十二指肠镜乳头括约肌切开联合胆道镜治疗残余胆总管末段嵌顿结石

目的：探讨十二指肠镜乳头括约肌切开（EST）联合胆道镜治疗残余胆总管末段嵌顿结石的方法和效果。方法：14例残余胆总管末段嵌顿结石在经T管瘘道不能取出结石时联合EST，在乳头括约肌切开后，再用胆道镜将嵌顿结石推入十二指肠以清除结石。结果：全组病例行EST联合胆道镜技术均获成功，胆总管末段嵌顿结石完全清除，仅3例合并中量消化道出血，无严重并发症。结论：EST联合胆道镜治疗术后残余胆总管末段嵌顿结石安全有效，表明了内镜能解决临床的疑难问题。     

针形刀预切开及乳头开窗术治疗胆管疾病28例

临床常遇到一些胆管扩张的病例，需行逆行胆管造影(ERC)及内镜下乳头括约肌切开(EST)，由于壶腹部曲度过大、结石壶腹部嵌顿等原因，选择性胆管插管失败，致使胆管疾病的内镜下诊断和，或治疗无法进行。在这种情况下，采用乳头预切开或开窗技术，多能进一步完成ERC及EST。2001年9月～2004年3月我院采用针形刀预切开及乳头开窗术治疗胆管疾病28例。现报道如下：     

内镜乳头小切开联合气囊扩张术治疗胆总管结石和蛔虫嵌顿

内镜乳头括约肌切开术 (EST)是胆总管结石和蛔虫嵌顿的常规治疗方法之一。为保留Oddi’s括约肌天然生理功能 ,降低EST所致出血和穿孔等严重并发症 ,作者用内镜乳头小切开联合气囊扩张术治疗胆总管结石嵌顿 7例、胆总管蛔虫嵌顿残留 2例。结果 :胆总管 1次结石排净率 85 .7% ,排虫率 10 0 % ,ACST缓解率10 0 % ,无出血穿孔和死亡。结论 :EST应严格掌握适应证、能不切开尽量不切开 ,能作小切开不作大切开 ,尽量保护Oddi’s括约肌这一天然生理屏障。EST与气囊扩张相结合可负补其不足 ,增加胆管插管成功率 ,降低并发症。控制切开长度和重视术后处理是防治并发症的关键     

ERCP在诊治十二指肠壶腹周围疾病中的应用

目的：探讨ERCP在诊断和治疗十二指肠壶腹周围良恶性疾病中的应用。方法：自1999年1月～2003年4月，173例壶腹周围良恶性疾病患者经ERCP选用十二指肠乳头活检，常规乳头切开或针刀切开，乳头气囊扩张，胆道结石取石术，放置鼻胆管、塑料内支架或金属内支架等方法。结果：173例壶腹周围疾病中，良性病变99例，95例(95．9％)得到内镜诊断或治疗，其中壶腹周围炎性狭窄治疗成功率95．4％(83／87)，同时伴有结石40例，结石取出率92．5％(37／40)，其中乳头结石嵌顿取石治疗成功率100％(12／12)。壶腹周围恶性肿瘤74例，内镜活检病理证实壶腹周围腺癌48例(64．9％)，经内镜引流共43例(58．1％)，其中鼻胆管引流20例、塑料内支架13例、金属内支架10例。结论：在乳头结石嵌顿、壶腹周围炎性狭窄治疗中．内镜治疗效果显著，在壶腹周围恶性肿瘤术前病理诊断、胆道置管减黄，晚期患者姑息性胆道置管引流中，有一定的临床应用价值。     

内镜治疗胆道蛔虫病的临床价值

目的 探讨内镜治疗胆道蛔虫病的临床价值。方法 回顾性分析104例经十二指肠镜治疗的胆道蛔虫病临床资料。结果 7例蛔虫嵌顿于乳头者，取虫成功率100％；在97例疑为胆管腔内蛔虫者中，直接取虫成功者23例，结合ERCP取虫者74例，71例插管成功者中66例经EPBD或EST后取虫成功，3例插管不成功而转手术治疗；总的成功率92．3％(96／104)。术后发生急性胆管炎3例(2．9％)，急性胰腺炎1例(0．9％)。结论 经内镜取虫治疗胆道蛔虫病是一种安全、有效、并发症少的新方法。     

