经内镜逆行胰胆管造影术后高淀粉酶血症的危险因素分析

目的探讨经内镜逆行胰胆管造影(ERCP)术后高淀粉酶血症(PEPH)发生的危险因素。方法对2012年1月-2014年12月在新疆维吾尔自治区人民医院行治疗性ERCP并符合纳入标准的233例患者的临床资料进行回顾性分析,提取患者年龄、性别、饮酒史、单发结石、甘油三酯、民族等基本信息并详细录入ERCP术中操作、术中诊断以及并发症等情况。计数资料组间比较采用χ2检验,采用Logistic回归分析寻找PEPH发生的危险因素。结果 PEPH发生率为26.6%(62/233)。单因素分析显示女性(χ2=3.320,P=0.045)、有饮酒史(χ2=6.108,P=0.010)、胆总管狭窄(χ2=5.767,P=0.012)、单发结石(χ2=9.121,P=0.020)、十二指肠乳头憩室(χ2=28.170,P0.001)、异常的甘油三酯(χ2=54.717,P0.001)为PEPH发生的影响因素。多因素Logistic回归分析显示女性[比值比(OR)=1.616,P=0.025]、饮酒史(OR=2.360,P=0.010)、胆总管狭窄(OR=2.163,P=0.012)、十二指肠乳头憩室(OR=5.502,P0.001)、甘油三酯异常(OR=12.924,P0.001)为PEPH发生的独立危险因素。结论女性、有饮酒史、胆总管狭窄、十二指肠乳头憩室、异常的甘油三酯是PEPH的独立危险因素。对这一类高危人群进行针对性的预防可有效降低PEPH及ERCP术后胰腺炎的发生。     

Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation

BACKGROUND AND AIMS: Hypoxemia can occur during endoscopic retrograde cholangiopancreatography probably induced by the analgesia and sedation done. Moreover the patients prone position difficults the adequate ventilation. The hypoxemia and hypoventilation may not be noticed by nursing staff. A transversal study was used to investigate possible predictive factors of oxygen desaturation in sedated patients with midazolam associated to meperidine undergoing endoscopic retrograde cholangiopancreatography. PATIENTS AND METHODS: A total of 186 patients were monitored with continuous pulse oximetry. Poisson regression was used to measure the independent effect of each factor adjusted for effects of each of the other factors. The variables studied were: age, gender, hematocrit and hemoglobin levels, scopolamine use, diagnostic or therapeutic exam, American Society of Anesthesiologists Scores (ASA), duration time of exam, sedative used midazolam in the average of 0.07 mg/kg and analgesic drug meperidine in the average of 0.7 mg/kg that was titrated according patients reaction. RESULTS: No desaturation was found in 113 (60.8%) patients, mild desaturation (SpO2 <92%) in 22 (11.8%) and severe desaturation (SpO2 <90%) in 51 (27.4%). This desaturation was recognized only by the pulse oximeter. There was no need to use any antagonist drug of the sedatives in patients who had severe desaturation, they were just stimulated to deep breaths and oxygen was offered at 2 liters per minute via catheter. The variables found to predict desaturation were age >60 years old and ASA score III. The duration of exam was barely significant for desaturation. CONCLUSIONS:The variables of age of 60 years old or more, and ASA III score are identified as increased risk for desaturation for patients who undergo endoscopic retrograde cholangiopancreatography under conscious sedation. Long time of exam suggests the patient oxygen desaturate. Such patients require very close monitoring to desaturation and hypoventilation by the assistants and nursing staff alerting to respiratory depression. The use of pulse oximeter and asking for deep breaths during the exam helps to diminish such risks.     

门诊内镜逆行胰胆管造影

内镜逆行胰胆管造影术（ERCP）在实现微创治疗和诊断的同时，操作本身存在着一定的风险，为了密切监护患者，及时控制并治疗ERCP术后并发症，住院治疗作为内镜介入的首选方式。但部分学者认为门诊ERCP是一种安全有效的方法，在国外门诊ERCP已积累了多年的临床经验，研究显示门诊ERCP是一种安全有效的模式，它可以有效的利用医疗资源并降低医疗成本。     

Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography

Complications and technical failures of endoscopic retrograde cholangiopancreatography (ERCP) cause significant morbidity and, occasionally, mortality. An understanding of patient- and procedure-related risks is important for decision making with regard to whether or how ERCP should be performed. Instances in which ERCP is the least clearly indicated are often the most likely to cause complications. Patient-related risk factors include suspected sphincter of Oddi (SO) dysfunction, female sex, normal serum bilirubin, or previous history of post-ERCP pancreatitis, with multiple risk factors conferring especially high risk. Techniquerelated risk factors include difficult cannulation, pancreatic contrast injection, balloon sphincter dilation, and precut sphincterotomy performed by endoscopists of varied experience. Pancreatic stents may reduce the risk of pancreatitis in a number of settings including SO dysfunction. Hemorrhage and perforation are rare and can be avoided with endoscopic technique and attention to the patient’s coagulation status. Cholangitis is avoidable with adequate biliary drainage. Because success rates are higher and complication rates lower for endoscopists performing large volumes of ERCP, ERCP should be concentrated as much as possible among endoscopists with adequate experience. Patients with a high risk for complications may be best served by referral to an advanced center.     

