磁共振胰胆管造影诊断胰胆管炎症及肿瘤性病变的价值

磁共振胰胆管造影(MRCP)是一种单纯的诊断方法。这种非侵入性方法可以显示胰胆管的通畅情况,其诊断适应证可与经内镜逆行胰胆管造影(ERCP)相提并论。无论是在上消化道术前十二指肠镜检失败者,还是泛特氏壶腹部病变插管不成功者,MRCP都是可供选择的有效方法。由于MRCP不需使用造影剂,而且无放射线辐射,故适用于检查儿童和孕妇或过敏体质的病人。检查时不需用镇静剂,可在门诊进行。

胆肠序贯式外内引流术应用于合并肝硬化腹腔镜胰十二指肠切除术病人的临床研究

目的探讨胆肠序贯式外内引流术应用于肝硬化腹腔镜胰十二指肠切除术(laparoscopic pancreaticoduodenectomy,LPD)病人的临床价值。方法回顾性分析2019年1月1日至2020年11月30日河北医科大学第二医院肝胆胰腺外科行LPD病人的临床资料,术中行胆肠序贯式外内引流术的肝硬化病人9例(A组),行传统胆肠吻合术的肝硬化病人12例(B组),无肝硬化术前行经皮经肝胆管置管引流的传统胆肠吻合术病人53例(C组)。分析A组和B组的年龄、性别、体质量指数(BMI)、术前胆道引流例数、手术时间、术中出血量、病人住院时间、胰十二指肠切除术后胆管炎(cholangitis following pancreaticoduodenectomy,CFPD)等并发症和严重并发症(Clavein-DindoⅢ级及以上并发症);观察A、B两组肝功能的变化趋势并分析A、C两组胆汁培养动态结果来评估胆肠序贯式外内引流术的有效性。结果A组和B组术前和术中资料各观察指标对比分析差异无统计学意义。A组病人术后发生CFPD 0例,胃排空延迟1例;B组病人发生CFPD 3例,B级胰瘘1例。A组随访时间为6.5~21.4个月,B组随访时间为4.5~20.8个月,C组随访时间为3.5~22.5个月,三组病人均无因胆肠吻合口狭窄行二次手术者。A、B两组病人术前肝功能指标差异无统计学意义,而术后A组病人的肝功能变化趋势优于B组;C组病人术后胆汁细菌阳性率增高,术后第7天细菌阳性率降至术前水平,A组术后7 d内胆汁培养均阴性。结论在合并肝硬化LPD中采用胆肠序贯式外内引流术,术后早期隔离胆道和肠道系统,杜绝肠内容物反流造成CFPD,在围手术期有效保护肝硬化病人肝功能的同时,未增加病人并发症的发生率,此项技术的作用可在临床实践中进一步验证。

Presence and density of common bile duct microlithiasis in acute biliary pancreatitis

AIM:Common bile duct microlithiasis(CBDM)is found in majority of patients with acute biliary pancreatitis(ABP)and no CBD stones in fluoroscopy during urgent ERCP.It is unclear,however,weather CBDM is a cause or the result of the disease.This prospective study was done to investigate the presence and density of CBDM in patients with ABP,when endoscopic retrograde cholangiopancreatography(ERCP) done in different periods from the onset of the disease. METHODS:One hundred fifty one consecutive patients with ABP and no CBDS on ERCP,performed as an urgent(<24 h of admission)procedure,(101-with gallbladder stones, 50 post-cholecystectomy patients),treated during last 4 years were prospectively included to the study.The presence and density of CBDM(cholesterol monohydrate crystals-CMCs and calcium bilirubinate granules-CBGs)in bile collected directly from common bile duct during ERCP was prospectively calculated according to Juniper and Burson criteria.High density of crystals was considered,when we found >10 CMCs and/or >25 clusters of CBGs on 1 slide. RESULTS:CBD microlithiasis was present in given number of patients:on d 1-30/34(88.2%,),on d2 41/49(83.7%), on d 3-23/33(69.5%,),on d4-7-24/35(58.6%)[ P for trend =0.018 ].In patients with CBD microlithiasis the high density of crystals was observed in given number of patients:on d 1-27/30(90%),on d 2-34/41(82.9%),on d3-18/23 (78.3%),on d4-7-16/24(66.7%)[P for trend=0.039]. CONCLUSION:In patients with ABP and no CBDS on ERCP, CBD microlithiasis is observed in the majority of patients, especially during the first day of the disease.Density of CBD microlithiasis is the highest in the first day of the disease.This suggests that CBD microlithiasis can be the cause and not the result of ABP.

