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 (E...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.展开更多
BACKGROUND There is minimal objective data regarding adverse events related to endoscopic retrograde cholangio-pancreatography(ERCP)in patients with cirrhosis compared to those without cirrhosis and even fewer data co...BACKGROUND There is minimal objective data regarding adverse events related to endoscopic retrograde cholangio-pancreatography(ERCP)in patients with cirrhosis compared to those without cirrhosis and even fewer data comparing complications among cirrhosis patients based on severity of cirrhosis.AIM To determine if patients with cirrhosis are at increased risk of adverse events related to ERCP:mainly pancreatitis,bleeding,perforation,cholangitis,and mortality;And to see if higher Child-Pugh(CP)score and Model for End-Stage Liver Disease(MELD)score are associated with higher post-ERCP complications.METHODS We performed a retrospective analysis of 692 patients who underwent ERCP and analyzed the impact of cirrhosis etiology,gender,type of sedation used during procedure,interventions performed,and co-morbidities on the rate of complications in cirrhosis patients as compared to non-cirrhosis patients.RESULTS Overall complications were higher in those with cirrhosis as compared to those without cirrhosis(P=0.015 at significance level of 0.05).CP class,especially CP class C,was shown to be associated with a significantly higher rate of ERCP complications as compared to CP class A and CP class B(P=0.010 at significance level of 0.05).CONCLUSION The results of our study reaffirm that liver cirrhosis has an impact on the occurrence of complications during ERCP.Our study shows that CP class seems to be more reliable as compared to MELD score in predicting complications of ERCP in cirrhosis patients.展开更多
AIM:To assess the safety and efficacy of carbon dioxide (CO2) insufflation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS:The Cochrane Library, Medical Literature Analysis and Retrieval System O...AIM:To assess the safety and efficacy of carbon dioxide (CO2) insufflation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS:The Cochrane Library, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Science Citation Index Expanded, Chinese Biomedical Literature Database, and references in relevant publications were searched up to December 2011 to identify randomized controlled trials (RCTs) comparing CO2 insufflation with air insufflation during ERCP. The trials were included in the review irrespec-tive of sample size, publication status, or language. Study selection and data extraction were performed by two independent authors. The meta-analysis was performed using Review Manager 5.1.6. A random-effects model was used to analyze various outcomes.Sensitivity and subgroup analyses were performed if necessary. R ESULTS:Seven double-blind RCTs involving a total of 818 patients were identified that compared CO2 insufflation (n = 404) with air insufflation (n = 401) during ERCP. There were a total of 13 post-random- ization dropouts in four RCTs. Six RCTs had a high risk of bias and one had a low risk of bias. None of the RCTs reported any severe gas-related adverse events in either group. A meta-analysis of 5 RCTs (n = 459) indicated that patients in the CO2 insufflation group had less post-ERCP abdominal pain and distension for at least 1 h compared with patients in the air insuf-flation group. There were no significant differences in mild cardiopulmonary complications [risk ratio (RR) = 0.43, 95% CI:0.07-2.66, P = 0.36], cardiopulmonary (e.g., blood CO2 level) changes [standardized mean difference (SMD) = -0.97, 95% CI: -2.58-0.63, P = 0.23], cost analysis (mean difference = 3.14, 95% CI:-14.57-20.85, P = 0.73), and total procedure time (SMD = -0.05, 95% CI:-0.26-0.17, P = 0.67) between the two groups. C ONCLUSION:CO2 insufflation during ERCP appears to be safe and reduces post-ERCP abdominal pain and discomfort.展开更多
Various complications have been related to laparoscopic cholecystectomy but most occur shortly after the procedure. In this report, we present a case with very late complications in which an abscess developed within t...Various complications have been related to laparoscopic cholecystectomy but most occur shortly after the procedure. In this report, we present a case with very late complications in which an abscess developed within the gallbladder fossa 6 years after laparoscopic cholecystectomy. The abscess resolved after treatment with CT-guided extrahepatic aspiration. However, 4 years later, an endoscopic retrograde cholangiopancreatography (ERCP) performed for choledocholithiasis demonstrated a “gallbladder” which communicated with the common bile duct via a patent cystic duct. This unique case indicates that a cystic duct stump may communicate with the gallbladder fossa many years following cholecystectomy.展开更多
