Oddi括约肌(sphincter of Oddi)是机体内一个复杂而精细调节的结构,它是由围绕于胆总管末段、胰管末段及胆胰管汇合Vater壶腹的三部分肌束组成。近年来,随着对Oddi括约肌的解剖结构与生理功能研究的不断深入,人们已认识到Oddi括约肌在...Oddi括约肌(sphincter of Oddi)是机体内一个复杂而精细调节的结构,它是由围绕于胆总管末段、胰管末段及胆胰管汇合Vater壶腹的三部分肌束组成。近年来,随着对Oddi括约肌的解剖结构与生理功能研究的不断深入,人们已认识到Oddi括约肌在维护胆道系统与胰管系统的正常压力、胆汁与胰液的流体力学、胆道与胰管系统的无菌状态以及阻止十二指肠液反流等方面均具有不可替代的关键作用;其结构与功能的受损或被废弃可导致一系列胆胰疾病的发生。因此,当代胆道外科医生应该充分认识到保护Oddi括约肌的重要性。展开更多
The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis.We searched for and evaluated all articles describing the diagnosis,epidemiology,pat...The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis.We searched for and evaluated all articles describing the diagnosis,epidemiology,pathophysiology,morbidity,mortality and prevention of post-ERCP pancreatitis(PEP) in adult patients using the PubMed database.Search terms included endoscopic retrograde cholangiopancreatography,pancreatitis,ampulla of vater,endoscopic sphincterotomy,balloon dilatation,cholangiography,adverse events,standards and utilization.We limited our review of articles to those published between January 1,1994 and August 15,2009 regarding human adults and written in the English language.Publicat ions from the reference sections were reviewed and included if they were salient and fell into the time period of interest.Between the dates queried,seventeen large(> 500 patients) prospective and four large retrospective trials were conducted.PEP occurred in 1-15 in the prospective trials and in 1-4 in the retrospective trials.PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis.Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last f ifteen years in 63 trials.Although 22 of 63 trials published during our period of review suggested a reduction in PEP,no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP.In conclusion,PEP is a well-recognized complication of ERCP.Medical treatment for prevention has been disappointing.Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.展开更多
BACKGROUND: It is unclear whether the presence of periampullary diverticula (PAD) affects technical success and complication rates during endoscopic retrograde cholangio- pancreatography (ERCP). Moreover, the impact o...BACKGROUND: It is unclear whether the presence of periampullary diverticula (PAD) affects technical success and complication rates during endoscopic retrograde cholangio- pancreatography (ERCP). Moreover, the impact of PAD on fluoroscopy duration is still unknown. The present study aimed to investigate the success rate and difficulty of common bile duct (CBD) cannulation, post-procedure complications and fluoroscopy duration in patients with and without PAD. METHODS: Patients from January 2008 to December 2010 with PAD (group A) and without PAD (group B) and similar indications for therapeutic ERCP were prospectively compared. The comparison included patient characteristics, findings of ERCP, and details of procedure and fluoroscopy time. The influence of papilla’s location with respect to the diverticulum on procedure was also investigated. RESULTS: A total of 428 consecutive patients who had undergone therapeutic ERCP for similar indications were divided in two groups according to the presence (group A, 107 patients) or absence (group B, 321 patients) of PAD. The mean age and ASA score of the patients with PAD were significantly higher than those patients without PAD. The main indication was choledocholithiasis. Successful final CBD cannulation was achieved in 97.20% of the patients in group A vs 99.69% in group B (P=0.05). CBD diameter, number of stones and the largest stone size were significantly higher in group A thangroup B (P【0.001). Complete clearance of the CBD after the first attempt was achieved in 85.86% and 94.75% of the patients in groups A and B, respectively (P=0.03). In both groups, the time needed to complete the procedure and fluoroscopy time was significantly longer in patients with PAD (22.87 vs 18.99 minutes, P【0.001; 76.51 vs 47.42 seconds, P【0.001). There was no significant difference between the two groups in the complication rate. The type of papilla’s location with respect to the diverticulum did not influence the total cannulation rate and post-procedure complications. CO展开更多
AIM: To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography(ERCP) in surgically altered anatomy patients. METHODS: Betw...AIM: To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography(ERCP) in surgically altered anatomy patients. METHODS: Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy(39 with gastric bypass Roux-en-Y, 2 with Billroth Ⅱ gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42(30.9%), biliary obstruction suggested on imaging: 20 of 42(47.6%), suspected sphincter of Oddi dysfunction: 4 of 42(9.5%), abnormal liver enzymes: 1 of 42(2.4%), ascending cholangitis: 2 of 42(4.8%), and bile leak: 2 of 42(4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical. RESULTS: Successful visualization of the major ampulla was accomplished in 32 of 42 procedures(76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla(81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bileduct was cannulated(92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients(23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients(7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d.CONCLUSION: It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.展开更多
