ERCP文献快讯创刊号2009年11月

创刊号2009年11月南京大学医学院附属鼓楼医院消化科编者按：由邹主任倡导的ERCP 文献快讯终于正式和大家见面了！本刊的目的是为大家提供ERCP方面最新的文献资讯。

在创刊初期也许还存在许多的不足，敬请大家对本刊的形式和内容提出宝贵的意见，使之不断的完善，更好地为大家服务。

本刊初步确定为每月一期，在每月的月底推出，并适时补充最近三年的文献。

本期导读Coté GA等统计了2345例ERCP患者，针对困难的胆管插管患者放置胰管支架有利于提高胆管插管成功率，可以减少预切开的机会。

病例报道：一例胰腺导管内乳头状粘液瘤（IPMN）同时侵犯胃和十二指肠，良性IPMN同时侵犯相邻两个脏器非常少见。

4. Face and construct validity of a computer-based virtual reality simulator for ERCP. Gastrointest Endosc. 2009 Nov 16. [Epub ahead of print]介绍一种计算机模拟ERCP培训方法。

5. Clinical application of intraductal ultrasound during endoscopic retrograd e cholangiopancreatography. Gastrointest Endosc Clin N Am. 2009 Oct;19(4):615-28.介绍了IDUS在诊断胆管不明原因狭窄、充盈缺损及壶腹部肿瘤方面有重要意义。

6. Can endoscopic palliation of large neoplasm increase the risk of pancreatitis after endoscopic retrograde cholangiopancreatography?讨论了ERCP术后胰腺炎的危险因素，认为预防性胰管支架置入是预防术后胰腺炎的有效方法，但需要更多的随机对照研究来证实。

7. Magnetic resonance cholangio-pancreatography versus endoscopic retrograde cholangio-pancreatography in the diagnosis of common bile duct stones: a prospective comparative study. Minerva Med. 2009 Oct;100(5):341-8.一项MRCP与ERCP在诊断胆总管结石方面的前瞻性对照研究，认为MRCP在诊断小结石方面有局限性，但何种病人采取哪种检查方法仍然难以确定。

8. Pancreaticopleural fistula: a rare complication of ERCP-induced pancreatitis. Sut M, Gray R, Ramachandran M, Diamond T.Ulster Med J. 2009 Sep;78(3):185-6. No abstract available. PMID: 19907687 [PubMed - in process]报道一例ERCP术后胰腺炎并发胰胸膜瘘患者，最终行外科手术分析了在胰管正常的患者为了预防ERCP术后胰腺炎放置胰管支架引起的胰管损伤的情况，提示这类患者放置支架需谨慎小心。

