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The link between sphincter of Oddi function with biliary system (gallbladder and bile duct) diseases is considered to be very complicated. Whether routine prophylactic laparos-copic cholecystectomy should be carried out after endoscopic sphincterotomy to remove bile duct stones has been controversial worldwide. Actually, this is a very common and important clinical question which needs to be answered. The author spends a lot of time and efforts to broadly read and analyze on published articles related to this topic, and tries, from the aspects of the anatomy and function of sphincter of Oddi, the biliary diseases causing by dysfunction or discordance of sphincter of Oddi, and the impacting of artificial destruction of sphincter of Oddi on the gallbladder and bile duct of patients, to come up with an answer to this question based on scientific and medical evidence.
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Objective:To compare safety and efficacy of one-stage laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+ LC) with endoscopic retrodrade cholangiopancreatography plus laparoscopic cholecystectomy (ERCP+ LC) in elderly patients with concomitant gallbladder and common bile duct (CBD) stones.Methods:This is a two-center retrospective study with clinical data on 492 patients aged over 80 years diagnosed with concomitant gallbladder and CBD stones treated between January, 2014 and December, 2020 at The First Affiliated Hospital of Wenzhou Medical University and Quzhou Hospital Affiliated to Wenzhou Medical University. There were 254 males and 238 females, aged (83.9±3.0) years. These patients were divided into two groups based on their operative methods: the one-stage group (LCBDE+ LC, n=186) and the two-stage group (ERCP+ LC, n=306). Differences in surgery, stones and hospitalization costs were compared between the two groups. Results:When compared with the ERCP+ LC group, the LCBDE+ LC group had significantly higher incidences of previous gastrectomy [21.5%(40/186) vs 4.2%(13/306)], multiple stones [77.4%(144/186) vs 49.3%(151/306)], larger stone diameter [13.7(6.4, 18.6)mm vs 10.9(5.7, 16.1) mm], and increased hospitalization expenditure [(2.37±0.31) Wanyuan vs (3.26±0.44) Wanyuan] (all P<0.05). However, the rates of residual stone [2.7%(5/186) vs 1.3%(4/306)], stone recurrence [2.2%(4/186) vs 5.2%(16/306)], postoperatively overall complications [3.2%(6/186) vs 1.3%(4/306)], and total hospital stay [(10.7±6.2) d vs (11.3±5.4) d] were not significantly different between the two groups (all P>0.05). Conclusions:Allowing for the similar safety and effectiveness, and lower hospitalization expenditure, LCBDE+ LC was a preferred choice for patients aged over 80 year, especially in patients who had previous gastrectomy, multiple large CBD stones, or who could not accept endoscopic procedures for treatment of CBD stones.
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ABSTRACT BACKGROUND: A successful bile duct cannulation is a prerequisite for the realization of endoscopic retrograde cholangiopancreatography (ERCP). When biliary cannulation is not possible, needle-knife fistulotomy (NKF) can be performed. However, when biliary access is not successfully achieved even after performing NKF, it is possible to interrupt the procedure, and repeat the ERCP after a short interval. OBJECTIVE: The aim of this study is to analyze if repeating an ERCP after a short interval of 48 hours is effective in achieving biliary access after an initial NKF was unsuccessfully performed. METHODS: A total of 1024 patients with a naive papilla, that underwent ERCP between the years of 2009-2019, were retrospectively reviewed. Difficult biliary cannulation was identified in 238 of these cases and NKF was performed. Success of biliary cannulation, NKF success at the first and second ERCPs, the associations between the type of the papilla, biliary dilatation, and overall success of NKF and adverse events rates were evaluated. RESULTS: Biliary access was initially achieved in 183 (76.8%) cases. Of the 55 (23.1%) remaining cases a second attempt was performed after 48 hours, and biliary access was successfully achieved in 46 (83.6%) of them. The overall success of NKF after the first and second ERCP, the success rate was 96.2%. Papilla located out of its normal position was related to a minor chance of success at NKF (P<0.05). CONCLUSION: We conclude that when biliary access is not achieved after the performance of a NKF, a second attempt is safe and effective and should be attempted.
