BACKGROUND Esophageal cancer is a clinically common malignant tumor of the digestive sys-tem.In 2022,it ranked fifth among the leading causes of cancer-related deaths in China.Its predominant symptom is dysphagia,and ...BACKGROUND Esophageal cancer is a clinically common malignant tumor of the digestive sys-tem.In 2022,it ranked fifth among the leading causes of cancer-related deaths in China.Its predominant symptom is dysphagia,and approximately 30%–40%of patients are prone to developing postoperative recurrent stenosis,necessitating repeated esophageal dilation,which significantly affects patients’quality of life.The self-dilation technique,performed by patients,enables preventive esophageal dilation and aims to reduce the frequency of recurrent stenosis.CASE SUMMARY We report the case of a 61-year-old man who underwent repeated esophageal di-lations following endoscopic submucosal dissection.During his eighth hospital admission,a multidisciplinary management team was established to implement an evidence-based self-help balloon dilation technique,facilitate early identifi-cation of nursing concerns and complications,and provide transitional care fo-llowing discharge.The patient reported a high level of satisfaction during the hospital stay.During the 6-month follow-up after discharge,the patient’s quality of life improved,with a substantial reduction in dysphagia.The esophageal stric-ture was successfully dilated from 5 mm to 6 mm,the interval between readmi-ssions was prolonged,and the patient’s weight increased from 49 kg to 50 kg.CONCLUSION The establishment of a multidisciplinary case management team,combined with the implementation of a self-help balloon dilation technique,early identification and management of nursing issues and complications,and person-alized extended care,can significantly enhance patient satisfaction during hospitalization,improve quality of life,and extend the interval between readmissions.These strategies can provide valuable practical guidance for the clinical treatment and nursing of patients with recurrent esophageal stenosis.展开更多
AIM:To compare the efficacy of different administration regimens of compound tropicamide eyedrops(CTE)for pupil dilation for children with dark iris.METHODS:A prospective,comparative,randomized interventional study wa...AIM:To compare the efficacy of different administration regimens of compound tropicamide eyedrops(CTE)for pupil dilation for children with dark iris.METHODS:A prospective,comparative,randomized interventional study was conducted.Children in Group 1 received CTE 3 times with a 3min interval between each application.Children in Group 2 received CTE 4 times with a 5min interval between each application.We measured their pupil diameters at baseline(pre-drug instillation)and 30min and 60min post-drug instillation and assessed the pupillary light reflex at 60min post-drug instillation.RESULTS:In total,194 eyes of 101 children were enrolled.The changes of pupil diameter at 30min and 60min post-drug instillation were 1.2±0.6 mm and 2.3±1.0 mm in Group 1,and 2.3±0.9 mm and 3.7±1.0 mm in Group 2,respectively.Group 2 showed a larger change in pupil size than Group 1 at 30min(P<0.01)and 60min(P<0.01).The effect of pupil dilation in Group 2 was 1.25 times that in Group 1.The change in pupil size was positively associated with age.A higher proportion of children in Group 1 had smaller pupil diameter and reactive pupils at the final time point,with only 33 children(33.7%)had final pupil size≥6.5 mm,and only 9 children(9.2%)had non-reactive pupils.Children in Group 2 achieved larger pupil diameter and more nonreactive pupils at the final time point,with 84 children(87.5%)had final pupil size≥6.5 mm,and only 22 children(22.9%)had reactive pupils.CONCLUSION:Increasing the frequency of compound tropicamide and lengthening the interval between eye drop applications can produce stronger mydriatic effects.展开更多
Notch1 is a mechanosensitive endothelial receptor that responds to vascular wall shear stress.However,data on Notch1 activity in humans remains limited,particularly regarding its role in endothelial function.Objective...Notch1 is a mechanosensitive endothelial receptor that responds to vascular wall shear stress.However,data on Notch1 activity in humans remains limited,particularly regarding its role in endothelial function.Objectives:Accordingly,the purpose of this study was to determine whether Notch1 is associated with the flow-mediated dilatory(FMD)response and whether it is related to aerobic fitness.A secondary purpose was to determine whether Notch1 is related to concentrations of vascular endothelial growth factor(VEGF).Methods:Sixteen(8M/8F)young(20-30 yrs old)and healthy(BMI:25±4.2 kg/m^(2),blood pressure:117±11.63/69±11.25 mmHg)adults participated in the study.Aerobic fitness was determined by cycle VO_(2) peak.An FMDwas performed on the brachial artery,and blood samples were taken from an antecubital vein at rest(baseline)and 1min after cuff deflation(to align with peak vessel dilation).Concentrations of Notch1 extracellular domain(NECD)and VEGFwere determined from plasma using enzyme-linked immunosorbent assays.Results:In contrast to our hypothesis,concentrations of NECD and VEGF did not change throughout the FMDandwere unrelated to allometrically scaled FMD values(p all>0.05).Likewise,there was no relationship between changes inNECD and VEGF(p=0.331,r=0.127).However,the change in NECD across the FMD was moderately(r=0.515)and significantly(p=0.024)correlated with VO_(2) peak.Conclusions:These novel data indicate that in healthy young adults,Notch1 activity is linked to aerobic fitness but may not be acutely involved in the shear-mediated vasodilatory response.展开更多
