Endoscopic retrograde cholangiopancreatography (ERCP) is currently the first-line minimally invasive diagnosis and treatment of biliary and pancreatic diseases. With the increasing popularity of ERCP, ERCP-related adverse events which include post-ERCP pancreatitis, cholecystitis, cholangitis, bleeding, perforation, etc., have received more and more attention. In response to the controversy and problems in the management of these adverse events, the European Society of Gastrointestinal Endoscopy published the guidelines for ERCP-related adverse events in December 2019. The paper interprets the key points in the guideline to provide references for clinical practice.
ObjectiveTo investigate the etiology of pediatric pancreatitis and the effect of endoscopic retrograde cholangiopancreatography (ERCP) in it. MethodsPatients hospitalized for pancreatitis in West China Hospital of Sichuan University from Jan. 2008 to Jun. 2023 were included according to the inclusion and exclusion criteria. Totally, 241 cases (207 cases with acute pancreatitis and 34 with chronic pancreatitis) were included. Patients were divided into primary group (n=168) and recurrent group (n=73) according to their previous medical history. ResultsThe duration of hospitalization in the primary group was longer than that in the recurrent group [10.0 (7.0, 16.0) d vs. 7.5 (6.0, 11.8) d, P=0.012]. The proportion of acute pancreatitis in primary group (163/168, 97.0%) was higher than that in the recurrent group (44/73, 60.3%), P<0.001. There was no significant difference in the etiological component ratio between the primary and recurrent groups (χ2=7.504, P=0.347). However, in the primary group, the first etiology was biliary factors (38/163, 23.3%), and the second was biliary pancreatic anatomic abnormality (22/163, 13.5%). In the recurrence group, biliary pancreatic anatomic abnormality (13/44, 29.5%) was the first cause, and biliary factor (7/44, 15.9%) was the second cause. Among 207 cases with acute pancreatitis, there were 114 cases (55.1%) with clear etiology, including 45 cases (21.7%) of biliary factors, 35 cases (16.9%) of abnormal biliary pancreatic structure, 12 cases (5.8%) of traumatic factors, and 10 cases (4.8%) of drug-induced factors. In this study, 66 cases were treated with ERCP for pancreatitis, and a total of 103 ERCP operations were performed with cannulation success rate of 100%. Twenty-three cases (23/37, 62.2%) of acute pancreatitis resulted from biliary and biliary pancreatic structure abnormalities received ERCP. In biliary acute pancreatitis, the removal rate of choledocholithiasis in single ERCP operation was 80.0% (8/10). The clinical symptoms (abdominal pain, jaundice, and fever) of all cases were significantly improved after surgery, and no complications such as cholangitis, bleeding and perforation occurred. ConclusionsBiliary, congenital pancreatic anatomical abnormalities, drugs and trauma are the common causes of acute pancreatitis in children. ERCP is a safe and effective treatment for children with biliary pancreatitis, pancreatic anatomical abnormalities, and chronic pancreatitis.
Objective To explore the value of endoscopic retrograde cholangiopancreatograph (ERCP) and extracorporeal shock wave lithotripsy (ESWL) in the treatment of pancreatic duct stones. Methods A retrospective collection of 28 patients with chronic pancreatitis and pancreatic duct stones admitted to the Department of Gastroenterology from January 2010 to August 2021 was performed. According to the treatment of patients, they were divided into ERCP direct stone extraction group and ESWL combined ERCP stone extraction group. We compared the treatment effects of the two groups of patients, including the success rate of stone extraction, postoperative complications of ERCP, postoperative symptom improvement, and so on. Results Among the 28 patients, 19 cases underwent ERCP direct stone extraction, and 9 cases underwent ESWL combined with ERCP stone extraction. In the ERCP direct stone extraction group, 7 cases (36.84%) were completely extracted, 1 case was partially extracted (5.26%), and 11 cases (57.89%) failed to extract and only placed stents and drained; 5 cases (26.32%) had elevated white blood cells at 6 hours postoperatively, C-reactive protein increased in 4 cases (21.05%), 3 cases (15.79%) were diagnosed as ERCP-related pancreatitis, and 2 cases (10.53%) were diagnosed as hyperamylaseemia. The abdominal pain symptoms were completely relieved in 14 cases (73.68%) during a follow-up period of 3 to 6 months. The body mass of 17 cases (89.47%) increased in the 6 months after stone extraction. ESWL combined with ERCP had complete stone extraction in 5 cases (55.56%), partial stone extraction in 3 cases (33.33%), and failure in stone extraction and only stent drainage in 1 case (11.11%). One case (11.11%) had elevated white blood cells at 6 hours postoperatively, and 1 case (11.11%) had elevated C-reactive protein . One case (11.11%) was diagnosed with ERCP-related pancreatitis. One case (11.11%) got abdominal pain and transient hematuria during ESWL, which resolved spontaneously 3 days later. After 3 to 6 months of follow-up, 9 patients (100%) had complete relief of abdominal pain symptoms, and the body mass of 9 patients (100%) increased in the 6 months after stone extraction. The stone clearance rate of the ESWL combined with ERCP stone extraction group was higher than that of the ERCP direct stone extraction group (P=0.033), but there was no statistically significant difference between the two groups in terms of ERCP-related complications, relief of abdominal pain, and weight gain (P>0.05). Conclusion ESWL combined with ERCP in the treatment of chronic pancreatitis complicated with pancreatic duct stone extraction is more effective than ERCP direct stone extraction.
