Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP),with its clinical ad-vantages of less trauma and faster recovery,has become the primary treatment for choledocholithiasis.AIM To investigate the effects of different ERCP procedures on the sphincter of Oddi.METHODS The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively.The patients were divided into endoscopic sphinc-terotomy(EST,n=24)and endoscopic papillary balloon dilation(EPBD,n=67)groups.The duration of operation,pancreatic development,pancreatic sphinc-terotomy,intubation difficulties,stone recurrence,and incidence of reflux cho-langitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction in the EST and EPBD groups.RESULTS Differences in hypertension,diabetes,increased bilirubin,small diameter of the common bile duct,or ampullary diverticulum between the two groups were not significant.Statistically significant differences were observed between the two groups concerning sex and age(<60 years).Patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group.The number of cases of pancreatic development,pancreatic duct sphincterotomy,and difficult intubation were higher in the EST group than in the EPBD group.The number of Oddi’s sphincter manometries,ERCP surgical outcomes,and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group.The numbers of stone recurrences,reflux cholangitis,and cholecystitis were higher in the EST group than in the EPBD group.CONCLUSION In summary,common bile duct stones,pancreatitis history,and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD.Based on this evidence,this study can provide actionable insights for clinicians and researchers.

Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS: There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047). CONCLUSION: Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.

Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones:A meta-analysis

AIM: To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (&#x02265; 10 mm).

Large balloon dilation post endoscopic sphincterotomy in removal of difficult common bile duct stones:A literature review

Endoscopic sphincterotomy (ES) is the standard therapy in common bile duct (CBD) stones extraction. Large stones (&#x02265; 12 mm) or multiple stones extraction may be challenging after ES alone. Endoscopic sphincterotomy followed by large balloon dilation (ESLBD) has been described as an alternative to ES in these indications. Efficacy, safety, cost-effectiveness and technical aspects of the procedure have been here reviewed. PubMed and Google Scholar search resulted in forty-one articles dealing with CBD stone extraction with 12 mm or more dilation balloons after ES. ESLBD is at least as effective as ES, and reduces the need for additional mechanical lithotripsy. Adverse events rates are not statistically different after ESLBD compared to ES for pancreatitis, bleeding and perforation. However, particular attention should be paid in patients with CBD strictures, which is identified as a risk factor of perforation. ESLBD is slightly cost-effective compared to ES. A small sphincterotomy is usually performed, and may reduce bleeding rates compared to full sphincterotomy. Dilation is performed with 12-20 mm enteral balloons. Optimal inflation time is yet to be determined. The procedure can be performed safely even in patients with peri-ampullary diverticula and surgically altered anatomy. ESLBD is effective and safe in the removal of large CBD stones, however, small sphincterotomy might be preferred and CBD strictures should be considered as a relative contraindication.

Minor endoscopic sphincterotomy followed by large balloon dilation for large choledocholith treatment

AIM To evaluate early and late outcomes of endoscopic papillary large balloon dilation(EPLBD) with minor endoscopic sphincterotomy(m EST) for stone removal.METHODS A total of 149 consecutive patients with difficult common bile duct(CBD) stones(diameter ≥ 10 mm or ≥ 3 stones) underwent conventional endoscopic sphincterotomy(EST) or m EST plus EPLBD from May 2012 to April 2016. Their demographic, laboratory and procedural data were collected, and pancreaticobiliary complications were recorded.RESULTS Sixty-nine(94.5%) of the patients in the EPLBD + m EST group and 64(84.2%) in the conventional EST group achieved stone clearance following the first session(P = 0.0421). The procedure time for EPLBD + m EST was shorter than for EST alone(42.1 ± 13.6 min vs 47.3 ± 11.8 min, P = 0.0128). The overall rate of early complications in the EPLBD + m EST group(11%) was lower than in the EST group(21.1%); however, the difference was not significant(P = 0.0938). The cumulative recurrence rate of cholangitis and CBD stones between the two groups was also similar. The procedure time was independently associated with post-endoscopic retrograde cholangiopancreatography pancreatitis(OR = 6.374, 95%CI: 1.193-22.624, P = 0.023), CBD stone diameter ≥ 16 mm(OR = 7.463, 95%CI: 2.705-21.246, P = 0.0452) and use of mechanical lithotripsy(OR = 9.913, 95%CI: 3.446-23.154, P = 0.0133) were independent risk factors for stone recurrence. CONCLUSION EPLBD with m EST is more effective than EST alone for difficult CBD stone removal, with shorter procedure time and fewer early complications.

Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction

To evaluate the safety and efficacy of limited endoscopic sphincterotomy (ES) before placement of self-expandable metal stent (SEMS).METHODSThis was a retrospective analysis of 244 consecutive patients with unresectable malignant biliary obstruction, who underwent placement of SEMSs following limited ES from December 2008 to February 2015. The diagnosis of malignant biliary obstruction and assessment of patient eligibility for the study was established by a combination of clinical findings, laboratory investigations, imaging and pathological results. All patients were monitored in the hospital for at least 24 h following endoscopic retrograde cholangio pancreatography (ERCP). The incidence of immediate or early post-ERCP complications such as post-ERCP pancreatitis (PEP) and bleeding related to limited ES were considered as primary outcomes. Also, characteristics and complications according to the cancer type were classified.RESULTSAmong the 244 patients included, the underlying diagnosis was cholangiocarcinoma in 118 patients, pancreatic cancer in 79, and non-pancreatic or non-biliary malignancies in the remaining 47 patients. Early post-ERCP complications occurred in 9 patients (3.7%), with PEP in 7 patients (2.9%; mild, 6; moderate, 1) and mild bleeding in 2 patients (0.8%). There was no significant association between the incidence of post-ERCP complications and the type of malignancy (cholangiocarcinoma vs pancreatic cancer vs others, P = 0.696) or the type of SEMS used (uncovered vs covered, P = 1.000). Patients who had more than one SEMS placed at the first instance were at a significantly higher risk of post-ERCP complications (one SEMS vs two SEMS, P = 0.031). No other factors were predictive of post-ERCP complications.CONCLUSIONLimited ES is feasible and safe, and effectively facilitates the placement of SEMS, without any significant risk of PEP or severe bleeding.

Medical treatment for sphincter of oddi dysfunction:Can it replace endoscopic sphincterotomy?

AIM:To report the results of a medical management of sphincter of oddi dysfunction(SOD) after an intermediate follow-up period.METHODS:A total of 59 patients with SOD(2 men and 57 women,mean age 51 years old) were included in this prospective study.After medical treatment for one year,the patients were clinically re-evaluated after an average period of 30 mo.RESULTS:The distribution of the patients according to the Milwaukee's classification was the following:11 patients were type 1,34 were type 2 and 14 were type 3.Fourteen patients underwent an endoscopic sphincterotomy(ES) after one year of medical treatment.The median intermediate follow-up period was 29.8 ± 3 mo(3-72 mo).The initial effectiveness of the medical treatment was complete,partial and poor among 50.8%,13.5% and 35%,respectively,of the patients.At the end of the follow-up period,37 patients(62.7%) showed more than 50% improvement.The rate of improvement in patients who required ES was not significantly different compared with the patients treated conservatively(64.2% vs 62.2%,respectively).CONCLUSION:Our study confirms that conservative medical treatment could be an alternative to endoscopic sphincterotomy because,after an intermediate follow-up period,the two treatments show the same success rates.

Risk factors for delayed hemorrhage after endoscopic sphincterotomy

Background:Hemorrhage is one of the most serious complications of endoscopic sphincterotomy(EST).The risk factors for delayed hemorrhage are not clear.This study aimed to explore the risk factors for post-EST delayed hemorrhage and suggest some precautionary measures.Methods:This study analyzed 8477 patients who successfully underwent endoscopic retrograde cholangiopancreatography(ERCP)and EST between January 2007 and June 2015 in the First Affiliated Hospital of Nanchang University.Univariate and multivariate analyses were performed to find the risk factors for delayed hemorrhage after EST.Results:Of the 8477 patients screened,137(1.62%)experienced delayed hemorrhage.Univariate analysis showed that male,the severity of jaundice,duodenal papillary adenoma and carcinoma,diabetes,intraoperative bleeding,moderate and large incisions,and directional deviation of incision were risk factors for post-EST delayed hemorrhage(P<0.05).Multivariate analysis showed that intraoperative bleeding[odds ratio(OR)=3.326;95%CI:1.785–6.196;P<0.001]and directional deviation of incision(OR=2.184;95%CI:1.266–3.767;P=0.005)were independent risk factors for post-EST delayed hemorrhage.Conclusions:Delayed hemorrhage is the most common and dangerous complication of EST.Intraoperative bleeding and directional deviation of incision are independent risk factors for post-EST delayed hemorrhage.

