The duodenoscopic technique consists of.
Diagnostic endoscopic retrograde cholangiopancreatography and therapeutic ERCP. therapeutic ERCP includes endoscopic duodenal papillary sphincterotomy, endoscopic biliary drainage, endoscopic nasobiliary drainage, transendoscopic pancreatic drainage and corresponding endoscopic endovascular fistulas.
1.Can extrahepatic bile duct stones be treated without incision?
The previous treatment for common bile duct stones is open common bile duct extraction, which is undoubtedly a very traumatic operation with many comorbidities and long recovery time, especially for the critically ill and elderly. The introduction of ERCP technology (duodenoscopy) has opened up a more ideal way to treat common bile duct stones, which can be removed from the mouth without anesthesia and without opening the abdomen, and the stones can be removed immediately after surgery. This method is another typical representative of minimally invasive biliary endoscopy, which has replaced some biliary surgical procedures and brought great progress to biliary surgery.
EST (duodenal papillotomy) is mainly applied to primary or secondary common bile duct stones and residual common bile duct stones after biliary surgery, and is even more indicated for acute obstructive purulent cholangitis caused by common bile duct stones, and the effect of emergency papillotomy for stone extraction is especially obvious.
2.Is there any danger of EST (duodenal papillotomy) + stone extraction?
EST is a difficult and complex technique in the field of endoscopic treatment and has become increasingly mature. Complications of endoscopic papillotomy lithotripsy have been reported differently, with an incidence of 3%-17%. Although the serious comorbidities of EST include perforation, bleeding, acute septic cholangitis, acute necrotizing pancreatic-pancreatitis, etc., and even have a certain mortality rate, the incidence of comorbidities can be reduced by mastering the operation technique.
3. Should we use “ERCP/EST (duodenal papillotomy)” or “choledochoscopy” to remove the residual stones of the common bile duct with T-tube after surgery? Which is better and safer?
For residual stones in the common bile duct or intrahepatic bile ducts with T-tubes remaining after choledochotomy, a simpler, safer and more reliable choledochoscopic stone extraction should be performed 4-6 weeks after surgery, and ERCP/EST should be avoided because
(1) choledochoscopy allows direct visualization of the bile ducts, clarifies lesions and smaller residual stones, has a higher and more accurate diagnostic rate than T-tube angiography and ERCP, and is less likely to be missed.
(2) Less painful, without complications such as bleeding, perforation and pancreatitis of ERCP/EST, with much lower risk.
(3) Economical: the cost of choledochoscopic lithotripsy is much less than that of ERCP/EST lithotripsy.
(4) The function of the sphincter is preserved, avoiding the occurrence of reflux, and the complete biliary confinement plays an important role in postoperative results and stone recurrence, especially for those with intrahepatic biliary stenosis, although choledochoscopy can resolve the stenosis, but for those with significant pathological intrahepatic biliary dilatation, there is still the presence of relative stenosis, artificially destroying the sphincter confinement function, leading to recurrent reflux cholangitis and accelerated recurrence For these reasons, biliary endoscopists should be cautioned not to ignore this! Otherwise, it will bring great pain and economic burden to patients.
4.What kind of treatment should be chosen for extrahepatic bile duct stones combined with intrahepatic bile duct stones?
Surgery + choledochoscopy is the best solution for intrahepatic bile duct stones! For patients with combined intrahepatic bile duct stones, in principle, EST (duodenal papillotomy) should not be performed to avoid damaging the function of the sphincter muscle and destroying the confinement of the bile duct leading to reflux, but to adopt the principle of combining surgery and choledochoscopy to avoid blind ERCP/EST extraction. In the case of acute obstructive biliary cholangitis, ENBD can be used to save the risk and give a chance for surgical treatment. In addition, ERBD (endoscopic biliary drainage) is also feasible for patients of advanced age who are difficult to tolerate surgery to relieve common bile duct obstruction and relieve symptoms.
5.What is e-Duodenoscopy about?
The electronic duodenoscope is widely used in the diagnosis and treatment of diseases of the liver, biliary and pancreatic systems. For diagnosis, such as bile duct stones, bile duct strictures and malformations, gallbladder and bile duct lesions, and differential diagnosis of difficult abdominal pain. It is especially valuable for the diagnosis of obstructive jaundice. Endoscopic treatment of biliary and pancreatic diseases, and in recent years, the “oral lithotomy” applied to the treatment of common bile duct stones has become the preferred treatment method in developed countries or regions because of its advantages of no incision, less pain and lower cost. In addition to common bile duct stones, it has been extended to more than ten kinds of diseases such as acute severe cholangitis, biliary pancreatitis, papillary sphincter stenosis, etc. The technology has also developed to papillary sphincterotomy (EST), mesh basket lithotomy, mesh basket lithotripsy, nasobiliary drainage, internal drainage, and balloon and mechanical bile duct dilatation.
6.What is ERCP (Endoscopic Retrograde Cholangiopancreatography)?
Retrograde cholangiopancreatography (ERCP) is a unique and irreplaceable method of pancreaticobiliary duct examination with electronic duodenoscopy. It is an important tool for diagnosing biliary tract diseases. It can identify the cause of jaundice, the site of infarction, the distribution of stones, and the location of bile duct strictures, which is very important for making surgical plans. At present, before laparoscopic cholecystectomy (LC) surgery in developed countries or regions, ERCP examination is routinely performed to clarify the relationship between the gallbladder, cystic duct and common bile duct to reduce the damage to the bile duct during LC.
7.What kind of patients choose to have ERCP (endoscopic retrograde cholangiopancreatography) examination?
(1) Infarct jaundice.
(2) Biliary stones: Especially for intra- and extra-hepatic bile duct stones, ERCP is better than CT and ultrasound.
(3) Biliary tumors: Especially for non-jaundiced biliary tumors, early detection of lesions is possible.
(4) Post-biliary tract syndrome: ERCP can confirm the diagnosis, such as residual stone and stricture.
(5) Biliary tract malformation or injury.
(6) Biliary roundworm. Confirmation of diagnosis and treatment of roundworm extraction will have immediate effect.
(7) Chronic pancreatitis: pancreatic duct stenosis, pancreatic duct stones, combined biliary obstruction, pancreatic cyst, pseudocyst or abscess.
8.What should I pay attention to and prepare before ERCP (endoscopic retrograde cholangiopancreatography) examination?
(1) Fasting from food and water for 6-8 hours before the procedure.
(2) Perform iodine allergy test.
(3) Pre-operative medication: Valium 10mg, pethidine 50mg, atropine 0.5mg intramuscularly, or 20mg of antispasmodic agent can be injected sedately.
(4) Take one oral epi-anesthetic expectorant (dacronin mixture) 15-20 minutes before the examination.
9.Is ERCP (endoscopic retrograde cholangiopancreatography) painful during the examination?
The operation process is similar to gastroscopy, but the operation technique is more complicated. The patient’s feeling is similar to that of gastroscopy, and after the examination, the patient can go down immediately without obvious pain.