注: 所有文献及摘要均来自Pubmed, 如果需要全文可以申请文献传递。

——编者文献摘要1. Endoscopic Appearance of the Minor Papilla Predicts Findings at Pancreatography.Dig Dis Sci. 2009 Oct 29. [Epub ahead of print]Lawrence C, Stefan AM, Howell DA.Medical University of South Carolina, 25 Courtenay Drive, ART 7100A, Charleston, SC, 29425-2900, USA, Lawrench@.BACKGROUND: The minor papilla serves as a site of alternative pancreatic duct drainage via the accessory pancreatic duct. AIMS: The objectives of this study were to assess the endoscopic appearance of the minor papilla for characteristics that might predict increased accessory pancreatic duct flow and hence suggest pathology of the downstream pancreatic ductal system. METHODS: This was a nonrandomized, prospective analysis of consecutively enrolled patients from a tertiary care medical center (Maine Medical Center, Portland, Maine). The study cohort consisted of consecutive patients presenting for endoscopic retrograde cholangiopancreatography (ERCP) without prior pancreaticobiliary endotherapy or ductography. RESULTS: Sixty-four patients received a minor papilla score prior to ERCP. A normal pancreatogram was found in 37 of 64 (57.8%) patients; the remaining 27 (42.2%) patients had an abnormal pancreatogram. The median minor papilla bulge score was 0.49 (range 0-3) in the normal pancreatogram group and 2 (range 0-3) in the abnormal pancreatogram group (P < 0.0001). The median minor papilla orifice score of those with a normal pancreatogram was 0 (range 0-2) compared to 2 (range 0-3) in the abnormal pancreatogram group (P < 0.001). The median minor papilla cumulative score of 1 (range 0-5) for the normal pancreatogram group was significantly less than that for the abnormal pancreatogram group (3, range 0-6, P < 0.0001), resulting in a sensitivity of 96.3% for an abnormal pancreatogram. The minor papilla orifice was noted to be either gaping or actively dripping pancreatic juice in four out of five patients with pancreas divisum. CONCLUSIONS: A minor papilla without bulging or a visible orifice would suggest a normal pancreatogram at ERP. Conversely, an abnormal minor papilla, particularly a patent minor papilla orifice, should raise suspicion of pancreatic ductal pathology and can help direct pancreatic endotherapy at the major or minor papillae.2. Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video).Gastrointest Endosc. 2009 Nov 16. [Epub ahead of print]CotéGA, Ansstas M, Pawa R, Edmundowicz SA, Jonnalagadda SS, Pleskow DK, Azar RR.Current affiliations: Division of Gastroenterology (G.A.C.), Indiana University, Indianapolis, Indiana, Department of Medicine (M.A., S.A.E., S.S.J., R.R.A.), Division of Gastroenterology, Washington University, St. Louis, Missouri, Department of Medicine (R.P., D.K.P.), Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.BACKGROUND: Successful cannulation of the common bile duct (CBD) remains the benchmark for ERCP. Use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, although the majority of patients require precut sphincterotomy to achieve CBD cannulation. OBJECTIVE: To report the performance characteristics of using a PD stent in conjunction with physician-controlled wire-guided cannulation (WGC) to facilitate bile duct cannulation. DESIGN: Retrospective cohort. SETTING: Two tertiary care, academic medical centers. PATIENTS: All undergoing ERCP with native papillae. INTERVENTION: In cases of difficult biliary access in which the PD is cannulated, a pancreatic stent is placed. After this, physician-controlled WGC is attempted by using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated. MAIN OUTCOME MEASUREMENTS: Frequency of successful bile duct cannulation and precut sphincterotomy. RESULTS: A total of 2345 ERCPs were identified, 1544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%) patients, whereas 76 (4.9%) patients receiveda PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71(93.4%) of 76 patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage, controlled during the procedure in 2 (13.3%) of 15. CONCLUSIONS: Physician-controlled WGC over aPD stent facilitates biliary cannulation while maintaining a low rate of precut sphincterotomy.PMID: 19922927 [PubMed - as supplied by publisher]3. A case of intraductal papillary mucinous neoplasm of the pancreas rupturing both the stomach and duodenum.Gastrointest Endosc. 