Pancreatitis aguda recurrente secundaria a disfunción del esfínter de oddi: Reporte de caso

La disfunción del esfínter de Oddi (DEO) es una patología poco frecuente que debe ser considerada en el diagnóstico diferencial de pacientes con episodios de dolor biliar o pancreatitis aguda recurrente y antecedente de colecistectomía. Generalmente son pacientes con múltiples consultas, en los cuales la patología ha afectado considerablemente su calidad de vida. El diagnóstico se sustenta en la clínica, los marcadores serológicos y los medios diagnósticos de soporte, que se solicitan según el componente esfinteriano sospechado. El tratamiento con mayor eficacia es la esfinterotomía endoscópica. El uso de prótesis es aceptado, pero discutido. Se presenta el caso de un paciente masculino en la cuarta década de la vida que consultó por múltiples episodios de pancreatitis aguda recurrente con estudios de etiología que sospecharon disfunción del esfínter de Oddi pancreático y quien fue llevado a manejo endoscópico, con mejoría de su cuadro clínico.

Sphincter of Oddi Dysfunction (SOD) is a rare pathology that should be considered in the differential diagnosis of patients with biliary pain episodes or recurrent acute pancreatitis and a background of cholecystectomy. Generally, these are patients with multiple consultations where this pathology has considerably affected their quality of life. Diagnosis is based on clinical findings, serological markers and supporting diagnostic tests requested according to the suspected sphincteric component. The most effective treatment is endoscopic sphincterotomy. The use of prosthesis is accepted but debated. We present the case of a male patient in his forties who consulted for multiple episodes of recurrent acute pancreatitis with etiology studies suspecting dysfunction of the pancreatic sphincter of Oddi and who was taken to endoscopic management with improvement of his clinical picture.

Clinical application of two kinds of minimally invasive methods in choledocholithiasis complicated with gallbladder stones / 中华胰腺病杂志

Objective:To compare the clinical effectiveness of laparoscopic cholecystectomy (LC)+ laparoscopic choledocholithotomy (LCBDE)+ one-stage suture and primary choledocholithotomy with endoscopic retrograde cholangiopancreatography (ERCP)+ endoscopic duodenal sphincterotomy (EST)+ nasobiliary drainage (ENBD)+ LC in the treatment of choledocholithiasis complicated with gallbladder stones.Methods:A total of 200 patients with choledocholithiasis complicated with gallbladder stones admitted to the General Surgery Department of Shanxi Bethune Hospital from June 2015 to February 2021 were collected, and patients were divided into LC+ LCBDE+ one-stage suture (one-stage suture group, n=130) and ERCP+ EST+ ENBD+ LC (endoscopic surgery group, n=70) according to different treatments. The amount of intraoperative blood loss, operation time, postoperative feeding time, postoperative incidence of pancreatitis, cholangitis and other complications (biliary leakage, abdominal bleeding, wound infection), hospitalization costs, postoperative hospital stay, etc were compared between two groups. Results:The postoperative incidence of pancreatitis in the one-stage suture group (0.7% vs 5.7%) and the hospitalization cost [(2.74±0.39) ten thousand yuan vs (3.86±0.63) ten thousand yuan] were significantly lower than those in the endoscopic surgery group. The operation time [(103.21±9.36) min vs (88.18±7.20)min] was significantly longer than that of the endoscopic surgery group, and postoperative feeding time [(3.3±0.3)d vs (2.2±0.8)d] were significantly later than the endoscopic surgery group ( P<0.05). The amount of intraoperative blood loss [(36.0±3.0)ml vs (37.3±2.7)ml], the incidence of postoperative cholangitis (1.5% vs 2.9%) and other complications [biliary leakage (2.3% vs 1.4%), abdominal bleeding (1.5% vs 4.3%), wound infection(0 vs 0)], postoperative hospital stay [(6.8±1.3)d vs (7.1)d] had no significant differences between the two group. Conclusions:The two minimally invasive methods for the treatment of choledocholithiasis complicated with gallbladder stones had good efficacy, but LC+ LCBDE+ one-stage suture can retain the sphincter function of Oddis, maintain the normal anatomy and physiology of the biliary tract, reduce the incidence of related complications, and contribute to the recovery of patients, with high safety, effectiveness and feasibility.

