Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology

Background: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography(ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy(TPS), needle-knife fistulotomy(NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. Methods: Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. Results: The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113(98.2%) with TPS, 35 of 36(97.2%) with NKF and 8 of 8(100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF(0%) compared with 11 cases(9.7%) after TPS and one case(12.5%) after NKF following TPS, but not significantly different( P = 0.07). No severe adverse event occurred during this study period. Conclusions: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.

Application of needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography

BACKGROUND: Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 5%-10% of cases, the CBD remains inaccessible, necessitating pre-cut papillotomy or fistulotomy with a needle-knife. The aim of this study was to assess the value of early application of the needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients with failed biliary cannulation after 10 minutes or guide wire entering the pancreatic tube 3 times were randomly divided into group of needle-knife cut and group of persistent cannulation by standard techniques. The cannulation times, success rates and complication rates were compared between the two groups. RESULTS: A total of 948 therapeutic biliary ERCP procedures were performed between October 2004 and February 2006. Of 91 patients with difficult biliary cannulation, 43 patients underwent needle-knife cut: the cannulation success rate was 90.7%, the mean cannulation time was 5.6 minutes, and the complication rate was 9.3%. The other 48 patients underwent persistent cannulation by standard techniques: the cannulation success rate was 75%, the mean cannulation time was 10.2 minutes, and the complication rate was 14.6%. Significant differences were observed in cannulation success rate and cannulation time but in complication rate between the two groups.CONCLUSION: The early application of the needle-knife in difficult biliary cannulation is time-saving, safe and effective, with no increase in complication rate.

Endoscopic treatment for pancreatic diseases:Needle-knife-guided cannulation via the minor papilla

AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulationsvia the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.RESULTS: Standard methods were successful in79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17(89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%,(79 +17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further(80.6%, 79/98 vs98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods(4.7% vs 10.5%, P = 0.301).CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.

Primary needle-knife fistulotomy for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis:Importance of the endoscopist’s expertise level

BACKGROUND Needle-knife fistulotomy(NKF)is used as a rescue technique for difficult cannulation.However,the data are limited regarding the use of NKF for primary biliary cannulation,especially when performed by beginners.AIM To assess the effectiveness and safety of primary NKF for biliary cannulation,and the role of the endoscopist’s expertise level(beginner vs expert).METHODS We retrospectively evaluated the records of 542 patients with naïve prominent bulging papilla and no history of pancreatitis,who underwent bile duct cannulation at a tertiary referral center.The patients were categorized according to the endoscopist’s expertise level and the technique used for bile duct cannulation.We assessed the rates of successful cannulation and adverse events.RESULTS The baseline characteristics did not differ between the experienced and lessexperienced endoscopists.The incidence rate of post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP)was significantly affected by the endoscopist’s expertise level in patients who received conventional cannulation with sphincterotomy(8.9%vs 3.4%for beginner vs expert,P=0.039),but not in those who received NKF.In the multivariable analysis,a lower expertise level of the biliary endoscopist(P=0.037)and longer total procedure time(P=0.026)were significant risk factor of PEP in patients who received conventional cannulation with sphincterotomy but only total procedure time(P=0.004)was significant risk factor of PEP in those who received NKF.CONCLUSION Primary NKF was effective and safe in patients with prominent and bulging ampulla,even when performed by less-experienced endoscopist.We need to confirm which level of endoscopist’s experience is needed for primary NKF through prospective randomized study.

Advances in needle-knife for the treatment of early and middle stage Osteonecrosis of the Femoral Head

Osteonecrosis of the Femoral Head (ONFH) is a refractory disease of orthopedics, and its incidence is gradually increasing. Often due to lack of timely intervention, the femoral head collapses, eventually causing hip pain and difficulty in activities. At present, the treatment of hip preservation after the collapse of osteonecrosis of the femoral head has received everyone's attention, but many hip-preserving measures are controversial in terms of efficacy and indications. Needle-knife therapy is a kind of hip-protection therapy with low risk, small trauma, bleeding, and less and shorter treatments. This article reviews the literatures related to needle-knife therapy for osteonecrosis of the femoral head, and summarizes the clinical treatment of osteonecrosis of the femoral head based on needle-knife, and prospects for its research.

