内镜下乳头括约肌小切开联合大球囊扩张治疗老年胆总管多发巨大结石的效果及安全性分析

目的评估经内镜下十二指肠乳头括约肌小切开(m EST)联合内镜下乳头大球囊扩张术(EPLBD)在老年患者胆总管多发巨大结石治疗中的安全性和有效性。方法回顾性分析2012年1月-2016年12月安康市中心医院因胆总管多发大结石在内镜中心行ERCP治疗的患者229例,根据患者结石大小及胆总管形态选择手术方式。所有纳入病例按照内镜手术方式不同分为m EST+EPLBD组(治疗组)与EST组(对照组),观察2组首次取石成功率,机械碎石使用率,取石时间及并发症发生率。计量资料组间比较采用t检验,计数资料组间比较采用χ~2检验。结果治疗组(136例)与对照组(93例)比较,2组在一次取石成功率上差异无统计学意义(91.17%vs 87.10%,χ~2=0.980,P>0.05);而在取石时间及机械碎石使用率方面比较差异有统计学意义[(18.2±4.3)min vs(37.4±6.7)min,χ~2=37.1526,P<0.01;6.71%vs 40.00%,t=24.411,P<0.01]。2组在胰腺炎(2.94%vs 6.45%)、出血发生率(2.21%vs 2.15%)方面比较差异无统计学意义(χ~2值分别为1.630、0.001,P值均>0.05),无穿孔及感染等并发症的发生。结论 m EST+EPLBD治疗老年胆总管多发巨大结石,疗效确切,可有效缩短取石时间,有效减少机械碎石的使用率,从而减少结石复发几率,同时该方法不增加ERCP术后并发症,是一种安全、有效的老年胆总管巨大多发结石微创治疗方法。     

经内镜逆行胰胆管造影术在十二指肠良性狭窄合并胆总管结石中的应用价值

目的分析经内镜逆行胰胆管造影术(ERCP)在十二指肠良性狭窄合并胆总管结石中的有效性及安全性。方法回顾性分析2013年1月至2017年12月14例因十二指肠良性狭窄合并胆总管结石接受ERCP的患者临床资料。分析病例特点、ERCP情况及预后等。结果14例患者中ERCP成功12例。共行22次ERCP,平均1.57次/例。8例因十二指肠狭窄接受球囊扩张术。ERCP失败2例均为扩张组患者。ERCP后1例出现轻症急性胰腺炎,1例出现高淀粉酶血症,经药物治疗均康复。14例中有4例于术后1~3年胆总管结石复发,其中3例再次内镜取石成功,1例接受外科手术。结论ERCP治疗十二指肠良性狭窄合并胆总管结石有较高成功率,但复发率也较高。     

治疗性经内镜逆行胰胆管造影在高龄人群胆总管结石中的应用(附91例临床分析)

目的评价内镜治疗70岁以上胆总管结石患者的安全性及有效性。方法回顾性分析2004年1月～2010年12月我院内镜中心91例70岁以上胆总管结石患者的内镜诊治资料及随访情况。结果 91例患者经内镜逆行胰胆管造影(ERCP)全部成功,其中18例因插管困难行十二指肠乳头括约肌预切开术。所有患者均有胆总管结石,其中1枚结石者48例,2枚结石者19例,3枚或3枚以上结石者24例;取石方法:网篮直接取石13例,机械碎石后取石52例,球囊扩张后取石11例;胆总管放置塑料支架而未能一次取石15例。胆总管结石直径1.4～4.5 cm,平均(1.9±0.7)cm。7例出现出血并发症,应用局部喷洒或黏膜下注射1∶10 000肾上腺素、局部电凝方法止血;11例患者术后出现一过性淀粉酶升高,2例患者发生ERCP相关胰腺炎,上述患者行禁食、抑制胰液分泌、抑制胰酶活性、抗炎补液等治疗。入组患者无ERCP相关性死亡,89例患者随访6～12个月,2例失访,5例出现结石再发。结论内镜下治疗高龄胆总管结石患者疗效确切,安全性较好。     