针状刀在逆行胰胆管造影术中应用的护理配合

目的探讨在逆行胰胆管造影术中对困难乳头插管和清除嵌顿结石手术采用针状刀的配合方法与技巧。方法针状刀连接高频电源,切开十二指肠乳头顶端与十二指肠乳头开口之间的黏膜,达到寻找胆管开口和清除嵌顿结石的目的。结果 143例患者采用针状刀行乳头开窗术或预切开术,有131例患者获得成功,其中行开窗术84例、行预切开术47例,12例未获成功。结论对内镜下行常规胆管插管困难者,可使用针状刀行乳头开窗术或预切开术以提高治疗成功率,而良好的护理配合对于保证手术成功有着重要的意义。     

急诊十二指肠乳头嵌顿性蛔虫症的诊断和治疗

目的探讨十二指肠乳头嵌顿性蛔虫症的诊断和内镜疗效。方法总结该院1985-2004年经B超、内镜诊治的203例十二指肠嵌顿性蛔虫症病例。结果B超诊断符合率为92．1％，内镜取虫成功率95．8％。结论内镜治疗十二指肠嵌顿性蛔虫症效果肯定。     

不同方式针形刀切开在十二指肠乳头结石嵌顿3种情况中的应用及术中配合

目的探讨内镜下针形刀乳头开窗术、针形刀乳头切开术及针形刀多点放射状切开在胆总管结石乳头部嵌顿3种情况中的临床应用及术中配合。方法 32例最终在十二指肠镜下确诊为胆总管结石乳头部嵌顿的患者,由于常规ERCP插管困难,根据胆总管结石乳头部嵌顿3种不同情况,分别用上述3种方式行针形刀预切开,再进行后续相应的内镜治疗。结果行针形刀乳头开窗术13例,全部成功取出乳头部嵌顿结石;行针形刀乳头切开术17例,成功取出乳头部嵌顿结石16例,1例术中渗血无法控制转外科手术治疗;行针形刀多点放射状切开2例,乳头部嵌顿结石取石成功。32例患者术后临床症状均缓解,无手术相关的严重并发症及死亡。结论胆总管结石乳头部嵌顿的3种不同情况分别使用不同方式针形刀预切开治疗,可有效取出乳头部嵌顿结石,与外科手术比较具有恢复快、创伤小、风险低、费用少、住院时间短等优势,但需有经验的内镜医师操作。 更多还原     

LC中胆囊管结石嵌顿的处理体会(附47例报告)

目的评价胆囊管切开与术中胆道造影在腹腔镜胆囊切除术(LC)中处理胆囊管结石嵌顿的临床意义。方法回顾分析1999年7月-2003年12月在该院肝胆外科行腹腔镜胆囊切除术病例。总结处理胆囊结石嵌顿的对策和技巧。结果47例均取石成功，术中胆道造影发现胆总管结石8例，5例于LC术中联合内镜下十二指肠乳头切开取石(EST)，3例中转开腹行胆总管切开取石 T管引流术；无严重并发症发生。结论用胆囊管切开取石结合术中胆道造影的方法处理胆囊管结石嵌顿疗效确切、恢复快、并发症少，值得临床推广。     

乳头括约肌气囊扩张术治疗胆管结石

乳头括约肌切开（ＥＳＴ）目前已成为一种成熟的胆管结石治疗方法，但ＥＳＴ及内镜下胆管取石术是一种创伤性治疗方法，且会引起出血，十二指肠后穿孔，急性胰腺一管炎，取石网蓝嵌顿等并发平，甚至危及患者生命。近二年来，该院应用ＥＰＢＤ治疗胆管结石１４例（结石直径≤１０ｍｍ）取得了满意的疗效。同期内，对于结石直径１０～２０ｍｍ的胆管结石则选择ＥＳＴ治疗。     