Research advances in the impairment of Oddi sphincter function caused by endoscopic sphincterotomy / 临床肝胆病杂志

The Oddi sphincter has a delicate structure, and the integrity of its function has an irreplaceable role in preventing retrograde infection due to the reflux of duodenal contents and bacteria and maintaining the balance of physiological environment inside and outside the liver, the pancreas, and the gallbladder. Endoscopic sphincterotomy impairs the integrity of the Oddi sphincter, and such negative effects have received more and more attention. This article reviews the research advances in the impairment of Oddi sphincter function caused by endoscopic sphincterotomy and points out that clinicians should understand and attach importance to such impairment, perform a comprehensive analysis from various aspects, and develop reasonable diagnosis and treatment regimens based on patient’s own conditions.

Efficacy and safety of endoscopic papillary large balloon dilation alone versus endoscopic sphincterotomy combined with large balloon dilation in treatment of large common bile duct stones: A Meta-analysis / 临床肝胆病杂志

ObjectiveTo systematically review the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) versus endoscopic sphincterotomy combined with large balloon dilation (ESBD) in the treatment of large common bile duct stones (≥10 mm). MethodsPubmed, Embase, Cochrane Library, CNKI, Wanfang Data, and VIP were searched for related articles published up to March 2020. Two reviewers independently performed article screening, data extraction, and quality assessment, and RevMan 5.3 software was used for statistical analysis. ResultsA total of 11 studies (6 randomized controlled trials and 5 non-randomized controlled trials) were included, with 1282 patients in total. The meta-analysis showed that in the 6 randomized controlled trials, there were no significant differences between the EPLBD group and the ESBD group in initial stone clearance rate (odds ratio ［OR］=0.71, 95% confidence interval ［CI］: 0.45-1.12, P=0.14), overall stone clearance rate (OR=1.39, 95%CI: 0.65-2.96, P=0.39), rate of use of mechanical lithotripsy (OR=1.19, 95%CI: 0.75-1.89, P=0.46), and incidence rate of early complications (OR=1.10, 95%CI: 0.60-2.03, P=075); in the 5 non-randomized controlled trials, there were no significant differences between the EPLBD group and the ESBD group in initial stone clearance rate (OR=0.64, 95%CI: 0.35-1.15, P=0.13), overall stone clearance rate (OR=0.46, 95%CI: 0.19-112, P=009), and incidence rate of early complications (OR=1.20, 95%CI: 0.65-2.21, P=0.56), but the EPLBD group had a significantly higher rate of use of mechanical lithotripsy than the ESBD group (OR=1.96, 95%CI: 1.26-3.05, P=0.003). ConclusionEPLBD and ESBD have similar efficacy and safety in the treatment of large common bile duct stones, while EPLBD may increase the risk of the use of mechanical lithotripsy. More high-quality randomized controlled trials are needed to confirm this conclusion.

Clinical effect of endoscopic sphincterotomy with balloon dilation versus sphincterotomy alone in treatment of large common bile duct stones: A Meta-analysis / 临床肝胆病杂志

ObjectiveTo investigate the clinical effect of endoscopic sphincterotomy with balloon dilation (ESBD) versus sphincterotomy (EST) alone in the treatment of large common bile duct stones. Methods Foreign databases (including PubMed, CochraneCentral, and Embase) and Chinese databases (including CNKI and Wanfang Data) were searched for randomized controlled trials (RCTs) on the clinical effect of ESBD versus EST in the treatment of large common bile duct stones published up to July 8, 2019. Related data were extracted and RevMan5.3 was used for analysis. Results A total of 13 RCTs with 1926 patients were included, with 973 patients in the ESBD group and 953 patients in the EST group. The meta-analysis showed that there were significant differences between the ESBD group and the EST group in stone clearance rate (odds ratio ［OR］=1.53, 95% confidence interval ［CI］: 1.03-2.29, P=0.04), one-time clearance rate (OR=1.77, 95%CI: 1.06-2.93, P=0.03), rate of use of mechanical lithotripsy (OR=0.40, 95%CI: 0.25-0.63, P＜0.000 1), bleeding rate (OR=0.23, 95%CI: 0.11-0.50, P＜0.001), incidence rate of cholangitis (OR=0.31, 95%CI: 0.12-0.78, P=0.01), incidence rate of early complications (OR=0.59, 95%CI: 0.42-0.84, P=0.003), and time of operation (mean difference=-8.89, 95%CI: -17.56 to -0.22, P=0.04), while there were no significant differences between the two groups in perforation (OR=0.27, 95%CI: 0.05-1.30, P=0.10) and pancreatitis after endoscopy (OR=1.03, 95% CI: 0.66-1.61, P=0.91). ConclusionIn endoscopic treatment of large common bile duct stones, ESBD has several advantages over EST in stone clearance rate, rate of use of mechanical lithotripsy, bleeding rate, incidence rate of cholangitis, and time of operation.

