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.

Retrospective analysis of complications related to endoscopic retrograde cholangio-pancreatography in patients with cirrhosis vs patients without cirrhosis

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.

Carbon dioxide insufflation for endoscopic retrograde cholangiopancreatography:A meta-analysis and systematic review

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.

A phantom gallbladder on endoscopic retrograde cholangiopancreatography

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.

亚麻醉剂量艾司氯胺酮对舒芬太尼复合丙泊酚用于无痛ERCP麻醉效果的影响

目的:探讨亚麻醉剂量艾司氯胺酮对舒芬太尼复合丙泊酚行无痛内镜逆行胰胆管造影术(ERCP)麻醉效果的影响。方法:选取2021年1月—2022年10月在无锡市第二人民医院择期行无痛ERCP的60例患者为研究对象。按入院时间先后顺序的不同,将60例手术患者分为观察组和对照组,各30例。两组均缓慢静注舒芬太尼、丙泊酚进行全麻诱导,在此基础上,观察组予艾司氯胺酮,对照组予氯化钠注射液。待患者入睡、睫毛反射消失后开始进行ERCP。观察记录两组在不同时间点生命体征的变化;记录两组手术时间、苏醒时间、丙泊酚总用量及不良反应发生情况。结果:入室后5 min(T_(0))至术毕撤镜(T_(3))时,两组心率(HR)比较,差异无统计学意义(P>0.05)。内镜操作开始(T_(1))、ERCP术中20 min(T_(2))时,观察组平均动脉压(MAP)高于对照组,差异有统计学意义(P<0.05);T_(1)时,观察组血氧饱和度(SpO_(2))高于对照组,差异有统计学意义(P<0.05)。两组手术时间、苏醒时间比较,差异无统计学意义(P>0.05);观察组丙泊酚总用量少于对照组,差异有统计学意义(P<0.05)。观察组术中体动、呼吸抑制、低血压的发生率均低于对照组,差异有统计学意义(P<0.05);两组术后头晕、恶心呕吐发生率比较,差异无统计学意义(P>0.05);两组术后均未见幻觉、噩梦等精神症状的发生。结论:亚麻醉剂量艾司氯胺酮可进一步优化舒芬太尼复合丙泊酚用于无痛ERCP的麻醉效果,提高术中循环、呼吸稳定性。

Post-cholecystectomy iatrogenic bile duct injuries:Emerging role for endoscopic management

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.

多学科协作模式在高龄胆总管结石ERCP围手术期全程管理中的应用

目的探讨多学科协作模式(MDT)在高龄胆总管结石内镜下逆行性胰胆管造影(ERCP)围手术期全程管理中的应用效果。方法回顾性分析2014年1月1日至2021年12月31日于西部战区总医院行ERCP手术的80岁以上胆总管结石患者的临床资料,以MDT团队正式实施时间2018年1月1日为界分为传统诊疗组59例和MDT组33例,比较2组手术相关指标、住院相关指标、围手术期并发症、医护满意度等。结果MDT组住院时间(7.97±3.06)d,较传统诊疗组时间(10.13±3.54)d更短(P<0.01);诊疗费用(30084.03±5714.09)元,较传统诊疗组(34252.76±10474.79)元更低(P<0.05);围手术期出血发生率[3.03%(1/33)]及高淀粉酶血症发生率[6.06%(2/33)]明显低于传统诊疗组[13.60%(8/59)、22.03%(13/59)],差异有统计学意义(P<0.05)。结论MDT模式应用于高龄胆总管结石ERCP围手术期的全程管理,在缩短手术时间、减少诊疗费用,减少并发症,提高患者满意度等方面均取得明显进步。

双导丝技术联合经胰管乳头括约肌预切开术在ERCP困难插管患者中的应用效果及对应激反应、插管成功率的影响

目的探讨双导丝技术联合经胰管乳头括约肌预切开术在经内镜逆行胰胆管造影术(ERCP)困难插管患者中的应用效果及对应激反应、插管成功率的影响。方法选取2019年1月至2022年1月的90例ERCP困难插管患者作为研究对象,按照随机数字表法将其分为对照组(n=45)和观察组(n=45)。对照组实施常规经胰管乳头括约肌预切开术,观察组在对照组基础上实施双导丝技术。比较两组的治疗效果。结果插管时(T_(1))、插管后5 min(T_(2)),观察组的皮质醇(Cor)、肾上腺素(E)水平低于对照组(P<0.05)。观察组的插管成功率显著高于对照组,成功插管耗时显著短于对照组(P<0.05)。观察组术后的胰腺炎发生率显著低于对照组(P<0.05)。结论双导丝技术联合经胰管乳头括约肌预切开术应用于ERCP困难插管患者中有助于减轻机体应激反应,提高插管成功率,缩短成功插管耗时,也能降低术后胰腺炎发生率,值得推广。