2009 Nov 16. [Epub ahead of print]Shimizu M, Kawaguchi A, Nagao S, Hozumi H, Komoto S, Hokari R, Miura S, Hatsuse K, Ogata S.Current affiliations: Department of Internal Medicine, Division of Gastroenterology and Hepatology (M.S., A.K., S.N., H.H., S.K., R.H., S.M.), Departments of Surgery (K.H.) and Clinical Pathology (S.O.), National Defense Medical College, Saitama, Japan.BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas may extend to other organs. However, it is rare for a histopathologically benign IPMN to rupture other organs, particularly multiple organs. There has been no report of a benign IPMN rupturing both the stomach and duodenum. OBJECTIVE: We experienced a very rare case and make personal remarks based on bibliographical consideration. DESIGN: Case report. SETTING: National Defense Medical College. PATIENT: A patient with IPMN. INTERVENTION: EGD, ERCP, and pancreatoduodenectomy. CONCLUSIONS: We report a case of benign IPMN of the pancreas extending to two adjacent organs. A 77-year-old male who was diagnosed as having IPMN by CT, MRI, upper GIF, and ERCP underwent pancreatoduodenectomy for a mass of 4.2 cm in diameter. Pathological examinations revealed that the IPMN was composed of adenoma. Intraluminal nodular growth was observed in the duodenal gland tissue, and abnormal growth was observed in the fistula to the stomach. According to a literature review based on PubMed data up until March 2009, it is rare for a benign IPMN to penetrate two adjacent organs.PMID: 19922925 [PubMed - as supplied by publisher]4. Face and construct validity of a computer-based virtual reality simulator for ERCP. Gastrointest Endosc. 2009 Nov 16. [Epub ahead of print]Bittner JG 4th, Mellinger JD, Imam T, Schade RR, Macfadyen BV Jr.Current affiliations: Department of Surgery (J.G.B., J.D.M., B.V.M.), the Virtual Education and Surgical Simulation Laboratory (J.G.B., J.D.M., T.I., B.V.M.), and the Department of Medicine, Section of Gastroenterology and Hepatology (R.R.S.), Medical College of Georgia School of Medicine, Augusta, Georgia, Department of Surgery (T.I.), Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.BACKGROUND: Currently, little evidence supports computer-based simulation for ERCP training. OBJECTIVE: To determine face and construct validity of a computer-based simulator for ERCP and assess its perceived utility as a training tool. DESIGN: Novice and expert endoscopists completed 2 simulated ERCP cases by using the GI Mentor II. SETTING: Virtual Education and Surgical Simulation Laboratory, Medical College of Georgia. MAIN OUTCOME MEASUREMENTS: Outcomes included times to complete the procedure, reach the papilla, and use fluoroscopy; attempts to cannulate the papilla, pancreatic duct, and common bile duct; and number of contrast injections and complications. Subjects assessed simulator graphics, procedural accuracy, difficulty, haptics, overall realism, and training potential. RESULTS: Only when performance data from cases A and B were combined did the GI Mentor II differentiate novices and experts based on times to complete the procedure, reach the papilla, and use fluoroscopy. Across skill levels, overall opinions were similar regarding graphics (moderately realistic), accuracy (similar to clinical ERCP), difficulty (similar to clinical ERCP), overall realism (moderately realistic), and haptics. Most participants (92%) claimed that the simulator has definite training potential or should be required for training. LIMITATIONS: Small sample size, single institution. CONCLUSIONS: The GI Mentor II demonstrated construct validity for ERCP based on select metrics. Most subjects thought that the simulated graphics, procedural accuracy, and overall realism exhibit face validity. Subjects deemed it a useful training tool. Study repetition involving more participants and cases may help confirm results and establish the simulator's ability to differentiate skill levels based on ERCP-specific metrics.PMID: 19922914 [PubMed - as supplied by publisher]5. Clinical application of intraductal ultrasound during endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am.2009 Oct;19(4):615-28.Kundu R, Pleskow D.Division of Gastroenterology, UCSF Fresno, 2823 Fresno Street, 1st Floor Endoscopy Suite, Fresno, CA 93721, USA.Intraductal ultrasound (IDUS) used during endoscopic retrograde cholangiopancreatography (ERCP) can facilitate reliable evaluation of biliary and pancreatic disorders. The smaller diameter, flexibility, and the image quality offered by IDUS devices makes them ideal for evaluating a variety of difficult biliary and pancreatic diseases, especially in undefined strictures, luminal filling defects, and ampullary neoplasms. This article examines the numerous possible roles for IDUS in the evaluation of biliary and pancreatic conditions, as well as in ampullary neoplasms. IDUS is a simple, easy to learn, and safe technique that should be considered an integral tool in the therapeutic endoscopist's armamentarium.PMID: 19917467 [PubMed - in process]6. Can endoscopic palliation of large neoplasm increase the risk of pancreatitis after endoscopic retrograde cholangiopancreatography?Surg Endosc. 2009 Nov 13. [Epub ahead of print]Fanello G, Fiocca F, Benedetti M, Martino G, Marengo M, Meniconi RL, Papini F, Chirletti P.Surg Endosc. 