Eighty Cases of Heel Bone Spikes Treated With Little Needle-Knife

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Is endoscopic mucosal resection-precutting superior to conventional methods for removing sessile colorectal polyps?

We reviewed a study that reported a comparative analysis of the effects of endoscopic mucosal resection(EMR)precutting and conventional EMR for removing non-pedunculated,10-20 mm sized colorectal polyps.We identified some statistical deficiencies in this study.In addition,we believe that the differences between the treatments failed to achieve significance,and therefore,further analysis is required.

环周预切开内镜黏膜切除术治疗直径小于1 cm的直肠神经内分泌肿瘤的有效性和安全性

目的探讨环周预切开内镜黏膜切除术(EMR-P)治疗直径小于1 cm的直肠神经内分泌肿瘤(RNEN)的有效性和安全性。方法回顾性分析2016年12月-2021年12月该院收治的177例直径<1 cm的RNEN患者的临床资料,根据治疗方案的不同,将患者分为内镜黏膜切除术(EMR)组(n=46)、EMR-P组(n=40)和内镜黏膜下剥离术(ESD)组(n=91),比较3组患者整块切除率、完整切除率、内镜下手术时间、术后住院时间和手术并发症等情况。结果EMR-P组完整切除率为95.0%,ESD组完整切除率为97.8%,高于EMR组的87.0%,差异有统计学意义(P<0.05);EMR-P组手术时间为(9.86±2.23)min,长于EMR组的(4.12±0.88)min,EMR-P组和EMR组手术时间短于ESD组的(19.55±3.67)min,差异均有统计学意义(P<0.05);EMR组住院时间为(2.45±0.29)d,EMR-P组住院时间为(2.43±0.23)d,EMR-P组和EMR组住院时间短于ESD组的(3.30±0.32)d,差异均有统计学意义(P<0.05);3组患者整块切除率和并发症发生率比较,差异均无统计学意义(P>0.05)。结论EMR-P用于治疗直径<1 cm的RNEN,操作简单,手术时间和住院时间短,且组织学完整切除率高,并发症发生率低,值得临床应用。

Precut技术在胆胰疾病治疗性内镜下逆行胰胆管造影术中的应用价值

摘要：目的探讨治疗性内镜下逆行胰胆管造影术（endoscopicretrogradecholangiopancreatography，ER—CP）在胆胰系统疾病中的治疗价值。方法对2004年2月～2011年11月的1328例经内镜下逆行胰胆管造影术ERCP治疗的病例资料进行回顾性分析，对经ERCP治疗中插管困难者运用Precut技术（乳头预切开技术，包括乳头弓形刀乳头括约肌预切开术、经胰管弓形刀乳头括约肌预切开术、针状刀乳头括约肌预切开术或针状刀乳头括约肌开窗术辅助插管及取石），使部分ERCP插管困难的病例均取得成功，评价治疗性ERCP在各种胆胰疾病中的应用价值。结果治疗病例中胆管结石最多，占65．13％，其次为恶性胆道梗阻，占18．56％，乳头良性狭窄占9．35％，急性胆源性胰腺炎占8．45％，急性梗阻}生化脓性胆管炎占7．25％，医源性胆道损伤占2．52％，慢性胰腺炎占2．11％，胆道蛔虫占0．26％，其他O．16％。并发症发生率3．12％，其中穿孔3例，死亡1例。结论治疗性ERCP对多种胆胰疾病疗效确切，是一种安全有效的胆胰疾病治疗手段，Precut技术是ERCP插管困难病例达到插管成功的有效、安全的办法，可由有经验的消化内镜医生应用于确实有需要进行治疗性ERCP的病例。

