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.

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.

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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CLINICAL STUDY ON LASER NEEDLE-KNIFE AND ACUPUNCTURE FOR VERTEBRAL-ARTERY-TYPE CERVICAL SPONDYLOSIS

Objective To compare the effect of laser needle-knife and acupuncture with medication for vertebral-artery-type cervical spondylosis （CSA）. Methods The 88 outpatients of CSA were divided with single-blind method into Treatment Group （treated by laser needle-knife and acupuncture） with 48 patients in it and Control Group （treated by Intravenous drip of Compound Salvia Miltiorrhiza Injection and oral taking of Flunarizine （Sibelium） with 40 patients in it. Before the treatment, the two groups were without difference statistically. Results In the treatment group, the curative rate was 60.42% and the total effective rate 97.92%. In the control group, the curative rate was 30% and the total effective rate 87.5%. In statistics, P〈0.05, a significant difference existed between the two groups. Conclusion The effect of laser needleknife and acupuncture for CSA is obviously better than that of medication, worth spreading.

Can early precut reduce post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with difficult bile duct cannulation?

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is associated with a variety of adverse events(AEs).One of the most important AEs is post-ERCP pancreatitis(PEP),which is most common in cases of difficult biliary cannulation.Although the precut technique has been reported as a PEP risk factor,recent studies indicate that early precut could reduce PEP,and that precut itself is not a risk factor.AIM To evaluate the safety of the precut technique,especially in terms of PEP.METHODS We conducted a retrospective study,spanning the period from November 2011 through December 2021.It included 1556 patients,aged≥20 years,who underwent their initial ERCP attempt for biliary disease with a naïve papilla at the Kawasaki University General Medical Center.We compared the PEP risk between the early precut and the delayed precut group.RESULTS The PEP incidence rate did not significantly differ between the precut and nonprecut groups.However,the PEP incidence was significantly lower in the early precut group than the delayed precut group(3.5%vs 10.5%;P=0.02).The PEP incidence in the delayed precut group without pancreatic stent insertion(17.3%)was significantly higher compared to other cases(P<0.01).CONCLUSION Our findings indicate that early precut may reduce PEP incidence.If the precut decision is delayed,a pancreatic stent should be inserted to prevent PEP.

Observation on Ultra-micro Structure of Eggshell and Analysis of Composition of Eggshell and Feather in Great Bustard

Ultra-micro structure of eggshell was observed and compositions of eggshell and feather were analyzed. The results showed that the structure of eggshell has special characters besides common structure. The content of poisonous elements in wild great bustard(Otis talda) eggshell and feather is significant lower than that in eggshell of crested foes(Nipponis nippon) and in feather of red crown crane(Grus japonesis) because of less disturbance by people. The contents of 14 elements of female’s feather all are higher than those of male’s.

Testing of the Ultra-Micro Gas Turbine Devices (1 - 10 kW) for Portable Power Generation at University of Roma 1: First Tests Results

The ever increasing development of portable electronics has led to a higher demand for compact and reliable power sources. Significant resources are being presently dedicated to the study of micro machined gas turbines, because of their remarkable power density. The paper reports the procedures and the results of a series of tests conducted at the Department of Mechanical & Aerospace Engineering of University of Roma 1, to obtain the map of an ultra-micro gas turbine device, and the head losses and the combustion efficiency of the corresponding ultra-micro combustion chamber, fed by a mixture of butane and propane. This work is a part of a research aimed at the conception, design and prototyping of an ultra-micro thermo-electrical device for portable power generation. The novelty of the research consists in the fact that the thermal engine is a (ultra-micro) gas turbine set. In a subsequent stage, several different configurations have been assessed to select the most proper geometry and structural characteristics of the most relevant components (radial compressor, radial turbine, combustion chamber, electric motor and generator, bearings, regenerative heat exchanger).

针刀联合复方骨肽治疗关节炎的临床研究

目的:研究针刀联合复方骨肽治疗关节炎的临床治疗效果.方法 :设立针刀联合复方骨肽的联合治疗组、单纯针刀治疗组和复方骨肽治疗组,通过对比三组之间HSS和VAS评分,对两组患者进行疗效分析.结果:联合方案治疗后术前HSS评分50.90±1.822,术后HSS评分84.2±2.225,术前VAS评分7.3±0.23,术后0.8±0.15,术前术后比较具有统计学差异(P<0.05),治疗后效果优于其他两组.结论:联合治疗方案在关节炎治疗方面要优于单一的治疗方式,而且远期效果更理想.

Effects of Needle-knife Therapy on iNOS Activity and NO Content in Skeletal Muscles in the L_3 Transverse Process Syndrome Model Rat

Objective: To study on relationship of inducible nitric oxide synthase (iNOS) activity and nitric oxide (NO) content in the injured local soft tissue with injured degrees of the soft tissue in the third lumbar vertebrae (L3) transverse process syndrome model rat and to observe the effect of needle-knife therapy. Methods: One hundred and sixty male SD rats were randomly divided into normal group, model group, aminoguanidine (AG) group, needle-knife group, 40 rats in each group. The L3 transverse process syndrome rat model was established, and after treatment of needle-knife and AG, iNOS activities and NO contents and histomorpholocal changes in the soft tissues around L3 transverse process on 1, 3, 7 and 14 days were observed in the groups. Results: Compared with the normal group, iNOS activity and NO content in the model group were significantly increased (P<0.01); Compared with the model group, iNOS activities and NO contents were significantly decreased in both the needle-knife group and the AG group (both P<0.01); And both iNOS activities and NO contents were identical with both local inflammation response and injured degrees of the injured tissue in the groups. Conclusion: Needle-knife therapy can significantly inhibit generation of NO, alleviate inflammatory response and injured degree of the injured soft tissue, improve microcirculation, prevent formation of pathological scar tissue, and promote repair of the chronic soft tissue injury.

Needle knife fstulotomy in flat and diverticular papillae:Is it time for redemption?

Background: European Society of Gastrointestinal Endoscopy( ESGE) recommends needle-knife fstulotomy(NKF) as the preferred precut technique in cases when standard cannulation techniques fail. Despite scarce scientifc evidence, flat and diverticular papillae are thought not to be ideal for NKF, as they are associated with poor outcomes. The present study aimed to determine the outcomes of the use of NKF in relation to flat and intradiverticular papillae. Methods: This prospective multicenter study enrolled consecutive patients, evidencing na?ve flat(group A, n = 49) or diverticular papilla(group B, n = 28), who underwent NKF after failure of standard cannulation techniques. Diverticular morphology was subdivided into intradiverticular(group B1, n = 14) and diverticular border papillae(group B2, n = 14), using a previously validated endoscopic classifcation of the major papilla. The success of biliary cannulation at initial endoscopic retrograde cholangiopancreatography(ERCP), overall biliary cannulation, overall cannulation time, and the rate of adverse events were assessed in the study. Results: The initial cannulation rates were 93.9%, 64.3% and 71.4% for group A, B1, and B2, respectively( P = 0.005);overall cannulation rates after a second ERCP were 98.0%, 92.9% and 85.7%, respectively( P = 0.134). Adverse events occurred in 11.7% of patients, with post-ERCP pancreatitis(PEP) being the most common adverse event(10.4%). Although there was a trend towards a higher incidence of PEP in flat papillae, univariate and multivariate analyses did not show any signifcant relationship between pancreatitis and trainee involvement, papillary morphology, nor overall cannulation time. Conclusions: Although flat papillae are associated with high success rates of biliary cannulation using NKF, the rate of PEP is not negligible. NKF is feasible in diverticular papillae, but it is associated with a modest success rate in the initial ERCP.