ERCP在不明原因复发性急性胰腺炎诊治中的作用

目的 探讨ERCP在不明原因复发性急性胰腺炎(RAP)诊治中的作用.方法 收集15例不明原因RAP患者.其中男5例,女10例,年龄25 ～ 65岁,中位年龄38岁,病程1 ～ 2年,发病次数2 ～ 5次.10例在急性发作期,5例在发作间期行ERCP诊治.结果 15例患者经ERCP明确病因者6例(3例胆管微结石,1例胆总管末端小囊肿,1例胰管小结石,1例胰管蛋白栓子),可疑病因者6例(乳头旁憩室2例,十二指肠乳头炎4例),未明确病因者3例.根据ERCP检查结果,9例行乳头括约肌切开术(EST),6例行胰管括约肌切开术.术后随访2年,15例患者均未复发胰腺炎.ERCP和EST术后2例出现一过性高淀粉酶血症,无其他并发症.结论 ERCP对不明原因RAP有明确病因和指导治疗的作用.     

内镜下胰管括约肌切开术后早期并发症的前瞻性研究

目的评价内镜下胰管括约肌切开术后早期并发症的发生率及相关危险因素。方法前瞻性观察2006年5月至2007年4月行ERCP的住院患者,将ERCP下行胰管括约肌切开术的患者纳入研究。在ERCP术前及术中分别将患者和操作相关情况记录在统一的观察表上;术后随访并发症的发生情况直至出院;有关数据进行统计学分析。结果在纳入观察的165例行胰管括约肌切开术的患者中,25例发生并发症（15．2％）,其中急性胰腺炎22例（13．3％,轻度15例、中度6例、重度1例）,出血1例（0．6％）,急性胆管炎2例（1．2％）,无穿孔或操作相关的死亡发生。多变量分析提示术后急性胰腺炎危险因素是：女性（OR=3．8,95％CI1．4～10．8）、复发性胰腺炎（OR=3．1,95％CI1．0-9．9）、副乳头切开术（OR=5．9,95％CI1．2—28．8）。结论与常规ERCP操作比较,内镜下胰管括约肌切开术后急性胰腺炎的发生率较高。特别是女性、复发性胰腺炎、行副乳头切开术的患者,术后更易发生急性胰腺炎。     

十二指肠乳头旁憩室对括约肌切开术治疗胰管结石的影响

目的探讨乳头旁憩室对内镜下括约肌切开术(endoscopic sphincterotomy,EST)治疗胰管结石及术后并发症的影响。方法回顾性分析194例胰管结石行内镜逆行胰胆管造影术(endoscopic retrograde cholangio-pancreatography,ERCP)治疗病例,其中无乳头旁憩室的胰管结石患者148例为对照组,46例合并乳头旁憩室为试验组;比较两组ERCP插管成功率、EST胰管取石成功率及并发症发生率。结果试验组与对照组ERCP插管成功率比较,差异无统计学意义(89.13%vs 89.19%,P0.05),试验组EST取石成功率明显降低(90.24%vs 97.73%,P0.05),试验组EST术后创面出血显著增多(13.04%vs 8.78%,P0.01),术后胰腺炎及结石复发两组差异无统计学意义(P0.05)。结论乳头旁憩室对EST治疗胰管结石有一定影响;EST仍是治疗乳头旁憩室胰管结石的一种相对安全、有效的手段。     

内镜逆行胰胆管造影在胰管结石诊治中的临床价值

目的：探讨内镜逆行胰胆管造影（ERCP）在胰管结石（PDS）诊断与治疗中的价值。方法：回顾分析1998年1月－2000年12月本院经ERCP诊治的18例PDS患者的治疗方式和结果。结果：18例PDS患者临床上均以上腹痛为主要首发症状且合并慢性胰腺炎,其中1例合并胰腺癌。经B超检查,10例患者检出有PDS或胰管扩张;全部病例经ERCP检查后均明确显著有PDS和胰管扩张。经ERCP＋乳头括约肌切开术（EST）／胰管括约肌切开术（EPST）成功取石4例;行EPST＋体外震波碎石（ESWL）及ESWL＋胰管内支架引流（ERPD）者各1例,半年后复查时胰石消失：行ERPD者12例。3例患者置管后3个月内因伴主胰管多发、巨大结石和胰腺癌而接受手术治疗。18例患者经1－11个月的随访,腹痛近期（＜3个月）缓解率为88．9％,远期（＞3个月）缓解率为75．0％,体重、脂肪泻、胰腺内、外分泌功能不足表现有不同程度的改善。ERCP术后早期并发症主要为一过性高淀粉酶血症,支架阻塞是其晚期并发症。结论：ERCP能清晰显示结石的位置、大小、形态及数量,是诊断PDS的主要手段。经ERCP取石具有安全可靠、创伤小、疗效满意及患者易于接受等优点,在PDS的治疗中亦具有较大临床应用价值。     