Objective To analyze and explain how to treat 1 patient with post-ERCP hemobilia based on best clinical evidence. Methods We used EST and EPBD, ENBD, Hemobilia as key words to search MEDLINE （1978 ～ 2004） and CBMdisc（1978 ～ 2004） to find the best clinical evidence and evaluated the quality of evidence. Results According to the evidence, we found that endoscopic papillary balloon dilation （EPBD） or endoscopic nasobiliary drainage （ ENBD ） may be more effective and better tolerated in the treatment ofpost-ERCP hemobilia. Our patient did not receive sufficient medical treatment after hemobilia. He was not given a general assessment before surgery including liver function tests. As a result, the patient died of liver failure and its complications. Conclusions We should treat such patients promptly and efficiendy after hemobilia. We should also evaluate their general condition properly before the operation.
Endoscopic retrograde cholangiopancreatography is one of the main methods for the diagnosis and treatment of biliary tract and pancreatic diseases. Compared with other digestive endoscopes, duodenoscopy has a special structure. Since the outbreaks of nosocomial infections caused by the transmission of multidrug-resistant organism through duodenoscopy in 2010, the reprocessing and design of digestive endoscopes represented by duodenoscopy have faced new challenges. This article reviews the international advances in duodenoscopy reprocessing in the past 10 years including the structural characteristics of duodenoscope, related infection outbreak cases, outbreak control measures, and the use of disposable duodenoscopy, so as to provide guidance and reference for the duodenoscopy reprocessing and related nosocomial infections prevention and control work in China.
Objective To discuss the value of biliary stent in treatment of malignant biliary obstruction with different pathways of bile duct stent insertion. Methods Fourty-two cases of malignant biliary obstruction whose biliary stent insertions were through operation (n=18), PTCD (n=17) and ERCP (n=7) respectively were reviewed retrospectively. Results The bile duct stents were successfully inserted in all patients through the malignant obstruction and achieved internal biliary drainage. Compared with the level of the bilirubin before operation, it decreased about 100 μmol/L one week after the stent insertion in all patients. Compared with the levels of glutamic oxalacetic transaminase, glutamic pyruvic transaminase, alkaline phosphatase and glutamyltranspeptidase before operation, they decreased 1 week after the stent insertion （Plt;0.05). The median survival time was 22 weeks. The average survival time was (32.89±33.87) weeks. Two patients died in hospital after PTCD, and the mortality was 4.76%. Complications included 8 cases of cholangitis, 3 cases of bile duct hemorrhage and 2 cases of hepatic failure. Conclusion The bile duct stent insertions through operation, PTCD and ERCP are all effective in relieving the bile duct construction with malignant biliary obstruction. Each method should be chosed according to the systemic and local condition for every patient so as to improve the safety and efficiency, and to decrease the occurrence of complications.
Objective To find the most effective treatment for a patient with difficult selective biliary cannulation (DSBC) during endoscopic retrograde cholangiopancreatography (ERCP) by EBM practice. Methods Evidence was retrieved from The Cochrane Library (Issue 1, 2010), ACP online, NGC (1998 to June 2010), PubMed (1950 to June 2010), and CBM (1994 to June 2010). The collected evidence was then graded. Results After preliminary research, we identified 18 relevant articles. The evidence showed that pre-cutting technique could increase cannulation success rates in DSBC and was safe, effective, and time-saving for an experienced endoscopist. Pancreatic duct occupation was easier to perform than pre-cutting technique and could also increase selective cannulation success rates in DSBC. According to the evidence, together with endoscopist’s experience and the preference of the patient and his family, needle-knife precut papillotomy was performed. Successful selective biliary cannulation was accomplished after pre-cutting. Conclusion The current evidence suggests that pre-cutting technique and pancreatic duct occupation could increase selective cannulation success rates in DSBC. Patients’ condition and endoscopist’s experience should be considered properly before the operation.
Pancreatic duct stones are secondary to chronic pancreatitis while conventional medical treatment is always not effective. Due to the advantages of less trauma, simple operation, and fewer complications, since endoscopic retrograde cholangiopancreatography (ERCP) combined with extracorporeal shock wave lithotripsy (ESWL) was first used in the treatment of pancreatic duct stones in 1987, the treatment method has been continuously improved for more than 30 years, and has experienced the development process from being questioned to becoming the first-line treatment for pancreatic duct stones in multinational guidelines nowadays. However, with the rapid development of science and technology today, the method of ERCP combined with extracorporeal lithotripsy is also facing the challenges of many other treatment methods.
Objective To investigate clinical application and safety evaluation of sedative demulcent anesthesia in therapeutic endoscopic retrograde cholangiopancreatography (ERCP).Methods Totally 1660 patients underwent ERCP at the First Hospital of Lanzhou University were prospectively divided into two groups: venous sedative demulcent group (n=800, using sufentanil and midazolam and propofol continuing infusion) and conventional sedative demulcent group (n=860, using common medicine). The heart rate (HR), respiration (R), blood pressure (BP) and peripheral oxygen saturation (SpO2) of pre-anesthesia, post-anesthesia, during operation and after analepsia in every group were detected. The narcotism was evaluated by Ramsaymin grading method and the related adverse reactions such as cough, restlessness, harmful memory, and abdominal pain after operation were recorded. Results Compared with conventional sedative demulcent group, vital signs of patients in venous sedative demulcent group were more stable. For postoperative adverse reactions, abdominal pain, abdominal distension and nausea and vomiting were respectively 4.4%(35/800), 2.6%(21/800) and 3.6%(29/800) in venous sedative demulcent group, which were respectively higher of the incidence of 36.3%(312/860), 49.0%(421/860) and 53.0%(456/860) in conventional sedative demulcent group (P＜0.01). The postoperative satisfaction and adverse reactions recall between venous sedative demulcent group and conventional sedative demulcent group was respectively significant different (96.9% vs. 2.9%, 4.8% vs. 97.9%, P＜0.01). Conclusion Sufentanil and midazolam and propofol continuing infusion have good effect of sedative demulcent anesthesia, which can be widely used.