BACKGROUND Intrahepatic and extrahepatic bile duct stones(BDSs)have a high rate of residual stones,a high risk of recurrence,and a high rate of reoperation.It is very important to take timely and effective surgical in...BACKGROUND Intrahepatic and extrahepatic bile duct stones(BDSs)have a high rate of residual stones,a high risk of recurrence,and a high rate of reoperation.It is very important to take timely and effective surgical intervention for patients.AIM To analyze the efficacy,postoperative rehabilitation,and quality of life(QoL)of patients with intra-and extrahepatic BDSs treated with endoscopic retrograde cholangiopancreatography(ERCP)+endoscopic papillary balloon dilation(EPBD)+laparoscopic hepatectomy(LH).METHODS This study selected 114 cases of intra-and extrahepatic BDSs from April 2021 to April 2024,consisting of 55 cases in the control group receiving laparoscopic common bile duct exploration and LH and 59 cases in the observation group treated with ERCP+EPBD+LH.Efficacy,surgical indicators[operation time(OT)and intraoperative blood loss(IBL)],postoperative rehabilitation(time for body temperature to return to normal,time for pain relief,and time for drainage to reduce jaundice),hospital stay,medical expenses,and QoL[Gastrointestinal Quality of Life Index(GIQLI)]were comparatively analyzed.Further,Logistic regression analysis was conducted to analyze factors influencing the QoL of patients with intra-and extrahepatic BDSs.RESULTS The data demonstrated a higher overall effective rate in the observation group compared to the control group(P=0.011),together with notably reduced OT,less IBL,shorter body temperature recovery time,pain relief time,time for drainage to reduce jaundice,and hospital stay(all P<0.05).The postoperative GIQLI of the observation group was more significantly increased compared to the control group(P<0.05).The two groups demonstrated no marked difference in medical expenses(P>0.05).CONCLUSION The above indicates that ERCP+EPBD+LH is effective in treating patients with intra-and extrahepatic BDSs,which is conducive to postoperative rehabilitation and QoL improvement,with promising prospects for clinical promotion.展开更多
BACKGROUND Repeated endoscopic probe dilatation is the most preferred treatment for esophageal stenosis which may cause high levels of symptom distress in the patient’s home rehabilitation stage.AIM To explore the ch...BACKGROUND Repeated endoscopic probe dilatation is the most preferred treatment for esophageal stenosis which may cause high levels of symptom distress in the patient’s home rehabilitation stage.AIM To explore the changes in the symptom distress level and its correlation with the dilation effect in patients with esophageal carcinoma undergoing repeated dilations for lumen stenosis.METHODS The difference(R2-R1)between the diameter of the esophageal stenosis opening(R1)of the patients before dilation(R1)and after dilation(R2)was calculated to describe the extent and expansion of the esophageal stenosis before and after dilation.The M.D.Anderson Symptom Inventory was used to describe the symptom distress level of patients with dilation intermittence during their stay at home and to explore the correlation between the dilation effect and symptom distress level.RESULTS The diameter of the esophagus(R1)increased before each dilation in patients undergoing esophageal dilation(P<0.05).The diameter(R2)increased after dilation(P<0.05);the dilation effect(R2-R1)decreased with the number of dilations(P<0.05).The total symptom distress score significantly increased with the number of dilations(P<0.05).The symptom distress scores of the patients were negatively correlated(P<0.05)with the previous dilation effect(R2-R1)and the esophageal diameter(R2)after the previous dilation.After the 1 st to 4 th dilations,the patient’s symptom distress score was negatively correlated with the esophageal diameter(R12)before the next dilation,while there was no significant correlation(P>0.05)with the other dilations.CONCLUSION In patients who have undergone repeated dilations,better effect stands for lower symptom distress level and the increase in symptom distress has a prompt effect on the severity of the next occurrence of restenosis.展开更多
Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endos...Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation(EPLBD) can facilitate the removal of large CBD stones.The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.展开更多
Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sp...Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.展开更多
AIM: To investigate the combined antegraderetrograde endoscopic rendezvous technique for complete oesophageal obstruction and the swallowing outcome.METHODS: This single-centre case series includes consecutive patient...AIM: To investigate the combined antegraderetrograde endoscopic rendezvous technique for complete oesophageal obstruction and the swallowing outcome.METHODS: This single-centre case series includes consecutive patients who were unable to swallow due to complete oesophageal obstruction and underwent combined antegrade-retrograde endoscopic dilation(CARD) within the last 10 years. The patients' demographic characteristics, clinical parameters, endoscopic therapy, adverse events, and outcomes were obtained retrospectively. Technical success was defined as effective restoration of oesophageal patency. Swallowing success was defined as either percutaneous endoscopic gastrostomy(PEG)-tube independency and/or relevant improvement of oral food intake, as assessed by the functional oral intake scale(FOIS)(≥ level 3).RESULTS: The cohort consisted of six patients [five males; mean age 71 years(range, 54-74)]. All but one patient had undergone radiotherapy for head and neck or oesophageal cancer. Technical success was achieved in five out of six patients. After discharge, repeated dilations were performed in all five patients. During follow-up(median 27 mo, range, 2-115), three patients remained PEG-tube dependent. Three of four patients achieved relevant improvement of swallowing(two patients: FOIS 6, one patient: FOIS 7). One patient developed mediastinal emphysema following CARD, without a need for surgery.CONCLUSION: The CARD technique is safe and a viable alternative to high-risk blind antegrade dilation in patients with complete proximal oesophageal obstruction. Although only half of the patients remained PEG-tube independent, the majority improved their ability to swallow.展开更多