Ampullary adenoma is a common indication for endoscopic papillectomy. Ampullary neuroendocrine tumor(NET) is a rare disease for which complete surgical resection is the treatment of choice. However, because of the mor...Ampullary adenoma is a common indication for endoscopic papillectomy. Ampullary neuroendocrine tumor(NET) is a rare disease for which complete surgical resection is the treatment of choice. However, because of the morbidity and mortality associated with surgical resection, endoscopic papillectomy is increasingly used in selected cases of low grade, with no metastasis and no invasion of the pancreatic or bile duct. Also, confirmed and complete endoscopic resection of ampullary NET accompanied by adenoma has not been reported to date. We report herein a rare case of an ampullary NET accompanied with adenoma, which was successfully and completely resected via endoscopic papillectomy. Prior to papillectomy, this case was diagnosed as an ampullary adenoma.展开更多
BACKGROUND:Only 105 cases of neuroendocrine tumor(NET)of the ampulla of Vater have been described, mostly as single case reports.The incidence of NET is rising.The changes in incidence may result from changes in detec...BACKGROUND:Only 105 cases of neuroendocrine tumor(NET)of the ampulla of Vater have been described, mostly as single case reports.The incidence of NET is rising.The changes in incidence may result from changes in detection.This study was to determine the relative incidence and clinicopathological characteristics of high- grade neuroendocrine carcinoma(small cell carcinoma and large cell carcinoma)of the ampulla of Vater at a single institution. METHODS:Sections from paraffin blocks of tumors of the ampulla of Vater taken from 45 patients who underwent Whipple’s procedure and 6 patients who underwent palliative bypass between September 2003 and January 2007 were subjected to immunohistochemical analysis.The clinical and pathological data from 5 patients diagnosed with NET of the ampulla of Vater were analyzed. RESULTS:The patients were 3 men and 2 women,ranging in age from 39 to 47 years(mean 44 years).Operative procedures included Whipple’s procedure in 4 patients and palliative bypass in 1 patient.Histopathological examination revealed large-cell neuroendocrine carcinoma in 2 patients,small cell carcinoma in 2,and carcinoid in 1.Three patients with high-grade neuroendocrine carcinoma who had undergone Whipple’s procedure died at postoperatively 7,11,and 13 months.The patient who had undergone palliative triple bypass died 3 months after surgery.CONCLUSIONS:The relative incidence of high-grade neuroendocrine carcinomas of the ampulla of Vater is higher than that generally expected.The tumors behave aggressively and have a dismal prognosis despite aggressive treatment.展开更多
文摘Oddi括约肌(sphincter of Oddi)是机体内一个复杂而精细调节的结构,它是由围绕于胆总管末段、胰管末段及胆胰管汇合Vater壶腹的三部分肌束组成。近年来,随着对Oddi括约肌的解剖结构与生理功能研究的不断深入,人们已认识到Oddi括约肌在维护胆道系统与胰管系统的正常压力、胆汁与胰液的流体力学、胆道与胰管系统的无菌状态以及阻止十二指肠液反流等方面均具有不可替代的关键作用;其结构与功能的受损或被废弃可导致一系列胆胰疾病的发生。因此,当代胆道外科医生应该充分认识到保护Oddi括约肌的重要性。
文摘The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis.We searched for and evaluated all articles describing the diagnosis,epidemiology,pathophysiology,morbidity,mortality and prevention of post-ERCP pancreatitis(PEP) in adult patients using the PubMed database.Search terms included endoscopic retrograde cholangiopancreatography,pancreatitis,ampulla of vater,endoscopic sphincterotomy,balloon dilatation,cholangiography,adverse events,standards and utilization.We limited our review of articles to those published between January 1,1994 and August 15,2009 regarding human adults and written in the English language.Publicat ions from the reference sections were reviewed and included if they were salient and fell into the time period of interest.Between the dates queried,seventeen large(> 500 patients) prospective and four large retrospective trials were conducted.PEP occurred in 1-15 in the prospective trials and in 1-4 in the retrospective trials.PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis.Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last f ifteen years in 63 trials.Although 22 of 63 trials published during our period of review suggested a reduction in PEP,no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP.In conclusion,PEP is a well-recognized complication of ERCP.Medical treatment for prevention has been disappointing.Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.