Post-cholecystectomy iatrogenic bile duct injuries(IBDIs),are not uncommon and although the frequency of IBDIs vary across the literature,the rates following the procedure of laparoscopic cholecystectomy are much high...Post-cholecystectomy iatrogenic bile duct injuries(IBDIs),are not uncommon and although the frequency of IBDIs vary across the literature,the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy.These injuries caries a great burden on the patients,physicians and the health care systems and sometime are life-threatening.IBDIs are associated with different manifestations that are not limited to abdominal pain,bile leaks from the surgical drains,peritonitis with fever and sometimes jaundice.Such injuries if not witnessed during the surgery,can be diagnosed by combining clinical manifestations,biochemical tests and imaging techniques.Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate.Surgical approach was the ideal approach for such cases,however the introduction of Endoscopic Retrograde Cholangio-Pancreatography(ERCP)was a paradigm shift in the management of such injuries due to accepted success rates,lower cost and lower rates of associated morbidity and mortality.However,the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs.ERCP management of IBDIs can be tailored according to the nature of the underlying injury.For the subgroup of patients with complete bile duct ligation and lost ductal continuity,transfer to surgery is indicated without delay.Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP.For low–flow leaks e.g.gallbladder bed leaks,conservative management for 1-2 wk prior to ERCP is advised,in contrary to high-flow leaks e.g.cystic duct leaks and stricture lesions in whom early ERCP is encouraged.Sphincterotomy plus stenting is the ideal management line for cases of IBDIs.Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy.Future studies will solve many unsolved issues in the management of IBDIs.展开更多
Biliary complications are signifi cant causes of morbidity and mortality after orthotopic liver transplantation (OLT). The estimated incidence of biliary complications after OLT ranges between 10%-25%,however,these nu...Biliary complications are signifi cant causes of morbidity and mortality after orthotopic liver transplantation (OLT). The estimated incidence of biliary complications after OLT ranges between 10%-25%,however,these numbers continue to decline due to improvement in surgical techniques. The most common biliary complications are strictures (both anastomotic and non-anastomotic) and bile leaks. Most of these problems can be appropriately managed with endoscopic retrograde colangiography (ERC). Other complications such as bile duct stones,bile casts,sphincter of Oddi dysfunction,and hemobilia,are less frequent and also can be managed with ERC. This article will review the risk factors,diagnosis,and endoscopic management of the most common biliary complications after OLT.展开更多
Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis(CP).For CP-related,uncomplicated,pancreatic pseudocysts(PPC),endoscopy is the first-choice therapeutic opt...Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis(CP).For CP-related,uncomplicated,pancreatic pseudocysts(PPC),endoscopy is the first-choice therapeutic option.Recent advances have focused on endosonography-guided PPC transmural drainage,which tends to replace the conventional,duodenoscope-based coma immediately approach.Ancillary material is being tested to facilitate the endosonography-guided procedure.In this review,the most adequate techniques depending on PPC characteristics are presented along with supporting evidence.For CP-related biliary obstructions,endoscopy and surgery are valid therapeutic options.Patient co-morbidities(e.g.,portal cavernoma)and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option.Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures.In endoscopy,the gold standard technique consists of placing simultaneous,multiple,side-by-side,plastic stents for a oneyear period.Fully covered self-expandable metal stents are challenging this method and have provided 50%mid-term success.展开更多
Biliary tract diseases are the most common complications following liver transplantation(LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults...Biliary tract diseases are the most common complications following liver transplantation(LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents(FCSEMSs) has not been demonstrated to be superior(except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.展开更多