Treating delayed endoscopic sphincterotomy-induced bleeding:Epinephrine injection with or without thermotherapy

AIM： To compare the hemostatic efficacy between epinephrine injection alone and epinephrine injection combined with thermotherapy for delayed postendoscopic sphincterotomy （ES） bleeding. METHODS： Cases with delayed post-ES bleeding undergoing epinephrine injection alone （epinephrine injection group, n = 26） or epinephrine combined with thermotherapy （combination therapy group, n = 33） in our institution between 1999 and 2007 were retrospectively investigated. The main outcome measurements were： initial endoscopic hemostasis, rebleeding, complications, requirement of angiographic embolization or surgery, requirement for blood transfusion, and mortality. RESULTS： The initial hemostatic efficacy was 96.2% for epinephrine injection alone and 100% for combination therapy （P = 0.44）. There were four patients with re-bleeding in each group （16.0% vs 12.1%, P = 0.72）. There was only one complication of pancreatitis from the combination therapy group. Three patients （11.5%） in the epinephrine injection group and one patient （3%） in the combination therapy group required angiographic embolization or surgery （P = 0.31）. The total number of blood transfusions was not significantly different between the two groups （3.5 ± 4.6 U vs 3.5 ± 4.5 U, P = 0.94）. There was no bleeding-related death in either group. CONCLUSION： Epinephrine injection alone is as effective as epinephrine injection combined with thermotherapy for the management of delayed post- ES bleeding.

Endoscopic sphincterotomy in patients with stenosis of ampulla of Vater:Three-year follow-up of exocrine pancreatic function and clinical symptoms

AIM: To investigate retrospectively the long-term effect of endoscopic sphincterotomy (ES) including exocrine pancreatic function in patients with stenosis of ampulla of Vater. METHODS: After diagnostic endoscopic retrograde cholangiopancreatography (ERCP) and ES because of stenosis of the ampulla of Vater (SOD Type Ⅰ), follow-up examinations were performed in 60 patients (mean follow-up time 37.7 mo). Patients were asked about clini-cal signs and symptoms at present and before interven-tion using a standard questionnaire. Before and after ES exocrine pancreatic function was assessed by determina-tion of immunoreactive fecal elastase 1. Serum enzymes indicating cholestasis as well as serum lipase and amy-lase were measured. RESULTS: Eighty percent of patients reported an im-provement in their general condition after ES. The fecal elastase 1 concentrations (FEC) in all patients increased significantly after ES. This effect was even more marked in patients with pathologically low concentrations (< 200 μg/g) of fecal elastase prior to ES. The levels of serum lipase and amylase as well as serum alcaline phosphatase (AP) and gamma-glutamyltranspeptidase (GGT) decreased signifi-cantly after ES. CONCLUSION: The results of this study demonstrate that patients with stenosis of the ampulla of Vater can be successfully treated with endoscopic sphincterotomy. The positive effect is not only indicated by sustained improvement of clinical symptoms and cholestasis but also by improvement of exocrine pancreatic function.

Comparative quality of life study between endoscopic sphincterotomy and surgical choledochotomy

AIM: To determine quality of life improvement in choledocholithiasis patients who underwent endoscopic sphincterotomy (EST) versus open choledochotomy (OCT).

Microbiologic risk factors of recurrent choledocholithiasis postendoscopic sphincterotomy