Randomized controlled trial of pancreatic stenting to prevent pancreatitis after endoscopic retrograde cholangiopancreatography

AIM:To determine the effectiveness of pancreatic duct(PD) stent placement for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography(ERCP) in high risk patients.METHODS:Authors conducted a single-blind,randomized controlled trial to evaluate the effectiveness of a pancreatic spontaneous dislodgement stent against post-ERCP pancreatitis,including rates of spontaneous dislodgement and complications.Authors defined high risk patients as having any of the following:sphincter of Oddi dysfunction,difficult cannulation,prior history of post-ERCP pancreatitis,pre-cut sphincterotomy,pancreatic ductal biopsy,pancreatic sphincterotomy,intraductal ultrasonography,or a procedure time of more than 30 min.Patients were randomized to a stent group(n = 60) or to a non-stent group(n = 60).An abdominal radiograph was obtained daily to assessspontaneous stent dislodgement.Post-ERCP pancreatitis was diagnosed according to consensus criteria.RESULTS:The mean age(± standard deviation) was 67.4 ± 13.8 years and the male:female ratio was 68:52.In the stent group,the mean age was 66 ± 13 years and the male:female ratio was 33:27,and in the non-stent group,the mean age was 68 ± 14 years and the male:female ratio was 35:25.There were no significant differences between groups with respect to age,gender,final diagnosis,or type of endoscopic intervention.The frequency of post-ERCP pancreatitis in PD stent and non-stent groups was 1.7%(1/60) and 13.3%(8/60),respectively.The severity of pancreatitis was mild in all cases.The frequency of post-ERCP pancreatitis in the stent group was significantly lower than in the non-stent group(P = 0.032,Fisher's exact test).The rate of hyperamylasemia were 30%(18/60) and 38.3%(23 of 60) in the stent and non-stent groups,respectively(P = 0.05,χ2 test).The placement of a PD stent was successful in all 60 patients.The rate of spontaneous dislodgement by the third day was 96.7%(58/60),and the median(range) time to dislodgement was 2.1(2-3) d.The rates of stent migration,hemorrhage,perforation,infection(cholangitis or cholecystitis) or other complicationss were 0%(0/60),0%(0/60),0%(0/60),0%(0/60),0%(0/60),respectively,in the stent group.Univariate analysis revealed no significant differences in high risk factors between the two groups.The pancreatic spontaneous dislodgement stent safely prevented post-ERCP pancreatitis in high risk patients.CONCLUSION:Pancreatic stent placement is a safe and effective technique to prevent post-ERCP pancreatitis.Therefore authors recommend pancreatic stent placement after ERCP in high risk patients.

Acute pancreatitis:Etiology and common pathogenesis

Acute pancreatitis is an inflammatory disease of the pancreas.The etiology and pathogenesis of acute pancreatitis have been intensively investigated for centuries worldwide.Many causes of acute pancreatitis have been discovered,but the pathogenetic theories are controversial.The most common cause of acute pancreatitis is gallstone impacting the distal common bile-pancreatic duct.The majority ofinvestigators accept that the main factors for acute billiary pancreatitis are pancreatic hyperstimulation and bile-pancreatic duct obstruction which increase pancreatic duct pressure and active trypsin reflux.Acute pancreatitis occurs when intracellular protective mechanisms to prevent trypsinogen activation or reduce trypsin activity are overwhelmed.However,little is known about the other acute pancreatitis.We hypothesize that acute biliary pancreatitis and other causes of acute pancreatitis possess a common pathogenesis.Pancreatic hyperstimulation and pancreatic duct obstruction increase pancreatic duct pressure,active trypsin reflux,and subsequent unregulated activation of trypsin within pancreatic acinar cells.Enzyme activation within the pancreas leads to auto-digestion of the gland and local inflammation.Once the hypothesis is confirmed,traditional therapeutic strategies against acute pancreatitis may be improved.Decompression of pancreatic duct pressure should be advocated in the treatment of acute pancreatitits which may greatly improve its outcome.