Endoscopic Sphincterotomy, Balloon Stone Extraction, and Basket Stone Extraction / 대한췌담도학회지

Endoscopic sphincterotomy is performed after selective cannulation to remove the gallstone. Endoscopic sphincterotomy can cause complications such as bleeding, perforation and pancreatitis. Various types of endoscopic sphincter incision method and current generators used for incisions have been developed to reduce the incidence of such complications and increase the success rate of the procedure. In addition, guidelines for the direction and extent of endoscopic sphincterotomy and incision technique are established. The method used for the removal of gallstones after the endoscopic sphincterotomy is a method using a balloon and/or a basket. This review introduces the technical methods of endoscopic sphincterotomy and discusses the clinical indications and technical methods for representative methods of effective gallstone removal.

Timing for laparoscopic cholecystectomy after ERCP + EST in patients of gall stones and choledocholithiasis / 中华普通外科杂志

Objective To evaluate the timing of postoperative laparoscopic cholecystectomy (LC after ERCP for the treatment of gallstones.Method A retrospective analysis was made on 120 patients with choledocholithiasis and cholecystolithiasis from Feb 2015 to Feb 2018 in the First Affiliated Hospital of Xinjiang Medical University,including 62 patients receiving LC at 48-72 h after ERCP + EST (observation group),and 58 patients receiving LC at 72h after ERCP + EST (control group).The hospital stay,hospitalization costs,operation time,intraoperative blood loss,convertion to open laparotomy,the postoperative complications were compared between the two groups.Results The difference of age,gender,ERCP operation time,common bile duct stones diameter,postoperative complications were not statistically significant in two groups.Operation time,intraoperative blood loss,hospital stay,incidence of laparotomy and hospitalization costs in group A were significantly less than that in group B (P ＜ 0.05).Conclusions ERCP + EST followed by LC for choledocholithiasis with cholecystolithiasis within 48-72 hours were with shorter operation time,lower hospital costs,without an increase of postoperative complications compared with ERCP + EST followed by LC after 72 hours.

One stage percutaneous transhepatic rigid choledochoscope lithotomy (PTCSL) vs ERCP plus EST for choledocholithiasis / 中华普通外科杂志

Objective To investigate the curative effect on patients with choledocholithiasis by percutaneous transhepatic rigid choledochoscope lithotomy (PTCSL) vs endoscopic retrograde cholangiopancreatography (ERCP) plus EST.Methods From Jan 2010 to Dec 2015,92 cases of choledocholithiasis were treated by one-stage PTCSL (n =23) vs ERCP (n =69).The curative effects and postoperative complications in two groups were observed and analyzed.Results In PTCSL group,the complete stone clearance at one-time achieved in all 23 cases (100％).While in ERCP group stone clearance was achieved in 72.46％ cases at first attempt and the final clearance rate was 82.60％,leaving 12 cases with residual stones and among those 12 cases 5 cases were converted to surgical operation.The average intra-operative hemorrhage in two groups was (20.6 ± 4.6) ml vs (3.0 ± 0.3) ml,and the average hospital stay after operation was 6.8 d and 7 d respectively.The post-operative complications (30.43％) and stone recurrence (13.04％) were similar in the two groups.Conclusions PTCSL is safe,effective,and more suitable to patients with large stones and those with a history of biliary surgeries.