Precut技术在ERCP插管困难患者中的有效应用

目的探讨Precut技术在经内镜逆行胰胆管造影(ERCP)插管困难患者中的有效应用。方法收集胆囊切除术后良性胆管狭窄行治疗性ERCP患者68例,按照就诊顺序随机分为试验组和对照组,各34例。对照组予以双导丝辅助切开术进行治疗,试验组予以经胰管乳头括约肌预切开术(Precut技术)进行治疗。比较两组患者ERCP成功率、术中并发症发生情况、中期临床疗效以及狭窄复发情况。结果试验组ERCP成功率为94.12%,对照组ERCP成功率为67.65%,试验组ERCP成功率高于对照组,差异具有统计学意义(P<0.05)。试验组并发症总发生率52.94%,对照组并发症总发生率20.59%,试验组并发症总发生率高于对照组,差异具有统计学意义(P<0.05)。试验组治疗有效率93.75%,对照组治疗有效率60.87%,试验组治疗后中期临床有效率高于对照组,差异具有统计学意义(P<0.05)。随诊12个月观察患者是否存在狭窄复发,对照组出现7例狭窄复发,狭窄复发率为30.43%,试验组出现3例狭窄复发,狭窄复发率为9.38%,试验组狭窄复发率低于对照组,差异具有统计学意义(P<0.05)。结论 Precut技术可以提高胆管插管成功率,但是术后胰腺炎、高淀粉酶血症等并发症发生率较双导丝辅助切开术高。

Precut技术在ERCP插管困难病例中的作用及安全性研究

目的探讨Precut技术在ERCP插管困难病例中的作用及其安全性。方法回顾性分析1997年9月至2007年12月间进行ERCP诊断与治疗操作中常规插管,包括导丝辅助均无法插入胆管且实施了Precut操作的病例。Precut实施采用的是弓形刀和/或针状刀,Precut方法包括经乳头弓形刀乳头括约肌预切开术、经胰管弓形刀乳头括约肌预切开术、针状刀乳头括约肌预切开术和针状刀乳头括约肌开窗术。所有行Precut后能成功深插管的病例如有必要则改用常规方法将十二指肠乳头开口扩大至理想的大小。结果共有65例因ERCP插管困难而实施了Precut操作,年龄19～78岁,平均53岁。总的成功率为83.1%(54/65)。术后高淀粉酶血症的发生率为46.2%(30/65),轻症急性胰腺炎发生率为3.1%(2/65),经治疗3～5天后均能恢复至正常。未出现术后出血与穿孔并发症。结论Precut技术是ERCP插管困难病例达到插管成功的有效、安全的办法,可由资深的消化内镜医生应用于确实有需要进行治疗性ERCP的病例。

Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation

AIM:To compare the outcomes between doubleguidewire technique(DGT) and transpancreatic precut sphincterotomy(TPS) in patients with difficult biliary cannulation.METHODS:This was a prospective,randomized study conducted in single tertiary referral hospital in Korea.Between January 2005 and September 2010.A total of 71 patients,who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved,were randomized into DGT(n = 34) and TPS(n = 37) groups.DGT or TPS was done for selective biliary cannulation.We measured the technical success rates of biliary cannulation,median cannulation time,and procedure related complications.RESULTS:The distribution of patients after randomization was balanced,and both groups were comparable in baseline characteristics,except the higher percentage of endoscopic nasobiliary drainage in the DGT group(55.9% vs 13.5%,P < 0.001).Successful cannulation rate and mean cannulation times in DGT and TPS groups were 91.2% vs 91.9% and 14.1 ± 13.2 min vs 15.4 ± 17.9 min,P = 0.732,respectively.There was no significant difference between the two groups.The overall incidence of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis was 38.2% vs 10.8%,P < 0.011 in the DGT group and the TPS group;post-procedure pancreatitis was significantly higher in the DGT group.But the overall incidence of post-ERCP hyperamylasemia was no significant difference between the two groups;DGT group vs TPS group:14.7% vs 16.2%,P < 1.0.CONCLUSION:When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved,DGT and TPS facilitated biliary cannulation and showed similar success rates.However,post-procedure pancreatitis was significantly higher in the DGT group.

Precut sphincterotomy:A reliable salvage for difficult biliary cannulation

Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and pre- cut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% success- ful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when adminis- tered to the proper patient. Although precut sphincter- otomy ensures over 90% success of biliary cannula- tion, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also re- ported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilata- tion of their biliary tract. Nevertheless, precut sphinc- terotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, ef- ficacy and potential complications of precut sphincter- otomy.