内镜下逆行胰胆管造影术治疗老年胆总管巨大结石40例

目的探讨内镜下逆行胰胆管造影术(ERCP)治疗老年胆总管巨大结石的可行性及安全性。方法 40例老年胆总管巨大结石患者完善术前准备,密切监护下经十二指肠镜先行ERCP,发现胆总管结石后行内镜下十二指肠乳头括约肌切开(EST)和机械碎石(EML)取石,视具体情况留置鼻胆管引流及支架置入引流。结果 40例患者37例取石获得成功,成功率92.5%;其中10例经过二次取石。所有患者腹痛症状明显改善,皮肤巩膜黄染迅速消褪,发热患者48 h内体温趋于正常。术后并发轻型胰腺炎4例,乳头肌切口创面轻度渗血2例,均经内科保守治疗痊愈,未发生肠穿孔、胆道撕脱等严重并发症和死亡。结论 ERCP治疗老年胆总管巨大结石是一种安全、有效的治疗方法,应考虑作为治疗的首选方案。     

继发性胆总管结石的临床及内镜逆行胰胆管造影表现特点

[目的]探讨继发性胆总管结石的临床特点和内镜逆行胰胆管造影(ERCP)表现.[方法]回顾经ERCP检查确诊的58例胆囊结石切除术后继发胆总管结石患者的相关资料,观察其临床特点及ERCP表现,并与原发组作对比分析.[结果]继发性胆总管结石的发病年龄大,误诊时间长,临床表现主要为腹痛、消化不良.ERCP表现以多发结石、大结石常见.[结论]胆囊结石切除术后胆总管结石仍有较高的发生率.ERCP检查是诊断胆总管结石的安全有效方法.     

经内镜乳头气囊扩张术治疗胆总管结石16例分析

1998年 1 1月～ 2 0 0 0年 5月 ,我们采用内镜下乳头气囊扩张术 ( EPBD)治疗胆总管小结石 1 6例 ,取得了较好的效果。现报告如下。1　资料和方法1 .1　一般资料　本组中 ,男 9例 ,女 7例 ;年龄 30～ 76岁 ,平均 49.6岁。其中 5例曾接受胆囊切除术 ,7例有乳头旁憩室 ,1例为扁平样乳头 ,所有病例术前皆经 B超或最后经 ERCP证实有胆总管结石 ,其中发现胆总管结石 1枚者 9例 ,2枚者 4例 ,3枚者 2例 ,6枚者 1例 ,结石横径 <0 .8cm9例 ,结石横径 0 .8～ 1 .0 cm者 6例 ,最大 1例为 1 .2 cm×1 .2 cm。1 .2　方法　术前半小时予安定和 654～ 2…     

经内镜逆行胰胆管造影诊治肝移植术后胆总管十二指肠瘘 一例

胆总管十二指肠瘘（choledochoduodenal fistula,CDF）是一种特殊类型的胆肠内瘘,临床少见。目前针对CDF的治疗手段除了外科手术进行胆道重建外,还可尝试经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography, ERCP)进行治疗,与ERCP治疗胆瘘类似,通过放置鼻胆管引流,促进CDF的愈合,从而避免外科手术。本文报道1例ERCP诊治肝移植术后CDF的过程。     

内镜下机械碎石术治疗胆总管结石102例

使用内镜下机械碎石术(endoscopic mechanical lithotripsy,EML)可使大于1.0 cm的胆总管结石顺利排出[1],在EML的操作过程中,除结石坚硬不易碎石成功外,只要掌握好网篮插入,网篮套石,网篮碎石,清除结石和EST切口大小等关键性技术操作,一般均能成功地将结石取出.我院至1998-06治疗胆总管结石102例,成功率97.1%,报告如下.     

内镜下胆总管取石术患者不同时期生存质量比较分析

目的 探讨行ERCP胆总管结石取石患者不同时期生存质量的变化情况,为改善患者的生存质量提供必要依据.方法 采用GIQLI消化系统疾病生存质量量表对35例行ERCP胆总管结石取石患者手术前、手术后第2、6周的生存质量变化进行问卷调查.结果 术前平均GIQLI生存质量指数99.9分,术后2周和6周明显升高,分别为112.2和121.9分.在本组小样本系列中,术后2周,患者生存质量较术前有明显提高 术后6周,患者生存质量恢复正常人水平 统计学处理差异有统计学意义（P＜0.01）.结论 行ERCP胆总管结石取石患者术后恢复快、生存质量高.     

