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Objective To investigate the efficacy of pancreatic duct guidewire pre-occupying in ERCP with difficult biliary cannulation.Methods During a four-year study period from June 2008 to June 2012,a total of 3505 patients were included in this retrospective analysis.Initial biliary cannulation method consisted of single-guidewire technique for up to 5 attempts,followed by double-guidewire technique when repeated unintentional pancreatic duct cannulation had taken place.Pre-cut papillotomy technique was reserved for when double-guidewire technique had failed or no pancreatic duct cannulation had been previously achieved.Biliary cannulation success and post-ERCP complication rate were compared.Results Single-guidewire technique was characterized by statistically significant higher success rate (93.4％),compared with the double-guidewire technique (54.8％,P ＜0.001),pre-cut failed double-guidewire technique (81.3％,P ＜0.001) or precut as first step method (84.6％,P =0.011).Pre-cut failed double-guidewire technique and pre-cut as first step method offered a statistically significantly more favorable outcome compared with the double-guidewire technique (both P ＜ 0.001).The incidence of post-ERCP pancreatitis did not differ in a statistically significant manner among the four methods.Numbers of patients who got bleeding in pre-cut papillotomy technique and sphincterotomy after successful single-guidewire technique were 5 and 2 respectively.One case of perforation was recorded using pre-cut papillotomy technique.There was no procedure-related mortality within 30 days.Conclusion Although double-guidewire technique success rate proved not to be superior to singleguidewire technique or pre-cut papillotomy,it is considered highly satisfactory in terms of safety in order to avoid the risk of a pre-cut when biliary therapy is necessary in difficult-to-cannulate cases.
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Objective To investigate the methods and strategies of therapeutic ERCP in patients with duodenum stricture.Methods Endoscopic procedure,success rate and complications in patients with duodenum stricture who underwent ERCP were retrospectively analyzed.Results In 7276 patients who underwent therapeutic ERCP,duodenum stricture was found in 158 (2.17％),patients with malignant tumor infiltration in 120 and benign stricture in 38.The total success rate of ERCP and biliary drainage was 84.2％,with posture change or guidewire leading method in 96 patients,stylolitic water sac dilation in 33and duodenum metal stent placement before biliary drainage in 4.The procedure was failed in 25 patients.Minor bleeding occurred in 5 patients and no major complication including massive bleeding or perforation was observed.Conclusion ERCP is safe,effective and feasible for patients with duodenum stricture,which can be performed by posture change or guidewire leading method in mild stricture,and stylolitic water sac dilation or duodenum metal stent placement in severe stricture.
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ObjectiveTo evaluate the feasibility and safety of endoscopic intraductal radiofrequency ablation (RFA) for unresectable malignant biliary strictures.MethodsA total of 12 patients with malignant biliary obstructions,who were unsuitable for surgical resection,were prospectively selected for this study.During ERCP,when successful biliary cannulation achieved,a bipolar radiofrequency probe was introduced into bile duct over a guidewire.RFA was given to the tumor lesion under fluoroscopy,followed by stent placement.The patients were closely observed and followed up after the procedure.ResultsSuccessful RFA was achieved in all patients before stents insertion ( plastic and metal stents in 6 respectively,additional pancreatic stents were given to 3).Mild complications of cholangitis and pancreatitis occurred in 1 patient respectively,which were cured with short-term management.Jaundice was promptly controlled in 7 patients (58.3％ ).During the mean follow-up duration of 3.4 (range 0.5-5.5) months,one patient died of cardiocerebral accident and others survived without obvious disconffort.The 1- month and 3- month stent patency was 100％ (12/12) and 80％ (8/10),respectively.ConclusionIt is technically feasible and safe to perform endoscopic intraductal RFA for the palliation of biliary malignancies.The short-term outcome is satisfying,however,long-term result and the better therapeutic schedule need further evaluation.
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Objective To evaluate endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and management of biliary cast syndrome after orthotropic liver transplantation. Methods A total of 71 consecutive patients with abnormal liver function and MRCP findings after liver transplantation underwent ERCP for diagnosis and management. Their data were retrospectively reviewed. Results A total of 188 sessions of ERCP were carried out on the 71 patients, most of whom were found to have stenosis of anastomotic stoma and/or bile duct. Bile sludge was found and removed in all patients diagnosed within 3 months after liver transplantation, while pigmentoid stones were found and removed in patients diagnosed within 3-6 months and biliary casts in patients diagnosed at more than 6 months. Each patient underwent 2.6 sessions averagely. Biliary casts were formed at an average time of 22. 7 ± 15.6 months after transplantation. PostERCP complications included 2 cases of pancreatitis and 3 cholangitis, with an occurrence rate of 2. 6%(5/188), which were all controlled with conservative treatment. The follow-up data was available in 56 patients showing improvement in liver function after ERCP, among who 42 met the endoscopic criteria of cure,1 0 received second liver transplantation because of progressive sclerosing cholangitis and 4 died from diseases other than liver transplantation. Conclusion Therapeutic ERCP for the biliary cast syndrome after liver transplantation is feasible, safe and effective, and can be performed repeatedly with good short-term effect.