BACKGROUND Choledocholithiasis is a severe disorder that affects a significant portion of the world’s population.Treatment using endoscopic sphincterotomy(EST)has become widespread;however,recurrence post-EST is relatively common.The bile microbiome has a profound influence on the recurrence of choledocholithiasis in patients after EST;however,the key pathogens and their functions in the biliary tract remain unclear.AIM To investigate the biliary microbial characteristics of patients with recurrent choledocholithiasis post-EST,using next-generation sequencing.METHODS This cohort study included 43 patients,who presented with choledocholithiasis at the Guangdong Second Provincial General Hospital between May and June 2020.The patients had undergone EST or endoscopic papillary balloon dilation and were followed up for over a year.They were divided into either the stable or recurrent groups.We collected bile samples and extracted microbial DNA for analysis through next-generation sequencing.Resulting sequences were analyzed for core microbiome and statistical differences between the diagnosis groups;they were examined using the Kyoto Encyclopedia of Genes and Genomes pathway hierarchy level using analysis of variance.Correlation between the key genera and metabolic pathways in bile,were analyzed using Pearson’s correlation test.RESULTS The results revealed distinct clustering of biliary microbiota in recurrent choledocholithiasis.Higher relative abundances(RAs)of Fusobacterium and Neisseria(56.61%±14.81%vs 3.47%±1.10%,8.95%±3.42%vs 0.69%±0.32%,respectively)and the absence of Lactobacillus were observed in the bile of patients with recurrent disease,compared to that in stable patients.Construction of a microbiological co-occurrence network revealed a mutual relationship among Fusobacterium,Neisseria,and Leptotrichia,and an antagonistic relationship among Lactobacillales,Fusobacteriales,and Clostridiales.Functional prediction of biliary microbiome revealed that the loss of transcription and metabolic abilities may lead to recurrent choledocholithiasis.Furthermore,the prediction model based on the RA of Lactobacillales in the bile was effective in identifying the risk of recurrent choledocholithiasis(P=0.03).CONCLUSION We demonstrated differences in the bile microbiome of patients with recurrent choledocholithiasis compared to that in patients with stable disease,thereby adding to the current knowledge on its microbiologic etiology.

Partially covered vs uncovered sphincterotome and postendoscopic sphincterotomy bleeding

AIM: To prospectively compare partially covered vs uncovered sphincterotome use on post-endoscopic biliary sphincterotomy (ES) hemorrhage and other complications. METHODS: All patients referred for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) were randomly assigned to undergo ES either with a partially covered or an uncovered sphincterotome. Both patient and technical risk factors contributing to the development of post-ES bleeding were recorded and analyzed. The characteristics of bleeding was recorded during and after ES. Other complications were also compared. RESULTS: Three-hundred and eighty-seven patients were recruited in this study; 194 patients underwent ES with a partially covered sphincterotome and 193 with conventional uncovered sphincterotome. No statistical difference was noted in the baseline characteristics and risk factors for post-ES induced hemorrhage between the 2 groups. No significant difference in the incidence and pattern of visible bleeding rates was found between the 2 groups (immediate bleeding in 24 patients with the partially covered sphincterotome vs 19 patients with the uncovered sphincterotome, P = 0.418). Delayed bleeding was observed in 2 patients with a partially covered sphincterotome and in 1 patient with an uncovered sphincterotome (P = 0.62). No statistical difference was noted in the rate of other complications. CONCLUSION: The partially covered sphincterotome was not associated with a lower frequency of bleeding. Also, there was no difference in the incidence of other significant complications between the 2 types of sphincterotome.

Safety advantage of endocut mode over endoscopic sphincterotomy for choledocholithiasis

AIM： To evaluate whether an automatically controlled cut system （endocut mode） could reduce the complication rate of endoscopic sphincterotomy （EST） and serum hyperamylasemia after EST compared to the conventional blended cut mode. METHODS： From January 2001 to October 2003, 134 patients with choledocholithiasis were assigned to either endocut mode group or conventional blended cut mode group at the time of sphincterotomy. The two groups were retrospectively compared for the complications after EST and serum amylase level before and 24 h after the procedure. RESULTS： Of the 134 patients treated, 79 were assigned to conventional blended cut mode group and 55 to endocut mode group. There was no significant difference in age, sex, and serum amylase level before EST between the two groups. Complications were found in 5 patients of the endocut mode group （9%）： hyperamylasemia （5 times higher than normal） in 4 and moderate pancreatitis in 1. Complications were found in 13 patients of the conventional blended cut mode group （16%）： hyperamylasemia in 12 and moderate pancreatitis in 1. Serum amylase levels were elevated in both groups 24 h after EST （P〈0.02）. The average serum amylase level 24 h after EST in the conventional blended cut mode group was significantly higher than that in the endocut mode group （P〈 0.05）. CONCLUSION： Endocut mode offers a safety advantage over conventional blended cut mode for pancreatitis after EST by reducing hyperamylasemia.