RESUMO CONTEXTO: A canulação biliar de sucesso é pré-requisito para a realização da colangiopancreatografia retrógrada endoscópica (CPRE). Quando a canulação biliar não é possível, a fistulotomia com auxílio do cateter Needle-Knife (NKF) pode ser realizada. Entretanto, quando o acesso biliar não é atingido mesmo após a realização de um NKF, é possível optar-se pela interrupção do procedimento, e pela repetição da CPRE após curto intervalo de 48 horas. OBJETIVO: O objetivo desse estudo é analisar se a repetição da CPRE após um curto intervalo de 48 horas é efetivo em atingir o acesso biliar, quando um NKF foi realizado inicialmente sem sucesso. MÉTODOS: Um total de 1024 pacientes com papila virgem de tratamento, submetidos à CPRE entre os anos de 2009-2019, foram retrospectivamente analisados. Canulação biliar difícil foi identificada em 238 deles, e NKF foi então realizado. Foram avaliadas as taxas de sucesso durante a canulação biliar, assim como durante a realização de NKF na primeira e segunda CPREs. A associação entre o tipo de papila, dilatação biliar e o sucesso final na realização do NFK também foi avaliada, assim como a presença de eventos adversos associados à realização do NKF. RESULTADOS: Dentre todos os NKF realizados, acesso biliar foi inicialmente atingido em 183 (76,8%) casos. Os 55 (23,1%) casos restantes, foram submetidos a uma segunda CPRE após 48 horas e o acesso biliar foi atingido em 46 (83,6%) deles, resultando em uma taxa final de sucesso, após a primeira e segunda CPREs, de 96,2%. Papila localizada fora da sua posição habitual foi relacionada a menor chance de sucesso durante a realização de NKF (P<0,05). CONCLUSÃO: Concluiu-se que quando o acesso biliar não pode ser atingido após a realização de um NKF, uma segunda CPRE é segura, efetiva e deve ser realizada.
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Resumen La disfunción del esfínter de Oddi es un síndrome clínico causado por una enfermedad funcional (discinesia) o estructural (estenosis). La prevalencia estimada de disfunción del esfínter de Oddi en la población en general es del 1 %; aumentando a 20 % para pacientes con dolor persistente posterior a colecistectomía y a 70 % en pacientes con pancreatitis aguda recurrente idiopática. Se caracteriza clínicamente por la presencia de dolor abdominal, similar al cólico biliar o dolor tipo pancreático en ausencia de patología biliar orgánica; así como en pacientes con pancreatitis recurrente idiopática asociada con elevación de enzimas pancreáticas o hepáticas, y dilatación del conducto biliar o pancreático. El tratamiento para la disfunción del esfínter de Oddi tipo I se basa en la realización de esfinterotomía endoscópica, pero existe controversia en el manejo de la disfunción del esfínter de Oddi tipo II y III. En este artículo se presenta el caso clínico de una paciente de 67 años con antecedente de colecistectomía por laparotomía. Después del procedimiento quirúrgico refirió un dolor abdominal de predominio en el hipocondrio derecho tipo cólico asociado con emesis de características biliares. En el reporte de colangiorresonancia se encontró una ligera dilatación de la vía biliar intrahepática y gammagrafía con ácido iminodiacético hepatobiliar (HIDA) diagnóstica de disfunción del esfínter de Oddi. Se realizó una esfinterotomía endoscópica. En el seguimiento, dos años después, la paciente se encontraba asintomática con la disfunción del esfínter de Oddi resuelta.
Abstract Sphincter of Oddi dysfunction is a clinical syndrome caused by functional (dyskinesia) or structural (stenosis) disease. The estimated prevalence of this condition in the general population is 1%, reaching 20% in patients with persistent pain after cholecystectomy and 70% in patients with idiopathic recurrent acute pancreatitis. It is clinically characterized by the presence of abdominal pain, similar to biliary colic or pancreatic pain in the absence of organic biliary disease. It is also observed in patients with idiopathic recurrent pancreatitis, associated with elevated pancreatic or hepatic enzymes, and bile duct and/or pancreatic duct dilatation. Treatment for sphincter of Oddi dysfunction type I is based on endoscopic sphincterotomy, but there is controversy regarding the management of sphincter of Oddi dysfunction types II and III. This article presents the clinical case of a 67-year-old female patient with a history of cholecystectomy by laparotomy. After the surgical procedure, she reported abdominal pain predominantly in the right hypochondrium, colicky, associated with emesis of biliary characteristics. Cholangioresonance report revealed mild intrahepatic bile duct dilatation, and scintigraphy with HIDA scan showed sphincter of Oddi dysfunction. Endoscopic sphincterotomy was performed. The patient was asymptomatic and the sphincter of Oddi dysfunction had resolved at two-year follow-up.