AIM To report data on Dilation-Assisted Stone Extraction(DASE) use in clinical practice and its efficacy and safety trough three Italian referral centers for biliopancreatic diseases treatment. METHODS From January 20...AIM To report data on Dilation-Assisted Stone Extraction(DASE) use in clinical practice and its efficacy and safety trough three Italian referral centers for biliopancreatic diseases treatment. METHODS From January 2011 to December 2015 we collected data on 120 patients treated with DASE. Technical success was obtained when the endoscopist was able to place the balloon trough the papilla inflating the balloon until the final diameter for an adequate time(at least 30 s). Clinical success was obtained after complete stone removal(no remaining stones were visible at the cholangiogram).RESULTS Forty-nine male(40.8%) and 71 female(59%) were enrolled. The mean age was 67.8 years ± 15.7. The mean common bile duct(CBD) dilation was 19.2 mm± 3.9 and the mean size of stones 15.8 ± 2.9. DASE was applied as first approach in 38%(62% after initial failure of stones extraction). Technical and clinical success was of 91% and 87% respectively. In those in which DASE failed alternative treatment were adopted. After DASE 18% of patients experienced a complication(bleeding 9%, pancreatitis 8%, perforation 0.8%). At univariable analysis, elective endoscopic retrograde cholangiopancreatography(P = 0.031), DASE as first approach(P = 0.032), and cannulation of major papilla followed by guidewire insertion(P = 0.004) were related to low risk of complications. Pre-cut was related to an increased risk of complications(P = 0.01). CONCLUSION DASE allowed a higher first-session success rate and can be consider a valid alternative to endoscopic sphincterotomy not only for bigger CBD stones.展开更多
BACKGROUND Crohn’s disease(CD)has a multitude of complications including intestinal strictures from fibrostenotic disease.Fibrostenotic disease has been reported in 10%-17%of children at presentation and leads to sur...BACKGROUND Crohn’s disease(CD)has a multitude of complications including intestinal strictures from fibrostenotic disease.Fibrostenotic disease has been reported in 10%-17%of children at presentation and leads to surgery in 20%-50%of cases within ten years of diagnosis.When symptoms develop from these strictures,the treatment in children has primarily been surgical resection.Endoscopic balloon dilation(EBD)has been shown to be a safe and efficacious alternative to surgery in adults,but evidence is poor in the literature regarding its safety and efficacy in children.AIM To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.METHODS In a single-center retrospective study,we looked at pediatric patients(ages 0-18)who carry the diagnosis of CD,who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1,2012 through May 1,2019.We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype.The type of intervention for patients’strictures was then identified through procedural and surgical billing codes.We evaluated their demographics,clinical variables,whether they underwent EBD vs surgery or both,and their clinical outcomes.RESULTS Of the 139 patients with CD,25(18%)developed strictures.The initial intervention for a stricture was surgical resection in 12 patients(48%)and EBD in 13 patients(52%).However,4(33%)patients whom initially had surgical resection required follow up EBD,and thus 17 total patients(68%)underwent EBD at some point in their treatment process.For those 8 patients who underwent successful surgical resection alone,4 of these patients(50%)had a fistula present near the stricture site and 4(50%)had strictures greater than 5 cm in length.All patients who underwent EBD had no procedural complications,such as a perforation.Twenty-two(88%)of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.CONCLUSION EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.展开更多
BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.AIM To assess the feasibility of balloon dilation to remove difficult stones in pat...BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.AIM To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.METHODS Data from 1289 endoscopic retrograde cholangiopancreatography(ERCP)procedures were obtained from two prospective studies.While 258 cases had difficult stones(>1 cm,multiple>8,impacted,or having a thin distal duct),191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy.Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number.Primary outcomes were clearance rate at first ERCP and complications.RESULTS Of the 191 patients(122 women and 69 men;mean age:60 years)who underwent biliary dilation for difficult stones,113(59%)had a nondilated or tapered distal duct.Patients with a dilated distal duct were older than those with nondilated distal ducts(mean 68 and 52 years of age,respectively;P<0.05),had more stones(median 4 and 2 stones per patient,respectively;P<0.05),and had less need for additional mechanical lithotripsy(6.4%vs 25%,respectively;P<0.05).Clearance rate at first ERCP was comparable between patients with a dilated(73/78;94%)and nondilated distal ducts(103/113;91%).Procedures were faster in patients with a dilated distal duct(mean 17 vs 24 min,respectively;P<0.005).Complications were similar in both groups(6.4%vs 7.1%,respectively).CONCLUSION Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.展开更多
Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography.Endoscopic sphincterotomy(EST)has been used for the removal of bile du...Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography.Endoscopic sphincterotomy(EST)has been used for the removal of bile duct stones for the past 40 years,providing a wide opening to allow extraction.Up to 15%of patients present with complicated choledocholithiasis.In this context,additional therapeutic approaches have been proposed such as endoscopic mechanical lithotripsy,intraductal or extracorporeal lithotripsy,or endoscopic papillary large balloon dilation(EPLBD).EPLBD combined with EST was introduced in 2003 to facilitate the passage of large or multiple bile duct stones using a balloon greater than 12 mm in diameter.EPLBD without EST was introduced as a simplified technique in 2009.Dilation-assisted stone extraction(DASE)is the combination of two techniques:EPLBD and sub-maximal EST.Several studies have reported this technique as safe and effective in patients with large bile duct stones,without any increased risk of adverse events such as pancreatitis,bleeding,or perforation.Nevertheless,it is difficult to analyze the outcomes of DASE because there are no standard techniques and definitions between studies.The purpose of this paper is to provide technical guidance and specific information about the main issues regarding DASE,based on current literature and daily clinical experience in biliary referral centers.展开更多