Pancreatic duct guidewire placement for biliary cannulation in a single-session therapeutic ERCP

AIM: To investigate the technical success and clinical complication rate of a cannulated pancreatic duct with guidewire for biliary access. METHODS: During a five-year study period, a total of 2843 patients were included in this retrospective analysis. Initial biliary cannulation method consisted of single-guidewire technique (SGT) for up to 5 attempts, followed by double-guidewire technique (DGT) when repeated unintentional pancreatic duct cannulation had taken place. Pre-cut papillotomy technique was reserved for when DGT had failed or no pancreatic duct cannulation had been previously achieved. Main outcome measurements were defined as biliary cannu-lation success and post-endoscopic retrograde cholangiopancreatography (ERCP) complication rate. RESULTS: SGT (92.3% success rate) was characterized by statistically significant enhanced patient outcome compared to either the DGT (43.8%, P < 0.001), pre-cut failed DGT (73%, P < 0.001) or pre-cut as first step method (80.6%, P = 0.002). Pre-cut as first step method offered a statistically significantly more favorable outcome compared to the DGT (P < 0.001). The incidence of post-ERCP pancreatitis did not differ in a statistically significant manner between either method (SGT: 5.3%, DGT: 6.1%, Pre-cut failed DGT: 7.9%, Pre-cut as first step: 7.5%) or with patients' gender. CONCLUSION: Although DGT success rate proved not to be superior to SGT or pre-cut papillotomy, it is considered highly satisfactory in terms of safety in order to avoid the risk of a pre-cut when biliary therapy is necessary in difficult-to-cannulate cases.

Pancreatits after endoscopic retrograde cholangio-pancreatography

Pancreatitis is the most common complication after endoscopic retrograde cholangio-pancreatography (ERCP); the reported incidence of this complication varies from less than 1% to 40%, but a rate of 4%-8% is reported in most prospective studies involving non-selected patients. Differences in criteria for defining pancreatitis, methods of data collection, and patient populations (i.e. number of high-risk patients included in the published series) are factors that are likely to affect the varying rates of post-ERCP pancreatitis. The severity of post-ERCP pancreatitis (PEP) can range from a minor inconvenience with one or two days of added hospitalization with full recovery to a devastating illness with pancreatic necrosis, multiorgan failure, permanent disability, and even death. Although, most episodes of PEP are mild (about 90%), a small percentage of patients (about 10%) develop moderate or severe pancreatitis. In the past, PEP was often viewed as an unpredictable and unavoidable complication, with no realistic strategy for its avoidance. New data have aided in stratifi cation of patients into PEP risk categories and new measures have been introduced to decrease the risk of PEP. As most ERCPs are performed on an outpatient basis, the majority of patients will not develop PEP and can be discharged. Alternatively, early detection of those patients who will go on to develop PEP can guide decisions regarding hospital admission and aggressive management. In the last decade, great efforts have been addressed toward prevention of this complication. Points of emphasis have included technical measures, pharmacological prophylaxis, and patient selection. This review provides a comprehensive, evidence-based assessment of published data on PEP and current suggestions for its avoidance.

Oral allopurinol to prevent hyperamylasemia and acute pancreatitis after endoscopic retrograde cholangiopancreatography