AIM: To investigate our clinical experience with combined laparo-endoscopic Rendezvous (RV) for the treatment of patients affected by gallstones and common bile duct (CBD) stones and especially to study the never eval...AIM: To investigate our clinical experience with combined laparo-endoscopic Rendezvous (RV) for the treatment of patients affected by gallstones and common bile duct (CBD) stones and especially to study the never evaluated opinion of the endoscopist concerning the difficulty of the intraoperative endoscopic procedure during the RV in comparison with standard endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: Eighty consecutive patients affected by cholecystolithiasis and diagnosed or suspected CBD stones were treated with a standardized "tailored" RV. The relevant technical features, the feasibility, the effectiveness in stone clearance, the safety but also the simple evaluation of difficulty and agreement of the endoscopist were analyzed with a questionnaire. RESULTS: The feasibility was 97.5% and the effectiveness 100% concerning CBD clearance and solution of coexisting problems at the papilla. Minor morbidity was 3.3%, the operating time was prolonged by a mean of 14 min, the mean hospital stay was 3.8 d and only one stone’s recurrence occurred. The endoscopist evaluated the procedure to be simpler than standard ERCP-ES in 81.2% of the cases.CONCLUSION: Simultaneous RV carries higheffectiveness and safety at least comparable to those reported for other options. The endoscopist is very often satisfied with this approach because of the minimization of some steps of the endoscopic procedure and avoidance of relevant iatrogenic risk factors. If the mandatory collaboration between surgeons and endoscopists is guaranteed, this approach can often be preferable for the patient, the surgeon, the endoscopist and the hospital.展开更多
AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complic...AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated. RESULTS: Of 175 patients, 52 aged ≥ 60 years (groupⅠ, age < 60 years; group Ⅱ, age ≥ 60 years) and 105 were men. Fever was present in 38 of 52 patients of group Ⅱ compared to 120 of 123 in groupⅠ. High fever (fever ≥ 38.0℃) was more common in groupⅠ(118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group Ⅱ. Biliopancreatic malignancy was a common cause of biliary obstruction in group Ⅱ (n = 34) and benign diseases in groupⅠ(n = 120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of ≥ 38.0℃ (n = 136), hypotension (n = 18), peritonism (n = 36), altered sensorium (n = 22), and failure to improve within 72 h of conservative management (n = 22). High grade fever was more common indication of biliary drainage in groupⅠand hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group Ⅱ. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 groupⅠ, 24 group Ⅱ, stent: 64 groupⅠ, 28 group Ⅱ) without any significant age related difference in the success rate. Abdominalpain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in groupⅠ(2-15 d) compared to 10 d in 47 patients of group Ⅱ (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in groupⅠcompared to 15 d (5-26 d) in 47 patients in group Ⅱ. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n = 3, CBD stones n = 2) died in group Ⅱ and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group Ⅱ despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group Ⅱ patients (16.4 ± 5.6, 7-30 d) than in groupⅠpatients (8.2 ± 2.4, 7-20 d).CONCLUSION: Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.展开更多
文摘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.
文摘BACKGROUND There is minimal objective data regarding adverse events related to endoscopic retrograde cholangio-pancreatography(ERCP)in patients with cirrhosis compared to those without cirrhosis and even fewer data comparing complications among cirrhosis patients based on severity of cirrhosis.AIM To determine if patients with cirrhosis are at increased risk of adverse events related to ERCP:mainly pancreatitis,bleeding,perforation,cholangitis,and mortality;And to see if higher Child-Pugh(CP)score and Model for End-Stage Liver Disease(MELD)score are associated with higher post-ERCP complications.METHODS We performed a retrospective analysis of 692 patients who underwent ERCP and analyzed the impact of cirrhosis etiology,gender,type of sedation used during procedure,interventions performed,and co-morbidities on the rate of complications in cirrhosis patients as compared to non-cirrhosis patients.RESULTS Overall complications were higher in those with cirrhosis as compared to those without cirrhosis(P=0.015 at significance level of 0.05).CP class,especially CP class C,was shown to be associated with a significantly higher rate of ERCP complications as compared to CP class A and CP class B(P=0.010 at significance level of 0.05).CONCLUSION The results of our study reaffirm that liver cirrhosis has an impact on the occurrence of complications during ERCP.Our study shows that CP class seems to be more reliable as compared to MELD score in predicting complications of ERCP in cirrhosis patients.
