ABSTRACT
Objective:To investigate the clinical characteristics of choledocholithiasis com-bined with periampullary diverticulum and influencing factor for difficult cannulation of endoscopic retrograde cholangiopancreatography (ERCP).Methods:The retrospective case-control study was conducted. The clinical data of 1 920 patients who underwent ERCP for choledocholithiasis in 15 medical centers, including the First Hospital of Lanzhou University, et al, from July 2015 to December 2017 were collected. There were 915 males and 1 005 females, aged (63±16)years. Of 1 920 patients, there were 228 cases with periampullary diverticulum and 1 692 cases without periampullary diverticulum. Observation indicators: (1) clinical characteristics of patients with choledocholithiasis; (2) intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis; (3) influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range) or M( Q1, Q3), and com-parison between groups was conducted using the Wilcoxon rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Logistic regression model was used for univariate and multivariate analyses. Results:(1) Clinical characteristics of patients with choledocholithiasis. Age, body mass index, cases with complications as chronic obstructive pulmonary disease, diameter of common bile duct, cases with diameter of common bile duct as <8 mm, 8?12 mm, >12 mm, diameter of stone, cases with number of stones as single and multiple were (69±12)years, (23.3±3.0)kg/m 2, 16, (14±4)mm, 11, 95, 122, (12±4)mm, 89, 139 in patients with choledocholithiasis combined with periampullary diverticulum, versus (62±16)years, (23.8±2.8)kg/m 2, 67, (12±4)mm, 159, 892, 641, (10±4)mm, 817, 875 in patients with choledocholithiasis not combined with periampullary diver-ticulum, showing significant differences in the above indicators between the two groups ( t=?7.55, 2.45, χ2=4.54, t=?4.92, Z=4.66, t=?7.31, χ2=6.90, P<0.05). (2) Intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis. The balloon expansion diameter, cases with intraoperative bleeding, cases with hemorrhage management of submucosal injection, hemostatic clip, spray hemostasis, electrocoagulation hemostasis and other treatment, cases with endoscopic plastic stent placement, cases with endoscopic nasal bile duct drainage, cases with mechanical lithotripsy, cases with stone complete clearing, cases with difficult cannulation, cases with delayed intubation, cases undergoing >5 times of cannulation attempts, cannulation time, X-ray exposure time, operation time were 10.0(range, 8.5?12.0)mm, 56, 6, 5, 43, 1, 1, 52, 177, 67, 201, 74, 38, 74, (7.4±3.1)minutes, (6±3)minutes, (46±19)minutes in patients with choledocholithiasis combined with periampullary diverticulum, versus 9.0(range, 8.0?11.0)mm, 243, 35, 14, 109, 73, 12, 230, 1 457, 167, 1 565, 395, 171, 395, (6.6±2.9)minutes, (6±5)minutes, (41±17)minutes in patients with choledocholithiasis not combined with periampullary diverticulum, showing significant differences in the above indicators between the two groups ( Z=6.31, χ2=15.90, 26.02, 13.61, 11.40, 71.51, 5.12, 9.04, 8.92, 9.04, t=?3.89, 2.67, ?3.61, P<0.05). (3) Influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Results of multivariate analysis showed total bilirubin >30 umol/L, number of stones >1, combined with periampullary diverticulum were indepen-dent risk factors for difficult cannulation in patients with periampullary diverticulum who underwent ERCP for choledocholithiasis ( odds ratio=1.31, 1.48, 1.44, 95% confidence interval as 1.06?1.61, 1.20?1.84, 1.06?1.95, P<0.05). Results of further analysis showed that, of 1 920 patients undergoing ERCP for choledocholithiasis, the incidence of postoperative pancreatitis was 17.271%(81/469) and 8.132%(118/1 451) in the 469 cases with difficult cannulation and 1 451 cases without difficult cannula-tion, respectively, showing a significant difference between them ( χ2=31.86, P<0.05). In the 1 692 patients with choledocholithiasis not combined with periampullary diverticulum, the incidence of postopera-tive pancreatitis was 17.722%(70/395) and 8.250%(107/1 297) in 395 cases with difficult cannula-tion and 1 297 cases without difficult cannulation, respectively, showing a significant difference between them ( χ2=29.00, P<0.05). In