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Humans , Female , Aged , Sphincterotomy, Endoscopic , Sphincter of Oddi Dysfunction , Syndrome , Cholecystectomy , LaparotomyABSTRACT
Objective@#To evaluate the efficacy and safety of laparoscopic surgery in the treatment of gallstones and common bile duct stones.@*Methods@#Eighty-seven patients with gallstones complicated with common bile duct stones who underwent concurrent laparoscopic surgery at Zhoushan Hospital from December 2015 to December 2017 were enrolled.The patients were divided into A group and B group according to the digital table.A group(38 cases) underwent laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE), and B group(49 cases) underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) combined with laparoscopic cholecystectomy (LC). The curative effect of the two groups was observed.The operation time, the success rate of the operation and the rate of laparotomy were recorded in the two groups.The corresponding hospitalization time and cost were compared.The safety of the two different procedures was compared after surgery, and the complications of the two groups were recorded.@*Results@#In A group, the average diameter of common bile duct stones was (1.02±0.25)cm, the average diameter of common bile duct diameter was (1.15±0.25)cm.In B group, the mean diameter of common bile duct stones was (0.99±0.26)cm, and the average diameter of common bile duct was (1.13±0.26) cm.The differences between the two groups were not statistically significant (t=0.513, 0.437, 0.367, P=2.083, 1.533, 1.095). The successful operation rate of A group was 92.11%(35/38), which in B group was 91.84%(45/49), the difference was not statistically significant between the two groups(χ2=0.006, P=0.974). The incidence rate of complications in B group was 20.41%, which was significantly higher than that in A group, the difference was statistically significant(χ2=3.654, P=0.019). The hospitalization time, hospitalization expenses in A group were (10.6±2.6)d, (26 649.8±3 478.6)CNY, respectively, which were significantly better than those in B group (t=21.971, 17.168, all P<0.05).@*Conclusion@#The efficacy of LC combined with LCBDE for patients with gallstones complicated with common bile duct stones is better than ERCP/EST combined with LC surgery, and the safety of the former is higher than the latter.
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Objective To evaluate the efficacy and safety of laparoscopic surgery in the treatment of gallstones and common bile duct stones.Methods Eighty-seven patients with gallstones complicated with common bile duct stones who underwent concurrent laparoscopic surgery at Zhoushan Hospital from December 2015 to December 2017 were enrolled.The patients were divided into A group and B group according to the digital table.A group (38 cases) underwent laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE),and B group (49 cases) underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) combined with laparoscopic cholecystectomy (LC).The curative effect of the two groups was observed.The operation time,the success rate of the operation and the rate of laparotomy were recorded in the two groups.The corresponding hospitalization time and cost were compared.The safety of the two different procedures was compared after surgery,and the complications of the two groups were recorded.Results In A group,the average diameter of common bile duct stones was (1.02 ± 0.25) cm,the average diameter of common bile duct diameter was (1.15 ± 0.25) cm.In B group,the mean diameter of common bile duct stones was (0.99 ± 0.26) cm,and the average diameter of common bile duct was (1.13 ± 0.26) cm.The differences between the two groups were not statistically significant (t =0.513,0.437,0.367,P =2.083,1.533,1.095).The successful operation rate of A group was 92.11％ (35/38),which in B group was 91.84％ (45/49),the difference was not statistically significant between the two groups (x2 =0.006,P =0.974).The incidence rate of complications in B group was 20.41％,which was significantly higher than that in A group,the difference was statistically significant(x2 =3.654,P =0.019).The hospitalization time,hospitalization expenses in A group were (10.6 ± 2.6) d,(26 649.8 ± 3 478.6) CNY,respectively,which were significantly better than those in B group (t =21.971,17.168,all P ＜ 0.05).Conclusion The efficacy of LC combined with LCBDE for patients with gallstones complicated with common bile duct stones is better than ERCP/EST combined with LC surgery,and the safety of the former is higher than the latter.
