Endoscopic retrograde cholangiopancreatography (ERCP) is currently the first-line minimally invasive diagnosis and treatment of biliary and pancreatic diseases. With the increasing popularity of ERCP, ERCP-related adverse events which include post-ERCP pancreatitis, cholecystitis, cholangitis, bleeding, perforation, etc., have received more and more attention. In response to the controversy and problems in the management of these adverse events, the European Society of Gastrointestinal Endoscopy published the guidelines for ERCP-related adverse events in December 2019. The paper interprets the key points in the guideline to provide references for clinical practice.
Objective To evaluate the clinical effectiveness of laparoscopic cholecystectomy and laparoscopic common bile duct exploration （LC＋LCBDE） and endoscopic retrograde cholangiopancreatography/endoscopic sphincterectomy with LC（ERCP/EST＋LC） in treatment for cholecystolithiasis with choledocholithiasis. Methods From January 2008 to July 2011， 127 patients suffered from cholecystolithiasis with choledocholithiasis underwent either LC＋LCBDE（85 cases， LC＋LCBDE group） or ERCP/EST＋LC（42 cases， ERCP/EST＋LC group） were collected retrospectively. The clearance rate of calculus， hospital stay， hospitalization expenses， and the rate of postoperative complications were compared between two groups. Results Eighty-five patients were performed successfully in the LC＋LCBDE group， out of which 54 patients had primary closure of common bile duct （LC＋LCBDE primary closure group）， whereas in 28 patients common bile ducts were closed over T tube （LC＋LCBDE＋T tube group）. Forty-two patients were performed successfully in the ERCP/EST＋LC group. There were no differences in the clearance rate of calculus〔100%（82/82） versus 97.37%（37/38）， P=0.317〕 and postoperative complications rate 〔（4.71% （4/85） versus 4.76%（2/42）， P=1.000〕 between the LC＋LCBDE group and ERCP/EST＋LC group. The median （quartile） hospital stay in the LC＋LCBDE group was shorter than that in the ERCP/EST＋LC group 〔12 （6） d versus 17（9） d， P＜0.001〕. In the LC＋LCBDE primary closure group， both median （quartile）?hospital stay and median（quartile） hospitalization expenses were less than those of ERCP/EST＋LC〔hospital stay：11（5） d versus 17（9） d， P＜0.001；hospitalization expenses：27 054（8 452） yuan versus 31 595（11 743） yuan， P=0.005〕 . Conclusions In the management of patients suffered from cholecystolithiasis with choledocholithiasis， both LC＋LCBDE and ERCP/EST＋LC are safe and effective. LC＋LCBDE， especially primary closure after LCBDE， is associated with significantly less costs as compared with ERCP/EST＋LC. Moreover， patients can be cured by LC＋LCBDE through one-stage treatment with the protection of the papilla function and no limits to the amount or size of the choledocholithiasis. The LC＋LCBDE is a preferable choice for the appropriate cases of cholecystolithiasis with choledocholithiasis.