文摘AIM:To assess the safety and efficacy of carbon dioxide (CO2) insufflation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS:The Cochrane Library, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Science Citation Index Expanded, Chinese Biomedical Literature Database, and references in relevant publications were searched up to December 2011 to identify randomized controlled trials (RCTs) comparing CO2 insufflation with air insufflation during ERCP. The trials were included in the review irrespec-tive of sample size, publication status, or language. Study selection and data extraction were performed by two independent authors. The meta-analysis was performed using Review Manager 5.1.6. A random-effects model was used to analyze various outcomes.Sensitivity and subgroup analyses were performed if necessary. R ESULTS:Seven double-blind RCTs involving a total of 818 patients were identified that compared CO2 insufflation (n = 404) with air insufflation (n = 401) during ERCP. There were a total of 13 post-random- ization dropouts in four RCTs. Six RCTs had a high risk of bias and one had a low risk of bias. None of the RCTs reported any severe gas-related adverse events in either group. A meta-analysis of 5 RCTs (n = 459) indicated that patients in the CO2 insufflation group had less post-ERCP abdominal pain and distension for at least 1 h compared with patients in the air insuf-flation group. There were no significant differences in mild cardiopulmonary complications [risk ratio (RR) = 0.43, 95% CI:0.07-2.66, P = 0.36], cardiopulmonary (e.g., blood CO2 level) changes [standardized mean difference (SMD) = -0.97, 95% CI: -2.58-0.63, P = 0.23], cost analysis (mean difference = 3.14, 95% CI:-14.57-20.85, P = 0.73), and total procedure time (SMD = -0.05, 95% CI:-0.26-0.17, P = 0.67) between the two groups. C ONCLUSION:CO2 insufflation during ERCP appears to be safe and reduces post-ERCP abdominal pain and discomfort.
文摘Various complications have been related to laparoscopic cholecystectomy but most occur shortly after the procedure. In this report, we present a case with very late complications in which an abscess developed within the gallbladder fossa 6 years after laparoscopic cholecystectomy. The abscess resolved after treatment with CT-guided extrahepatic aspiration. However, 4 years later, an endoscopic retrograde cholangiopancreatography (ERCP) performed for choledocholithiasis demonstrated a “gallbladder” which communicated with the common bile duct via a patent cystic duct. This unique case indicates that a cystic duct stump may communicate with the gallbladder fossa many years following cholecystectomy.
文摘Post-cholecystectomy iatrogenic bile duct injuries(IBDIs),are not uncommon and although the frequency of IBDIs vary across the literature,the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy.These injuries caries a great burden on the patients,physicians and the health care systems and sometime are life-threatening.IBDIs are associated with different manifestations that are not limited to abdominal pain,bile leaks from the surgical drains,peritonitis with fever and sometimes jaundice.Such injuries if not witnessed during the surgery,can be diagnosed by combining clinical manifestations,biochemical tests and imaging techniques.Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate.Surgical approach was the ideal approach for such cases,however the introduction of Endoscopic Retrograde Cholangio-Pancreatography(ERCP)was a paradigm shift in the management of such injuries due to accepted success rates,lower cost and lower rates of associated morbidity and mortality.However,the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs.ERCP management of IBDIs can be tailored according to the nature of the underlying injury.For the subgroup of patients with complete bile duct ligation and lost ductal continuity,transfer to surgery is indicated without delay.Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP.For low–flow leaks e.g.gallbladder bed leaks,conservative management for 1-2 wk prior to ERCP is advised,in contrary to high-flow leaks e.g.cystic duct leaks and stricture lesions in whom early ERCP is encouraged.Sphincterotomy plus stenting is the ideal management line for cases of IBDIs.Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy.Future studies will solve many unsolved issues in the management of IBDIs.
文摘Biliary complications are signifi cant causes of morbidity and mortality after orthotopic liver transplantation (OLT). The estimated incidence of biliary complications after OLT ranges between 10%-25%,however,these numbers continue to decline due to improvement in surgical techniques. The most common biliary complications are strictures (both anastomotic and non-anastomotic) and bile leaks. Most of these problems can be appropriately managed with endoscopic retrograde colangiography (ERC). Other complications such as bile duct stones,bile casts,sphincter of Oddi dysfunction,and hemobilia,are less frequent and also can be managed with ERC. This article will review the risk factors,diagnosis,and endoscopic management of the most common biliary complications after OLT.