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Objective To evaluate the curative effect and prognosis of endoscopic papillary large balloon dilatation ( EPLBD) in the treatment of choledocholithiasis. Methods A total of 153 patients with choledocholithiasis (>1. 0 cm in stone diameter) admitted and treated in Shanxi People's Hospital from August 2016 to November 2017 were randomly divided into two groups according to the random number table: the EPLBD group ( n=83) and the small endoscopic sphincterotomy plus large balloon dilatation ( ESLBD) group ( n=70) . The success rate of stone removal, the rate of lithotripsy, and the incidence of short-term and long-term complications were compared between the two groups. Results There were no statistical differences between the EPLBD group and the ESLBD group in total stone removal rate [ 95. 2％( 79/83) VS 97. 1％ ( 68/70) ,χ2=0. 388, P=0. 533] and one-time stone removal rate [ 92. 8％ ( 77/83) VS 90. 0％ ( 63/70) ,χ2=0. 375, P=0. 540] . The lithotripsy rate between the two groups had no statistical difference [ 25. 3％ ( 21/83 ) VS 35. 7％ ( 25/70 ) , χ2 = 1. 958, P= 0. 162 ] . There was no statistical difference in the incidence of recent complications between the two groups [ 43. 4％ ( 36/83 ) VS 40. 0％(28/70), χ2=0. 178, P=0. 673]. No postoperative perforation was found in either group. The follow-up time was 22. 7 ± 4. 3 months in the EPLBD group, and 20. 8 ± 6. 3 months in the ESLBD group. The cumulative recurrent rate of choledocholithiasis in the two groups were 2. 4％ ( 2/83) and 15. 7％ ( 11/70) , respectively, and the difference was significant ( P=0. 003) . Conclusion Simple EPLBD in the treatment of choledocholithiasis is equivalent to ESLBD in the success rate of stone removal, utilization rate of lithotripsy, and incidence of recent complications, but the long-term stone recurrence rate of EPLBD is lower than that of ESLBD. EPLBD is effective and safe on the treatment of choledocholithiasis.
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Objective To compare the efficacy of endoscopic sphincterotomy ( EST) combined with large-balloon dilation ( LBD) and that of LBD alone for large bile duct stones. Methods Data of 61 patients who received EST combined with LBD ( the combination group ) and 48 patients who received LBD alone ( the LBD group) from February 2008 to November 2014 were collected. The efficacy and adverse events of two groups were compared. Results The procedure time from successful cannulating to complete stone removal was shorter in the LBD group than that in the combination group [ 17. 3 min ( 8-35 min ) VS 21. 5 min ( 10-42 min) , P=0. 041] . There were no significant differences in overall complete stone removal rate[90. 2％ (55/61) VS 91. 7％ (44/48), P=1. 000] and complete stone removal rate without mechanical lithotripsy[78. 7％ (48/61) VS 83. 3％ (40/48), P=0. 542] in the combination group and the LBD group. Massive bleeding occurred in one patient of the combination group, but was successfully coagulated under endoscopy. There was no significant difference in the incidence of postoperative pancreatitis between the two groups[4. 9％ (3/61) VS 6. 3％ (3/48), P=1. 000]. Conclusion EST combined with LBD offers no significant advantage over LBD alone for the removal of large bile duct stones. LBD can simplify the procedure compared with EST combined with LBD in terms of shortening the procedure time.
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Objective To study the clinical efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) in the treatment of common bile duct (CBD) stones.Methods This retrospective study of EPLBD for CBD stoneswas conducted between May 2015 and March 2017 on 116 patients.The patients were divided into two groups based on the different methods of treatment:group A (the EPLBD group) and B(the EST + EPBD group).Results Treatment with EPLBD when compared with EST + EPBD produced similar outcomes with regard to the overall stone removal rates (96.2％ vs.93.5％,P ＞ 0.05) and complete ductal clearance in one session (92.6％ vs.92％,P ＞0.05).There were no significant differences in the rates of overall complication (22.2％ vs.22.2％,P ＞ 0.05),hemorrhage (7.4％ vs.11.3％,P ＞ 0.05),post-ERCP pancreatitis (9.3％ vs.6.6％,P ＞ 0.05) and acute cholangitis (5.6％ vs.8.1％,P ＞0.05).When compared with EST + EPBD,mechanical lithotripsy was performed less in the EPLBD group (16.6％ vs.27.4t％,p ＜ 0.05).Conclusions EPLBD was an effective and safe method to treat CBD stones.EPLBD reduced the use of mechanical lithotripsy when compared with EST + EPBD.