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Objective To evaluate the effectiveness and safety of needle-knife fistulotomy (NKF)for difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP). Methods Data of patients, who received NKF on the back of major papilla when bile duct could not be accessed by conventional cannulation and/or other pre-cut methods during ERCP, were retrospectively reviewed. The success rate of deep cannulation and its complications were observed and analyzed. Results NKF was performed in 108patients due to difficult cannulation, which succeeded in 97 (91.2%) in access to the bile duct and failed in 11 patients with malignant biliary strictures. The failure rate in patients with distal malignant obstruction was higher (25. 8%, 8/31) than those with proximal lesions (5.3%, 3/57) (P = 0. 014, χ2 = 5. 983).Post-ERCP pancreatitis occurred in 5 cases (4. 6%), with the incidence significantly higher in NKF-failure group (18. 2%, 2/11) than that in NKF-suocess group (3.1% ,3/97) (P = 0. 006, χ2 = 7.418). Intestinal perforation occurred in 1 patient and cholangitis developed in 4 others, which all recovered after conservative managements. Conclusion NKF for difficult cannulations in ERCP is safe and effective, especially in hands of experienced operators, but cannulation success rate is relatively low in distal malignant biliary obstruction.
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Objective To investigate the efficiency and safety of endoscopic large balloon dilation following small sphincterotomy (ESBD) for treatment of common bile duct (CBD) stones, and to prospectively compare it with traditional sphincterotomy (ES). Methods Patients with single or multiple calculi in extra-hepatic bile ducts and with the diameter of CBD larger than 13 mm, were randomized into 2 groups to receive maximal sphincterotomy (ES group), or partial sphincterotomy plus sphincteroplasty with 15mm-balloon (ESBD group), respectively, followed by conventional stones removal and/or lithotripsy. The success rate of stone clearance, operation time and related complications were observed. Results A total of 86 patients were enrolled in 2 endoscopy centers, with 2 excluded because of papillary pre-cut in 1 and non-compliance with the protocol in the other, and were randomly divided into groups ES and ESBD, with 42 patients in each. The clinical characteristics, including average diameter of CBD, size and quantity of calculi, and incidences of peri-ampullary diverticulum, of patients in both groups were all similar. Stones clearance with single session in 2 groups were 88% and 93%, respectively (P =0. 531 ). The operation time were (25.76 ± 12. 74) min and (26. 38 ± 12. 86) min ( P = 0. 825 ). The rate of mechanical lithotripsy was 36% and 25%, respectively (P=0. 363). Complications occurred in 5 cases in ES group (3 mild, 2 medium), and 2 mild complications occurred in ESBD group (no statistical difference). No death happened in any group.Conclusion ESBD is an effective method for clearance of extra-hepatic bile duct stones with the similar safety, compared with traditional sphincterotomy. It could be an optimal alternative for those with large stones or difficult sphincterotomy.
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Objective To evaluate the safety and efficacy of a newly designed anti-reflux metallic stent (ARMS) for malignant extra-hepatic biliary obstruction. Methods A total of 23 patients with unresectable biliary malignancy in the middle or lower part of common bile duct underwent endoscopic retrograde cholangiopancreatography (ERCP) and ARMs placement. The success rate, early complications, stent patency and patients' survival were recorded. Results The ARMSs were successfully placed in all patients and no procedure-related complication was recorded. The average operation time was similar to that of self-expanding metallic stents (SEMs). In 22 patients completing the follow-up, the total serum bilirubin dropped to normal within one month in 20. ARMs dysfunction occurred in 6, including tumor in-growth in 1, overgrowth in 2, and stent dislodgement in 3. Other patients were free of biliary symptoms until death or at the end of follow-up. The average stent patency of ARMs was 14 months. Patency rates at 3, 6, and 12 months were 95%, 74% and 56%, respectively. The mean patient survival was 7. 9 months ( 1-14 months).Postoperative survival rates at 3,6 and 12 months were 91.0%, 81.3% and 17. 2%, respectively. Conclusion Endoscopic placement of novel ARMs in patients with extra-hepatic biliary tumors is feasible,safe and effective.