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis:A systematic review and meta-analysis

AIM:To conduct a systemic review and meta-analysis to investigate the role of early precut technique.Multiple randomized controlled trails(RCTs)have reported conflicting results of the early precut sphincterotomy.METHODS:MEDLINE/PubMed,EMBASE,Cochrane Central Register of Controlled Trials and Database of Systematic Reviews,and recent abstracts from major conference proceedings were searched(June 2013).Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included.Pooled estimates of post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP),cannulation and adverse events were analyzed by using odds ratio(OR).Random and fixed effects models were used as appropriate.Publication bias was assessed by funnel plots.Heterogeneity among studies was assessed by calculating I2 measure of inconsistency.RESULTS:Seven randomized and seven non-randomized trials met inclusion criteria.Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant(OR=0.58;95%CI:0.32-1.05;P=0.07).No heterogeneity was noted among the studies with I2 of 0%.CONCLUSION:Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.

Study on magnetic memory signals of medium carbon steel specimens with surface crack precut during loading process

Static tensile test and tensile-tensile fatigue test of medium carbon steel sheet specimens with surface crack precut were performed on MTS810 hydraulic testing machine to clear the meaning of the point of Hp(y) value zero. Magnetic memory signals were measured during the test process. The results show that only one point of Hp(y) zero value exists in all measured magnetic signal curves during the loading process, which should be a sign of intersection of positive-negative magnetic poles after magnetic ordered state appears and does not indicate the position of surface crack precut. The analysis shows that the surface crack precut can not interrupt the magnetic ordered state occurred during the test completely, hence its Hp(y) value is not zero. However, the crack extending to a penetrated defect at the instant of specimen′s fracture leads to the discontinuance of magnetic ordered state.

Precut技术在ERCP插管困难患者中的应用研究

目的探讨经胰管乳头括约肌预切开术(Precut术)在经内镜逆行胰胆管造影(ERCP)插管困难患者中的应用效果。方法选取2016年3月～2018年2月本院收治的86例ERCP插管困难患者,依照治疗方式的不同将其分为对照组(n=43)与观察组(n=43),对照组施以双导丝辅助切开术治疗,观察组施以Precut术治疗,观察两组患者ERCP成功率、并发症发生情况、治疗后中期疗效与狭窄复发情况。结果观察组的ERCP成功率、总有效率与并发症发生率明显高于对照组,差异有统计学意义(P <0.05);观察组的复发率明显低于对照组,差异有统计学意义(P <0.05)。结论 Precut技术在ERCP插管困难患者中的应用具有显著效果,不仅能够提升ERCP成功率与治疗后中期疗效,同时能够有效的降低狭窄复发率,具有较高的临床价值。

Safety and success of precut biliary sphincterotomy: Is it linked to experience or expertise?

瞄准：决定成功的率和按规格裁切的复杂并发症胆汁的括约肌切开术(PBS ) 基于优先的经验并且到比较在 PBS 和标准内视镜的括约肌切开术(ES ) 之间的复杂并发症率。方法：回顾的评估有希望地在一个学术第三级的工作分派中心收集了非使随机化的数据。包括的学习没有 formal 在 PBS 训练的由单个 endoscopist 经历了 PBS 和 ES 的在一个八年的时期的所有病人。学习的主要结果措施是有到 ES 的复杂并发症的比较的 PBS 的成功和复杂并发症。结果：一个总数 2939 内视镜后退 cholangiopancreatographies (ERCP ) 在学习时期期间被执行，包括 818 (28%) ES 并且 150 (5%) PBS 过程。经由 PBS 的选择胆汁的管子在在 75% 病人的第一次尝试是成功的。管子被完成在一另外在一次随后的尝试(总数 87%) 的 13% 病人。从 PBS 的复杂并发症率比 ES 高是 45% ，但是没显著地不同[7%(10/50 ) 对 5%(38/818 ) ， P = 0.29 ] 。任何一个从 PBS 的复杂并发症都不是严重的。向增加成功的一个重要趋势关于 endoscopist 存在 ?&#713;s 在按规格裁切的第一次尝试(P = 0.0393，为趋势的 Cochran-Armitage 准确测试， Z =-1.7588) 。结论：尽管有在这种技术的特定的训练的缺乏， PBS 从另外的富有经验的中心与高成功率和类似于的复杂并发症率或不到报告被执行。这些结果建议内视镜的经验和也许天生的内视镜的技巧可以在这个过程的结果起一个重要作用。

