗性ERCP术后患者并发PEP的原因及防治措施。[结果]592例患者中,35例(5.9%)并发PEP,其中33例均为轻型胰腺炎,均经内科综合治疗后痊愈;2例为重症胰腺炎,1例治愈出院,1例死亡。与诱发PEP相关的高危因素有:女性,插管困难,既往有胰腺炎或胰腺癌,胰腺管显影或导丝插入胰管。[结论]治疗性ERCP发生PEP的因素不仅与患者自身临床因素有关,且与医师的操作技术有很大关系,改善患者身体条件、提高医师操作水平可减少PEP的发生。     

Pharmacologic prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: Present and future

Despite extensive research over the past 2 decades, effective prevention of post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP) using pharmacologic agents has been elusive. Recently, research that is focused on nonsteroidal anti-inflammatory drugs has provided renewed hope by demonstrating that a medication can indeed prevent PEP. Today, based on high-quality clinical trial data, rectal nonsteroidal anti-inflammatory drugs can be recommended for preventing PEP in high-risk cases,and given the highly favorable risk and cost-benefit ratios, they should be considered for all patients undergoing endoscopic retrograde cholangiopancreatography. Ongoing research will define the optimal dose of rectal indomethacin and whether this medication can eliminate the need for prophylactic pancreatic stent placement in high-risk cases. Additional research is necessary to define the role of other promising pharmacologic agents in clinical practice.     

经内镜逆行胰胆管造影术后急性胰腺炎与高淀粉酶血症对比观察

目的 比较经内镜逆行胰胆管造影术(ERCP)后急性胰腺炎(PEP)与高淀粉酶血症(PEHA)患者的临床特点及影响因素,为预防病情进展提供依据。 方法 选取武汉大学人民医院2017年1月-2019年8月住院行ERCP的患者117例,所有患者术前均预防性使用双氯芬酸钠栓塞肛。术后发生PEHA组77例,PEP组40例,比较2组患者临床特点及影响因素。符合正态分布的计量资料2组间比较采用t检验;不符合正态分布的计量资料2组间比较采用Mann-Whitney U检验;计数资料2组间比较采用χ2检验;采用多因素logistic回归分析PEP的独立影响因素。结果 术前ALP(Z=-2.518,P=0.012)、GGT(Z=-2.313,P=0.021)、TBil(Z=-2.978,P=0.003)、DBil(Z=-3.069,P=0.002)水平及术中是否行导丝进入胰管检查(χ2=4.176,P=0.041)在两组之间差异显著。进一步logistic回归分析结果显示,导丝进入胰管次数≥3次[优势比(OR)=2.469,95%可信区间(95%CI): 1.199~5.188,P=0.047]、ALP<125 U/L(OR=5.499,95%CI: 1.452~18.830,P=0.012)、TBil<22 μmol/L(OR=4.249,95%CI: 1.023~17.648,P=0.046)是影响PEP发生的独立危险因素。结论 即使预防性使用双氯芬酸钠栓剂,术前ALP、TBil水平正常及术中导丝多次进入胰管的患者更易发生PEP,需引起手术医师警惕。根据病情,术前及术后采取早期干预措施可能减少PEHA向PEP进展,减少中重度PEP的发生,改善预后。     

Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis

Background and Aims:  Acute pancreatitis following endoscopic retrograde cholangiography presents a unique opportunity for prophylaxis and early modification of the disease process because the initial triggering event is temporally well defined and takes place in the hospital. We report a prospective, single-center, randomized, double-blind controlled trial to determine if rectal diclofenac reduces the incidence of pancreatitis following cholangiopancreatography.
Methods:  Entry to the trial was restricted to patients who underwent endoscopic retrograde pancreatography. Immediately after endoscopy, patients were given a suppository containing either 100 mg diclofenac or placebo. Estimation of serum amylase level and clinical evaluation were performed in all patients.
Results:  One hundred patients entered the trial, and 50 received rectal diclofenac. Fifteen patients developed pancreatitis (15%), of whom two received rectal diclofenac and 13 received placebo ( P  < 0.01).
Conclusions:  This trial shows that rectal diclofenac given immediately after endoscopic retrograde cholangiopancreatography can reduce the incidence of acute pancreatitis.     