经胰管乳头括约肌预切开术在困难胆道插管中的临床应用

目的评价经胰管乳头括约肌预切开术在困难胆道插管中的安全性和疗效。方法回顾性分析2005年7月至2006年7月在我院行ERCP的患者。对常规胆管插管失败且导丝反复进入胰管（〉4次）者行经胰管乳头括约肌预切开，胆管插管成功后，导丝留置胆管内，继续完成胆管括约肌切开及相应的治疗。统计插管的成功率及并发症的发生率。结果在整个研究期间内共行ER—CP1576例次，需胆管深插管879例次，经胰管乳头括约肌预切开者30例。经胰管乳头括约肌预切开后，首次ERCP胆管深插管成功率为93．3％（28／30），2次ERCP插管成功率为96．7％（29／30）。2例（占6．7％）发生并发症，为轻型胰腺炎。无出血、穿孔或操作相关的死亡发生。结论在困难胆道插管中采用经胰管乳头括约肌预切开术是一种安全有效的方法。     

治疗性ERCP在78例高龄人群中的临床研究

目的高龄人群(≥70岁)行治疗性逆行胰胆管造影(ERCP)的疗效观察。方法对78例高龄胰胆管疾病患者行治疗性ERCP,分析诊治经过及并发症的处理。结果 78例患者中成功行治疗性ERCP 74例,其中胆总管结石52例,行十二指肠乳头括约肌切开术(EST)取石40例,行胆管支架引流术(ERBD)8例(3～6个月再次行ERCP取石治疗),行鼻胆管引流(ENBD)4例;胰胆肿瘤18例,均行ERBD后病情减轻;十二指肠乳头炎症4例,行EST后治愈。术后6例患者出现高淀粉酶血症,2例出现ERCP相关胰腺炎,2例合并胆管炎,1例发生小穿孔。结论 ERCP对高龄患者治疗安全有效。     

ERCP在腹腔镜胆囊切除术后胆管并发症诊治中的应用

目的探讨内镜逆行胰胆管造影（ERCP）在腹腔镜胆囊切除术（LC）后胆管并发症诊治中的应用价值。方法对96例LC术后胆管并发症者行ERCP检查,并根据检查结果给予相应处理。结果本组ERCP显示,胆管残余结石70例,45例采用括约肌切开术（EST）,25例采用乳头气囊扩张术（EPBD）,结石排出67例;胆总管部分狭窄17例,行胆管扩张和内镜逆行胆管内引流术（ERBD）,术后随访1a狭窄解除12例;胆总管完全横断5例,2例行ERBD,黄疸减退后均行外科胆管空肠Roux—en—Y吻合;胆瘘4例,3例经EST治疗后症状减轻,避免手术,1例症状无改善接受手术治疗。结论对Lc术后胆管并发症者行ERCP,有助于明确病因,并指导相应的治疗。     

胆囊切除术后综合征的内镜诊断和治疗

目的 探讨内镜在胆囊切除术后综合征病因诊断和治疗中的应用价值。方法 对326例胆囊切除术后综合征患者ERCP检查明确病因后,对胆管结石行内镜乳头括约肌切开术（EST）和内镜乳头气囊扩张术（EPBD）后取石;对乳头炎必狭窄行EST或EPBD治疗;对乳头旁憩室压迫乳头开口和Oddi括约肌功能紊乱（SOD）行EPBD治疗;对乳头肿瘤和肝门胆管癌行内镜胆管金属内支架治疗（EMBE）;对化脓性胆管炎,继发性胆总管多发结石、结石难以一次取净及术后胆瘘,胆管中段狭窄行内镜鼻胆管引流（ENBD）。结果 315例（96．6％）ERCP成功。未发现异常30例。胆管结石191例,186例经1－3次内镜取石后取净。乳头炎性狭窄39例,经EST或EPBD治疗1次成功。乳头旁憩室压迫乳头开口9例,行EPBD治疗1次成功。胆管中段狭窄16例,11例行ENBD成功。乳头肿瘤6例,肝门胆管癌5例,EMBE治疗后黄疸减退。SOD7例,行EPBD治疗成功。胃十二指肠溃疡6例。胆囊管结石残留4例。胆囊切除术后胆瘘2例,行ENBD治疗成功,避免再次外科手术。总的并发症发生率4．8％,其中急性轻型胰腺炎11例,急性胆管炎3例,上消化道出血1例。结论 ERCP能及早发现胆囊切除术后综合征确切病因并给予相应内镜治疗。熟练掌握ERCP技术可减少并发症的发生。     