the 228 patients with choledocholithiasis combined with peri-ampullary diverticulum, the incidence of postoperative pancreatitis was 14.865%(11/74) and 7.143%(11/154) in 74 cases with difficult cannulation and 154 cases without difficult cannulation, respectively, showing no significant difference between them ( χ2=3.42, P>0.05). Conclusions:Compared with patients with choledocholithiasis not combined with periampullary divertioulum, periampullary divertioulum often occurs in choledocholithiasis patients of elderly and low body mass index. The proportion of chronic obstructive pulmonary disease is high in choledocholithiasis patients with periampullary diverticulum, and the diameter of stone is large, the number of stone is more in these patients. Combined with periampullary diverticulum will increase the difficult of cannulation and the ratio of patient with mechanical lithotripsy, and reduce the ratio of patient with stone complete clearing without increasing postoperative complications of choledocholithiasis patients undergoing ERCP. Total bilirubin >30 μmol/L, number of stones >1, combined with periampullary diverticulum are independent risk factors for difficult cannulation in patients of periampullary diverticulum who underwent ERCP for choledocholithiasis.
ABSTRACT
La colangiopancreatografía retrógrada endoscópica (CPRE) es la técnica de elección para el tratamiento de diferentes enfermedades biliopancreáticas. La canulación selectiva del conducto deseado (biliar o pancreático) es el punto clave inicial del objetivo terapéutico. Actualmente, la forma más utilizada para conseguir el acceso a la vía biliar, y que podemos denominar "técnica estándar", es la que emplea un esfinterótomo asociado con una guía hidrófila. Cuando dicha canulación estándar falla, existen diferentes alternativas que nos permitirán conseguir la canulación en un alto porcentaje de pacientes. En situaciones de canulación difícil, las técnicas de rescate a utilizar pueden estar condicionadas, entre otras, por el perfil de riesgo de complicaciones del paciente, por la experiencia o las preferencias del endoscopista y por haber conseguido o no previamente la canulación del conducto pancreático. Si se consiguió la canulación del conducto pancreático puede intentarse la técnica de doble guía, la esfinterotomía transpancreática y el precorte de aguja sobre prótesis pancreática. Si no se consiguió la canulación del conducto pancreático, probablemente la mejor opción sea una fistulotomía. Es conveniente conocer, en el contexto de una canulación difícil, cuándo hay que decidir la finalización de la prueba, principalmente si no existe una urgencia de drenaje de la vía biliar para el paciente. En estos casos debemos considerar repetir el procedimiento unos días más tarde. Si la urgencia del paciente es evidente, puede intentarse el acceso de la vía biliar asistido por técnicas alternativas.
Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice in treating different biliopancreatic diseases. Selective cannulation of the desired duct (biliary or pancreatic) is the initial key point of the therapeutic goal. Currently, the most used method to obtain access to the bile duct is what we can call "standard technique", which uses the sphincterotome associated with a hydrophilic guide. When such standard cannulation fails, there are different alternatives that will allow us to achieve cannulation in a high percentage of patients. In situations of difficult cannulation the rescue techniques may be conditioned by the risk profile of the patient's complications, by the experience and/or preferences of the endoscopist, or by whether or not he has previously been able to cannulate the pancreatic duct. If cannulation of the pancreatic duct is achieved, the double guide technique, and needle precut on pancreatic prosthesis can be attempted. If cannulation of the pancreatic duct is not achieved, fistulotomy is probably the best option. In the case of a difficult cannulation, it is important to know when to decide the end of the test, especially if there is no urgency to drain the bile duct. In these cases we should consider repeating the procedure a few days later. If the patient's urgency is evident, access to the bile duct assisted by alternative techniques can be attempted.