AIM:To assess the efficacy of allopurinol to prevent hyperamylasemia and pancreatitis after endoscopic retrograde cholangiopancreatography(PEP).METHODS:One hundred and seventy patients were enrolled and randomized to two groups:a study group(n=85)who received 300 mg of oral allopurinol at 15 h and 3 h before endoscopic retrograde cholangiopancreatography(ERCP)and a control group(n=85)receiving an oral placebo at the same times.Main Outcome Measurements included serum amylase levels and the number severity of the episodes of pancreatitis.Serum amylase levels were classified as normal(<150 IU/L)or hyperamylasemia(>151 IU/L).Episodes of PEP were classified following Ranson's criteria and CT severity index.RESULTS:Gender distribution was similar between groups.Mean age was 53.5±18.9 years for study group and 52.8±19.8 years for controls.Also,the distribution of benign pathology was similar between groups.Hyperamylasemia was more common in the control group(P=0.003).Mild PEP developed in two patients from the study group(2.3%)and eight(9.4%) from control group(P=0.04),seven episodes were observed in high-risk patients of the control group(25%) and one in the allopurinol group(3.3%,P=0.02).Risk factors for PEP were precut sphincterotomy(P=0.02),pancreatic duct manipulation(P=0.002)and multiple procedures(P=0.000).There were no deaths or side effects.CONCLUSION:Oral allopurinol before ERCP decreased the incidences of hyperamylasemia and pancreatitis in patients submitted to high-risk procedures.

Acute pancreatitis and cholangitis: A complication caused by a migrated gastrostomy tube

Percutaneous endoscopic gastrostomy (PEG) is generally considered safe with a low rate of serious complications. However, dislocation of the PEG-tube into the duodenum can lead to serious complications. An 86-year old Japanese woman with PEG-tube feeding sometimes vomited after her family doctor replaced the PEG-tube without radiologic confirmation. At her hospitalization, she complained of severe tenderness at the epigastric region and the PEG-tube was drawn into the stomach. Imaging studies showed that the tip of PEG-tube with the infl ated balloon was migrated into the second portion of the duodenum, suggesting that it might have obstructed the bile and pancreatic ducts, inducing cholangitis and pancreatitis. After the PEG- tube was replaced at the appropriate position, vomiting and abdominal tenderness improved dramatically and laboratory studies became normal immediately. Our case suggests that it is important to secure PEG-tube at the level of skin, especially after replacement.

Long-term outcome of endoscopic metallic stenting for benign biliary stenosis associated with chronic pancreatitis

AIM： Endoscopic metal stenting （EMS） offers good results in short to medium term follow-up for bile duct stenosis associated wfth chronic pancreatitis （CP）; however, longer follow-up is needed to determine if EMS has the potential to become the treatment of first choice. METHODS： EMS was performed in eight patients with severe common bile duct stenosis due to CP. After the resolution of cholestasis by endoscopic naso-biliary drainage three patients were subjected to EMS while, the other five underwent EMS following plastic tube stenting. The patients were followed up for more than 5 years through periodical laboratory tests and imaging techniques. RESULTS： EMS was successfully performed in all the patients. Two patients died due to causes unrelated to the procedure： one with an acute myocardial infarction and the other with maxillary carcinoma at 2.8 and 5.5 years after EMS, respectively. One patient died with cholangitis because of EMS clogging 3.6 years after EMS. None of these three patients had showed symptoms of cholestasis during the follow-up period. Two patients developed choledocholithiasis and two suffered from duodenal ulcers due to dislodgement of the stent between 4.8 and 7.3 years after stenting; however, they were successfully treated endoscopically. Thus, five of eight patients are alive at present after a mean follow-up period of 7.4 years. CONCLUSION： EMS is evidently one of the very promising treatment options for bile duct stenosis associated with CP, provided the patients are closely followed up; thus setting a system for their prompt management on emergency is desirable.

Endoscopic therapy in acute recurrent pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a largely diagnostic to a largely therapeutic modality. Cross-sectional imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI), and less invasive endoscopy, especially endoscopic ultrasound (EUS), have largely taken over from ERCP for diagnosis. However, ERCP remains the "first line" therapeutic tool in the management of mechanical causes of acute recurrent pancreatitis, including bile duct stones (choledocholithiasis), ampullary masses (benign and malignant), congenital variants of biliary and pancreatic anatomy (e.g. pancreas divisum, choledochoceles), sphincter of Oddi dysfunction (SOD), pancreatic stones and strictures, and parasitic disorders involving the biliary tree and/or pancreatic duct (e.g Ascariasis, Clonorchiasis).

