Duodenoscopy in treatment of acute gallstone pancreatitis

Objective: To probe the potential use of duodenosco- py in the diagnosis and treatment of acute gallstone pancreatitis (GP). Methods: Fourty-five patients with acute GP were randomly divided into endoscopic retrograde cholan- giopancreatography (ERCP) group (n=20) and non-ERCP group (n=25). Each group was subdivi- ded into mild and severe groups according to A- PACHE Ⅱ scores. They were given supportive treat- ment combined with traditional Chinese medicine. The patients in the ERCP group received ERCP within 24 hours after admission. If there were stones in the common bile duct with stenosis of the inferior extremity or ampulla, endoscopic sphincterotomy (ES) was performed to extract the stones by basket. If no calculi were identified or multiple stones were large, endoscopic naso-biliary drainage (ENBD) was carried out. Results: The incidence of complication, length of hospitalization and cost were markedly lower in pa- tients with severe acute GP in the ERCP group than those in the non-ERCP group (P<0.05), in contrast to the 2 mild subgroups of the ERCP and non-ERCP groups (P>0.05). Conclusion: It is feasible, effective and safe to apply duodenoseopy in the treatment of severe acute GP.

Combined laparoscopic and endoscopic treatment for bile duct diseases

BACKGROUND: Clinical application of laparoscopy, duo- denoscopy and choledochoscopy has been accepted as a mini-invasive surgical therapy for bile duct diseases; but ei- ther endoscopic or laparoscopic therapy alone is disadvanta- geous in its narrow indications and in failure to give full play to the individual superiority. The present study was to evaluate the procedures and therapeutic results of combined laparoscopic and endoscopic treatment for bile duct disea- ses. METHODS: Clinical data of 1990 patients with bile duct diseases treated by combination of laparoscopy, duodenos- copy and choledochoscopy in two hospitals were reviewed and analyzed. RESULTS: Patients with cholecystolithiasis and choledo- cholithiasis were treated with combined laparoscopy and duodenoscopy (n =1350) in a single operation with a cure rate of 93.6%. Those with choledocholithiasis (n =332) were treated with combined laparoscopy and choledocho- scopy with a cure rate of 100%. Combined laparoscopy, duo- denoscopy and choledochoscopy was used in 258 patients with choledocholithiasis (29 of them complicated with pan- creatitis) and 24 patients with Mirizzi's syndrome, with a cure rate of 100%. Laparoscopic choledochoenterostomy and preoperative endoscopic nasobiliary drainage were done in 26 patients with a cure rate of 100%. There were no serious operative complications. A follow-up study of 1051 patients for 3 months to 12 years (mean 7.8 years) showed that 10 patients had recurrence of stones but no stenosis of the bile duct. CONCLUSION: Combined laparoscopic and endoscopic procedures are mini-invasive and cause less pain and mini- mal operative complications.

Underwater endoscopic mucosal resection for neoplasms in the pyloric ring of the stomach: Four case reports

BACKGROUND Tumors located in the pylorus are technically more complex to resect by endoscopic resection,as the anatomical characteristics of this region can affect the adequate assessment of margins and performance of the procedure.We reported the results of underwater endoscopic mucosal resection(UEMR)of benign mucosal neoplasms located in the pyloric ring.CASE SUMMARY This case series describes 4 patients with 4 mucosal neoplasms located in the pyloric ring.The diameter of each neoplasm was less than 15 mm.We performed UEMR for the lesions.Water immersion enabled slight floating of the lesions,resulting in easy identification.We achieved en bloc resection with a snare and electrosurgical unit.All procedure were performed within 3 min without adverse events.Pathologic examination showed low-grade dysplasia with clear resection margins in one case and hyperplastic polyps in three cases.CONCLUSION UEMR can be an effective and safe treatment method for neoplasms in the gastric pyloric ring.

Preoperative endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors, including magnifying endoscopy

Superficial non-ampullary duodenal epithelial tumor(SNADET) is defined as a sporadic tumor that is confined to the mucosa or submucosa that does not arise from Vater's papilla, and it includes adenoma a n d a d e n o c a r c i n o m a. R e c e n t d e v e l o p m e n t s i n endoscopic technology, such as high-resolution endoscopy and image-enhanced endoscopy, may increase the chances of detecting SNADET lesions. However, because SNADET is rare, little is known about its preoperative endoscopic diagnosis. The use of endoscopic resection for SNADET, which has no risk of metastasis, is increasing, but the incidence of complications, such as perforation, is significantly higher than in any other part of the digestive tract. A preoperative diagnosis is required to distinguish between lesions that should be followed up and those that require treatment. Retrospective studies have revealed certain endoscopic findings that suggest malignancy. In recent years, several new imaging modalities have been developed and explored for realtime diagnosis of these lesion types. Establishing an endoscopic diagnostic tool to differentiate between adenoma and adenocarcinoma in SNADET lesions is required to select the most appropriate treatment. This review describes the current state of knowledge about preoperative endoscopic diagnosis of SNADETs, such as duodenal adenoma and duodenal adenocarcinoma. Newer endoscopic techniques, including magnifying endoscopy, may help to guide these diagnostics, but their additional advantages remain unclear, and further studies are required to clarify these issues.

Local resection for tumor of papilla of Vater: an analysis of 25 cases

Objective: To investigate the clinical features, diagnostic methods, and treatment choice of tumor of the papilla of Vater. Methods: The clinical data of 25 patients with tumor of the papilla of Vater treated by local resection in our hospital from December 1983 to May 2006 were retrospectively analyzed. Results: The morbidities of abdominal pain, jaundice and recurrent cholangitis were 84%, 80% and 48%, respectively. The accordant rate for preoperative duodenoscopic biopsy and post-operative pathological diagnosis was 80%. Intraoperative frozen section examination accurately predicted the final pathological results in all the patients. The post-operative complication rate was 20% and the operative mortality rate was 4%. The 5-year survival rates of local resection for benign tumors and malignant tumors were 75% and 28.5%, respectively. Conclusion: Abdominal pain, jaundice and recurrent cholangitis are the main symptoms and signs of tumor of the papilla of Vater. Duodenoscopy is the principal preoperative diagnostic method and intraoperative frozen section examination is reliable in assessing the operative specimens. Selective local resection is an effective treatment option for tumor of the papilla of Vater.

Strategies of minimally invasive treatment for intrahepatic and extrahepatic bile duct stones

Cholellthiasis is a kind of common and multiple diseases. In recent years, traolttonal laparommy has been challenged by a minimally invasive surgery. Through literature review, the therapeutic method, effect, and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows. （1） For intrahepatic bile duct stones, the operation may be selected by laparoscopie liver resection, laparoscopic common bile duct exploration （LCBDE）, or percutaneous transhepatic cholangioscopy. （2） For concomitant gallstones and common bile duct stones, the surgical approach can be selected as follows： laparoscopic cholecystectomy （LC） combined with endoscopic sphincterotomy （EST） or endoscopic papillary balloon dilatation, LC plus laparoscopic transcystic common bile duct exploration, LC plus LCBDE, and T-tube drainage or primary suture. （3） For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross section, LCBDE, EST, and percutaneous transhepatic cholangioscopic lithotripsy could be used. According to the abovementioned principle, the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.