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Objective To evaluate the feasibility of simultaneous endoscopic bilateral placement of self-expandable metal biliary stents. Methods A total of 9 patients with hilar malignancy of Bismuth type Ⅱ to Ⅳ were enrolled in the current study, with a mean serum bilirubin at 162. 8 ± 193. 8 μmol/L before the procedure. Two guide wires were selectively inserted into the left and right intrahepatic ducts and kept in site. After aggressive dilatation for beth sides, the metal stents were deployed one by one bilaterally. Success rate of the procedure, remission of jaundice, early complications, and short-term clinical outcome were ob-served. Results The procedure was succeeded in all patients with Y type stent in 2, plastic stent transition in 1 and parallel stenting in 6, which took an average time of 38. 1 min. The most convenient way was the parallel method with both distal ends of the stents remaining at outside of papilla. The serum bilirubin re-turned to normal level within 3 weeks in all patients except 1, and no major complications were observed. Conclusion Simultaneous endoscopic bilateral metal stent placement is technically feasible and safe, with the benefit of prompt and effective control of jaundice and infection, caused by hilar tumors. A better method is to place specially designed endoprotheses in parallel and leave the distal ends outside papilla.
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ObjectiveTo retrospectively investigate the clinical features of the biliary tract complieations after living donor liver transplantation (LDLT) and the efficacy of endoscopy.MethodsThe LDLT patients with hiliary eomplieations were given endoscopic retrograde eholangiopanereatography (ERCP) and endoscopic therapies were carried out according to the result of eholangiogram.ResultsTwenty-one patients,among whom 43.8% were at early postoperative stage,underwent 28 endoscopic procedures.Nineteen patients (90.4%) had biliary anastomotic strictures with angled malformation.Bile leakage was found in 9 patients (42.9%).The success rate of endoscopic therapy was 85.7% ,including nose-bile drainage in 5,stent placement in 10,balloon dilatation and/or multiple stents placement in 9 and bile collection drainage in 2.During follow-up,leak heal was confirmed in 3 patients and stricture resolution was achieved in another 2 eases. ConclusionBiliary complication is relatively common in the early stage after LDIX,and severe anastomotie stricture with angled malformation is most frequently seen, usually associated with bile leakage. Series of endoscopic interventions with the strategy of "leak first,and then stricture"might achieve satisfactory outcome.
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Objective To investigate an effective endoscopic management of biliary anastomotic stric-tures (AS) following orthotopic liver transplantation (OLT) and to evaluate the factors which may effect the ontcome. Methods Sixty-five patients, who were diagnosed as AS 3 months after OLT, underwent ERCP. Af-ter adequate dilation of the narrowing bile ducts, plastic stents, as many as possible, were inserted across the strictures and kept in place for at least six months. Results A total of 90 consecutive endoscopic procedures were performed in 65 patients. Before stents placement, the strictures were dilated by catheter or balloon (di-ameter range: 6-10 mm), or not dilated, according to the status of the bile ducts. An average of 3 (ranging from 2 to 6) plastic stents were placed with mean total size of 22.8 F (range 14-42 F), and the stents were kept for 8. 0 months on average (range 0.2-37.8 months). Of 90 procedures of stents placement, 54 (60%) were followed by stents removal and cholangiography, which confirmed stricture resolution in 26 (48.1%). The stricture resolution rate was 81.0% (17/21) in patients who underwent balloon dilation followed by more than 3 stents (> 21 F) for at least 3 months. Stricture re-occurred in 3 patients after stents removal, in whom stents were kept less than six months. Conclusion Endoscopic sequential intervention is effective for post-OLT biliary strictures according to the stage and grade. Radical dilation with maximal stenting can lead to complete resolution of AS. To achieve better result, if possible, balloon dilatation followed by three or mere endoprothe-ses (of at least 21 F) sustaining for more than 6 months is necessary.
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Objective To determine the effectiveness of ETCD ( endoscopic transpapillary cyst drainage) in treatmen! of pancreatic pseudocysts. Methods Twenty-six patients with pancreatic pesudocysts were selected. They are presented some indications for treatment and the pesudocyst were ranged in size from 1.5 to 15 cm. Of 23 cases 38 sessions of ETCD were performed. In two of thirty-eight cases the cyst bulges were invisible in the stomach or duodenum due to its compression. In one case ETCD was employed after percutaneous drainage of the pseudocyst, the other one was treated after combination therapy of plastic stent ing because of jaundice. Results Improvement of abdominal pain, changes in appetite, body weight and fat in stool were recorded in follow-ups of 60 ~ 850 days. There was only one asymptomatic recurrence. One case was complicated with pancreatic abscess. There was no mortality related to the procedure. Surgical intervention became necessary in three cases because of inadequate drainage or complication. Conclusion ETCD treatment of symptomatic pancreatic pseudocysts with ductal communication, the transpapillary pancreatic duct stenting is a safe, effective modality and should be considered as the first line therapy; on the other hand for those pancreatic pseudocyst without communication to the main pancreatic duct it is not effective.