Pancreatitis complicating mucin-hypersecreting common bile duct adenoma

Villous adenomas of the bile ducts are extremely uncommon. We describe a 58-year-old man presenting with clinical signs and laboratory findings of acute pancreatitis and obstructive jaundice. Preoperative investigation demonstrated a dilated papillary orifice with mucus exiting （fish-mouth sign） and a filling defect in the distal common bile duct. He underwent a modified Whipple operation and histological examination of the surgical specimen showed villous adenoma with rich secretion of mucus.

Acute pancreatitis in pregnancy

Acute pancreatitis (AP) is a rare event in pregnancy, occurring in approximately 3 in 10 000 pregnancies. The spectrum of AP in pregnancy ranges from mild pancreatitis to serious pancreatitis associated with necrosis, abscesses, pseudocysts and multiple organ dysfunction syndromes. Pregnancy related hematological and biochemical alterations infl uence the interpretation of diagnostic tests and assessment of severity of AP. As in any other disease associated with pregnancy, AP is associated with greater concerns as it deals with two lives rather than just one as in the non-pregnant population. The recent advances in clinical gastroenterology have improved the early diagnosis and effective management of biliary pancreatitis. Diagnostic studies such as endoscopic ultrasound, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography and therapeutic modalities that include endoscopic sphincterotomy, biliary stenting, common bile duct stone extraction and laparoscopic cholecystectomy are major milestones in gastroenterology. When properly managed AP in pregnancy does not carry a dismal prognosis as in the past.

Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

AIM: To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement (P-GW) in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated. RESULTS: Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% (14 patients: mild, 13; moderate, 1). Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis (4.7%). Of the 49 patients without stent placement, 11 developed pancreatitis (22%: mild, 10; moderate, 1). Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.CONCLUSION: P-GW is useful for achieving selective biliary cannulation. Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials.

Newly developed autoimmune cholangitis without relapse of autoimmune pancreatitis after discontinuing prednisolone

A 57-year-old man presented with a 2-wk history of painless jaundice and weight Iossl He had a large ill- defined enhancing mass-like lesion in the uncinate pro- cess of the pancreas with stricture of the distal common bile duct. Aspiration cytology of the pancreatic mass demonstrated inflammatory cells without evidence of malignancy. Total serum immunoglobulin G level was slightly elevated, but IgG4 level was normal. After the 2-wk 40 mg prednisolone trial, the patient＇s symptoms and bilirubin level improved significantly. A follow-up computed tomography （CT） scan showed a dramatic resolution of the pancreatic lesion. A low dose steroid was continued. After six months he self-discontinued prednisolone for 3 wk, and was presented with jaundice again. ACT scan showed newly developed intrahepatic biliary dilatation and marked concentric wall thickening of the common hepatic duct and the proximal common bile duct without pancreatic aggravation. The patient＇ s IgG4 level was elevated to 2.51 g/L. Prednisolone was started again, after which his serum bilirubin level became normal and the thickening of the bile duct was resolved. This case suggests that autoimmune pancre- atitis can progress to other organs that are not involved at the initial diagnosis, even with sustained pancreatic remission.

Relationship between post-ERCP pancreatitis and the change of serum amylase level after the procedure

AIM: To clarify the relationship between the change of serum amylase level and post-ERCP pancreatitis. METHODS: Between January 1999 and December 2002, 1291 ERCP-related procedures were performed. Serum amylase concentrations were measured before the procedure and 3, 6, and 24 h afterward. The frequency and severity of post-ERCP pancreatitis and the relationship between these phenomena and the change in amylase level were estimated. RESULTS: Post-ERCP pancreatitis occurred in 47 patients (3.6%). Pancreatitis occurred in 1% of patients with normal amylase levels 3 h after ERCP, and in 1%, 5%, 20%, 31% and 39% of patients with amylase levels elevated 1-2 times, 2-3 times, 3-5 times, 5-10 times and over 10 times the upper normal limit at 3 h after ERCP, respectively (level < 2 times vs ≥ 2 times, P < 0.001). Of the 143 patients with levels higher than the normal limit at 3 h after ERCP followed by elevation at 6 h, pancreatitis occurred in 26%. In contrast, pancreatitis occurred in 9% of 45 patients with a level higher than two times the normal limit at 3 h after ERCP followed by a decrease at 6 h (26% vs 9%, P < 0.05). CONCLUSION: Post-ERCP pancreatitis is frequently associated with an increase in serum amylase level greater than twice the normal limit at 3 h after ERCP with an elevation at 6 h. A decrease in amylase level at 6 h after ERCP suggests the unlikelihood of development of post-ERCP pancreatitis.