Techniques of selective cannulation and sphincterotomy

Selective access into the desired duct followed by incision of the sphincter, i. e. sphincterotomy, forms the cornerstone of any endoscopic intervention within the pancreaticobiliary system. The apprehensive beginner's performance and hesitance is aggravated by ignorance of ampullary anatomy and he considers selective cannulation to be the greatest hurdle. An understanding of ampullary morphology and its variations is vital in achieving selective cannulation. Technological advances have assisted in the form of development of better accessories, progressing from "immovable" catheters to movable cannulae and to single-, double-, and even triple-lumen sphincterotomes. Orientation along the long axis of the bile duct ensures access and avoids inadvertent and hazardous manipulation of the pancreatitic duct. Using guide wires, especially the 'angulated-tip' glide wire improves cannulation successs rates considerably. Precut accessotomy complements wire-guided selective cannulation, and can be used analogously to a controlled surgical incision to facilitate cannulation of the desired system after deroofing the papilla layer by layer. Published data have validated its role, demonstrating high efficacy and minimal complications when it is properly performed. Biliary sphincterotomy, using the right mode of blended current in the 11-12 o'clock direction and with the tip of the sphincterotome wire, provides a clean and bloodless splitting open of the sphincter of Oddi. Pancreatic precut, over-the-stent papillotomy and sphincterotomy over a guide wire have all been proven to be safe and effective measures, in large groups of patients. In special situations, such as where there are impacted stones or ampullary lesions, needle-knife infundibulotomy achieves reliable access. Techniques such as saline infiltration into the papilla and subtle body movements to re-position the scope enable biliary cannulation in difficult situations. Alterations in anatomy, for instance post Billroth II gastrectomy, no longer discourage the endoscopist from attempting intervention. Application of knowledge of reverse anatomy, specially designed instruments, and adherence to the proper technique improves success in these patients. Our experience of 9000 sphincterotomies over the past 12 years with minimal morbidity stands proof to the principles and techniques highlighted in this monograph. We recommend these to all aspiring endoscopists, with the assurance of improved technical success when they are implemented.     

Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage

Endoscopic biliary stenting is the most common method of treating obstructive jaundice. We present a new technique of biliary drainage using endoscopic ultrasound (EUS) and EUS-guided puncture of the common bile duct (CBD). A 56-year-old man with obstructive jaundice was referred for EUS and endoscopic retrograde cholangiopancreatography (ERCP) because a computed tomography (CT) scan had shown a pancreatic mass in the head of the pancreas and a dilated CBD. The patient was enrolled in a preoperative chemoradiotherapy protocol and biliary stenting was required. Deep cannulation was not obtained even after a precut and the procedure was stopped. Using a therapeutic EUS scope (FG 38X Pentax), the CBD was punctured with a 5-F needle-knife under EUS guidance and a cholangiogram was obtained. A 0.35-inch guide wire was introduced into the CBD. The EUS scope was removed and a duodenoscope was introduced, allowing the placement through the duodenum of a 10-F plastic stent. The CBD was drained properly. No complication occurred.     

针形刀预切开术在老年患者胆道远端恶性狭窄支架置入中的应用

目的 研究针形刀预切开术在老年胆管远端恶性狭窄患者中行内镜逆行胰胆管造影术(ERCP)支架置入的应用效果.方法 选取常州市第一人民医院2018年1月-2021年1月47例明确诊断为胆管远端恶性狭窄且常规插管失败而行针形刀预切开术的老年患者(年龄>70岁).其中,男29例,女18例;年龄71～93岁,平均81.04岁;十...     

Pancreatic sphincter precutting to gain selective access to the common bile duct: a series of 172 patients

BACKGROUND AND STUDY AIMS: Several precutting techniques have been described in cases of failed access to the common bile duct. We describe our experience with pancreatic sphincter precutting in an upward direction, and report its success rates and complications. PATIENTS AND METHODS: A total of 172 patients underwent a procedure using this technique between January 1989 and December 2001. The technique consisted of a medium-to-large precut along the midline, above the papillary elevation, using either the common channel or the pancreatic duct in the ampulla of Vater as a guide. The septum between the pancreatic duct and the bile duct was removed and separate openings to the pancreatic and bile ducts were created, followed by complete biliary sphincterotomy. RESULTS: Biliary cannulation and sphincterotomy was successful in 163 of the 172 study patients (95 %). Mild complications, which were all managed conservatively, occurred in 17 patients (10 %). This complication rate was significantly higher than our complication rate for standard endoscopic sphincterotomy, which was 0.8 % in 1770 patients ( P < 0.0001). CONCLUSIONS: Pancreatic sphincter precutting is an effective and safe technique for patients in whom selective cannulation of the common bile duct has failed. Further prospective comparative studies of other precutting techniques will better define its clinical value.     

肝移植术后胆道并发症的内镜诊治

目的：探讨肝移植术后胆道并发症的内镜诊疗价值。方法：2001年4月～2004年7月对12例肝移植术后胆道并发症患者，应用电子十二指肠镜进行胆道造影，乳头切开、取石、放置鼻胆管或塑料内支架引流等诊疗方法。结果：原位肝移植术后出现胆道并发症12例，共行ERCP15次：胆管吻合口狭窄、胆总管结石伴急性梗阻性化脓性胆管炎3例，急诊内镜取石、鼻胆管引流，再次内镜胆总管塑料内支架引流。胆管吻合口狭窄伴胆管泥沙样结石2例，内镜乳头切开、取石、引流。胆管吻合口狭窄5例，其中塑料内支架引流2例，未置引流1例，鼻胆管放置失败1例，胆管吻合口严重狭窄导丝无法通过1例。胆漏2例，因胆总管吻合口严重狭窄，导丝未能通过。结论：肝移植术后胆道并发症经内镜诊疗具有微创、安全、有效，有一定的诊疗价值。     