吲哚美辛栓剂预防经内镜逆行胰胆管取石术后胰腺炎的疗效观察

目的明确经内镜行胰胆管造影术(ERCP)取石术后吲哚美辛对胰腺炎的预防作用。方法回顾性分析178例因胆总管结石行ERCP治疗的患者资料,根据是否术后应用吲哚美辛,分为吲哚美辛组(96例)及对照组(82例)。吲哚美辛组患者术后0.5 h使用吲哚美辛100 mg塞肛。比较两组患者术前、术后3 h、12 h和24 h血淀粉酶监测值及胰腺炎发生情况。结果吲哚美辛组96例,术后发生PEP 1例(1.0%)。对照组82例,术后胰腺炎(PEP)8例(9.7%),两组比较差异有显著(P<0.05)。吲哚美辛组高胰淀粉酶血症明显低于对照组(5.21%比18.29%,P<0.05)。结论内镜下取石术后使用吲哚美辛栓能够降低术后胰腺炎和高淀粉酶血症的发生率。

内镜下胆道内支架置入治疗恶性梗阻性黄疸58例疗效分析

目的:探讨经十二指肠镜行胆道支架置入术以及鼻胆管引流治疗恶性梗阻性黄疸的疗效。方法:58例恶性梗阻性黄疸的患者,均行ERCP(经内镜逆行胰胆管造影)术,根据情况置入不同支架或行鼻胆管引流术,观察其疗效和3个月、6个月生存率。结果:56例病人插管成功,插管成功率97%。其中36例置入金属支架。18例置入塑料支架,2例行单纯鼻胆管引流,2例未能插管成功而放弃ERCP。并发症5例,其中急性胰腺炎2例,高淀粉酶血症2例,急性胆管炎1例,并发症率8.9%。插管成功的56名患者血清胆红素从(377.4±155.5)μmol/L下降到术后1周(146.4±54.5)μmol/L(P<0.01),支架组随访40例中总体3个月、6个月存活率分别达到94%及77%。结论:通过ERCP所进行的支架的放置术以及鼻胆管引流是姑息治疗恶性梗阻性黄疸的有效方法。

十二味疏肝利胆冲剂联合ERCP治疗胆总管结石30例临床分析

目的观察十二味疏肝利胆冲剂联合ERCP治疗胆总管结石的临床疗效。方法将60例胆总管结石的患者采用随机按数字表法分成对照组30例和研究组30例,对照组予以ERCP治疗,术后常规抑酶、抑酸、抗感染;研究组在对照组治疗的基础上给予十二味疏肝利胆冲剂口服。观察比较2组患者右上腹部疼痛、发热和黄疸的临床症状积分的改善情况及治疗前后血常规指标(白细胞、中性粒细胞、中性粒细胞百分比)、肝功能指标(谷丙转氨酶、谷草转氨酶、AKP)、血淀粉酶(AMY)、血清胆石形成生化指标(总胆汁酸、总胆红素、直接胆红素、间接胆红素)、鼻胆管引流量的变化。结果 2组的症状积分较治疗前均明显好转(P<0.05),研究组优于对照组(P<0.05);2组能降低血常规指标、肝功能指标、血清胆汁生化指标和提高胆汁引流量,均较治疗前明显好转(P<0.05),研究组较对照组差异显著(P<0.05)。结论疏肝利胆冲剂联合ERCP治疗胆总管结石可以明显改善临床症状、控制术后胆总管炎症、促进肝功能早日恢复、降低术后淀粉酶和增加胆汁引流量,防治术后结石再生。

硝基咪唑类抗菌药在急性重症胆源性胰腺炎患者胆汁中代谢特点的实验研究

目的探讨部分硝基咪唑类抗菌药在急性胆源性胰腺炎胆汁中的代谢特点,为临床选择抗菌药提供实验依据。方法选择我院2009年6月—2010年9月住院治疗的急性重症胆源性胰腺炎病人68例,随机分成治疗组Ⅰ和治疗组Ⅱ各34例。68例病人均在入院48 h内行内镜逆行胰胆管造影,并通过经内镜鼻胆管引流术留取胆汁,两组在给予头孢哌酮治疗的基础上分别给予甲硝唑和替硝唑治疗,利用高效液相色谱法,连续动态监测给药后胆汁药物浓度的变化。结果甲硝唑具有达峰时间短,峰浓度高的特点,而替硝唑达峰时间长,但是胆汁中药物浓度稳定。结论甲硝唑具有达峰时间短,峰浓度高的特点,是临床治疗重症胆源性胰腺炎(SAP)合并胆道感染的最佳抗菌药。

