Background: Pre-cutting techniques have been used to gain biliary access at the expense of an increased complication rate. This may be because of the multiple attempts to achieve cannulation by using standard methods ...Background: Pre-cutting techniques have been used to gain biliary access at the expense of an increased complication rate. This may be because of the multiple attempts to achieve cannulation by using standard methods before pre-cutting and causing excess edema and papillary trauma. There are limited data on the early use of pre-cutting techniques. Methods: We performed a prospective study of the early introduction of needle-knife techniques in patients with difficult biliary cannulation. Standard biliary cannulation was attempted with a sphincterotome and a guidewire. If this failed within 10 minutes or if there were more than 5 pancreatic cannulations, the needle-knife technique was used. Either a standard method of pre-cutting (below-up-ward) from the papillary orifice or the modified technique of pre-cutting (above-downward), stopping short of the papillary orifice, was adopted, as per the discretion of the endoscopist. If pre-cutting failed, the cannulation was reattempted 24 to 48 hours later. Results: A total of 346 therapeutic biliary ERCP procedures were performed between April and August 2003. Of these, 70 patients (20%) (mean age, 54 years; 38 men) underwent needle-knife pre-cut sphincterotomy (16 with the standard technique). In 58 patients (83%), the procedure was successful with the initial pre-cutting, making the total success at initial ERCP 334/346 (96.5%). Nine patients in whom pre-cut failed, returned for a second-attempt ERCP, with 7 completed successfully. The total success rate of pre-cutting was 65/70 (93%). The overall success rate of biliary cannulation, after two ERCP attempts, was 341/346 (98.5%). Six patients had mild bleeding, and one had mild pancreatitis. There was no difference in these complications between the two types of precut techniques. Conclusions: The early use of needle knife for difficult biliary cannulation is safe and effective, irrespective of the technique used.展开更多
Background: Bile leak is a recognized complication of cholecystectomy. Endosc opic intervention is widely ac cepted as a treatment for this complication, but the optimal form is not well defined. Methods: An ERCP data...Background: Bile leak is a recognized complication of cholecystectomy. Endosc opic intervention is widely ac cepted as a treatment for this complication, but the optimal form is not well defined. Methods: An ERCP database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy. Patient records and endoscopy re ports were reviewed, and structured telephone interviews were conducted to colle ct data. Results: A total of 100 patients (61 women, 39 men; mean age, 53 [17] y ears) with suspected postcholecystectomy bile leak were referred for ERCP. Chole cystectomy was commenced laparoscopically in 83 patients (with an open conversio n rate of 30% ). The most common symptoms were pain (n=62) and fever (n = 37). Cholangiography was obtained in 96 patients. A leak was identified in 80/96 pati ents, the most common site being the cystic- duct stump (48), followed by ducts of Luschka (15), the T- tube site (7), and other sites (10). Treatment include d stent insertion alone (40), sphincterotomy alone (18), combination stent/sphin cterotomy (31), none (6), and other (1). Three patients with major bile- duct i njuries were excluded from the analysis. Endoscopic therapy was unsuccessful in 7 patients (6 in the sphincterotomy alone group; p=0.001). Four patients underwe nt surgery subsequent to ERCP to control the leak. All 4 were in the sphincterot omy alone group (p = 0.001). Post- ERCP pancreatitis developed in 4 patients (3 mild, 1 moderate). Conclusions: The optimal endoscopic intervention for postcho lecystectomy bile leak should include temporary insertion of a biliary stent.展开更多
文摘Background: Pre-cutting techniques have been used to gain biliary access at the expense of an increased complication rate. This may be because of the multiple attempts to achieve cannulation by using standard methods before pre-cutting and causing excess edema and papillary trauma. There are limited data on the early use of pre-cutting techniques. Methods: We performed a prospective study of the early introduction of needle-knife techniques in patients with difficult biliary cannulation. Standard biliary cannulation was attempted with a sphincterotome and a guidewire. If this failed within 10 minutes or if there were more than 5 pancreatic cannulations, the needle-knife technique was used. Either a standard method of pre-cutting (below-up-ward) from the papillary orifice or the modified technique of pre-cutting (above-downward), stopping short of the papillary orifice, was adopted, as per the discretion of the endoscopist. If pre-cutting failed, the cannulation was reattempted 24 to 48 hours later. Results: A total of 346 therapeutic biliary ERCP procedures were performed between April and August 2003. Of these, 70 patients (20%) (mean age, 54 years; 38 men) underwent needle-knife pre-cut sphincterotomy (16 with the standard technique). In 58 patients (83%), the procedure was successful with the initial pre-cutting, making the total success at initial ERCP 334/346 (96.5%). Nine patients in whom pre-cut failed, returned for a second-attempt ERCP, with 7 completed successfully. The total success rate of pre-cutting was 65/70 (93%). The overall success rate of biliary cannulation, after two ERCP attempts, was 341/346 (98.5%). Six patients had mild bleeding, and one had mild pancreatitis. There was no difference in these complications between the two types of precut techniques. Conclusions: The early use of needle knife for difficult biliary cannulation is safe and effective, irrespective of the technique used.
文摘Background: Bile leak is a recognized complication of cholecystectomy. Endosc opic intervention is widely ac cepted as a treatment for this complication, but the optimal form is not well defined. Methods: An ERCP database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy. Patient records and endoscopy re ports were reviewed, and structured telephone interviews were conducted to colle ct data. Results: A total of 100 patients (61 women, 39 men; mean age, 53 [17] y ears) with suspected postcholecystectomy bile leak were referred for ERCP. Chole cystectomy was commenced laparoscopically in 83 patients (with an open conversio n rate of 30% ). The most common symptoms were pain (n=62) and fever (n = 37). Cholangiography was obtained in 96 patients. A leak was identified in 80/96 pati ents, the most common site being the cystic- duct stump (48), followed by ducts of Luschka (15), the T- tube site (7), and other sites (10). Treatment include d stent insertion alone (40), sphincterotomy alone (18), combination stent/sphin cterotomy (31), none (6), and other (1). Three patients with major bile- duct i njuries were excluded from the analysis. Endoscopic therapy was unsuccessful in 7 patients (6 in the sphincterotomy alone group; p=0.001). Four patients underwe nt surgery subsequent to ERCP to control the leak. All 4 were in the sphincterot omy alone group (p = 0.001). Post- ERCP pancreatitis developed in 4 patients (3 mild, 1 moderate). Conclusions: The optimal endoscopic intervention for postcho lecystectomy bile leak should include temporary insertion of a biliary stent.