Éxito de CPRE 72 horas después de precorte / ERCP success after 72 hours of pre-cut

Introducción A pesar de los avances en las técnicas para canalizar la vía biliar no se puede asegurar su éxito. Se han publicado pocos estudios que soporten un segundo intento de CPRE que, sin embargo, reportan un aumento en la tasa de canalización. Objetivo: Determinar si una CPRE 72 horas después de realizarse una papilotomía por precorte permite la canalización de la vía biliar. Materiales y métodos: Se realizó un estudio de cohorte descriptiva, se incluyeron todos los pacientes llevados a CPRE más papilotomía por precorte sin lograr el ingreso a la vía biliar y que 72 horas después fueron programados para una nueva CPRE entre septiembre de 2015 y septiembre de 2016.Los pacientes en quienes no se logró canalizar la via biliar a pesar de la papilotomia por precorte no tenían ninguna característica de edad, género o anatómica que se asocie con fracaso en la canalización respecto a la población general. Se analizó el porcentaje de éxito en la canalización a las 72 horas y las complicaciones asociadas a la papilotomía por precorte en el procedimiento inicial. Resultados: Ingresaron al estudio 16 pacientes, con edad promedio de 61.3 años (DE: 10.6), se logró canalizar la vía biliar en 14 de los casos que se llevaron a una CPRE 72 horas después de una papilotomía por precorte. No se presentaron complicaciones después de la papilotomía por precorte. En los dos pacientes no canalizados se indicó cirugía: Conclusiones: La experiencia reportada en este estudio sobre el éxito de canalización de la vía biliar 72 horas después de la realización de una papilotomía por precorte en un 87% sin complicaciones nos permite sugerirla como una alternativa de manejo antes de una exploración quirúrgica.

Introduction: Despite the advances of bile duct catheterization, its success is still not guaranteed. Few studies have been published regarding a second ERCP attempt, however those reports enhance the catheterization success Objective: To determine whether an ERCP performed 72 hours after a first precut papillotomy enhances the bile duct catheterization. Material and methods: A cohort study was performed including all patients that had ERCP with precut papilotomy without catheterization of the bile duct and 72 hours later were programmed to a new ERCP between September 2015 and September 2016. These patients did not have any distinctive characteristic such as age, gender or anatomy that were associated with the failure to catheterize the bile duct, compared to the general population. Result: 16 patients were included with a mean age of 61,3 years (SD: 10,6), bile duct catheterization was successful in 14 cases. No complications presented after precut papilotomy. Both failures went to surgery. Conclusions: Our experience about an 87% successful bile duct catheterization, 72 hours after precut papillotomy allows us to suggest it as an alternative before considering surgery

Emergency endoscopic needle-knife sphincterotomy for the treatment of acute biliary pancreatitis caused by impacted bile duct stones at duodenal papilla / 中华普通外科杂志

Objective To evaluate the efficacy and safety of emergency endoscopic needle-knife sphincterotomy in acute biliary pancreatitis caused by impacted common bile duct stones at duodenal papilla.Methods Between Jan 2007 and Jan 2017,115 cases underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) and needle-knife sphincterotomy.Clinical data were recorded and analyzed.Results Procedures were successful in all cases.The mean operative time of needle-knife sphincterotomy was (22.5 ± 13.7) min.The clearence of impacted stone at duodenal papilla was 87.8％(101/115).The syptoms of pancreatitis promptly relieved after emergency ERCP.Postoperative white blood cell count,serum amylase and liver function improved significantly.The complication rate was 5.2％ (6/115),including 3 cases of hemorrhage and 3 cases of acute cholangitis,which were cured by conservative treatment.There was not procedure-related mortality.Conclusions Emergency endoscopic needle-knife precut sphincterotomy is effective and safe for acute biliary pancreatitis caused by impacted common bile duct stones at the duodenal papilla.

The outcome of endoscopic management of bile leakage after hepatobiliary surgery

BACKGROUND/AIMS: Despite improvements in surgical techniques and postoperative patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery. METHODS: The medical records of 20 patients who underwent endoscopic retrograde cholangiopancreatography because of bile leakage after hepatobiliary surgery from August 2009 to September 2014 were reviewed retrospectively. Endoscopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy. RESULTS: Most cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liver beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modalities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincterotomy. CONCLUSIONS: The endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

The sphincter of Oddi: from incision to repair / 临床肝胆病杂志

The sphincter of Oddi is a valve that controls the biliopancreatic duct and plays an irreplaceable role in maintaining normal physiological functions of the biliopancreatic duct.However,sphincteroplasty and sphincterotomy may cause varying degrees of damage to the function of the sphincter of Oddi,which may further result in postoperative reflux of duodenal fluids and bacterial contamination in bile and increase the risks of recurrent common bile duct stones,reflux cholangitis,and even cholangiocarcinoma.Therefore,clinical physicians should protect the structure and function of the sphincter of Oddi.Based on our experience,under the premise that the extrahepatic bile duct can be preserved,patients with iatrogenic injury of the sphincter of Oddi can be treated with transduodenal sphincteroplasty to restore the structural integrity of the sphincter of Oddi and reduce biliopancreatic duct complications secondary to loss of function.