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Objective To investigate the value of endoscopic papillary incision combined with balloon di-lation in the treatment of choledocholithiasis with periampullary diverticula(PAD). Methods A total of 118 pa-tients with choledocholithiasis and PAD admitted to our hospital from January 2015 to January 2017 were retrospec-tively analyzed.According to the operation method,all patients were divided into two groups:sEST+EPBD group (60 cases)and EST group(58 cases).The success rate of ERCP and the success rate of one-step stone removal, the changes of serum TBil and DBil before and after operation,and the incidence of postoperative complications were compared between the two groups. Results The successful rates of ERCP and stone removal in sEST+EPBD group were significantly higher than those in EST group(P < 0.05). The levels of serum TBil and DBil in both groups were significantly lower than those before operation(P<0.05).The overall incidence of postoperative com-plications in sEST + EPBD group was significantly lower than that in EST group(P < 0.05). Conclusions The treatment of choledocholithiasis with PAD in patients with endoscopic papillary small incision and balloon dilation treatment effect is significant,which can significantly improve the success rate of ERCP and success rate of one-time stone,benefitting the prognosis of patients.
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Objective To investigate the anesthetic effect and adverse events on different doses of oxyco-done combined with propofol target controlled infusion(TCI)in patients with choledocholithiasis undergoing endo-scopic retrograde cholangio pancreatography(ERCP)with endoscopic sphincterotomy(EST).Methods One hun-dred and twenty patients with choledocholithiasis underwent ERCP with EST in Department of Gastroenterology, Fuzhou General Hospital,from January,2016 to March,2017 were enrolled in this study.Patients were randomly divided into 4 groups(n=30 in each group)including the sufentanil control group(Group A),low dose of oxyco-done group(Group B),moderate dose of oxycodone group(Group C),and high dose of oxycodone group(Group D).Patients in Group A received 0.10 μg/kg intravenous sufentanil,and patients in Group B,C,and D received 0.08 mg/kg,0.10 mg/kg,and 0.12 mg/kg intravenous oxycodone,respectively,at 5 min before induction of gener-al anesthesia followed by propofol TCI. Effect of compartment concentration(Ce)of propofol,mean arterial pres-sure(MAP),and heart rate(HR)at the given time point when patients transferring to operation room(T0),after induction(T1),endoscope through throat(T2),and endoscope through major duodenal papilla(T3)were record-ed.The accumulative dose of propofol,duration of operation,and recovery time were also recorded.Intraoperative sever hypotension,bradycardia,respiratory depression,coughing and moving,and postoperative nausea and vom-iting were recorded. Results Propofol Ce at T1~T3as well as MAP and HR at T2and T3in Group B were signifi-cantly higher than those in Group A,C,and D,respectively(P < 0.05). The accumulative dose of propofol in Group B was more than that in Group A and C,while the accumulative dose of propofol in Group D was less than that in Group A,B,and C,respectively(P<0.01).Recovery time in Group D was longer than that in Group A, B,and C,respectively(P<0.05).Similar incidences of intraoperative sever hypotension,bradycardia,respiratory depression,coughing and moving,and postoperative nausea and vomiting were also observed. Conclusions 0.10 mg/kg intravenous oxycodone at 5 min before induction of general anesthesia combined with propofol TCI presents a favorable anesthetic effect in patients with choledocholithiasis undergoing ERCP with EST without a prolonged recovery time and the increased incidence of adverse events.