Objective To explore and summarize the application of minimally invasive technique to every stage of severe acute pancreatitis (SAP). Methods The treatment of 101 SAP patients admitted to our hospital between January 1995 and December 2008 were retrospectively analyzed. After calculi were removed by endoscopic retrograde cholangiopancreatograpy (ERCP) and endoscopic sphincterotomy (EST), endoscopic nasobiliary drainage (ENBD) were applied, then rhubarb liquid was perfused into gut with a nutrient canal and ultrasound-guided abdominal drainage tube were simultaneously placed at the early stage. Some patients received continuous renal replacement therapy (CRRT) at the same time. Laparoscopic cholecystectomy (LC) was performed at the subacute stage, and choledochoscope was introduced to remove parapancreatic necrotic tissues at the late stage of SAP.Results Of all the 101 cases treated by the method mentioned above, 75 cases received ERCP (or EST) and ENBD, and 31 cases underwent rhubarb liquid perfusion with a nutrient canal. Eight cases underwent continuous renal replacement therapy (CRRT). Forty-eight cases underwent LC and ultrasoundguided abdominal drainage. Thirtysix cases with infected peripancreatic tissue or abscess underwent debridement under choledochoscope 3 to 14 times at the later stage. Five cases died of multiple organ failure (MOF) and acute respiratory distress syndrome (ARDS). The hemobilia ocurred in 2 patients during choledochoscopy and was cured under direct visualization by electric coagulation. Intestinal fistula happened in 3 cases and cured by drainage. Pancreatic pseudocyst was latterly seen in 3 cases and treated by the anastomosis of cyst with jejunum through selective operation. After the hospitalization of 9-132 d (mean 24 d), 96 cases completely recovered. Conclusion Timely application of minimally invasive technique to every stage of SAP can avoid the defects of traditional operations, decrease the injury and interference to the maximum, and raise the cure rate.
ObjectiveTo discuss the relation between bile duct anastomotic stricture and bile duct injury by endo-scopic observation following liver transplantation and it, s efficacy of endoscopic treatment. Method The clinical data of 24 cases of bile duct anastomotic stricture following liver transplantation diagnosed by cholangiography were analyzed retro-spectively. Results①Twenty-four cases of bile duct anastomotic strictures were included in 3 cases of typeⅠa, 2 cases of typeⅠb, 4 cases of typeⅡ, 1 case of typeⅢa, 5 cases of typeⅢb, and 9 cases of typeⅢc.②The redness of intrahepatic bile duct mucosa, banding erosion, ulcer and fusion of anastomotic stricture mucosa could be seen in typeⅠa andⅢa. The redness of intrahepatic bile duct and anastomotic stricture mucosa could be seen in typeⅡwithout ulcer and fusion. The extensive erosion and ulcer of intrahepatic bile duct and redness of anastomotic stricture mucosa could be seen in typeⅢb. The extensive erosion, ulcer and partial necrosis of intrahepatic bile duct and anastomotic stricture mucosa could be seen in typeⅠb andⅢc.③Seventeen cases were cured by choledochoscopy through T tube, the biliary casts were moved out and the anastomotic strictures were relieved by balloon dilatation and placement of plastic stenting for 2 to 6 months, no recurrence happened. One case of typeⅠb treated by percutaneous transhepatic cholangial drainage(PTCD) and percuta-neous transhepatic cholangioscopy(PTCS) was developed into the stricture of typeⅡduring following-up for 19 months. Two cases of typeⅠa were treated by ERCP, the biliary casts were moved, one of which was cured, another 1 case was developed into the stricture of typeⅡduring following-up for 5 months. Two cases of typeⅡwere treated by ERCP, the biliary casts were moved, balloon dilatation and placement of plastic stent were performed, one of which was cured, another 1 case was recurrent during following-up for 1 months. The strictures were not relieved by multiple plastic stents for 4 to 6 months in 3 patients with recurrence and progress, but which was relieved by full-covered self-expanding removable metal stents for 4 to 7 months, there was no recurrence during following-up. One case of typeⅢb and one case of typeⅢc received the secondary open operation or choledochoscopy and placement of plastic stent for biliary infection and jaundice after the treatment of ERCP were cured. ConclusionsBiliary stricture following liver transplantation accompanies different degree biliary injury. The slightest is typeⅡand typeⅠa, typeⅢa is the second, typeⅢb is more serious, and typeⅠb and typeⅢc are the worst. Choledochoscopy is a better choose for anastomotic strictures. ERCP is not a better choose for anastomotic strictures of typeⅠb, Ⅲb, andⅢc.