AIM:To perform a meta-analysis of large-balloon dilation(LBD)plus endoscopic sphincterotomy(EST)vs EST alone for removal of bile duct stones.METHODS:Databases including PubMed,EMBASE,the Cochrane Library,the Science C...AIM:To perform a meta-analysis of large-balloon dilation(LBD)plus endoscopic sphincterotomy(EST)vs EST alone for removal of bile duct stones.METHODS:Databases including PubMed,EMBASE,the Cochrane Library,the Science Citation Index,and important meeting abstracts were searched and evaluated by two reviewers independently.The main outcome measures included:complete stone removal,stone removal in the first session,use of mechanical lithotripsy,procedure time,and procedure-related complications.A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio(OR)when heterogeneity was not significant among the studies.When a Q test or I2statistic indicated substantial heterogeneity,a random-effects model weighted by the DerSimonian-Laird method was used.RESULTS:Six randomized controlled trials involving835 patients were analyzed.There was no significant heterogeneity for most results;we analyzed these using a fixed-effects model.Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone(OR=0.53,95%CI:0.33-0.85,P=0.008);sub-category analysis indicated a significantly lower risk of perforation in the EST plus LBD group(Peto OR=0.14,95%CI:0.20-0.98,P=0.05).Use of mechanical lithotripsy in the EST plus LBD group decreased significantly(OR=0.26,95%CI:0.08-0.82,P=0.02),especially in patients with a stone size larger than 15 mm(OR=0.15,95%CI:0.03-0.68,P=0.01).There were no significant differences between the two groups regarding complete stone removal,stone removal in the first session,post-endoscopic retrograde cholangiopancreatography pancreatitis,bleeding,infection of biliary tract,and procedure time.CONCLUSION:EST plus LBD is an effective approach for the removal of large bile duct stones,causing fewer complications than EST alone.展开更多
AIM:To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation(EPLBD)for bile duct stone extraction in patients with periampullary diverticula.METHODS:The records of 223 patients with larg...AIM:To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation(EPLBD)for bile duct stone extraction in patients with periampullary diverticula.METHODS:The records of 223 patients with large common bile duct stones(≥10 mm)who underwent EPLBD(12-20 mm balloon diameter)with or without limited endoscopic sphincterotomy(ES)from July 2006to April 2011 were retrospectively reviewed.Of these patients,93(41.7%)had periampullary diverticula(PAD),which was categorized into three types.The clinical variables of EPLBD with limited ES(EPLBD+ES)and EPLBD alone were analyzed according to the presence of PAD.RESULTS:Patients with PAD were significantly older than those without(75.2±8.8 years vs 69.7±10.9years,P=0.000).The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and nonPAD groups,however,there was significantly less need for mechanical lithotripsy in the PAD group(3.2%vs 11.5%,P=0.026).Overall stone removal rates,complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD+ES and EPLBD alone in patients with PAD(96.6%vs 97.1%;72.9%vs 88.2%;and 5.1%vs 0%,respectively).No significant differences with respect to the rates of pancreatitis,perforation,and bleeding were observed between EPLBD+ES and EPLBD alone in the PAD group(3.4%vs 14.7%,P=0.095;0%vs 0%;and 3.4%vs 8.8%,P=0.351,respectively).CONCLUSION:EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD,regardless of PAD subtypes.展开更多
AIM: To evaluate the efficacy and safety of endoscopic papillary large diameter balloon dilation (EPLBD) following limited endoscopic sphincterotomy (EST) and EST alone for removal of large common bile duct (CBD) stones.
Endoscopic papillary large balloon dilation(EPLBD)with endoscopic sphincterotomy(EST)has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy(EML)for the removal of large or difficul...Endoscopic papillary large balloon dilation(EPLBD)with endoscopic sphincterotomy(EST)has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy(EML)for the removal of large or difficult bile duct stones.Furthermore,EPLBD without EST was recently introduced as its simplified alternative technique.Thus,we systematically searched PubMed,Medline,the Cochrane Library and EMBASE,and analyzed all gathered data of EPLBD with and without EST,respectively,by using a single standardized definition,reviewing relevant literatures,published between 2003and June 2013,where it was performed with largediameter balloons(12-20 mm).The outcomes,including the initial success rate,the rate of needs for EML,and the overall success rate,and adverse events were assessed in each and compared between both of two procedures:"EPLBD with EST"and"EPLBD without EST".A total of 2511 procedures from 30 published articles were included in EPLBD with EST,while a total of413 procedures from 3 published articles were included in EPLBD without EST.In the results of outcomes,the overall success rate was 96.5%in EPLBD with EST and97.2%in EPLBD without EST,showing no significant difference between both of them.The initial success rate(84.0%vs 76.2%,P<0.001)and the success rate of EPLBD without EML(83.2%vs 76.7%,P=0.001)was significantly higher,while the rate of use of EML was significantly lower(14.1%vs 21.6%,P<0.001),in EPLBD with EST.The rate of overall adverse events,pancreatitis,bleeding,perforation,other adverse events,surgery for adverse events,and fatal adverse events were 8.3%,2.4%,3.6%,0.6%,1.7%,0.2%and 0.2%in EPLBD with EST and 7.0%,3.9%,1.9%,0.5%,0.7%,0%and 0%in EPLBD without EST,respectively,showing no significant difference between both of them.In conclusion,recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events,when performed under appropriate guidelines.展开更多
AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS:...AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS: There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047). CONCLUSION: Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.展开更多
AIM: To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (≥ 10 mm).