Effects of endoscopic sphincterotomy on biliary epithelium:A case-control study

AIM: To study the long-term effects of endoscopic sphincterotomy on biliary epithelium. METHODS: This is a prospective case-control study. A total of 25 patients with a median age of 71 years (range 49-89 years) and prior endoscopic sphincterotomy (ES) for benign disease formed the fi rst group. The median time from ES was 42 mo (range 8-144 mo). Another 25 patients with a median age of 76 years (range 44-94 mo) and similar characteristics who underwent current endoscopic retrograde cholangio-pancreatography (ERCP) and ES for benign disease formed the second group (control group). Brush cytology of the biliary tree with p53 immunocytology was performed in all patients of both groups. ERCPs and recruitment were conducted at the Endoscopic Unit of Aretaieion University Hospital and Tzaneio Hospital, Athens, from October 2006 to June 2010. RESULTS: No cases were positive or suspicious for malignancy. Epithelial atypia was higher in the first group (32% vs 8% in the second group, P = 0.034). Acute cholangitis and previous biliary operation rates were also higher in the fi rst group (acute cholangitis, 60% vs 24% in the second group, P = 0.01; previous biliary operation, 76% vs 24% in the second group, P = 0.001). Subgroup analysis showed that previous ES was the main causal factor for atypia, which was not related to the time interval from the ES (P = 0.407). Two patients (8%) with atypia in the fi rst group were p53-positive. CONCLUSION: ES causes biliary epithelial atypia that represents mostly reactive/proliferative rather than premalignant changes. The role of p53 immunoreactivity in biliary atypia needs to be further studied.

Composition of common bile duct stones in Chinese patients during and after endoscopic sphincterotomy

AIM： Endoscopic sphincterotomy （ES） is a well-established therapeutic modality for the removal of common bile duct （CBD） stones. Alter ES there are still around 10% of patients that experience recurrent CBD stones. The aim of this study is to investigate the composition of CBD stones before and alter ES and its clinical significance in Chinese patients.METHODS： From January 1996 to December 2003, 735 patients with CBD stones received ES at Kaohsiung Veterans General Hospital and stone specimens from 266 patients were sent for analysis. Seventy-five patients had recurrent CBD stones and stone specimens from 44 patients were sent for analysis. The composition of the stones was analyzed by infrared （IR） spectrometry and they were classified as cholesterol or bilirubinate stones according to the predominant composition. Clinical data were analyzed.RESULTS： In the initial 266 stone samples, 217 （82%） were bilirubinate stones, 42 （16%） were cholesterol stones,3 were calcium carbonate stones, 4 were mixed cholesterol and bilirubinate stones. Patients with bilirubinate stones were significantly older than patients with cholesterol stones （66＋13 years vs 56＋17 years, P = 0.001）. In the 44 recurrent stone samples, 38 （86%） were bilirubinate stones, 3 （7%） were cholesterol stones, and 3 were mixed cholesterol and bilirubinate stones. In 27 patients, both initial and recurrent stone specimens can be obtained,23 patients had bilirubinate stones initially and 2 became cholesterol stones in the recurrent attack. In the four patients with initial cholesterol stones, three patients had bilirubinate stones and one patient had a cholesterol stone in the recurrent attack.CONCLUSION： Bilirubinate stone is the predominant composition of initial or recurrent CBD stone in Chinese patients, The composition of CBD stones may be different from initial stones afl：er ES,

Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips

Perforation is one of the most serious complications of endoscopic sphincterotomy (ES) necessitating immediate surgical intervention. We present a case of successful management of such a complication with endoclipping. A85-year-old woman developed duodenal perforation after ES. The perforation was identified early and its closure was achieved using three metallic clips in a single session.There was no procedure-related morbidity or complications and our patient was discharged from hospital 10 d later.Endoclipping of duodenal perforation induced by ES is a safe, effective and alternative to surgery treatment.

