The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures.

BACKGROUND: Brush cytology, routinely performed at ERCP to assess malignant-appearing biliary strictures, is limited by relatively low sensitivity and negative predictive value. This study assessed whether the combination of stricture dilation, endoscopic needle aspiration, and biliary brushing improves diagnostic yield. METHODS: In a prospective nonrandomized study, 46 consecutive patients were evaluated with malignant-appearing biliary strictures at ERCP. Twenty-four patients (Group A) underwent standard brush cytology alone and 22 patients (Group B) underwent stricture dilatation to 10F, endoscopic needle aspiration, and subsequent biliary brushing by using the Howell biliary system. The diagnostic yields for both techniques were compared. RESULTS: Of the 46 patients, 34 had proven malignant strictures (14 Group A, 20 Group B). Compared with brushing alone, the combination of stricture dilatation, endoscopic needle aspiration, and subsequent biliary brushing significantly increased both the sensitivity (57% vs. 85%, p < 0.02) and specificity (80% vs. 100%, p < 0.02) of cytology with positive brushings in all patients with pancreatic or gallbladder carcinoma. CONCLUSIONS: The combination of stricture dilation, endoscopic needle aspiration, and biliary brushing significantly improves diagnostic yield for malignant bile duct strictures and may particularly be of benefit for extrinsic strictures caused by pancreatic or gallbladder carcinoma.     

Endoscopic treatment for biliary stricture secondary to chronic pancreatitis

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.     

Results of endoscopic retrograde cholangiopancreatography in the treatment of biliary tract complications after orthotopic liver transplantation: our experience

BACKGROUND/AIMS: Biliary tract complications are a common cause of morbidity and mortality after orthotopic liver transplantation. We report our experience in the use of ERCP in the treatment of post liver transplantation biliary complications. METHODOLOGY: Retrospectively we evaluated 34 patients who had undergone ERCP out of 460 who received a liver transplantation between January 1999 and December 2004. Eighteen patients presented biliary strictures, anastomotic in 12 cases and hilar in 6 cases; seven patients presented a biliary fistula and fifteen presented biliary stones in 8 cases associated to stricture and in 1 case to a fistula. Finally three patients underwent ERCP do to jaundice. The 18 patients with biliary strictures underwent sphincterotomy, dilation and stenting; the seven cases with fistulas were treated with a plastic biliary stent without sphincterotomy and the patients with biliary stones underwent sphincterotomy and endoscopic toilette of the common bile duct. RESULTS: An ERCP success rate of 97.7% was achieved without any significant complications. We obtained the resolution of all the biliary anastomotic strictures; resolution of hilar strictures was obtained in 66.6%. Biliary leak healed in 85.7% of patients. Complete endoscopic toilette was achieved in all the patients with biliary stones. CONCLUSIONS: In our experience ERCP has proved to be safe and effective in the treatment of post liver transplant biliary complications.     

两种胆胰管造影方法临床应用价值的荟萃分析

目的评价内镜下逆行胰胆管造影术（ERCP）和磁共振胰胆管造影术（MRCP）在具有可疑胆胰疾病患者中的应用价值。方法通过MEDLINE、EMBASE等数据库检索国内外已发表和未发表的相关文献。选择针对具有可疑胆胰疾病患者,使用ERCP和MRCP两种方法进行比较的前瞻性研究。由2位评价者分别按以上检索策略收集资料,按选择标准人选,主要对两种检查方法的敏感性和特异性进行荟萃分析。结果ERCP和MRCP诊断胆总管结石、胆胰管狭窄、胆胰系统恶性疾病的敏感性差异无统计学意义。两者对上述疾病诊断的特异性方面,仅在诊断胰胆管狭窄时,ERCP高于MRCP,OR为6．17,95％CI为1,35～20．24,P=0．02。对于总体胆胰系统疾病的诊断,ERCP的敏感性和特异性均优于MRCP,OR分别为1．72和4．05.95％CI分别为1．04～2．85和1．32．12．42,P值分别为0．04及0．01。结论在诊断胆胰系统疾病时,总体敏感性和特异性都是ERCP优于MRCP。临床医生可以根据患者耐受程度和价效分析进行对ERCP和MRCP的取舍决策。     