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Objective To evaluate the efficacy and safety of early endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) in patients of acute biliary pancreatitis (ABP).Methods Databases including PubMed,EMBASE,Cochrane library,CBM,CNKI,WanFang data and VIP data were searched with " Endoscopic retrograde cholangiopancreatography" "Endoscopic sphincterotomy" "ERCP" "Pancreatitis" "Biliary pancreatitis" resection up to September 2017.Randomized controlled trails (RCTs) conternming the comparison of ERCP with EST versus conservative management in ABP patients were enrolled in the study.Two reviewers independently screened literature,extracted data,and assess the risk of bias of the included studies.The Meta-analysis was conducted by RevMan 5.3 software.Results A total of 10 RCTs involving 1 752 cases were included in the Metaanalysis.The results of Meta-analysis showed that compared with the control group,early ERCP with EST reduced the systemic complication rate of ABP (RR =0.66;95％ CI:0.47-0.93;P ＜ 0.05).However,there were no significant differences in overall mortality,local complication rate,and ERCP related complication rate in ABP between early and selected ERCP with EST treat (P ＞ 0.05).Subgroup analyses indicated that early ERCP with EST therapy reduced the mortality of severe acute biliary pancreatitis (SABP),ABP with biliary obstruction and within 24 hours of admission (RR =0.48,0.35,0.25;95％ CI:0.24-0.96,0.17-0.74,0.09-0.73;P ＜ 0.05);decreased the local and systemic complication rate of SABP,ABP with biliary obstruction (RR =0.56,0.54,0.51,0.51;95％ CI:0.37-0.86,0.33-0.91,0.32-0.81,0.32-0.80;P ＜ 0.05);reduced the local and systemic complication rate of SABP (RR =0.42,0.47;95％ CI:0.25-0.70,0.25-0.87;P ＜0.05) and shortened the hospital stay of SABP (MD =-11.22 d;95％ CI:-16.09--6.36;P ＜ 0.01).However,there were no significant differences of overall complication rate in ABP without biliary obstruction and hospital stay in MABP.Conclusion Early ERCP with EST therapy appears to be safe and effective for ABP patients.
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Objective To explore the clinical value of sEST+EPBD applied in patients with mild-to-moderate biliary pancreatitis. Methods We selected out 60 cases mild or moderate biliary pancreatitis from January, 2013 to December, 2015, and randomly divided these cases into control group, EST group and sEST + EPBD group. We compared serological indexes, postoperative inflammation index, concurrent operation, hospitalization and follow-up indicators of these three groups. Results The levels of serum amylase, CRP and PCT were no statistical significance in three groups (P > 0.05). Total lengths of hospital stay and recurrence of pancreatitis in EST groups and sEST + EPBD group were significantly shorter than in control group (P < 0.05), and the total cost of hospitalization in sEST + EPBD group was obviously lower than in control group (P < 0.05). The level of postoperative serum amylase in sEST + EPBD group was obviously higher than in EST group, and the total length of hospital stay, cost and operative complications in sEST+EPBD group was significantly lower than that in EST group (P < 0.05); However, within one year, recurrences of pancreatitis and rates of cholecystectomy were no significant differences in these two groups. Conclusion sEST+EPBD is an effective and safe treatment in mild or moderate biliary pancreatitis, and can reduce the length of hospital stay and cost, operative complications, and assist the implementation of interval laparoscopic cholecystectomy.
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Objective To investigate the effect of endoscopic sphincterotomy(EST) combined with endoscopic papillary large balloon dilation(EPLBD) in the treatment of common bile duct stones. Methods A total of 128 patients treated with EST combined with EPLBD for common bile duct stones were divided into 0 min group, 1 min group, 3 min group and 5 min group, according to the different balloon expansion times. The balloon was extended to the required diameter and was maintained to the corresponding time, and then decreased the pressure to remove the balloon. Patients were given routine monitoring and treatment after operation. All patients were observed more than 48 h to determine whether there were early complications such as pancreatitis and bleeding. The effectiveness of EPLBD was evaluated by the stone diameter, expansion balloon diameter, ERCP operation time and use of stone breaker. The safety was evaluated by the occurrence of complications including postoperative pancreatitis, bleeding and perforation. Results All patients were successfully removed stones. There were no significant differences in the maximum diameter of stone, the diameter of bile duct dilatation and the diameter of balloon dilatation between groups. No bleeding, perforation, biliary tract infection and acute pancreatitis were found in patients. There were no significant differences in the utilization rates of stone breaker between groups. ERCP operation times showed a trend of decreased first and then increased in 0, 1 and 3 min groups (P<0.05). There was no significant difference in ERCP operation time between 3 min group and 0 min group. There were no significant differences in incidence rates of high amylase between groups. Conclusion EST combined with EPLBD is a safe and effective treatment for early stage of larger common bile duct stones, of which 1 minute group shows better effect.