AIM:To evaluate the efficacy and safety of endoscopic sphincterotomy(EST) + endoscopic papillary large balloon dilation(EPLBD)vs isolated EST.METHODS:We conducted a retrospective single center study over two years,fro...AIM:To evaluate the efficacy and safety of endoscopic sphincterotomy(EST) + endoscopic papillary large balloon dilation(EPLBD)vs isolated EST.METHODS:We conducted a retrospective single center study over two years,from February 2010 to January 2012.Patients with large(≥ 10 mm),single or multiple bile duct stones(BDS),submitted to endoscopic retrograde cholangio-pancreatography(ERCP) were included.Patients in Group A underwent papillary large balloon dilation after limited sphincterotomy(EST+EPLBD),using a through-the-scope balloon catheter gradually inflated to 12-18 mm according to the size of the largest stone and the maximal diameter of the distal bile duct on the cholangiogram.Patients in Group B(control group) underwent isolated sphincterotomy.Stones were removed using a retrieval balloon catheter and/or a dormia basket.When necessary,mechanical lithotripsy was performed.Complete clearance of the bile duct was documented with a balloon catheter cholangiogram at the end of the procedure.In case of residual lithiasis,a double pigtail plastic stent was placed and a second ERCP was planned within 4-6 wk.Some patients were sent for extracorporeal lithotripsy prior to subsequent ERCP.Outcomes of EST+EPLBD(Group A) vs isolated EST(Group B) were compared regarding efficacy(complete stone clearance,number of therapeutic sessions,mechanical and/or extracorporeal lithotripsy,biliary stent placement) and safety(frequency,type and grade of complications).Statistical analysis was performed using χ 2 or Fisher’s exact tests for the analysis of categorical parameters and Student’s t test for continuous variables.A P-value of less than 0.05 was considered statistically significant.RESULTS:One hundred and eleven patients were included,68(61.3%) in Group A and 43(38.7%) in Group B.The mean diameter of the stones was similar in the two groups(16.8 ± 4.4 and 16.0 ± 6.7 in Groups A and B,respectively).Forty-eight(70.6%) patients in Group A and 21(48.8%) in Group B had multiple BDS(P = 0.005).Overall,balloon dilation was performed up to 12 mm in 10(14.7%) patients,13.5 mm in 17(25.0%),15 mm in 33(48.6%),16.5 mm in 2(2.9%) and 18 mm in 6(8.8%) patients,taking into account the diameter of the largest stone and that of the bile duct.Complete stone clearance was achieved in sixty-five(95.6%) patients in Group A vs 30(69.8%) patients in Group B,and was attained within the first therapeutic session in 82.4% of patients in Group A vs 44.2% in Group B(P 【 0.001).Patients submitted to EST+EPLBD underwent fewer therapeutic sessions(1.1 ± 0.3 vs 1.8 ± 1.1,P 【 0.001),and fewer required mechanical(14.7% vs 37.2%,P = 0.007) or extracorporeal(0 vs 18.6%,P 【 0.001) lithotripsy,as well as biliary stenting(17.6% vs 60.5%,P 【 0.001).The rate of complications was not significantly different between the two groups.CONCLUSION:EST+EPLBD is a safe and effective technique for treatment of difficult BDS,leading to high rates of complete stone clearance and reducing the need for lithotripsy and biliary stenting.展开更多
Radiologists first described the removal of bile duct stones using balloon dilation in the early 1980s.Recently,there has been renewed interest in endoscopic balloon dilation with a small balloon to avoid the complica...Radiologists first described the removal of bile duct stones using balloon dilation in the early 1980s.Recently,there has been renewed interest in endoscopic balloon dilation with a small balloon to avoid the complications of endoscopic sphincterotomy(EST)in young patients undergoing laparoscopic cholecystectomy.However,there is a disparity in using endoscopic balloon papillary dilation(EPBD)between the East and the West,depending on the origin of the studies.In the early 2000s,EST followed by endoscopic balloon dilation with a large balloon was introduced to treat large or difficult biliary stones.Endoscopic balloon dilation with a large balloon has generally been recognized as an effective and safe method,unlike EPBD.However,fatal complications have occurred in patients with endoscopic papillary large balloon dilation(EPLBD).The safety of endoscopic balloon dilation is still a debatable issue.Moreover,guidelines of indications and techniques have not been established in performing endoscopic balloon dilation with a small balloon or a large balloon.In this article,we discuss the issue of conventional and large balloon endoscopic dilation.We also suggest the indications and optimal techniques of EPBD and EPLBD.展开更多
文摘BACKGROUND Esophageal cancer is a clinically common malignant tumor of the digestive sys-tem.In 2022,it ranked fifth among the leading causes of cancer-related deaths in China.Its predominant symptom is dysphagia,and approximately 30%–40%of patients are prone to developing postoperative recurrent stenosis,necessitating repeated esophageal dilation,which significantly affects patients’quality of life.The self-dilation technique,performed by patients,enables preventive esophageal dilation and aims to reduce the frequency of recurrent stenosis.CASE SUMMARY We report the case of a 61-year-old man who underwent repeated esophageal di-lations following endoscopic submucosal dissection.During his eighth hospital admission,a multidisciplinary management team was established to implement an evidence-based self-help balloon dilation technique,facilitate early identifi-cation of nursing concerns and complications,and provide transitional care fo-llowing discharge.The patient reported a high level of satisfaction during the hospital stay.During the 6-month follow-up after discharge,the patient’s quality of life improved,with a substantial reduction in dysphagia.The esophageal stric-ture was successfully dilated from 5 mm to 6 mm,the interval between readmi-ssions was prolonged,and the patient’s weight increased from 49 kg to 50 kg.CONCLUSION The establishment of a multidisciplinary case management team,combined with the implementation of a self-help balloon dilation technique,early identification and management of nursing issues and complications,and person-alized extended care,can significantly enhance patient satisfaction during hospitalization,improve quality of life,and extend the interval between readmissions.These strategies can provide valuable practical guidance for the clinical treatment and nursing of patients with recurrent esophageal stenosis.
基金Supported by the National Natural Science Foundation of China(No.82371093,No.72342015)R&D Program of Beijing Municipal Education Commission(No.KZ202110025039).