文摘Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis(CP).For CP-related,uncomplicated,pancreatic pseudocysts(PPC),endoscopy is the first-choice therapeutic option.Recent advances have focused on endosonography-guided PPC transmural drainage,which tends to replace the conventional,duodenoscope-based coma immediately approach.Ancillary material is being tested to facilitate the endosonography-guided procedure.In this review,the most adequate techniques depending on PPC characteristics are presented along with supporting evidence.For CP-related biliary obstructions,endoscopy and surgery are valid therapeutic options.Patient co-morbidities(e.g.,portal cavernoma)and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option.Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures.In endoscopy,the gold standard technique consists of placing simultaneous,multiple,side-by-side,plastic stents for a oneyear period.Fully covered self-expandable metal stents are challenging this method and have provided 50%mid-term success.
文摘Biliary tract diseases are the most common complications following liver transplantation(LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents(FCSEMSs) has not been demonstrated to be superior(except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.
文摘AIM: To investigate our clinical experience with combined laparo-endoscopic Rendezvous (RV) for the treatment of patients affected by gallstones and common bile duct (CBD) stones and especially to study the never evaluated opinion of the endoscopist concerning the difficulty of the intraoperative endoscopic procedure during the RV in comparison with standard endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: Eighty consecutive patients affected by cholecystolithiasis and diagnosed or suspected CBD stones were treated with a standardized "tailored" RV. The relevant technical features, the feasibility, the effectiveness in stone clearance, the safety but also the simple evaluation of difficulty and agreement of the endoscopist were analyzed with a questionnaire. RESULTS: The feasibility was 97.5% and the effectiveness 100% concerning CBD clearance and solution of coexisting problems at the papilla. Minor morbidity was 3.3%, the operating time was prolonged by a mean of 14 min, the mean hospital stay was 3.8 d and only one stone’s recurrence occurred. The endoscopist evaluated the procedure to be simpler than standard ERCP-ES in 81.2% of the cases.CONCLUSION: Simultaneous RV carries higheffectiveness and safety at least comparable to those reported for other options. The endoscopist is very often satisfied with this approach because of the minimization of some steps of the endoscopic procedure and avoidance of relevant iatrogenic risk factors. If the mandatory collaboration between surgeons and endoscopists is guaranteed, this approach can often be preferable for the patient, the surgeon, the endoscopist and the hospital.
文摘AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated. RESULTS: Of 175 patients, 52 aged ≥ 60 years (groupⅠ, age < 60 years; group Ⅱ, age ≥ 60 years) and 105 were men. Fever was present in 38 of 52 patients of group Ⅱ compared to 120 of 123 in groupⅠ. High fever (fever ≥ 38.0℃) was more common in groupⅠ(118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group Ⅱ. Biliopancreatic malignancy was a common cause of biliary obstruction in group Ⅱ (n = 34) and benign diseases in groupⅠ(n = 120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of ≥ 38.0℃ (n = 136), hypotension (n = 18), peritonism (n = 36), altered sensorium (n = 22), and failure to improve within 72 h of conservative management (n = 22). High grade fever was more common indication of biliary drainage in groupⅠand hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group Ⅱ. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 groupⅠ, 24 group Ⅱ, stent: 64 groupⅠ, 28 group Ⅱ) without any significant age related difference in the success rate. Abdominalpain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in groupⅠ(2-15 d) compared to 10 d in 47 patients of group Ⅱ (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in groupⅠcompared to 15 d (5-26 d) in 47 patients in group Ⅱ. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n = 3, CBD stones n = 2) died in group Ⅱ and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group Ⅱ despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group Ⅱ patients (16.4 ± 5.6, 7-30 d) than in groupⅠpatients (8.2 ± 2.4, 7-20 d).CONCLUSION: Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.