Objective To evaluate the effectiveness and safety of pancreatic duct stenting in prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis for patients at high risk. Methods We searched the Controlled Trials Database of the Cochrane Upper Gastro-Intestinal and Pancreatic Disease Group (Issue 1, 2004), Cochrane Controlled Trials Register (Issue 1, 2004), MEDLINE (1966-2004, 4), EMBASE (1985-2004, 4), CBMdisk (1970-2004, 4), and the Chinese Cochrane Center Database of Clinical Trials; we handsearched 8 Chinese journals, and references of eligible studies were also screened for inclusion. Randomized controlled trials on pancreatic stent for preventing post-endoscopic restrograde cholangiopancreatography pancreatitis (PEP) were identified.The systematic review was conducted using methods recommended by the Cochrane Collaboration. Results Six trials involving 468 high-risk patients for post-ERCP pancreatitis were included. The incidence of post-ERCP pancreatitis was significantly reduced by pancreatic duct stenting (Peto RR 0.31, 95% CI 0.19 to 0.52; P＜0.000 01; NNT=6). The incidence of severe PEP was also significantly lower in pancreatic duct stenting group compared with the control group (Peto OR 0.13, 95% CI 0.04 to 0.47; P=0.002; NNT=24). The results were consistent with the sensitivity-analysis when abstracts were excluded. Conclusion Pancreatic duct stenting appears to be an effective method to prevent PEP. Due to the limitation of the included trials and their methodology, the results should be considered with caution. High quality and large-scale trials are required.
Objective?To assess the effectiveness and safety of diclofenac, one of the routine-used NSAIDs, in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Methods Firstly, the electronic searches were conducted to retrieve Randomized controlled trials (RCTs) from The Cochrane Library, PubMed, Embase, OVID, CBM, CNKI, VIP and WanFang Data. Secondly, 12 kinds of specific Chinese journals like Chinese Journal of Gastroenterology and conference proceedings were hand-searched till June 2011, and all references in all included trials were searched, too. The RCTs on diclofenac for preventing PEP were identified and retrieved. The systematic review was conducted by using methods and principles recommended by the Cochrane Collaboration. Results A total of 5 RCTs involving 675 PEP patients were included. The Meta-analysis showed that diclofenac might reduce the incidence of PEP (OR=0.41, 95%CI 0.18 to 0.95, P=0.04), but the sensitivity analysis indicated this result was not stable. No evidence showed diclofenac could reduce the incidence of severe PEP (OR=0.40, 95%CI 0.08 to 2.06, P=0.27). And no adverse reactions related to the drug were reported. Conclusion Diclofenac may be safe and effective in reducing the incidence of PEP, but it has no significant effect on preventing severe PEP. Considering the methodological and scale limitation of included studies, this conclusion still needs to be proved by more large-scale and high-quality RCTs.
Endoscopic retrograde cholangiopancreatography is one of the main methods for the diagnosis and treatment of biliary tract and pancreatic diseases. Compared with other digestive endoscopes, duodenoscopy has a special structure. Since the outbreaks of nosocomial infections caused by the transmission of multidrug-resistant organism through duodenoscopy in 2010, the reprocessing and design of digestive endoscopes represented by duodenoscopy have faced new challenges. This article reviews the international advances in duodenoscopy reprocessing in the past 10 years including the structural characteristics of duodenoscope, related infection outbreak cases, outbreak control measures, and the use of disposable duodenoscopy, so as to provide guidance and reference for the duodenoscopy reprocessing and related nosocomial infections prevention and control work in China.
目的 总结肝硬变状态下腹腔镜胆囊切除术（LC）治疗胆囊疾病的经验。方法 回顾性分析30例肝硬变合并胆囊疾病患者行LC的临床资料。结果 30例患者中肝功能Child-Pugh A级8例，B级11例，C级11例。LC术后6例(20.0%)发生并发症，其中Child-Pugh B级2例,C级4例。治愈29例（96.7%）； 死亡1例(3.3%)，死亡者为Child-Pugh C级。结论 存在肝硬变时,肝功能Child-Pugh A及B级者行LC比较安全,C级风险较大,应列为手术禁忌。