文摘AIM:To compare the efficacy of different administration regimens of compound tropicamide eyedrops(CTE)for pupil dilation for children with dark iris.METHODS:A prospective,comparative,randomized interventional study was conducted.Children in Group 1 received CTE 3 times with a 3min interval between each application.Children in Group 2 received CTE 4 times with a 5min interval between each application.We measured their pupil diameters at baseline(pre-drug instillation)and 30min and 60min post-drug instillation and assessed the pupillary light reflex at 60min post-drug instillation.RESULTS:In total,194 eyes of 101 children were enrolled.The changes of pupil diameter at 30min and 60min post-drug instillation were 1.2±0.6 mm and 2.3±1.0 mm in Group 1,and 2.3±0.9 mm and 3.7±1.0 mm in Group 2,respectively.Group 2 showed a larger change in pupil size than Group 1 at 30min(P<0.01)and 60min(P<0.01).The effect of pupil dilation in Group 2 was 1.25 times that in Group 1.The change in pupil size was positively associated with age.A higher proportion of children in Group 1 had smaller pupil diameter and reactive pupils at the final time point,with only 33 children(33.7%)had final pupil size≥6.5 mm,and only 9 children(9.2%)had non-reactive pupils.Children in Group 2 achieved larger pupil diameter and more nonreactive pupils at the final time point,with 84 children(87.5%)had final pupil size≥6.5 mm,and only 22 children(22.9%)had reactive pupils.CONCLUSION:Increasing the frequency of compound tropicamide and lengthening the interval between eye drop applications can produce stronger mydriatic effects.
基金supported by the Natural Sciences and Engineering Research Council of Canada(NSERC)Discovery Grant,held by Dr.Bain(RGPIN-2020-05760).
文摘Notch1 is a mechanosensitive endothelial receptor that responds to vascular wall shear stress.However,data on Notch1 activity in humans remains limited,particularly regarding its role in endothelial function.Objectives:Accordingly,the purpose of this study was to determine whether Notch1 is associated with the flow-mediated dilatory(FMD)response and whether it is related to aerobic fitness.A secondary purpose was to determine whether Notch1 is related to concentrations of vascular endothelial growth factor(VEGF).Methods:Sixteen(8M/8F)young(20-30 yrs old)and healthy(BMI:25±4.2 kg/m^(2),blood pressure:117±11.63/69±11.25 mmHg)adults participated in the study.Aerobic fitness was determined by cycle VO_(2) peak.An FMDwas performed on the brachial artery,and blood samples were taken from an antecubital vein at rest(baseline)and 1min after cuff deflation(to align with peak vessel dilation).Concentrations of Notch1 extracellular domain(NECD)and VEGFwere determined from plasma using enzyme-linked immunosorbent assays.Results:In contrast to our hypothesis,concentrations of NECD and VEGF did not change throughout the FMDandwere unrelated to allometrically scaled FMD values(p all>0.05).Likewise,there was no relationship between changes inNECD and VEGF(p=0.331,r=0.127).However,the change in NECD across the FMD was moderately(r=0.515)and significantly(p=0.024)correlated with VO_(2) peak.Conclusions:These novel data indicate that in healthy young adults,Notch1 activity is linked to aerobic fitness but may not be acutely involved in the shear-mediated vasodilatory response.
文摘BACKGROUND Intrahepatic and extrahepatic bile duct stones(BDSs)have a high rate of residual stones,a high risk of recurrence,and a high rate of reoperation.It is very important to take timely and effective surgical intervention for patients.AIM To analyze the efficacy,postoperative rehabilitation,and quality of life(QoL)of patients with intra-and extrahepatic BDSs treated with endoscopic retrograde cholangiopancreatography(ERCP)+endoscopic papillary balloon dilation(EPBD)+laparoscopic hepatectomy(LH).METHODS This study selected 114 cases of intra-and extrahepatic BDSs from April 2021 to April 2024,consisting of 55 cases in the control group receiving laparoscopic common bile duct exploration and LH and 59 cases in the observation group treated with ERCP+EPBD+LH.Efficacy,surgical indicators[operation time(OT)and intraoperative blood loss(IBL)],postoperative rehabilitation(time for body temperature to return to normal,time for pain relief,and time for drainage to reduce jaundice),hospital stay,medical expenses,and QoL[Gastrointestinal Quality of Life Index(GIQLI)]were comparatively analyzed.Further,Logistic regression analysis was conducted to analyze factors influencing the QoL of patients with intra-and extrahepatic BDSs.RESULTS The data demonstrated a higher overall effective rate in the observation group compared to the control group(P=0.011),together with notably reduced OT,less IBL,shorter body temperature recovery time,pain relief time,time for drainage to reduce jaundice,and hospital stay(all P<0.05).The postoperative GIQLI of the observation group was more significantly increased compared to the control group(P<0.05).The two groups demonstrated no marked difference in medical expenses(P>0.05).CONCLUSION The above indicates that ERCP+EPBD+LH is effective in treating patients with intra-and extrahepatic BDSs,which is conducive to postoperative rehabilitation and QoL improvement,with promising prospects for clinical promotion.