经内镜逆行胰胆管造影术后胰腺炎预防策略研究进展

经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）已成为诊治胆胰系统疾病的主要手段。在ERCP介入治疗越来越多的趋势下,术后不良事件发生率也呈上升趋势。其中,ERCP术后胰腺炎（post-ERCP pancreatitis,PEP）是最常见的术后并发症,严重时甚至会威胁患者生命,并使得ERCP广泛开展受到一定困扰。如何有效预防和降低该并发症发生是目前临床研究的热点和难点。本文对PEP的定义、发病机制、危险因素和预防措施的研究现状进行综述,并对其优化的预防策略进行概括和总结。     

应用EST技术治疗急性胆源性胰腺炎的临床体会

目的 探讨内镜下乳头Oddi括约肌切开术(endoscopic sphincterotomy,EST)在急性肌源性胰腺炎(acute gallstone pancreatitis,AGP)诊治中的应用价值。方法 将入选的189例AGP患者随机分为EST治疗组(n=79)和对照组(n=110),并根据APACHE Ⅱ评分,将每组再进一步分为重症组和轻症组,两组患者均给予中西医结合治疗。EST治疗组在入院后24h内行内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)+EST,如发现胆总管或胆胰共同通道有结石,则行网篮、气囊取石或碎石器碎石后取石,如结石多、结石直径大或取石未净,则EST术后再行鼻胆管引流术(endoscopic nasobilliary drainage,ENBD)。结果 对重症AGP,EST治疗组的并发症发生率转开腹手术率、住院天数及住院费用均明显低于对照组(P<0.05);而轻症AGP,两组之间无显著差异结论 早期应用EST技术治疗重症AGP是有效的和安全的。     

内镜超声和经内镜逆行胰胆管造影在慢性胰腺炎诊断中的价值

目的 评价EUS和ERCP对慢性胰腺炎(CP)的诊断灵敏度和特异度,探讨在CP诊断中EUS和ERCP的价值.方法 采用多中心联合调查方法,回顾分析1994年5月至2004年5月全国22个分研究中心的确诊的CP病例,以组织学诊断为"金标准",采用接受者工作曲线(receiver operating characteristic,ROC)分析EUS和ERCP的诊断灵敏度和特异度.结果 共人选CP患者1994例,男1298例,女696例.年龄5～85(48.9 ±15.0)岁.所有CP患者中,有组织学诊断239例(11.98%);胰腺外分泌功能试验(BT-PABA)261例(13.09%),腹部平片416例(20.86%),腹部B超1424例(71.41%),CT 889例(44.58%),MRI和MRCP245例(12.29%),ERCP628例(31.49%),EUS258例(12.94%).各诊断方法的诊断灵敏度和特异度分别为EUS(88%和93%)、ERCP(87%和93%)、MRI和MRCP(66%和85%)、CT(61%和85%)、B超(69%和82%)、腹部平片(32%和80%)、BT-PABA(83%和80%).结论 在CP诊断方法中,EUS和ERCP对CP且具有较高的灵敏度和特异度,EUS较ERCP灵敏度和特异度更高.     

Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis

BackgroundIndication of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) is challenging.AimsIn this retrospective study, we analyzed real-world data to understand the ERCP practice in ABP in Hungarian centers.MethodsClinical data on ABP patients (2013–2015) were extracted from our large multicentric database. Outcomes, quality indicators and the role of early timing of ERCP (<24 h from admission) were analyzed.ResultsThere were 356 patients with ABP. ERCP was performed in 267 (75%). Performance indicators of ERCP proved to be suboptimal with a biliary cannulation rate of 84%. Successful vs unsuccessful cannulation of naïve papilla resulted in lower rates of local [22.9% vs 40.9%, (P = 0.012)] and systemic [4.9% vs 13.6%, (P = 0.042)] complications. Successful vs unsuccessful clearance resulted in lower rates of local complications [22.5% vs 40.8%, (P = 0.008)]. Successful cannulation and drainage correlated with less severe course of ABP [3.6% vs 15.9%, (P = 0.001) and 4.1% vs 12.2%, (P = 0.033)] respectively. A tendency of an increased rate of local complications was observed if ERCP was performed later [<24 h: 21.1% (35/166); between 24–48 h: 23.4% (11/47); >48h: 37.2% (16/43) (P = 0.088)].ConclusionOptimization of ERCP indication in ABP patients is critical as suboptimal ERCP practices in ABP without definitive stone detection are associated with poorer clinical outcomes.     