90岁及以上胆总管结石患者内镜疗效分析

目的 探讨经内镜十二指肠乳头括约肌切开术(EST)及胆道塑料支架置入(ERBD)治疗90岁及以上患者胆总管结石的疗效及安全性.方法 对37例行EST及ERBD治疗胆总管结石的90岁及以上患者的临床资料进行回顾性分析.结果 EST 1次取石成功30例;1次取出部分结石4例,经行内镜下鼻胆引流,5 d后再次取石成功;成功率为91.9%.2例因结石大,碎石失败后行ERBD,6个月后结石变小,取出胆管结石;1例因乳头旁巨大憩室插胆管未成功而致取石失败.37例患者中并发出血1例(2.7%),无肠穿孔、胰腺炎等并发症发生.结论 内镜行EST及ERBD治疗90岁及以上老年人胆总管结石安全、有效,具有创伤小、并发症少、操作灵活简便等优点.     

经内镜乳头括约肌切开术后的肠胆反流和胰胆反流

经内镜乳头括约肌切开术（ endoscopic sphincterotomy,EST）是在ERCP诊断性技术的基础上发展起来的,是一种内镜下高频电切开十二指肠乳头及胆总管末端括约肌的治疗技术。EST经过近40年的临床应用和发展,已经成为胆总管结石、胆源性胰腺炎、急性梗阻性化脓性胆管炎及乳头括约肌功能障碍（sphincter of Oddi dysfunction,SOD）等胆胰疾病的内镜下标准治疗方式。但EST需部分或全部切开胆管或胰管括约肌,势必会带来Oddi括约肌结构和功能的损伤。     

Idiopathic recurrent pancreatitis: long-term results after ERCP, endoscopic sphincterotomy, or ursodeoxycholic acid treatment

OBJECTIVE: In about 30% of cases, the etiology of acute recurrent pancreatitis remains unexplained, and the term "idiopathic" is currently used to define such disease. We aimed to evaluate the long-term outcome of patients with idiopathic recurrent pancreatitis who underwent endoscopic cholangiopancreatography (ERCP) followed by either endoscopic biliary (and seldom pancreatic) sphincterotomy or ursodeoxycholic acid (UDCA) treatment, in a prospective follow-up study. METHODS: A total of 40 consecutive patients with intact gallbladder entered the study protocol after a 24-month observation period during which at least two episodes of pancreatitis occurred. All patients underwent diagnostic ERCP, followed by biliary or minor papilla sphincterotomy in cases of documented or suspected bile duct microlithiasis and sludge, type 2 sphincter of Oddi dysfunction, or pancreas divisum with dilated dorsal duct. Patients with no definite anatomical or functional abnormalities received long-term treatment with UDCA. After biliary sphincterotomy, patients with further episodes of pancreatitis underwent main pancreatic duct stenting followed by pancreatic sphincterotomy if the stent had proved to be effective. RESULTS: ERCP found an underlying cause of pancreatitis in 70% of cases. Patients were followed-up for a period ranging from 27 to 73 months. Effective therapeutic ERCP or UDCA oral treatment proved that occult bile stone disease and type 2 or 3 sphincter of Oddi dysfunction (biliary or pancreatic segment) had been etiological factors in 35 of the 40 cases (87.5%) After therapeutic ERCP or UDCA, only three patients still continued to have episodes of pancreatitis. CONCLUSIONS: Diagnostic and therapeutic ERCP and UDCA were effective in 92.5% of our cases, over a long follow-up, indicating that the term "idiopathic" was justified only in a few patients with acute recurrent pancreatitis.     

Acute recurrent pancreatitis.