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Objective To investigate the therapeutic effects of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic bile duct exploration lithotomy (LBDEL) in treatment of intra/extra-hepatic duct stones. Methods There were 110 patients whose intrahepatic stones located in Ⅰ , Ⅱ hepatic duct and 378 patients whose stones only located in the common bile duct. These patients respectively underwent LBDE combined with choledochoscope laser lithotripsy or ERCP combined with endoscopic sphincterotomy (EST) and endoscopic nasobiliary drainage (ENBD) to remove the stones. Common bile ducts were performed primary suture or T tube placement in the LBDEL cases. The evaluation was carried out for perioperative complications and postoperative recovery of the surgical methods. Results The residual stone rate was 31.82% in 110 cases. The rate was higher in ERCP group (51.06%) than that in LBDEL group (17.46%) (P < 0.05). Postoperative recovery was better in LBDEL group than that in ERCP group. The residual stone rate was 8.20% in 378 cases. The rate was lower in ERCP group (3.68%) than that in LBDEL group(11.63%) (P < 0.05). Between the two groups, there had no statistical significance in postoperative recovery. The incidences of bile leakage and pulmonary infection were higher in LBDEL group than in ERCP group. The incidences of abdominal cavity infection, acute pancreatitis, digestive tract perforation and gastrointestinal bleeding were higher in ERCP group than that in LBDEL group. 2 of the 378 patients occurred death were happened digestive tract perforation which were induced during ERCP procedure. Conclusion LBDEL and ERCP demonstrated the same therapeutic effects in the treatment of common bile duct stones. However, ERCP has no large advantages in the treatment of hepatolithiasis, and shows higher complication rates. LBDEL has a significant curative effect for intra-and extrahepatic bile duct calculi and can maintain the integrity of Oddi sphincter. This technology is easy to spread to the basic-level hospital to benefit the majority of patients.
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Abstact: Objective To investigate the diagnostic value of endoscopic sphineter Oddi manometry (SOM) in patients with recurring abdominal pain and observe the value of endoscopic sphincterotomy (EST) in treatment of patients with sphincter of Oddi dysfunction (SOD).MethodsClinical data of 30 patients with chronic abdominal pain after cholecystectomy who were suspected SOD from 2012 October to 2014 September were collected and retrospectively analyzed. These patients received SOM in ERCP examination and the observation of Oddi sphincter basal pressure, contraction amplitude, frequency and mode of transmission were carried out. The EST were carried out in patients with basal pressure of Oddi sphincter higher than 40.0 mmHg or higher than 30.0 mmHg, and the presence of serum amylase, lipase, ALT, AST, AKP increased more than 2 times of the normal value and (or) of common bile duct, pancreatic duct widening.ResultThe SOM of all the 30 patients were all abnormal. The basal pressure of Oddi sphincter, the contraction amplitude, the contraction frequency and the reverse shrinkage were (36.6 ± 21.1) mmHg, (210.6 ± 25.7) mmHg, (10.1 ± 3.1) times/min and (55.0 ± 8.0)%. All the patients were treated with EST, of which 27 cases (90.0%) received good results.Conclusion SOM is helpful in evaluation of Oddisphincter function, it is of great value in diagnosis of SOD. EST treatment obtained satisfactory effect in patients with elevated basal pressure of Oddi sphincter.
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Objective To study the clinical results of patients with gallbladder stones and common bile duct stones treated either by laparoscopic cholecystectomy followed by endoscopic sphincterotomy (EST + LC) or laparoscopic cholecystectomy + common bile duct exploration (LC + LCBDE) in the elderly patients.Methods A retrospective study was conducted on 96 patients who had common bile duct and gallbladder stones treated from January 2012 to January 2016.The patients were divided into the control group and the observation group.46 patients were in the observation group who underwent LC three days after EST,while the remaining patients were in the control group who underwent LC and LCBDE.The serum amylase levels before LC,operation time,intraoperation bleeding volume,postoperative time to first flatus,total hospitalization stay and total hospitalization costs and incidences of postoperative complication were compared.Results The total operation time was (95.0 ±7.0) minutes and (125.0 ± 18.0) minutes,respectively,(P＜0.05).The total costs in the two group were (39515.0 ±4 135.0) yuan and (28287.0 ± 2 254.0) yuan (P ＜ 0.05),respectively.Postoperative complications were observed in 5 (6.1％) and 10 (13.2％) patients (P ＜ 0.05),respectively.The preoperative serum amylase levels were (97.6 ± 48.5) IU/L and (131.4 ± 68.7) IU/L,respectively.The blood loss was (35.7 ± 8.5) ml and (31.8 ± 7.3) ml,respectively.The postoperative time to first flatus was (1.7 ± 0.5) days and (1.9 ± 0.4) days,respectively.The total hospitalization stay was (16.3 ±2.8) days and (15.2 ±3.7) days.There were no significantly differences (P ＞ 0.05).Conclusions LC carried out on day 3 after EST to treat elderly patients with cholecystolithiasis and choledocholithiasis was safe and efficacious and the treatment had the advantages of minimal trauma,short operative time,rapid recovery and low complication rates.This should be recommended in clinical practice.