Clinical comparative analysis on LCBDE + LC and ERCP/EST + LC for gall stones and choledocholithiasis / 中华普通外科杂志

Objective To Compare the therapeutic effects of laparoscopic cholecystectomy (LC) + laparoscopic common bile duct exploration (LCBDE) and primary suture with endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + LC for cholecystolithiasis combined with choledocholithiasis.Methods The clinical data of 144 patients with cholecystolithiasis and choledocholithiasis who were treated in First Affiliated Hospital,Xinjiang Medical University from Dec 2014 to Jan 2016 were retrospectively analyzed,72 cases being treated by LC + LCBDE (group A) and 72 cases by ERCP/EST + LC (group B).The hospitallization time,hospitalization costs and complication rate were compared between the two groups.Results There were no statistically differences in terms of incidence of postoperative complication (P ＞ 0.05) in two groups.However,hospital stay [(10.25 ± 1.26) d vs.(14.25 ± 1.50)d),P =0.006] and hospitalization costs [(19 600 ± 1 521) yuan vs.(23 931 ± 1 629) yuan,P =0.008] were in favor of LC + LCBDE group than those in ERCP/EST + LC group.Conclusions LC + LCBDE is better than ERCP/EST + LC in the treatment of gall stone and choledocholithiasis.

Therapeutic value of endoscopic papillectomy for duodenal papilla lesion / 中华消化内镜杂志

Objective To investigate the therapeutic value of endoscopic papillectomy (EP) for duodenal papilla lesion.Methods Patients with duodenal papilla lesion treated with EP from June 2007 to December 2015 were enrolled.The clinical characteristics,EP technical features,complications,the treatment,postoperative recurrence were analyzed.Results A total of 43 patients were enrolled.The mean diameter of the lesion was 22.8±1.2 mm.Thirty-two patients (69.8％) received en bloc resection,and 11 (25.6％) received endoscopic piecemeal mucosal resection (EPMR).After the operation,duodenal papilla lesions recurred in 3 patients (7.0％),5 patients (11.6％) had delayed bleeding,4 (9.3％) had postoperative pancreatitis,6 (14.0％) had long-term bile duct stricture.Intraoperative pancreatic stenting (OR =0.000,95％ CI:0.000-) was the independent protective factor for postoperative pancreatitis.Pancreatic duct dilation (OR =13.500,95％ CI:1.400-130.191) was the independent risk factor for postoperative bile duct stenosis.Conclusion EP is minimally invasive with rapid recovery and less cost,and could be recommended for duodenal papilla lesions.

Efficacy and complications in endoscopic sphincterotomy and limited endoscopic sphincterotomy plus endoscopic papillary balloon dilation for choledocholithiasis / 中华消化内镜杂志

Objective To compare efficacy and complications of endoscopic sphincterotomy(EST) and limited endoscopic sphincterotomy plus endoscopic papillary balloon dilation (ESBD) for choledocholithiasis.Methods A total of 120 choledocholithiasis patients (stone diameter ≤ 2 cm)underwent endoscopic treatment,including 60 cases of EST,60 ESBD.The stone-free rate,complication rate of postERCP pancreatitis,hemorrhage,perforation and recurrence rate of stones were compared between two groups.Results Success rates of one-time removal were 90.0％ (54 cases) and 93.3％ (56 cases) in group EST and ESBD (x2 =0.436,P =0.743).Eleven case (18.3％) and 4 case (6.7％) underwent mechanical lithotripsy(x2=3.733,P =0.053).There were 4 cases of hemorrhage,6 post-ERCP pancreatitis and 1 perforation in EST group,while in ESBD group,there was 1 case of hemorrhage,4 pancreatitis and no perforation.The total rates of early complications were 18.3％ (11/60) and 8.3％ (5/60) in two groups (x2 =3.322,P =1.422) and recurrence rate of stones were 21.7％ (13/60) and 6.7％ (4/60) respectively (x2=5.551,P =0.034).Conclusion There are no significant differences between EST group and ESBD group in treatment of choledocholithiasis,in success rate of one-time removal and the occurrence of early complications,but the recurrence rate of late complications in ESBD group is lower than that in EST group.ESBD shows high efficacy and safety for younger patient of choledocholithiasis.