History, physical examination, simple laboratory and radiological tests, and endoscopic retrograde cholangiopancreatography (ERCP) are able to establish the cause of recurrent acute pancreatitis in 70% to 90% of patients. Dysfunction of the biliary and/or pancreatic sphincter, as identified by sphincter of Oddi manometry, accounts for the majority of the remaining cases. The diagnosis may be missed if the pancreatic sphincter is not evaluated. Pancreas divisum is a prevalent congenital abnormality that is usually innocuous but can lead to recurrent attacks of acute pancreatitis or abdominal pain. In select cases, endoscopic sphincterotomy of the minor papilla can provide relief of symptoms and prevent further attacks. A small proportion of patients with idiopathic pancreatitis have tiny stones in the common bile duct (microlithiasis). Crystals can be visualized during microscopic analysis of bile that is aspirated at the time of ERCP. Neoplasia is a rare cause of pancreatitis, and the diagnosis can usually be established by computerized tomography or ERCP. A wide variety of medications can also cause recurrent pancreatitis. ERCP, sphincter of Oddi manometry, and microscopy of aspirated bile should be undertaken in patients with recurrent pancreatitis in whom the diagnosis is not obvious.     

ENDOSCOPIC APPROACH TO THE MINOR DUODENAL PAPILLA: SPECIAL EMPHASIS ON ENDOSCOPIC MANAGEMENT ON PANCREAS DIVISUM

Diagnostic and therapeutic approach to the minor duodenal papilla including standardized technique was reviewed. In cases in which a pancreatogram is not achieved or those in which only a small portion of the ductal anatomy is visualized via the major duodenal papilla, cannulation of the minor papilla provides a second route of access to the ductal system. Successful minor papilla cannulation requires meticulous attention to technique. As the orifice of the minor papilla is usually of pinpoint size, needle‐tipped catheters are useful. As minor papilla cannulation in pancreas divisum carries the risk of severe pancreatitis, the procedure should be performed with more caution. In some patients with pancreas divisum, an increased resistance to flow across the small orifice results in dorsal pancreatic duct hypertension and clinical symptoms including acute recurrent pancreatitis, chronic pancreatitis, and pancreatic‐type pain. Pancreas divisum patients with acute recurrent pancreatitis are the best candidates for endoscopic management for dorsal‐duct decompression including endoscopic minor papilla sphincterotomy and stenting.     

Long-term results of endoscopic management of pancreas divisum with recurrent acute pancreatitis

BACKGROUND: The long-term efficacy of endoscopic treatment in pancreas divisum is controversial. This study evaluated the long-term results of dorsal duct stent insertion and endoscopic sphincterotomy of the minor papilla in patients presenting with recurrent acute pancreatitis or chronic pain. METHODS: Pancreas divisum was diagnosed in 175 patients between 1980 and 1998. Twenty-four patients seen with recurrent acute pancreatitis without underlying chronic calcifying pancreatitis or significant alcohol consumption were included in this study with a follow-up of at least 24 months. Eight were treated by sphincterotomy of the minor papilla alone, and 16 underwent dorsal duct stent insertion for a median duration of 8 months. RESULTS: The median duration of follow-up after endoscopic management was 39 months (range 24-105; interquartile range 40.5). All patients had recurrent acute pancreatitis before endoscopic treatment during a median period of 5 years. At the end of the follow-up there were only 2 recurrences of acute pancreatitis (p < 0.01). The number of patients with chronic pain before endoscopic treatment and at the end of follow-up decreased from 20 of 24 (83%) to 7 of 24 (29%) without reaching statistical significance. The 25% recurrence rate was estimated at 50 months by Kaplan-Meier analysis. Nine patients presented with a dilated dorsal duct before endoscopic treatment. After stent insertion, dorsal duct dilatation appeared in all 16 patients who underwent stent placement, and pancreatic duct stenosis developed in 3. Four patients (19%) required further treatment for pain recurrence or acute pancreatitis, with surgical procedures being performed in 2 cases. Complications occurred in 9 of 24 patients (38%), mainly acute pancreatitis or stenosis of the minor papilla. All complications except one were managed conservatively. Complications seemed to be less frequent after minor papilla sphincterotomy than after pancreatic stent insertion (25% vs. 44%). CONCLUSION: In patients with pancreas divisum, both dorsal duct stent insertion and minor papilla sphincterotomy decrease the rate of recurrent acute pancreatitis, whereas relief of chronic pain was less obvious.     