Endoscopic approach to acute pancreatitis

This review focuses on the use of endoscopic techniques in the diagnosis and management of pancreatic disorders. Endoscopic retrograde cholangiopancreatography (ERCP) has been used primarily to evaluate and treat disorders of the biliary tree. Recently, endoscopic techniques have been adapted for pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections, and stone extraction via the major and minor papillae. In patients with acute and recurrent pancreatitis, ERCP carries a higher than average risk of post-ERCP pancreatitis. This risk can be reduced with the placement of a prophylactic pancreatic stent. Magnetic resonance cholangiopancreatography (MRCP) can establish the anatomy of the biliary and pancreatic ducts, identify pancreas divisum or pancreatic ductal strictures, depict bile duct stones, and demonstrate pancreatic or biliary duct dilation. Endoscopic ultrasound (EUS) provides a safer, less invasive, and often more sensitive measure for evaluating the pancreas and biliary tree, and allows some options for therapy. In acute and recurrent pancreatitis, EUS and MRCP can be used to establish a diagnosis; ERCP can be reserved for therapy.     

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.     

Progress in the endoscopic management of benign biliary strictures

Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Despite recent developments in imaging techniques (endoscopic ultrasound and magnetic resonance imaging), it is often difficult to differentiate benign from malignant biliary strictures. The sensitivity of tissue diagnosis (cytology and needle biopsy) at endoscopic retrograde cholangiopancreatography (ERCP) remains poor (40-50%), and further diagnostic methods are required. Endoscopic therapy offers a definitive treatment in 70-90% of patients following post-operative biliary stricture, including anastomotic strictures following liver transplant. Endoscopic therapy successfully achieves symptomatic, biochemical, and cholangiographic response, and may improve survival in patients with primary sclerosing cholangitis. Strictures secondary to chronic pancreatitis are resistant to standard endoscopic therapy and metallic endoprotheses have been trialed with varying success. Endoscopic therapy is technically difficult and should be performed in specialized centres using a multidisciplinary approach.     

Endoscopic pancreatic duct and biliary duct stenting in treatment of chronic pancreatitis with distal benign biliary stricture: a single-center experience

BACKGROUND: The development of endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and stenting are relatively new alternatives to surgery for the treatment of benign lesions in the biliary duct and pancreas. The objective of this study was to assess the value of stenting in the endoscopic pancreatic duct and biliary duct in the treatment of chronic pancreatitis with distal benign biliary stricture. METHODS: Twenty-two patients diagnosed with ...     

Endoscopic therapy in acute recurrent pancreatitis

Endoscopic retrograde cholangiopancreatography （ERCP） has evolved from a largely diagnostic to a largely therapeutic modality. Cross-sectional imaging, such as computed tomography （CT） and magnetic resonance imaging （MRI）, and less invasive endoscopy, especially endoscopic ultrasound （EUS）, have largely taken over from ERCP for diagnosis. However, ERCP remains the ＂first line＂ therapeutic tool in the management of mechanical causes of acute recurrent pancreatitis, including bile duct stones （choledocholithiasis）, ampullary masses （benign and malignant）, congenital variants of biliary and pancreatic anatomy （e.g. pancreas divisum, choledochoceles）, sphincter of Oddi dysfunction （SOD）, pancreatic stones and strictures, and parasitic disorders involving the biliary tree and/or pancreatic duct （e.g Ascariasis, Clonorchiasis）.     