治疗性经内镜逆行胰胆管造影在胆胰疾病治疗中的应用

目的分析治疗性经内镜逆行胰胆管造影(ERCP)对胆胰疾病患者肝功能和治疗效果的影响。方法筛选2005年1月-2015年7月北京市垂杨柳医院应用电子十二指肠镜行ERCP治疗的397例胆胰疾病患者。根据不同病种分为8组:良性梗阻组(109例)、恶性梗阻组(47例)、胰腺炎组(27例)、异物梗阻组(127例)、单纯性胆管炎组(19例)、胆瘘组(15例)、十二指肠乳头憩室组(29例)、肝移植术后组(24例)。实施ERCP前1天和实施ERCP 4周后检测受试者的肝功能:ALT、AST、ALP、GGT和TBil。ERCP治疗完成后1个月对疗效进行全面评估。计量资料同组治疗前后比较采用配对t检验,多组间比较采用方差分析;计数资料组间比较采用χ~2检验。结果各组受试者实施ERCP后,其ALT、AST、ALP、GGT以及TBil均有显著改善,即ERCP可以明显改善受试者肝功能(P值均0.05)。疗效评估发现,ERCP治疗后,各组的症状均有明显缓解,单纯性胆管炎组全部治愈,而肝移植术后组和恶性梗阻组只能达到好转的效果。结论治疗性ERCP可显著改善患者的肝功能;但对肝移植术后患者和胆胰肿瘤患者,需要在进行ERCP治疗的同时实施腹腔镜手术联合治疗。     

乳头括约肌小切开合并气囊扩张术治疗胆总管结石532例分析

目的探讨乳头小切口合并气囊扩张术治疗总胆管结石的应用体会。方法对2008年1月至2009年1月沈阳军区总医院收治的532例诊断总胆管结石明确的患者先行EST乳头小切开,再行EPBD,然后行胆总管取石术。结果所有患者行EST、EPBD、胆总管取石治疗均一次成功,术后无出血、穿孔发生。结论乳头小切开合并气囊扩张术治疗胆总管结石操作容易,安全性高,副反应小,术后合并症少,值得广泛在临床工作中推广应用。     

Success rate and complications of endoscopic extraction of common bile duct stones over 2 cm in diameter

BACKGROUND:Clinically,common bile duct (CBD) stones >2 cm are difficult to remove by endoscopic retrograde cholangiopancreatography (ERCP).To evaluate this observation,the rates of successful clearance of CBD stones and complications were compared between ERCP extraction of CBD stones of >2 cm and <2 cm in diameter.METHODS:All patients who had undergone endoscopic extraction of CBD stones at the Endoscopy Center of Shanghai First People's Hospital from May 2004 to May 2008 were reviewed.Patients with CBD st...     

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．     

Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation

BACKGROUND: Choledocholithiasis can be difficult to diagnose, even with direct cholangiography. We examined the role of biliary intraductal ultrasonography in detecting common bile duct stones that had been overlooked during endoscopic retrograde cholangiopancreatography. METHODS: Eighty consecutive patients who underwent endoscopic retrograde cholangiography for suspected choledocholithiasis with negative results were evaluated with intraductal ultrasonography (20 MHz) for the presence of biliary concrements. The diagnostic criterion for stones was a strong-echo structure with acoustic shadowing. Materials of low amplitude echoes without acoustic shadowing were considered sludge. RESULTS: Intrabile duct scanning was successful in all patients. Of the 80 patients, 20 (25%) had ultrasonic evidence of common bile duct stones. The stones measured 5 mm or less on ultrasound and their presence was confirmed macroscopically during endoscopic (17 patients) or laparoscopic (three patients) bile duct clearance. Another 37 patients (46%) had biliary sludge alone and have been followed up uneventfully. CONCLUSIONS: Biliary intraductal ultrasonography may become a useful adjunct to establish the diagnosis of occult bile duct concrements and a guide to appropriate therapeutic selection during endoscopic biliary cannulation.     

Endoscopic papillary large balloon dilation for large common bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) involves endoscopic biliary sphincterotomy (EBS) followed by balloon dilation using a 12–20-mm balloon to remove large or difficult stones from the common bile duct. The complications and limitations of endoscopic biliary sphincterotomy (EBS) are well known. Endoscopic papillary balloon dilation (EPBD) with a smaller diameter balloon but without sphincterotomy is widely used in a number of regions of the world for removal of routine bile duct stones and has been investigated as an alternative to EBS. EPBD, however, appears to be associated with an increased risk of pancreatitis. EPLBD differs from EPBD as it involves EBS followed by large balloon dilation. EPLBD would theoretically combine advantages of sphincterotomy and balloon dilation by increasing efficacy at stone extraction while minimizing complications of both EBS and EBD. A review of the available literature for EPBLD shows that it is relatively safe and effective. A high success rate (up to 95%) has been described for stone removal using EPLBD, with a low complication rate. Unlike EPBD, EBLBD does not appear to be associated with a higher risk of post-ERCP pancreatitis, probably because of separation of the biliary and pancreatic sphincters after EBS. EPLBD appears to be a reasonable option for removal of large or difficult common bile duct stones. This technique may be especially helpful in patients with difficult papillary anatomy, such as those with small papillae, intra- or peri-diverticular papilla. Its role in patients with coagulopathy or other risks for bleeding remains to be investigated.     