Risk factors for postoperative pancreatitis associated with diagnostic and therapeutic endoscopic retrograde cholangiopancreatography

OBJECTIVE : To investigate the risk factors for postoperative pancreatitis following endoscopic retrograde cholangiography (ERC), endoscopic retrograde pancreatography (ERP), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and endoscopic biliary stenting. METHODS : Four hundred and twelve patients referred to the endoscopy unit were divided into seven groups: (i) double ducts (pancreatic duct and biliary duct) contrast media filling group (ERCP group); (ii) biliary duct contrast media filling group (ERC group); (iii) pancreatic duct contrast media filling group (ERP group); (iv) ERCP plus biliary stenting group (ERCP + stent group); (v) ERC plus stenting group (ERC + stent group); (vi) ERCP plus EST and stone extraction (SE) group (ERCP + EST + SE group); and (vii) ERC plus EST and SE group (ERC + EST + SE group). Differences in postoperative serum amylase at 4 and 24 h, as well as clinical symptoms, were compared among the different groups. RESULTS : The incidence of postoperative hyperamylasemia at 4 and 24 h was 17.7 and 4.4%, respectively. The overall incidence of postoperative acute pancreatitis was 3.9% and the ERP group had the highest incidence of postoperative acute pancreatitis among the seven groups. CONCLUSIONS : Repeated pancreatic duct contrast filling during ERCP manipulation is the main risk factor for postoperative pancreatitis and therapeutic ERCP, such as EST, stenting and SE, does not increase the incidence of postoperative pancreatitis.     

Sphincter of Oddi dysfunction and bile duct microlithiasis in acute idiopathic pancreatitis

Although there are numerous causes of acute panc-reatitis, an etiology cannot always be found. Two potential etiologies, microlithiasis and sphincter of Oddi dysfunction, are discussed in this review. Gallbladder microlithiasis, missed on transcutaneous ultrasound, is reported as the cause of idiopathic acute pancreatitis in a wide frequency range of 6%-80%. The best diagnostic technique for gallbladder microlithiasis is endoscopic ultrasound although biliary crystal analysis and empiric cholecystectomy remain as reasonable options. In contrast, in patients who are post-cholecystectomy, bile duct microlithiasis does not appear to have a role in the pathogenesis of acute pancreatitis. Sphincter of Oddi dysfunction is present in 30%-65% of patients with idiopathic acute recurrent pancreatitis in whom other diagnoses have been excluded. It is unclear if this sphincter dysfunction was the original etiology of the first episode of pancreatitis although it appears to have a causative role in recurring episodes since sphincter ablation decreases the frequency of recurrent attacks. Unfortunately, this conclusion is primarily based on small retrospective case series; larger prospective studies of the outcome of pancreatic sphincterotomy for SOD-associated acute pancreatitis are sorely needed. Another problem with this diagnosis and its treatment is the concern over potential procedure related complications from endoscopic retrograde cholangiopancreatography （ERCP）, manometry and pancreatic sphincterotomy. For these reasons, patients should have recurrent acute pancreatitis, not a single episode, and have a careful informed consent before assessment of the sphincter of Oddi is undertaken.     

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。     

内镜扩约肌切开术治疗胆总管继发性结石

目的评价逆行胰胆管造影术（ＥＲＣＰ）和内镜括约肌切开术（ＥＳＴ）在腹腔镜胆囊切除前后诊断和治疗胆总管继发结石中的作用．方法采用ＥＲＣＰ和ＥＳＴ在ＬＣ术前或术后诊断和治疗胆总管继发结石２２８例,其中包括ＬＣ术前发现的１８５例和术后确诊的４３例．常规ＥＲＣＰ检查,证实胆总管内有结石后行ＥＳＴ．然后根据结石形态、大小和数目不同采取不同方法处理结石．①自然排石,适合于直径在０３ｃｍ～０８ｃｍ的结石;②取石网篮取石,适合于直径在０９ｃｍ～１５ｃｍ的结石;③碎石篮碎石,适宜直径大于１５ｃｍ以上的结石．结果全部２２８例患者中,ＥＳＴ成功２１７例（９５２％）,胆总管结石完全排出２０９例（９１７％）,发生各种并发症１９例（８８％）,主要并发症为急性胰腺炎、急性胆管炎和Ｏｄｄｉ扩约肌切口渗血,全部经非手术治疗愈合,无死亡病例．结论ＥＲＣＰ和ＥＳＴ是ＬＣ术前和术后诊治胆总管结石安全有效的方法之一．