Endoscopic mucosal resection-precutting vs conventional endoscopic mucosal resection for sessile colorectal polyps sized 10-20 mm

BACKGROUND The optimal method to remove sessile colorectal lesions sized 10-20 mm remains uncertain.Piecemeal and incomplete resection are major limitations in current practice,such as endoscopic mucosal resection(EMR)and cold or hot snare polypectomy.Recently,EMR with circumferential precutting(EMR-P)has emerged as an effective technique,but the quality of current evidence in comparative studies of conventional EMR(CEMR)and EMR-P is limited.AIM To investigate whether EMR-P is superior to CEMR in removing sessile colorectal polyps.METHODS This multicenter randomized controlled trial involved seven medical institutions in China.Patients with colorectal polyps sized 10-20 mm were enrolled and randomly assigned to undergo EMR-P or CEMR.EMR-P was performed following submucosal injection,and a circumferential mucosa incision(precutting)was conducted using a snare tip.Primary outcomes included a comparison of the rates of en bloc and R0 resection,defined as one-piece resection and one-piece resection with histologically assessed clear margins,respectively.RESULTS A total of 110 patients in the EMR-P group and 110 patients in the CEMR group were finally evaluated.In the per-protocol analysis,the proportion of en bloc resections was 94.3%[95%confidence interval(CI):88.2%-97.4%]in the EMR-P group and 86%(95%CI:78.2%-91.3%)in the CEMR group(P=0.041),while subgroup analysis showed that for lesions>15 mm,EMR-P also resulted in a higher en bloc resection rate(92.0%vs 58.8%P=0.029).The proportion of R0 resections was 81.1%(95%CI:72.6%-87.4%)in the EMR-P group and 76.6%(95%CI:68.8%-84.4%)in the CEMR group(P=0.521).The EMR-P group showed a longer median procedure time(6.4 vs 3.0 min;P<0.001).No significant difference was found in the proportion of patients with adverse events(EMR-P:9.1%;CEMR:6.4%;P=0.449).CONCLUSION In this study,EMR-P served as an alternative to CEMR for removing nonpedunculated colorectal polyps sized 10-20 mm,particularly polyps>15 mm in diameter,with higher R0 and en bloc resection rates and without increasing adverse events.However,EMR-P required a relatively longer procedure time than CEMR.Considering its potential benefits for en bloc and R0 resection,EMR-P may be a promising technique in colorectal polyp resection.

Repeat endoscopic retrograde cholangiopancreaticography after failed initial precut sphincterotomy for biliary cannulation

AIM: To investigate the outcome of repeating endoscopic retrograde cholangiopancreaticography(ERCP) after initially failed precut sphincterotomy to achieve biliary cannulation.METHODS: In this retrospective study, consecutive ERCPs performed between January 2009 and September 2012 were included. Data from our endoscopy and radiology reporting databases were analysed for use of precut sphincterotomy, biliary access rate, repeat ERCP rate and complications. Patients with initially failed precut sphincterotomy were identified.RESULTS: From 1839 consecutive ERCPs, 187(10%) patients underwent a precut sphincterotomy during the initial ERCP in attempts to cannulate a native papilla. The initial precut was successful in 79/187(42%). ERCP was repeated in 89/108(82%) of patients with failed initial precut sphincterotomy after a median interval of 4 d, leading to successful biliary cannulation in 69/89(78%). In 5 patients a third ERCP was attempted(successful in 4 cases). Overall, repeat ERCP after failed precut at the index ERCP was successful in 73/89 patients(82%). Complications after precut-sphincterotomy were observed in 32/187(17%) patients including pancreatitis(13%), retroperitoneal perforations(1%), biliary sepsis(0.5%) and haemorrhage(3%).CONCLUSION: The high success rate of biliary cannulation in a second attempt ERCP justifies repeating ERCP within 2-7 d after unsuccessful precut sphincterotomy before more invasive approaches should be considered.

预切开术(Precut)是困难胆管插管的一有效和安全的方法?

内镜下十二指肠乳头切开术(EPT)的开始使胆道疾病的治疗有了根本性的转变。内镜下经乳头取石已不仅限于高危外科手术患者。如今EPT已被广泛地使用双腔或三腔乳头切开刀导线进行引导。