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Objective To compare the clinical efficacy and safety of endoscopic papillary balloon dilation (EPBD) and endoscopic papillary balloon dilation (EPBD) combined with small endoscopic sphincterotomy (SEST) in treatment of large choledocholithiasis. Methods 78 patients with large choledocholithiasis from January 2014 to December 2015 were randomly divided into EPBD group, and combination treatment group. The level of bilirubin, transaminase, alkaline phosphatase (ALP) before and after the operation, the success rates of stone removal, serum amylase of 24 h after the operation, the operation times of endoscopic retrograde cholangiopancreatography (ERCP) and whether complicated with postoperative pancreatitis were compared between the two groups. Results There was no significant difference of the success rates of stone removal, serum amylase of 24 h after the operation, the operation times of ERCP between the two groups. The level of bilirubin, transaminase, alkaline phosphatase (ALP) was declined after EPBD or EPBD and SEST, and the results of the two groups had no statistical significance (P > 0.05). Also there was no significant difference of the incidence of postoperative pancreatitis, postoperative bleeding and postoperative hyperamylasemia between the two groups (P > 0.05). Conclusion EPBD is worthy of promoting because it has a similar clinical efficacy and safety to EPBD and SEST in treatment of large choledocholithiasis.
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Endoscopic retrograde cholangiopancreatography (ERCP) is an essential method for diagnosis and treatment of various pancreatobiliary diseases and endoscopic sphincterotomy (EST) is the gateway to complete ERCP. Although techniques and instruments for EST have improved, bleeding is still the most common complication. Treatment of immediate post-EST bleeding is important because blood can interfere with subsequent procedures. Additionally, endoscopists should be cautious about delayed bleeding may cause hemobilia, cholangitis, and hemodynamic shock. Most cases of post-EST bleedings will stop spontaneously, however, endoscopic management is necessary in case of clinically significant and persistent bleeding. Various endoscopic methods including epinephrine or fibrin glue injection, electrocoagulation, hemoclipping and band ligation et al can be used through a sideviewing or forward-viewing endoscope similar to those used in hemostasis of peptic ulcer bleeding. Endoscopists who perform ERCP should use various methods of endoscopic hemostasis strategically.
Subject(s)
Arm , Cholangiopancreatography, Endoscopic Retrograde , Cholangitis , Diagnosis , Electrocoagulation , Endoscopes , Epinephrine , Fibrin Tissue Adhesive , Hemobilia , Hemodynamics , Hemorrhage , Hemostasis , Hemostasis, Endoscopic , Ligation , Methods , Peptic Ulcer , Shock , Sphincterotomy, EndoscopicABSTRACT
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential method for diagnosis and treatment of various pancreatobiliary diseases and endoscopic sphincterotomy (EST) is the gateway to complete ERCP. Although techniques and instruments for EST have improved, bleeding is still the most common complication. Treatment of immediate post-EST bleeding is important because blood can interfere with subsequent procedures. Additionally, endoscopists should be cautious about delayed bleeding may cause hemobilia, cholangitis, and hemodynamic shock. Most cases of post-EST bleedings will stop spontaneously, however, endoscopic management is necessary in case of clinically significant and persistent bleeding. Various endoscopic methods including epinephrine or fibrin glue injection, electrocoagulation, hemoclipping and band ligation et al can be used through a sideviewing or forward-viewing endoscope similar to those used in hemostasis of peptic ulcer bleeding. Endoscopists who perform ERCP should use various methods of endoscopic hemostasis strategically.