Selective biliary cannulation techniques for endoscopic retrograde cholangiopancreatography procedures and prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis

Numerous endoscopic retrograde cholangiopancreatography (ERCP) techniques have been reported to achieve selective biliary cannulation success. For standard biliary cannulation procedures, the wire-guided cannulation technique has been reported to reduce the rate of post-ERCP pancreatitis (PEP) and increase the biliary cannulation success rate, although conflicting reports exist. The pancreatic or double-guidewire technique and several precut techniques have been reported as useful techniques in difficult biliary cannulation cases. Although ERCP is a useful endoscopic procedure, the risk of adverse events, particularly post-ERCP pancreatitis, is inevitable. Previous studies and analyses have revealed the risk factors for PEP. The efficacy of prophylactic pancreatic duct stent placement and the administration of rectal nonsteroidal anti-inflammatory drugs for preventing PEP has also been reported. Herein, we reviewed reports in the literature regarding the current status of selective biliary cannulation techniques and PEP prevention.     

治疗性经内镜逆行胰胆管造影在慢性胰腺炎患者中的应用

目的：探讨治疗性经内镜逆行胰胆管造影（ERCP）在慢性胰腺炎（CP）治疗中的价值。方法对2008年1月－2012年12月间在南京医科大学附属苏州市立医院应用 ERCP 治疗的30例 CP 患者进行回顾性分析。观察术前及术后24h 血淀粉酶变化,动态观察患者治疗前后腹痛缓解情况,随访脂肪泻、焦虑患者病情,定期复查腹部影像学或 ERCP 明确胰腺病变及胰管支架情况。结果所有患者均顺利完成 ERCP 并放置胰管支架,术后72 h 腹痛缓解率83．3％,1例因症状改善不明显至外科手术,术后病死率为0。结论ERCP 是治疗 CP 的有效手段,具有安全、有效、创伤小等优点。     

Role of endoscopic retrograde cholangiopancreatography in pancreatic diseases

Over the last 15 years,endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool to one that is primarily used to provide therapy. This development occurred f irst for biliary disorders and subsequently to a lesser extent for pancreatic diseases. Computed tomography, magnetic resonance imaging,magnetic resonance cholangiopancreatography and endoscopic ultrasonography suggest a diagnosis in the majority of patients with pancreatic diseases today and can help physicians and pati...     

Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM: To investigate the efficacy and safety profile of pancreatic duct (PD) stent placement for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).METHODS: We performed a search of MEDLINE, EMBASE, and Cochrane Library to identify randomized controlled clinical trials of prophylactic PD stent placement after ERCP. RevMan 5 software provided by Cochrane was used for the heterogeneity and efficacy analyses, and a meta-analysis was performed for the data that showed homogeneity. Categorical data are presented as relative risks and 95% confidence intervals (CIs), and measurement data are presented as weighted mean differences and 95%CIs.RESULTS: The incidence rates of severe pancreatitis, operation failure, complications and patient pain severity were analyzed. Data on pancreatitis incidence were reported in 14 of 15 trials. There was no significant heterogeneity between the trials (I² = 0%, P = 0.93). In the stent group, 49 of the 1233 patients suffered from PEP, compared to 133 of the 1277 patients in the no-stent group. The results of this meta-analysis indicate that it may be possible to prevent PEP by placing a PD stent.CONCLUSION: PD stent placement can reduce postoperative hyperamylasemia and might be an effective and safe option to prevent PEP if the operation indications are well controlled.     

Efficacy and safety of emergency endoscopic retrograde cholangiopancreatography for acute cholangitis in the elderly

AIM To investigate the efficacy and safety of emergency endoscopic retrograde cholangiopancreatography(ERCP) in elderly patients with acute cholangitis. METHODS From June 2008 to May 2016, emergency ERCPs were performed in 207 cases of acute cholangitis at our institution. Patients were classified as elderly if they were aged 80 years and older(n = 102); controls were under the age of 80 years(n = 105). The patients' medical records were retrospectively reviewed for comorbidities, laboratory data, etiology of cholangitis(presence of biliary stones, biliary stricture and malignancy), details of the ERCP(therapeutic approaches, technical success rates, procedure duration), ERCP-related complications and mortality. RESULTS The frequency of comorbidities was higher in the elderly group than the control group(91.2% vs 67.6%). Periampullary diverticulum was observed in the elderly group at a higher frequency than the control group(24.5% vs 13.3%). Between the groups, there was no significant difference in the technical success rates(95.1% vs 95.2%) or endoscopicprocedure durations. With regard to the frequency of ERCP-related complications, there was no significant difference between the two groups(6.9% vs 6.7%), except for a lower rate of post-ERCP pancreatitis in the elderly group than in the control group(1.0% vs 3.8%). Neither angiographic nor surgical intervention was required in any of the cases with ERCP-related complications. There was no mortality during the observational periods. CONCLUSION Emergency ERCP for acute cholangitis can be performed safely even in elderly patients aged 80 years and older.