基金Supported by Natural Science Foundation of Guangdong Province of China,No.2017A030313449Science and Technology Planning Project of Guangdong Province of China,No.A2018057。
文摘BACKGROUND Repeated endoscopic probe dilatation is the most preferred treatment for esophageal stenosis which may cause high levels of symptom distress in the patient’s home rehabilitation stage.AIM To explore the changes in the symptom distress level and its correlation with the dilation effect in patients with esophageal carcinoma undergoing repeated dilations for lumen stenosis.METHODS The difference(R2-R1)between the diameter of the esophageal stenosis opening(R1)of the patients before dilation(R1)and after dilation(R2)was calculated to describe the extent and expansion of the esophageal stenosis before and after dilation.The M.D.Anderson Symptom Inventory was used to describe the symptom distress level of patients with dilation intermittence during their stay at home and to explore the correlation between the dilation effect and symptom distress level.RESULTS The diameter of the esophagus(R1)increased before each dilation in patients undergoing esophageal dilation(P<0.05).The diameter(R2)increased after dilation(P<0.05);the dilation effect(R2-R1)decreased with the number of dilations(P<0.05).The total symptom distress score significantly increased with the number of dilations(P<0.05).The symptom distress scores of the patients were negatively correlated(P<0.05)with the previous dilation effect(R2-R1)and the esophageal diameter(R2)after the previous dilation.After the 1 st to 4 th dilations,the patient’s symptom distress score was negatively correlated with the esophageal diameter(R12)before the next dilation,while there was no significant correlation(P>0.05)with the other dilations.CONCLUSION In patients who have undergone repeated dilations,better effect stands for lower symptom distress level and the increase in symptom distress has a prompt effect on the severity of the next occurrence of restenosis.
文摘Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation(EPLBD) can facilitate the removal of large CBD stones.The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.
文摘Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.
文摘AIM: To investigate the combined antegraderetrograde endoscopic rendezvous technique for complete oesophageal obstruction and the swallowing outcome.METHODS: This single-centre case series includes consecutive patients who were unable to swallow due to complete oesophageal obstruction and underwent combined antegrade-retrograde endoscopic dilation(CARD) within the last 10 years. The patients' demographic characteristics, clinical parameters, endoscopic therapy, adverse events, and outcomes were obtained retrospectively. Technical success was defined as effective restoration of oesophageal patency. Swallowing success was defined as either percutaneous endoscopic gastrostomy(PEG)-tube independency and/or relevant improvement of oral food intake, as assessed by the functional oral intake scale(FOIS)(≥ level 3).RESULTS: The cohort consisted of six patients [five males; mean age 71 years(range, 54-74)]. All but one patient had undergone radiotherapy for head and neck or oesophageal cancer. Technical success was achieved in five out of six patients. After discharge, repeated dilations were performed in all five patients. During follow-up(median 27 mo, range, 2-115), three patients remained PEG-tube dependent. Three of four patients achieved relevant improvement of swallowing(two patients: FOIS 6, one patient: FOIS 7). One patient developed mediastinal emphysema following CARD, without a need for surgery.CONCLUSION: The CARD technique is safe and a viable alternative to high-risk blind antegrade dilation in patients with complete proximal oesophageal obstruction. Although only half of the patients remained PEG-tube independent, the majority improved their ability to swallow.
文摘AIM To report data on Dilation-Assisted Stone Extraction(DASE) use in clinical practice and its efficacy and safety trough three Italian referral centers for biliopancreatic diseases treatment. METHODS From January 2011 to December 2015 we collected data on 120 patients treated with DASE. Technical success was obtained when the endoscopist was able to place the balloon trough the papilla inflating the balloon until the final diameter for an adequate time(at least 30 s). Clinical success was obtained after complete stone removal(no remaining stones were visible at the cholangiogram).RESULTS Forty-nine male(40.8%) and 71 female(59%) were enrolled. The mean age was 67.8 years ± 15.7. The mean common bile duct(CBD) dilation was 19.2 mm± 3.9 and the mean size of stones 15.8 ± 2.9. DASE was applied as first approach in 38%(62% after initial failure of stones extraction). Technical and clinical success was of 91% and 87% respectively. In those in which DASE failed alternative treatment were adopted. After DASE 18% of patients experienced a complication(bleeding 9%, pancreatitis 8%, perforation 0.8%). At univariable analysis, elective endoscopic retrograde cholangiopancreatography(P = 0.031), DASE as first approach(P = 0.032), and cannulation of major papilla followed by guidewire insertion(P = 0.004) were related to low risk of complications. Pre-cut was related to an increased risk of complications(P = 0.01). CONCLUSION DASE allowed a higher first-session success rate and can be consider a valid alternative to endoscopic sphincterotomy not only for bigger CBD stones.
文摘BACKGROUND Crohn’s disease(CD)has a multitude of complications including intestinal strictures from fibrostenotic disease.Fibrostenotic disease has been reported in 10%-17%of children at presentation and leads to surgery in 20%-50%of cases within ten years of diagnosis.When symptoms develop from these strictures,the treatment in children has primarily been surgical resection.Endoscopic balloon dilation(EBD)has been shown to be a safe and efficacious alternative to surgery in adults,but evidence is poor in the literature regarding its safety and efficacy in children.AIM To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.METHODS In a single-center retrospective study,we looked at pediatric patients(ages 0-18)who carry the diagnosis of CD,who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1,2012 through May 1,2019.We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype.The type of intervention for patients’strictures was then identified through procedural and surgical billing codes.We evaluated their demographics,clinical variables,whether they underwent EBD vs surgery or both,and their clinical outcomes.RESULTS Of the 139 patients with CD,25(18%)developed strictures.The initial intervention for a stricture was surgical resection in 12 patients(48%)and EBD in 13 patients(52%).However,4(33%)patients whom initially had surgical resection required follow up EBD,and thus 17 total patients(68%)underwent EBD at some point in their treatment process.For those 8 patients who underwent successful surgical resection alone,4 of these patients(50%)had a fistula present near the stricture site and 4(50%)had strictures greater than 5 cm in length.All patients who underwent EBD had no procedural complications,such as a perforation.Twenty-two(88%)of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.CONCLUSION EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.