舒适护理在内镜逆行胰胆管造影术中的应用

目的:探讨舒适护理在内镜逆行胰胆管造影术中的应用价值。方法:将83例来我院行内镜逆行胰胆管造影术的患者随机分成实验组42例和对照组41例,实验组由经过专业培训的护理组长主动为患者提供服务,实施舒适护理,对照组实行常规护理。通过发放护理满意度调查表和焦虑自评量表进行评估。结果:舒适护理干预后实验组配合程度、护理满意度均明显高于对照组(P<0.01),体位不适、疼痛不安发生人数明显少于对照组(P<0.01),焦虑指数评分明显低于对照组(P<0.01)。结论:舒适护理有利于患者以最佳的身心状态配合手术,确保手术安全,提高护理质量。

塑料内支架置入治疗不可切除的肝门部胆管癌的回顾性研究

目的探讨Ⅳ型肝门部胆管癌患者经ERCP置入塑料内支架进行减黄治疗的效果。方法对2003年10月到2009年10月期间63例不能切除的Ⅳ型肝门部胆管癌行单侧,塑料内支架置入的患者进行回顾性的研究。全部患者均经ERCP操作成功置入单侧塑料内支架引流,观察30d内的早期操作相关性并发症、病死率以及超过30d的远期效果等。结果63例患者均成功引流,80.7%(51/63)患者黄疸缓解(胆红素水平<50.3μmol/L),平均总胆红素水平从(310.3±152.4)μmol/L降到(30.6±18.5)μmol/L。其中52.3%(33/63)的患者胆红素水平降到正常水平(<17.1μmol/L)。早期并发症包括EST所致的乳头出血(7.9%)以及操作所致的胆管炎(23.8%),无早期死亡患者。所有患者均需要定期换管,首次中位换管时间为64d,中位内支架引流时间为5.05个月,左右侧组没有显著差异。结论置入单侧塑料内支架对不可切除的肝门部胆管癌患者是安全、可行、可以获得较长时间的充分引流的。

抗核周因子在胆道塑料内支架再阻塞中表达作用的研究

目的通过胆道内支架再阻塞内容物的生物化学研究,来进一步探讨胆道内支架阻塞机制。方法收集胆道疾病患者十二指肠内引流术(ERBD)后塑料内支架,肉眼分为支架阻塞组(20例)及未阻塞组(48例)。进行支架内膜抗核周因子(APF)的定量分析、细菌学和胆固醇、结晶钙盐红外透光率分析。结果阻塞组和非阻塞组APF蛋白定量分析分别为(10.39±2.17)和(17.29±9.52)ng/mL,两组差异有统计学意义(<0.05)。阻塞组支架内生物膜的胆红素钙和胆固醇含量均明显高于未阻塞组(<0.01)。与未阻塞的支架相比,大多阻塞的支架内含多种类的细菌。结论阻塞支架内生物膜的主要成份是胆红素钙和胆固醇。APF有助于减缓胆道支架蛋白生物膜的形成,从而保持胆道通畅。

Management of biliary complications after orthotopic liver transplantation:The role of endoscopy

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.

Endoscopic management of complications of chronic pancreatitis

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.

Endoscopic management of biliary complications after liver transplantation: An evidence-based review

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.

Laparo-endoscopic “Rendezvous” to treat cholecysto-choledocolithiasis: Effective,safe and simplifies the endoscopist’s work

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.

Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis?

Endoscopic papillary balloon dilatation(EPBD) is useful for decreasing early complications of endoscopic retrograde cholangio-pancreatography(ERCP), including bleeding, biliary infection, and perforation, but it is generally avoided in Western countries because of a relatively high reported incidence of post-ERCP pancreatitis(PEP). However, as the efficacy of endoscopic papillary largeballoon dilatation(EPLBD) becomes widely recognized, EPBD is attracting attention. Here we investigate whether EPBD is truly a risk factor for PEP, and seek safer and more effective EPBD procedures by reviewing past studies. We reviewed thirteen randomised control trials comparing EPBD and endoscopic sphincterotomy(EST) and ten studies comparing direct EPLBD and EST. Three randomized controlled trials of EPBD showed significantly higher incidence of PEP than EST, but no study of EPLBD did. Careful analysis of these studies suggested that longer and higher-pressure inflation of balloons might decrease PEP incidence. The paradoxical result that EPBD with small-calibre balloons increases PEP incidence while EPLBD does not may be due to insufficient papillary dilatation in the former. Insufficient dilatation could cause the high incidence of PEP through the use of mechanical lithotripsy and stress on the papilla at the time of stone removal. Sufficient dilation of the papilla may be useful in preventing PEP.