ERCP in orthotopic liver transplanted patients

BACKGROUND/AIMS: Biliary complications after orthotopic liver transplantation (OLT) are still common. The aim of the study was to assess the effectiveness of ERCP as a diagnostic and treatment tool in the management of biliary tract OLT complications. METHODOLOGY: The diagnostic and treatment effectiveness of ERCP in the management of biliary tract OLT complication from 1/1995 to 12/2001 was reviewed. RESULTS: 24/251 (9.6%) OLT patients presented biliary complications. These patients underwent a total of 31 ERCP (seven patients received two ERCP). The ERCP indication was cholestasis in 25 (80.6%). The success rate of these 31 ERCPs was 87%. In the 25 ERCPs indicated in patients with cholestasis, the procedure revealed strictures of the biliary anastomosis in 3, hepatic hilum strictures in 5, SOD in 4, lithiasis in 7 and sclerosing cholangitis in one. The final diagnosis of three patients with normal biliary tract was intrahepatic cholestasis. In three of the four patients with biliary leaks the ERCP's confirmed the diagnosis. The final treatment efficacy was 100% (7/7 patients), 50% (2/4 p.), 0% (0/3 p.), 75% (3/4 p.) and 100% (4/4 p.) for patients with biliary stones, strictures of the hilum, anastomotic strictures, biliary leaks and SOD, respectively. In the acute pancreatitis and in the PSC endoscopic treatment was not indicated. There were two mild cases of pancreatitis. CONCLUSIONS: Because of its availability, diagnostic accuracy, treatment efficacy and safety, ERCP should be used as the first-line procedure for treatment of biliary tract complications after OLT.     

The role of endoscopic ultrasound in biliary strictures

The role of endoscopic ultrasound (EUS) in the diagnosis of biliary strictures is well established, and emerging evidence suggests it may also play a therapeutic role. Differentiating between benign and malignant causes of biliary strictures can be challenging, but EUS can aid in their diagnosis and may predict resectability. The diagnostic yield of EUS combined with fine-needle aspiration (FNA) is excellent, especially in distal bile duct strictures, and far surpasses endoscopic retrograde cholangiopancreatography (ERCP) with brushings. Intraductal ultrasound may add to the diagnostic sensitivity of ERCP with brushings when no mass is seen on cross-sectional imaging or EUS, or when EUS with FNA is negative and suspicion of cancer persists. EUS-guided cholangiography is an emerging technique that may aid biliary decompression when ERCP has failed or is not possible; however, new therapeutic echoendoscopes or accessories are needed before the use of this technique can become more widespread.     