有关内镜下逆行胰胆管造影术的几点思考

内镜下逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography，ERCP）诞生于60年代后期，1974年内镜下乳头括约肌切开术首次报道。随着影像技术的进步，磁共振胆胰管成像因其无创、无射线、无需造影剂等优点己逐步取代诊断性ERCP，成为胰胆疾病首选的诊断方法。ERCP逐渐转向胰胆疾病的治疗，在短短几十年中ERCP取得了巨大的成就，成为当今胰胆疾病重要的治疗手段。[第一段]     

ERCP技术规范化要领

ERCP诞生于上个世纪60年代后期,短短几十年,现在已成为胰胆疾病重要的诊断治疗手段。对消化科医生来讲,ERCP是最富有挑战的技术。诊断性ERCP和治疗性ERCP是不可分割的,治疗性ERCP的重要性远远超过单纯的诊断性ERCP,不能实施ENBD的情况下,单纯进行诊断性ERCP操作非常危险。     

经内镜逆行胰胆管造影术的若干进展

作为一项成熟应用于胆胰疾病的高级内镜诊疗技术,经内镜逆行胰胆管造影(ERCP)近几年来在治疗理念和技术方面有了一些新的发展。对ERCP的若干进展进行了阐述,主要包括:运用胰管支架、非甾体抗炎类药物及大量水化预防术后胰腺炎,覆膜金属支架用于治疗良性胆管狭窄,恶性胆管狭窄的腔内射频消融治疗,体外冲击波碎石术和覆膜金属支架治疗慢性胰腺炎,经口胆道镜应用于胆管狭窄定性诊断和巨大难治性结石,困难插管的定义和预切开技术的时机以及胃肠道重建术后ERCP。     

Complications of endoscopic retrograde cholangiopancreatography

Complications occur after 5% to 10% of endoscopic retrograde cholangiopancreatography (ERCP), including diagnostic and therapeutic procedures, and may range from minimal to severe and life threatening. Risk factors for post-ERCP pancreatitis include patient- as well as procedure-related variables, placing a premium on patient selection as well as details of technique. Placement of prophylactic pancreatic stents is effective in reducing risk of pancreatitis after ERCP and is the primary strategy for prevention of this complication once ERCP is undertaken. Newer data suggest that rectal nonsteroidal anti-inflammatory drugs are also effective at reducing risk of post-ERCP pancreatitis. Bleeding after sphincterotomy is primarily related to coagulation defects, but can almost always be treated by endoscopic hemostatic techniques. Perforation can involve bowel wall, sphincterotomy, or be caused by a guidewire; early recognition and management are key to satisfactory outcomes. There is an increasing role for endoscopic closure of perforations using stents, clips, and closure devices. Endoscopist experience is reflected in complication rates. With careful attention to patient selection and details of technique, complications of ERCP can be minimized.     

Indications for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most commonly performed endoscopic procedures for the evaluation and treatment of various conditions of the biliary and pancreatic ductal systems. It remains one of the most complex and higher risk procedures performed in endoscopy. This introductory chapter will cover basic procedural considerations, pertinent clinical indications and contraindications, potential complications, and special situations requiring ERCP.     

Risk factors of recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography

Background: The risk factors for the recurrent choledocholithiasis after endoscopic retrograde cholangiopancreatography(ERCP) have not been well studied. The aim of this study was to explore the risk factors of recurrent choledocholithiasis. Methods: We carried out a retrospective analysis of data collected between January 1, 2010 and January 1, 2020. Univariate analysis and multivariate analysis were used to explore the independent risk factors of recurrent choledocholithiasis following therape...     

小儿经内镜逆行胰胆管造影术插管的经验及影响因素分析

目的:探讨小儿经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）插管技巧,分析影响插管的因素。方法:回顾性分析2016年1月—2020年6月间于上海交通大学医学院附属新华医院完成的小儿和成人ERCP操作各90例,统计其解剖相关数据、插管时间、...     

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.     

Propofol use in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

Compared to standard endoscopy,endoscopic retrograde cholangiopancreatography(ERCP)and endoscopic ultrasound(EUS)are often lengthier and more complex,thus requiring higher doses of sedatives for patient comfort and compliance.The aim of this review is to provide the reader with information regarding the use,safety profile,and merits of propofol for sedation in advanced endoscopic procedures like ERCP and EUS,based on the current literature.     

Adverse outcomes of endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool into a primarily therapeutic procedure for a variety of biliary and pancreatic problems. ERCP can, however, cause a wide range of short-term complications, including pancreatitis, hemorrhage, and perforation. In general, complications appear to be associated primarily with patient-related factors and the technical skill of the endoscopist. Overall, the risk factors for complications include suspected sphincter of Oddi dysfunction and technique-related variables, such as difficult cannulation, precut sphincterotomy in inexperienced hands, failure to achieve drainage, and percutaneous transhepatic biliary access. Reviewed here are specific risk factors for post-ERCP pancreatitis and hemorrhage. A risk-factor assessment may be useful to help the endoscopist decide whether or not to perform ERCP and aids in making decisions regarding the techniques to be used. The principal strategies to reduce complications of ERCP include improving the training and education of endoscopists regarding risk factors; avoiding marginally indicated ERCP and preferentially using alternative imaging techniques; making referrals to advanced centers for complex or high-risk cases; and, in due course, concentrating ERCP practices among fewer endoscopists performing more ERCPs.     

Advances in endoscopic retrograde cholangiopancreatography cannulation

Endoscopic retrograde cholangiopancreatography is an important tool in the diagnosis and treatment of pancreatobiliary diseases. A critical step in this procedure is deep cannulation of the bile duct as failure of cannulation generally results in an aborted procedure and failed intervention. Expert endoscopists usually achieve a high rate of successful cannulation while those less experienced typically have a much lower rate and a greater incidence of complications. Prolonged attempts at cannulation can result in significant morbidity to patients, anxiety for endoscopists, unnecessary radiation exposure and inefficient patient care. Here we review the most common endoscopic techniques used to achieve selective biliary cannulation. Pharmacologic aids to cannulation are also discussed briefly in this review.