文摘BACKGROUND: It is unclear whether the presence of periampullary diverticula (PAD) affects technical success and complication rates during endoscopic retrograde cholangio- pancreatography (ERCP). Moreover, the impact of PAD on fluoroscopy duration is still unknown. The present study aimed to investigate the success rate and difficulty of common bile duct (CBD) cannulation, post-procedure complications and fluoroscopy duration in patients with and without PAD. METHODS: Patients from January 2008 to December 2010 with PAD (group A) and without PAD (group B) and similar indications for therapeutic ERCP were prospectively compared. The comparison included patient characteristics, findings of ERCP, and details of procedure and fluoroscopy time. The influence of papilla’s location with respect to the diverticulum on procedure was also investigated. RESULTS: A total of 428 consecutive patients who had undergone therapeutic ERCP for similar indications were divided in two groups according to the presence (group A, 107 patients) or absence (group B, 321 patients) of PAD. The mean age and ASA score of the patients with PAD were significantly higher than those patients without PAD. The main indication was choledocholithiasis. Successful final CBD cannulation was achieved in 97.20% of the patients in group A vs 99.69% in group B (P=0.05). CBD diameter, number of stones and the largest stone size were significantly higher in group A thangroup B (P【0.001). Complete clearance of the CBD after the first attempt was achieved in 85.86% and 94.75% of the patients in groups A and B, respectively (P=0.03). In both groups, the time needed to complete the procedure and fluoroscopy time was significantly longer in patients with PAD (22.87 vs 18.99 minutes, P【0.001; 76.51 vs 47.42 seconds, P【0.001). There was no significant difference between the two groups in the complication rate. The type of papilla’s location with respect to the diverticulum did not influence the total cannulation rate and post-procedure complications. CO
文摘AIM: To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography(ERCP) in surgically altered anatomy patients. METHODS: Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy(39 with gastric bypass Roux-en-Y, 2 with Billroth Ⅱ gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42(30.9%), biliary obstruction suggested on imaging: 20 of 42(47.6%), suspected sphincter of Oddi dysfunction: 4 of 42(9.5%), abnormal liver enzymes: 1 of 42(2.4%), ascending cholangitis: 2 of 42(4.8%), and bile leak: 2 of 42(4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical. RESULTS: Successful visualization of the major ampulla was accomplished in 32 of 42 procedures(76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla(81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bileduct was cannulated(92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients(23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients(7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d.CONCLUSION: It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.
基金Supported by the Soonchunhyang University Research Fund
文摘Ampullary adenoma is a common indication for endoscopic papillectomy. Ampullary neuroendocrine tumor(NET) is a rare disease for which complete surgical resection is the treatment of choice. However, because of the morbidity and mortality associated with surgical resection, endoscopic papillectomy is increasingly used in selected cases of low grade, with no metastasis and no invasion of the pancreatic or bile duct. Also, confirmed and complete endoscopic resection of ampullary NET accompanied by adenoma has not been reported to date. We report herein a rare case of an ampullary NET accompanied with adenoma, which was successfully and completely resected via endoscopic papillectomy. Prior to papillectomy, this case was diagnosed as an ampullary adenoma.
文摘BACKGROUND:Only 105 cases of neuroendocrine tumor(NET)of the ampulla of Vater have been described, mostly as single case reports.The incidence of NET is rising.The changes in incidence may result from changes in detection.This study was to determine the relative incidence and clinicopathological characteristics of high- grade neuroendocrine carcinoma(small cell carcinoma and large cell carcinoma)of the ampulla of Vater at a single institution. METHODS:Sections from paraffin blocks of tumors of the ampulla of Vater taken from 45 patients who underwent Whipple’s procedure and 6 patients who underwent palliative bypass between September 2003 and January 2007 were subjected to immunohistochemical analysis.The clinical and pathological data from 5 patients diagnosed with NET of the ampulla of Vater were analyzed. RESULTS:The patients were 3 men and 2 women,ranging in age from 39 to 47 years(mean 44 years).Operative procedures included Whipple’s procedure in 4 patients and palliative bypass in 1 patient.Histopathological examination revealed large-cell neuroendocrine carcinoma in 2 patients,small cell carcinoma in 2,and carcinoid in 1.Three patients with high-grade neuroendocrine carcinoma who had undergone Whipple’s procedure died at postoperatively 7,11,and 13 months.The patient who had undergone palliative triple bypass died 3 months after surgery.CONCLUSIONS:The relative incidence of high-grade neuroendocrine carcinomas of the ampulla of Vater is higher than that generally expected.The tumors behave aggressively and have a dismal prognosis despite aggressive treatment.