内镜逆行胰胆管造影术中选择性胆管插管困难的循证处理

目的内镜逆行胰胆管造影（ERCP）术中选择性胆管插管困难（DSBC）是临床常见的问题,针对1例DSBC患者,通过检索当前最佳证据,为临床合理处理提供依据。方法全面检索Cochrane图书馆（2010年第1期）、ACP online、NGC（1998～2010.6）、PubMed（1950～2010.6）及CBM（1994～2010.6）,查找与ERCP及DSBC有关的系统评价和随机对照试验,并对所获得的证据进行质量评价。结果最终纳入18篇文献。当前证据表明,预切开术可提高DSBC患者插管成功率,对有经验的内镜医生而言安全有效,并能减少操作时间;胰管占据技术较预切开容易掌握,可提高插管成功率;但上述两种方法均有可能增加ERCP术后并发症的发生。根据以上证据,结合内镜医生的经验和患者及家属的愿望,我们为该例患者实施了针状刀预切开术,再行选择性胆管插管获得成功。结论当前证据显示,预切开和胰管占据均可提高DSBC的插管成功率,但应用时要结合患者具体情况和内镜医生的经验合理选择。     

内镜下乳头预切开术在ERCP中的应用

目的探讨内镜下乳头预切开术在ERCP中的应用价值。方法对标准乳头切开法不能应用的病例采用经胰管乳头预切开法或针状切开刀法。结果41例乳头预切开术中，成功36例(87．8％)，出现乳头出血3例，经电凝后血止。结论乳头预切开术作为常规ERCP和EST的补充方法，提高了ERCP的成功率，值得临床应用。     

ERCP在胆囊切除术后黄疸诊治中的应用

目的：探讨经内镜逆行胆胰管造影（endoscopicretrogradecholangiopancreatograp11y,ERCP）在胆囊切除术后黄疸患者的诊断和治疗中的应用价值。方法：对53例胆囊切除术后不明原因或考虑为外科原因的黄疸患者行ERCP检查,明确黄疸的原因并在内镜下采取相应的治疗措施。对于胆总管结石的患者行乳头括约肌切开（endoscopicsphincterotomy,EST）或乳头球囊扩张（endoscopicpapillaryballoondilation,EPBD）取石,对胆漏和胆道狭窄患者行内镜引流术,对乳头狭窄或括约肌功能异常的患者行EST或EPBD。结果：53例患者均成功行ERCP检查,结果显示胆总管结石38例、胆道损伤8例、乳头狭窄或括约肌功能异常3例、乳头癌1例、肝门胆管癌1例、未见异常2例。经相应治疗后,所有患者均未出现严重并发症。结论：对于胆囊切除术后出现黄疸的患者,ERCP是理想的诊断方法,同时还可以进行内镜下治疗。     

壶腹部癌19例诊断分析

目的：探讨壶腹部癌的诊断和治疗方法。方法：回顾分析19例经病理证实为壶腹部癌患者的临床资料。结果：19例壶腹部癌患者以梗阻性黄疸和上腹部不适、疼痛为突出表现;影像学检查主要表现为壶腹部肿物及胆、胰管扩张;内镜提示十二指肠乳头及附近粘膜病变。行胰十二指肠切除术15例,十二指肠肿瘤局部切除术1例,3例未行手术。结论：上腹部不适、疼痛是壶腹部癌的早期症状,超声及内镜检查,尤其是内镜检查和活检对壶腹部癌的发现和诊断具有重要的作用。胰十二指肠切除术是治疗的首选方法。     

经胆道镜治疗胆道难取性残留结石

目的：对碎石结合胆道镜取石治疗胆管难取性结石的有效性和安全性作出初步评估。方法：采用碎石后经胆道镜取石的方法治疗１５０例胆道难取性残留结石。其中活检钳碎石５５例,压电冲击波碎石１７例,液电冲击波碎石３８例,碎石篮碎石４０例。对取石失败者联合应用十二指肠镜括约肌切开或乳头气囊导管扩张术（ＥＳＴ／ＥＰＴ）。结果：活检钳碎石、压电冲击波、民冲击波和取石篮碎石取石成功率分别为９０．９％、９４．１％、９４．