Application of endoscopic sphincterotomy in acute pancreatitis with fluid collection:A prospective study

AIM: To elucidate the role of endoscopic sphincterotomy (EST) in the treatment of acute pancreatitis. METHODS: Ninety patients with acute pancreatitis were randomly divided into two groups: EST group and control group. All the patients underwent pancreatitis routine therapy, additionally the EST group was treated with EST and endoscopic naso-bile drainage (ENBD).The time of disappearance of abdominal symptoms and signs,normalization of amylase, hospitalization and absorption of acute fluid was recorded for all patients.RESULTS: The time of disappearance of abdominal pain,normalization of blood and urine amylase and hospitalization was significantly shorter in EST group than in control group. The ratios of disappearance of fluid in mild acute pancreatitis patients was significantly higher in EST group (51.52%, 84.85%, 90.91%,93.94%) than in the control group (0%, 30.30%, 69.70%, 72.73%, P＜0.01 or P＜0.05).When the ratios of reduction of fluid in severe acute pancreatitis patients of the EST group were compared (8.33%, 58.33%, 83.33%, 91.67%) with those in the control group (0%, 8.33%, 25% and 41.67%), there were significant differences. CONCLUSION: The effect of EST+ENBD on acute pancreatitis with fluid is rather good.

Evaluating the efficacy of endoscopic sphincterotomy on biliary-type sphincter of Oddi dysfunction: A retrospective clinical trial

BACKGROUND Although endoscopic sphincterotomy(EST)has a positive therapeutic effect on biliary-type sphincter of Oddi dysfunction(SOD),some patients still have little relief after EST,which implies that other functional abdominal pain may also be present with biliary-type SOD and interfere with the diagnosis and treatment of it.AIM To retrospectively assess EST as a treatment for biliary-type SOD and analyze the importance of functional gastrointestinal disorder(FGID)in guiding endoscopic treatment of SOD.METHODS Clinical data of 79 patients with biliary-type SOD(type I and type II)treated with EST at Affiliated Hospital of Guizhou Medical University from January 2014 to January 2019 were retrospectively collected to evaluate the clinical therapeutic effect of EST.The significance of relationship between FGID and biliary-type SOD was analyzed.RESULTS Seventy-nine patients with biliary-type SOD received EST,including 29 type 1 patients and 50 type 2 patients.The verbal rating scale-5(VRS-5)scores before EST were all 3 or 4 points,and the scores decreased after EST;the difference was statistically significant(P<0.05).After EST,the serum indexes of alanine aminotransferase,aspartate aminotransferase,alkaline phosphatase and total bilirubin in biliary-type SOD were significantly lower than before(P<0.05).After EST,67(84.8%)and 8(10.1%)of the 79 patients with biliary-type SOD had obviously effective(VRS-5=0 points)and effective treatment(VRS-5=1-2 points),with an overall effectiveness rate of 94.9%(75/79).There was no difference in VRS-5 scores between biliary-type SOD patients with or without FGID before EST(P>0.05).Of 12 biliary-type SOD(with FGID)patients,11 had abdominal pain after EST;of 67 biliary-type SOD(without FGID)patients,0 had abdominal pain after EST.The difference was statistically significant(P<0.05).The 11 biliary-type SOD(with FGID)patients with recurrence of symptoms,the recurrence time was about half a year after the EST,and the symptoms were significantly relieved after regular medical treatment.There were 4 cases of postendoscopic retrograde cholangiopancreatography pancreatitis(5.1%),and no cholangitis,bleeding or perforation occurred.Patients were followed up for 1 year to 5 years after EST,with an average follow-up time of 2.34 years,and there were no long-term adverse events such as sphincter of Oddi restenosis or cholangitis caused by intestinal bile reflux during the follow-up.CONCLUSION EST is a safe and effective treatment for SOD.For patients with type I and II SOD combined with FGID,single EST or medical treatment has limited efficacy.It is recommended that EST and medicine be combined to improve the cure rate of such patients.

Severe acute cholangitis after endoscopic sphincterotomy induced by barium examination:A case report

Endoscopic sphincterotomy (EST) is considered as a possible etiological factor for severe cholangitis. We herein report a case of severe cholangitis after endo-scopic sphincterotomy induced by barium examination. An adult male patient presented with epigastric pain was diagnosed as having choledocholithiasis by ultra-sonography. EST was performed and the stone was completely cleaned. Barium examination was done 3 d after EST and severe cholangitis appeared 4 h later. The patient was recovered after treated with tienam for 4 d. Barium examination may induce severe cholangitis in patients after EST, although rare, barium examination should be chosen cautiously. Cautions should be also used when EST is performed in patients younger than 50 years to avoid the damage to the sphincter of Oddi.