管腔内超声对胰胆疾病诊断价值的初探

目的 评价管腔内超声(IDUS)检查在胰胆疾病中的诊断价值.方法 回顾性分析北京协和医院2006年7月至2007年8月期间,对19例胰胆疾病患者的ERCP与IDUS检查结果及其相关临床资料.结果 (1)19例患者中梗阻性黄疸17例,胰腺导管内乳头状黏液瘤(IPMT)2例.17例梗阻性黄疸中胆管癌6例,胰腺癌2例,胆囊癌2例,胆管结石合并胆管狭窄2例,自身免疫性胰腺炎2例,十二指肠乳头腺癌1例,十二指肠乳头腺瘤1例,硬化性胆管炎1例.19例诊断中11例经手术或组织病理学证实.(2)ERCP对胰胆疾病诊断的正确率为73.7%(14/19),IDUS对胰胆疾病诊断的正确率为84.2%(16/19),ERCP联合IDUS对胰胆疾病诊断的正确率89.5%(17/19).(3)ERCP对胆管良恶性狭窄鉴别诊断的敏感性和特异性分别为100.0%(11/11)和83.3%(5/6),IDUS对胆管良恶性狭窄鉴别诊断的敏感性和特异性分别为100.0%(11/11)和100.O%(6/6).(4)ERCP对胆管癌诊断的敏感性和特异性分别为83.3%(5/6)和60.0%(3/5),IDUS对胆管癌诊断的敏感性和特异性分别为100.0%(6/6)和40.0%(2/5).结论 ERCP检查同时进行IDUS检查能提高胰胆疾病的诊断率.IDUS对胆管良恶性狭窄的鉴别诊断具有较高的敏感性和特异性,但在具体区分恶性狭窄的病因上尚存在一定的困难.     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的 探讨ERCP在治疗肝移植术后胆道并发症方面的作用.方法 回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料.对25例胆道狭窄患者(吻合口狭窄14例,非吻合口狭窄11例)行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者(其中合并胆道狭窄8例)行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗.结果 ERCP手术成功率为95.9%(94/98),未出现严重并发症.吻合口狭窄的ERCP治愈率为100%(14/14),非吻合口狭窄的ERCP治愈率为27.3%(3/11),胆漏的ERCP治愈率为83.3%(5/6),结道结石和胆泥形成患者的ERCP治愈率为81.3%(13/16).结论 ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低.     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的 探讨ERCP在治疗肝移植术后胆道并发症方面的作用.方法 回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料.对25例胆道狭窄患者(吻合口狭窄14例,非吻合口狭窄11例)行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者(其中合并胆道狭窄8例)行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗.结果 ERCP手术成功率为95.9%(94/98),未出现严重并发症.吻合口狭窄的ERCP治愈率为100%(14/14),非吻合口狭窄的ERCP治愈率为27.3%(3/11),胆漏的ERCP治愈率为83.3%(5/6),结道结石和胆泥形成患者的ERCP治愈率为81.3%(13/16).结论 ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低.     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的探讨ERCP在治疗肝移植术后胆道并发症方面的作用。方法回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料。对25例胆道狭窄患者（吻合口狭窄14例,非吻合口狭窄11例）行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者（其中合并胆道狭窄8例）行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗。结果ERCP手术成功率为95．9％（94／98）,未出现严重并发症。吻合口狭窄的ERCP治愈率为100％（14／14）,非吻合口狭窄的ERCP治愈率为27．3％（3／11）,胆漏的ERCP治愈率为83．3％（5／6）,结道结石和胆泥形成患者的ERCP治愈率为81．3％（13／16）。结论ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低。     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的 探讨ERCP在治疗肝移植术后胆道并发症方面的作用.方法 回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料.对25例胆道狭窄患者(吻合口狭窄14例,非吻合口狭窄11例)行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者(其中合并胆道狭窄8例)行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗.结果 ERCP手术成功率为95.9%(94/98),未出现严重并发症.吻合口狭窄的ERCP治愈率为100%(14/14),非吻合口狭窄的ERCP治愈率为27.3%(3/11),胆漏的ERCP治愈率为83.3%(5/6),结道结石和胆泥形成患者的ERCP治愈率为81.3%(13/16).结论 ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低.     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的 探讨ERCP在治疗肝移植术后胆道并发症方面的作用.方法 回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料.对25例胆道狭窄患者(吻合口狭窄14例,非吻合口狭窄11例)行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者(其中合并胆道狭窄8例)行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗.结果 ERCP手术成功率为95.9%(94/98),未出现严重并发症.吻合口狭窄的ERCP治愈率为100%(14/14),非吻合口狭窄的ERCP治愈率为27.3%(3/11),胆漏的ERCP治愈率为83.3%(5/6),结道结石和胆泥形成患者的ERCP治愈率为81.3%(13/16).结论 ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低.     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的 探讨ERCP在治疗肝移植术后胆道并发症方面的作用.方法 回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料.对25例胆道狭窄患者(吻合口狭窄14例,非吻合口狭窄11例)行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者(其中合并胆道狭窄8例)行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗.结果 ERCP手术成功率为95.9%(94/98),未出现严重并发症.吻合口狭窄的ERCP治愈率为100%(14/14),非吻合口狭窄的ERCP治愈率为27.3%(3/11),胆漏的ERCP治愈率为83.3%(5/6),结道结石和胆泥形成患者的ERCP治愈率为81.3%(13/16).结论 ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低.     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的 探讨ERCP在治疗肝移植术后胆道并发症方面的作用.方法 回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料.对25例胆道狭窄患者(吻合口狭窄14例,非吻合口狭窄11例)行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者(其中合并胆道狭窄8例)行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗.结果 ERCP手术成功率为95.9%(94/98),未出现严重并发症.吻合口狭窄的ERCP治愈率为100%(14/14),非吻合口狭窄的ERCP治愈率为27.3%(3/11),胆漏的ERCP治愈率为83.3%(5/6),结道结石和胆泥形成患者的ERCP治愈率为81.3%(13/16).结论 ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低.     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的 探讨ERCP在治疗肝移植术后胆道并发症方面的作用.方法 回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料.对25例胆道狭窄患者(吻合口狭窄14例,非吻合口狭窄11例)行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者(其中合并胆道狭窄8例)行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗.结果 ERCP手术成功率为95.9%(94/98),未出现严重并发症.吻合口狭窄的ERCP治愈率为100%(14/14),非吻合口狭窄的ERCP治愈率为27.3%(3/11),胆漏的ERCP治愈率为83.3%(5/6),结道结石和胆泥形成患者的ERCP治愈率为81.3%(13/16).结论 ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低.