The clinical course of common bile duct stone clearance with endoscopic retrograde cholangio-pancreaticography*

Objectives: Two-stage treatment of common bile duct stones by Endoscopic Retrograde Cholangio-Pancreatography and subsequent laparoscopic cholecystectomy is well established. In many cases multiple procedures are needed before clearance of the common bile duct is obtained. This study aimed to describe the clinical course from common bile duct stone diagnosis to successful clearance.

Materials and Methods: A prospective observational study from 2011 to 2014 of consecutive patients diagnosed with common bile duct stones undergoing Endoscopic Retrograde Cholangio-Pancreatography at a public university hospital.

Results: In this study 297 patients with common bile duct stones were identified. More than one Endoscopic Retrograde Cholangio-Pancreatography was performed in 174 (59%) patients and more than two in 51(17%) before clearance. A sphincterotomy was performed in 269 (91%) patients and 189 (64%) had a stent inserted. Bleeding occurred in 17 (6%) requiring injection treatment and post procedure complications occurred in 38 (13%). Subsequent laparoscopic cholecystectomy was performed in 180 (61%) patients. Overall, the patients were hospitalized for 11 (8.5) days and the length of treatment from diagnose to stone clearance was 49 (84.5) days. Overweight, pancreatitis at admission, universal anesthesia, and expert level endoscopist inversely determined common bile duct clearance failure.

Conclusions: Common bile duct clearance by Endoscopic Retrograde Cholangio-Pancreatography requires multiple procedures and complications are frequent leading to prolonged treatment and hospitalization suggesting a limited efficacy.     

Long-term prognosis of patients with endoscopically treated postoperative bile duct stricture and bile duct stricture due to chronic pancreatitis

Aim:  To compare the outcome of endoscopic therapy for postoperative benign bile duct stricture and benign bile duct stricture due to chronic pancreatitis, including long-term prognosis.
Methods:  The subjects were 20 patients with postoperative benign bile duct stricture and 13 patients with bile duct stricture due to chronic pancreatitis who were 2 years or more after initial therapy. The patients underwent transpapillary drainage with tube exchange every 3 to 6 months until being free from the tube. Successful therapy was defined as a stent-free condition without hepatic disorder.
Results:  Endoscopic therapy was successful in 90% (18/20) of the patients with postoperative bile duct stricture. The stent was removed (stent free) in 100% (20/20) of the patients, but jaundice resolved in only 10% (2/20) of patients while biliary enzymes kept increasing. Restricture occurred in 5% (1/20) of the patients, but after repeat treatment the stent could be removed. In patients with bile duct stricture due to chronic pancreatitis the therapy was successful in only 7.7% (1/13) of the patients; the stent was retained in 92.3% (12/13) of the patients during a long period. Severe acute pancreatitis occurred in 3.0% (1/33) of the patients as an accidental symptom attributable to endoscopic retrograde cholangiopancreatography (ERCP); however, it remitted after conservative treatment.
Conclusion:  Our results further confirm the usefulness of endoscopic therapy for postoperative benign bile duct strictures and good long-term prognosis of the patients.     

塑料支架内引流在老年难取性胆管结石中的应用

目的:回顾性分析在老年性难取性胆总管结石患者中胆道塑料支架置入治疗的安全性和有效性.方法:先行常规逆行性胆胰管造影(ERCP)明确诊断,根据胆管扩张及结石大小情况,行十二指肠乳头括约肌切开后经导丝引导放置胆道塑料支架通畅引流.结果:103例取石困难患者在常规ERCP后置入塑料支架.3-6mo后复查ERCP显示有60例(58.2%)结石成为小结石,经内镜应用网篮取出;13例(12.6%)结石未变化,重新更换支架引流;11例(10.6%)最后行腹腔镜胆囊切除胆管探查取石治疗;16例(15.5%)患者因无特殊不适未复查ERCP,长期行内支架引流.结论:对于老年性难取性胆管结石患者,塑料支架内引流是一种十分有效和相对安全的手术方式.