Selective sphincteroplasty of the papilla in cases at risk due to atypical anatomy

AIM： To analyze the indications, efficacy and safety of sphincteroplasty in our centre.METHODS： A retrospective study of sphincteroplasty in 53 cases of papilla at high risk was performed in 2004-2006. The procedure consisted of duodenoscopy with Olympus TJF 145 Videoduodenoscope, approach to the biliary tract using a catheter with a guidewire, and dilatation of the papilla with a dilatation balloon catheter using a syringe with a manometer for control of the filling pressure.RESULTS： The indications included intradiverticular papilla in 26 patients （49%）, stenosis of a previous sphincterotomy in 19 patients （35.8%）, small size of the papilla in 4 patients （7.5%）, Billroth R gastrectomy in 3 patients （5.6%）, and coagulopathy in one patient （1.9%）. The efficacy was 97.8%, with all the calculi extracted from the common bile duct in 84.4% of the patients, even though 21 of the patients （39.6%） had calculi with a diameter equal to or greater than 10 ram. Seven patients （13.2%） presented complications： haemorrhage in 1 patient （1.9%） and mild pancreatitis in 6 patients （11.3%）. The mean hospital stay in case of complications was of 3 ± 0.63 d.CONCLUSION： Sphincteroplasty is highly effective, with a compllcation rate similar to that of sphincterotomy, furthermore, the complications are of low clinical importance. The use of the 10 mm balloon makes it possible to extract calculi with a diameter of over 15 mm and to extract more than 3 calculi without increasing the rate of complications and reduces the need to resort to lithotripsy or rescue sphincterotomy.

Sclerosing cholangitis associated with autoimmune pancreatitis differs from primary sclerosing cholangitis

AIM:To clarify the characteristic features of biliary le-sions in patients with autoimmune pancreatitis(AIP) and compare them with those of primary sclerosing cholangitis(PSC) .METHODS:The clinicopathological characteristics of 34 patients with sclerosing cholangitis(SC) associated with AIP were compared with those of 4 patients with PSC.RESULTS:SC with AIP occurred predominantly in el-derly men.Obstructive jaundice was the most frequent initial symptom in SC with AIP.Only SC patients with AIP had elevated serum IgG4 levels,and sclerosing diseases were more frequent in these patients.SC pa-tients with AIP responded well to steroid therapy.Seg-mental stenosis of the lower bile duct was observed only in SC patients with AIP,but a beaded and pruned-tree appearance was detected only in PSC patients.Dense infi ltration of IgG4-positive plasma cells was de-tected in the bile duct wall and the periportal area,as well as in the pancreas,of SC patients with AIP.CONCLUSION:SC with AIP is distinctly different from PSC.The two diseases can be discriminated based on cholangiopancreatographic findings and serum IgG4 levels.

Case Report:Surgical intervention of severe post-ERCP-pancreatitis accompanied with duodenum perforation

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure widely used to diagnose and treat conditions of biliary or pancreatic ductal system. The post-ERCP severe acute pancreatitis (SAP) accompanied with duodenum perforation is rare but serious, remaining a challenge in clinic. In this study we report two such cases. Two Chinese women were treated for clinical suspicion of bile duct obstruction and underwent ERCP after admission. Both developed duodenum perforation and SAP after ERCP, and were managed in the intensive care unit (ICU) and required an organ-failure support. The surgical intervention of the peri-pancreatic debridement with lumber-abdominal compound incisions and postoperative washing and drainage was performed, and the two patients recovered well. The therapeutic effect of the peri-pancreatic debridement with lumber-abdominal compound incisions combined with postoperative washing and drainage in the patients of severe post-ERCP-pancreatitis (PEP) and duodenum perforation is satisfactory.