High-risk factors for cholangitis after endoscopic sphincterotomy / 临床肝胆病杂志

Objective To investigate the high-risk factors for cholangitis after endoscopic sphincterotomy (EST), and to provide a reference for clinical prevention and treatment.Methods A total of 196 patients who underwent EST in our hospital from June 2013 to January 2016 were enrolled, among whom 31 experienced cholangitis after EST (infection group) and 165 had no cholangitis (control group).Related factors were analyzed for both groups.The t-test was used for comparison of continuous data between groups;the chi-square test was used for comparison of categorical data between groups, and a multivariate non-conditional logistic regression analysis was performed for variables with statistical significance.Results The univariate analysis showed that there were significant differences between the two groups in the past history of biliary tract surgery [8 (25.81%) vs 10 (6.06%), χ2=12.200, P=0.000 5], number of common bile duct stones (2.8±0.5 vs 2.2±0.6, t=5.234, P=0.000 5), gallstones complicated by cholecystitis [8 (25.81%) vs 13 (7.88%), χ2=6.994, P=0.000 4], intrahepatic bile duct stones [6 (19.35%) vs 8 (4.85%), χ2=8.280, P=0.004 0], time of operation (35.6±5.8 min vs 27.1±6.2 min, t=7.072, P=0.000 4), presence or absence of lithotripsy [10 (32.26%) vs 15 (9.09%), χ2=10.591, P=0.000 1], postoperative pneumobilia [12(60.00%) vs 16 (21.82%), χ2=17.940, P=0.000 2], and duration of the use of antibiotics (3.6±0.7 d vs 4.5±0.8 d, t=5.854, P=0.000 6).The multivariate non-conditional logistic regression analysis showed that past history of biliary tract surgery [OR (95%CI)=1.962 (1.156-3.658), P=0.024], number of common bile duct stones [OR (95%CI)=2.632 (1.366-5.013), P=0.021], intrahepatic bile duct stones [OR (95%CI)=2.976 (1.482-5.536), P=0.024], time of operation [OR (95%CI)=4.859 (2.513-8.622), P=0.006], postoperative pneumobilia [OR (95%CI)=5.326 (2.633-10.524), P=0.005], and duration of the use of antibiotics [OR (95%CI)=0.565 (0.263-0.895), P=0.009] were independent risk factors for cholangitis after EST.Conclusion Positive intervention of related risk factors for cholangitis after EST has important clinical significance in the prevention of cholangitis after EST.

Clinical analysis of delayed papillary hemorrhage after endoscopic retrograde cholangiopancreatography / 中华消化内镜杂志

Objective To evaluate the clinical feature and potential reasons of delayed papillary bleeding after endoscopic retrograde cholangiopancreatography (ERCP),and search for effective hemostasis and strategies.Methods A total of 76 patients with post-ERCP bleeding underwent endoscopic treatment in the Eastern Hepatobiliary Hospital from August 2000 to August 2016.Clinical data,haemostatic methods,and treatment outcomes of patients were retrospectively analyzed.Results Delayed papillary hemorrhage mostly occmred within 48 hours after ERCP (67.2％,45/67),with main manifestations of hematemesis,bloody stool,and bile.The lowest incidence of delayed bleeding was detected after endoscopic papillary balloon dilation (EPBD,0.1％),which was followed by papillary precut (0.6％) and endoscopic sphincterotomy (EST,0.9％).And EST+EPBD had the highest incidence of delayed post-ERCP papillary hemorrhage (2.4％).The most bleeding site was the left side of the incision (67.1％,51/76).Emergent endoscopic interventions were applied in all patients with success of hemostasis in 71 out of 76 (93.4％),and injection with diluted epinephrine,electric coagulation,hemoclipping,and metal stenting were used sequentially for hemostasis.Among the 71 successful cases of hemostasis,66 patients were performed endoscopic hemostasis for once,4 patients took twice,and 1 case took thrice.Endoscopic hemoclipping was the most commonly used method with successful rate of 76.9％ (50/65) for hemostasis.Conclusion Precut papillotomy is safe and effective,and its complication occurrence rate is similar to that of EST.Hemorrhage should be prevented and timely dealt with in small/median EST and/or EPBD.Once hemorrhage is suspected clinically,endoscopic inventions should be applied timely,and hemoclipping is a safe and effective method.