Subject(s)
Humans , Pancreatitis , Catheterization , Cholangiopancreatography, Endoscopic Retrograde , Pancreatitis, Acute Necrotizing , SphincterotomyABSTRACT
INTRODUCCIÓN: la canulación profunda de la via biliar principal es requisito para una Pancreato-colangiografía Retrograda Endoscópica (PCRE) de carácter terapéutico. El pre corte es una técnica practicada en casos de canulación difícil. Objetivo: Reportar los casos de pacientes con canulación difícil y fistulotomia suprapapilar como un método para la canulación selectiva del colédoco. Reportar la eficacia, hallazgos demográficos, endoscópicos y complicaciones de éste procedimiento. MATERIAL Y MÉTODOS: estudio prospectivo, descriptivo y observacional de casos. Se ha realizado en 93 pacientes sometidos a PCRE con canulación difícil en quienes se practicó el pre corte tipo Fistulotomia, en un Centro privado de Endoscopia Digestiva del 2000 al 2010 en Lima. RESULTADOS: En 1205 (100%) CPRE se hicieron 1152 (96%) papiloesfinterotomias, de éstos en 93 casos (8%) casos se hizo fistulotomia previa a la papiloesfinterotomia. El grupo atareo más frecuente fue de 61 a 70 años, la relación F:M, 2.4:1. La eficacia fue 96%, los hallazgos endoscópicos más frecuentes fueron Odditis, impactación de cálculo y la presencia de ampuloma, los diagnósticos finales fueron enfermedad litiásica (34%), seguida de la Odditis con o sin litiasis coledociana (29%), en el 75% de casos se realizó terapéutica, el 8.5% de casos presentó complicaciones (pancreatitis y sangrado). No se registró perforaciones ni colangitis. CONCLUSIONES: en esta serie la fistulotomia en casos de canulación difícil es eficaz, es más frecuente en casos de Odditis, cálculo impactado y ampuloma y las complicaciones son bajas. RECOMENDACIONES: el pre corte tipo fistulotomia está dirigida a pacientes que requieren PCRE terapéutica, la decisión de realizarla debe ser precoz, la firma de un consentimiento informado es primordial.
INTRODUCTION: Biliary conducts deep cannulation is a requirement for therapeutic Endoscopic Retrograde Cholangio-Pancreatography (ERCP). The pre-cut papillotomy is a technique for difficult cannulation cases. Aims: Report cases of hard cannulation and suprapapilar fistulotomy as a method for selective common bile duct cannulation. Report efficacy, demographic and endoscopic findings and complications of this procedure. MATERIALS AND METHODS: Observational, descriptive and prospective study of cases. Sample of 93 patients who had a difficult cannulation ERCP, in which suprapapilar fistulotomy pre-cut type was done, in a private digestive endoscopic center between 2000 and 2010 in Lima, Peru. RESULTS: 1205 (100%) ERCP were made 1152 (96%) papillosphincterotomies. Fistulotomy was done in 93 cases (8%) of these papillosphincterotomies. The most prevalent age group was 61 to 70 years old, the female-male proportion was 2.4:1. The efficacy was 96%. The most prevalent endoscopy findings were odditis, gallstone impactation and ampulloma presence, final diagnosis were lithiasic disease (34%), Odditis with or without common bile duct lithiasis (29%). Therapeutic ERCP was done in 75% of the cases, 8.5% showed complications (pancreatitis and bleeding). No perforation or cholangitis were registered. CONCLUSIONS: In this case series, fistulotomy in difficult cannulation procedures had good efficacy. Is most prevalent in cases with odditis, gallstone impactation and ampulloma. Complications of the procedure are low. RECOMMENDATIONS: The fistulotomy type of pre-cut is leaded for patients who require therapeutic ERCP. The decision for doing the procedure must be precocious and informed consent is primordial.