2009 Nov 13. [Epub ahead of print] No abstract available. PMID: 19911230 [PubMed - as supplied by publisher]Related articlesWhen the main pancreatic duct cannulation is obtained，first, as often happens if the neoplastic lesion does not involve the duct, the clinician should place a pancreatic stent at once before proceeding to the CBD. The use of small-caliber (maximum, 5 Fr) short (2–3 cm) stents and elimination of flaps before insertion allow a spontaneous migration in 2 to 3 weeks without the need for endoscopic removal. Pancreatic stent positioning is recommended for patients with suspected or confirmed sphincter of Oddi dysfunction or a history of PEAP orrecurrent pancreatitis and for patients who have undergone repeated pancreatic duct injection, precut sphincterotomy, pancreatic sphincterotomy, or balloon dilation of the biliarysphincter . Although we agree withthese recommendations, we believe that the risk of PEAP could be higher also with voluminous pancreatic tumors. Therefore, for these patients, prophylactic pancreatic stenting may be considered, if technically feasible, to reduce the risk of thiscomplication. Further randomized controlled studies areneeded to validate our proposal.7. Magnetic resonance cholangio-pancreatography versus endoscopic retrograde cholangio-pancreatography in the diagnosis of common bile duct stones: a prospective comparative study.Minerva Med. 2009 Oct;100(5):341-8.Scaffidi MG, Luigiano C, Consolo P, Pellicano R, Giacobbe G, Gaeta M, Blandino A, Familiari L.Department of Medicine and Pharmacology, University of Messina, Messina, Italy - carmeluigiano@libero.it.AIM: As it is a non-invasive method, magnetic resonance cholangiography (MRCP) has almost completely replaced endoscopic retrograde cholangiography (ERCP) in the diagnosis of pancreato-biliary diseases. The aim of this study was to evaluate sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MRCP in diagnosis of choledocholithiasis using ERCP/endoscopic sphincterotomy (ES) as gold standard. METHODS: For this study 140 individuals, suspected for lithiasis of the common bile duct (CBD), were enrolled. After a clinical and biochemical evaluation, patients underwent upper abdominal ultrasonography, then MRCP and diagnostic and/or operative ERCP. RESULTS: Only 120 out of 140 patients completed the study. MRCP diagnosed lithiasis of CBD in 84. ERCP confirmed the lithiasis in 73/84 patients who were submitted to ES. Eleven were negative after ES. ERCP documented stones in 10 patients among the 36 negative at MRCP; stones were detected only in four patients after ES. In 26 out of 36 patients negative at MRCP, ERCP confirmed this response: only 12 out of 26 patients underwent ES. The sensitivity, specificity, diagnostic accuracy, PPV and NPV of MRCP were: 88%, 72%, 83%, 87%, 72%. CONCLUSIONS: As the MRCP diagnostic yield is still limited with small stones, the question of which patient is the best candidate to ERCP/ES is still unsolved.8. Pancreaticopleural fistula: a rare complication of ERCP-induced pancreatitis. Sut M, Gray R, Ramachandran M, Diamond T.Ulster Med J. 2009 Sep;78(3):185-6. No abstract available. PMID: 19907687 [PubMed - in process]9. Significant clinical implications of prophylactic pancreatic stent placement in previously normal pancreatic ducts.Endoscopy.2009 Nov 10. [Epub ahead of print]Bakman YG, Safdar K, Freeman ML.Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.Pancreatic duct stent placement is increasingly performed for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP); however stents can result in injury especially in normal ducts. The clinical significance and outcomes of subsequent endoscopic therapy are unknown. This study was a retrospective review of the management of symptomatic stent-inducedpancreatic duct injury following stent placement for prevention of post-ERCP pancreatitis in eight patients with previously normal pancreatic ducts. Subsequent treatment included pancreatic sphincterotomy, balloon dilation of stricture, and placement of multiple 3 - 5-Fr soft polymer pancreatic stents. All patients showed improvement or resolution of pancreatic strictures. Five patients had resolution or substantial improvement of pain, one patient showed a fair response with repeated ERCPs, and two patients failed to respond and underwent total pancreatectomy with islet autotransplantation. Pancreatic duct stent-induced ductal injury with significant clinical consequences can occur with conventional polyethylene stents. Endoscopic therapy is moderately effective but some patients develop irreversible damage. Caution should be used when placing standard polyethylene stents in normal ducts. Further research is required to identify safer materials and configurations of pancreatic stents.。