Dilatación con balón de gran diámetro en el manejo de coledocolitiasis de difícil extracción: experiencia clínica / Large balloon dilation for removal of choledocholithiasis difficult to extract: clinical experience

Objetivo: Describir la experiencia clínica con la técnica de dilatación de la esfinterotomía papilar con balones de gran diámetro en pacientes con coledocolitiasis de difícil extracción. Materiales y métodos: Estudio retrospectivo, diseño descriptivo. Serie de Casos. Se analizaron las historias clínicas de 18 pacientes que fueron sometidos a colangiopancreatografía retrograda endoscópica (CPRE) más dilatación papilar con balón de gran diámetro (DPBGD) por presentar coledocolitiasis de gran tamaño (≥15 mm), desproporción de diámetro entre cálculo y colédoco distal y/o papila yuxtadiverticular. Se emplearon balones dilatadores CRETM entre 12 y 20mm de diámetro. Se consignaron datos como éxito del procedimiento, uso de litotricia; así como complicaciones durante el procedimiento. Resultados: La edad promedio fue 66,1 años. Hubo predominio del género femenino (66,7%). El tamaño promedio de los cálculos en vía biliar fue de 16,7 mm. Las indicaciones de DPBGD fueron: coledocolitiasis gigante (12 pacientes, 66,7%), discordancia entre el diámetro del cálculo y el colédoco distal (6 pacientes, 33,3%). El diámetro de los balones de dilatación más frecuentemente empleados fueron: 15 mm (8 pacientes, 44,4%), 18 mm (5 pacientes, 27,8%), 12 mm (3 pacientes, 16,7%) y 20 mm (2 pacientes, 11,1%). Se consiguió la extracción completa de los cálculos en 15 pacientes (83,3%). Se precisó litotricia en 4 pacientes (22,2%). Hubo 3 pacientes en los que la extracción con balón fue frustra, realizándose manejo quirúrgico. Se reportó 1 caso de pancreatitis aguda leve (5,5%). Conclusiones: Los resultados demuestran que la dilatación con balón es una alternativa segura y eficaz en el manejo de los cálculos en vía biliar de difícil extracción

Objective: The aim of this study was to report the initial experience of the combined use of biliary sphincterotomy plus balloon dilatation of the papilla for management of large stones. Materials and methods: Design: Retrospective, descriptive. This study included 18 patients in whom a hydrostatic dilatation of the papilla with large balloons was performed between June 2012 and April 2014. Patients had multiple large stones, tapered distal common bile duct, previous sphincterotomy, or peri/ intradiverticular papilla. CRE™ dilatation balloons with diameters ranging from 12 to 20 mm were used. Data were recorded as successful procedure, use of lithotripsy and complications during the procedure. Results: The average age was 66.1 years. There was a predominance of the female gender (66.7%). The average size of the bile duct stones was 16.7 mm. The main indications were: giant choledocholithiasis (12 patients, 66.7%) and tapered distal common bile duct (6 patients, 33.3%). The dilatation balloons diameter used were: 15 mm (8 patients, 44.4%), 18 mm (5 patients, 27.8%), 12 mm (3 patients, 16.7%) and 20 mm (2 patients, 11.1%). Complete stone clearance was achieved in 15 patients (83.3%). Lithotripsy was performed in 4 patients (22.2%). There were 3 patients in whom the removal with balloon was unsuccessful, performed surgical management. It was reported 1 case of mild acute pancreatitis (5.5%). Conclusions: The results show that endoscopic papillary large balloon dilation after sphincterotomy is a safe and effective technique for treatment of difficult bile duct stones

Recurrent acute pancreatitis caused by pancreatic biliary maljunction due to long common channel / Pancreatitis aguda recurrente causada por deficiente unión pancreático-biliar debido a un colédoco largo

The pancreatic biliary maljunction is a rare anomaly that affects mainly females, defined as an anatomical maljunction of the pancreatic duct and the biliary duct confluence, and may be a rare cause of recurrent acute pancreatitis. In order to early diagnosis and prompt treatment, ERCP has an important role in it

La Malformación de la unión biliopancreática es una afección rara y ocurre más en mujeres jóvenes. Es una causa de pancreatitis aguda de causa no conocida. CPRE es una herramienta eficiente para el diagnóstico y también para ser de la terapéutica