文摘BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.AIM To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.METHODS Data from 1289 endoscopic retrograde cholangiopancreatography(ERCP)procedures were obtained from two prospective studies.While 258 cases had difficult stones(>1 cm,multiple>8,impacted,or having a thin distal duct),191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy.Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number.Primary outcomes were clearance rate at first ERCP and complications.RESULTS Of the 191 patients(122 women and 69 men;mean age:60 years)who underwent biliary dilation for difficult stones,113(59%)had a nondilated or tapered distal duct.Patients with a dilated distal duct were older than those with nondilated distal ducts(mean 68 and 52 years of age,respectively;P<0.05),had more stones(median 4 and 2 stones per patient,respectively;P<0.05),and had less need for additional mechanical lithotripsy(6.4%vs 25%,respectively;P<0.05).Clearance rate at first ERCP was comparable between patients with a dilated(73/78;94%)and nondilated distal ducts(103/113;91%).Procedures were faster in patients with a dilated distal duct(mean 17 vs 24 min,respectively;P<0.005).Complications were similar in both groups(6.4%vs 7.1%,respectively).CONCLUSION Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.
文摘Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography.Endoscopic sphincterotomy(EST)has been used for the removal of bile duct stones for the past 40 years,providing a wide opening to allow extraction.Up to 15%of patients present with complicated choledocholithiasis.In this context,additional therapeutic approaches have been proposed such as endoscopic mechanical lithotripsy,intraductal or extracorporeal lithotripsy,or endoscopic papillary large balloon dilation(EPLBD).EPLBD combined with EST was introduced in 2003 to facilitate the passage of large or multiple bile duct stones using a balloon greater than 12 mm in diameter.EPLBD without EST was introduced as a simplified technique in 2009.Dilation-assisted stone extraction(DASE)is the combination of two techniques:EPLBD and sub-maximal EST.Several studies have reported this technique as safe and effective in patients with large bile duct stones,without any increased risk of adverse events such as pancreatitis,bleeding,or perforation.Nevertheless,it is difficult to analyze the outcomes of DASE because there are no standard techniques and definitions between studies.The purpose of this paper is to provide technical guidance and specific information about the main issues regarding DASE,based on current literature and daily clinical experience in biliary referral centers.
文摘AIM:To perform a meta-analysis of large-balloon dilation(LBD)plus endoscopic sphincterotomy(EST)vs EST alone for removal of bile duct stones.METHODS:Databases including PubMed,EMBASE,the Cochrane Library,the Science Citation Index,and important meeting abstracts were searched and evaluated by two reviewers independently.The main outcome measures included:complete stone removal,stone removal in the first session,use of mechanical lithotripsy,procedure time,and procedure-related complications.A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio(OR)when heterogeneity was not significant among the studies.When a Q test or I2statistic indicated substantial heterogeneity,a random-effects model weighted by the DerSimonian-Laird method was used.RESULTS:Six randomized controlled trials involving835 patients were analyzed.There was no significant heterogeneity for most results;we analyzed these using a fixed-effects model.Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone(OR=0.53,95%CI:0.33-0.85,P=0.008);sub-category analysis indicated a significantly lower risk of perforation in the EST plus LBD group(Peto OR=0.14,95%CI:0.20-0.98,P=0.05).Use of mechanical lithotripsy in the EST plus LBD group decreased significantly(OR=0.26,95%CI:0.08-0.82,P=0.02),especially in patients with a stone size larger than 15 mm(OR=0.15,95%CI:0.03-0.68,P=0.01).There were no significant differences between the two groups regarding complete stone removal,stone removal in the first session,post-endoscopic retrograde cholangiopancreatography pancreatitis,bleeding,infection of biliary tract,and procedure time.CONCLUSION:EST plus LBD is an effective approach for the removal of large bile duct stones,causing fewer complications than EST alone.
基金Supported by A Yeungnam University Research Grant in 2012
文摘AIM:To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation(EPLBD)for bile duct stone extraction in patients with periampullary diverticula.METHODS:The records of 223 patients with large common bile duct stones(≥10 mm)who underwent EPLBD(12-20 mm balloon diameter)with or without limited endoscopic sphincterotomy(ES)from July 2006to April 2011 were retrospectively reviewed.Of these patients,93(41.7%)had periampullary diverticula(PAD),which was categorized into three types.The clinical variables of EPLBD with limited ES(EPLBD+ES)and EPLBD alone were analyzed according to the presence of PAD.RESULTS:Patients with PAD were significantly older than those without(75.2±8.8 years vs 69.7±10.9years,P=0.000).The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and nonPAD groups,however,there was significantly less need for mechanical lithotripsy in the PAD group(3.2%vs 11.5%,P=0.026).Overall stone removal rates,complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD+ES and EPLBD alone in patients with PAD(96.6%vs 97.1%;72.9%vs 88.2%;and 5.1%vs 0%,respectively).No significant differences with respect to the rates of pancreatitis,perforation,and bleeding were observed between EPLBD+ES and EPLBD alone in the PAD group(3.4%vs 14.7%,P=0.095;0%vs 0%;and 3.4%vs 8.8%,P=0.351,respectively).CONCLUSION:EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD,regardless of PAD subtypes.
文摘AIM: To evaluate the efficacy and safety of endoscopic papillary large diameter balloon dilation (EPLBD) following limited endoscopic sphincterotomy (EST) and EST alone for removal of large common bile duct (CBD) stones.
文摘Endoscopic papillary large balloon dilation(EPLBD)with endoscopic sphincterotomy(EST)has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy(EML)for the removal of large or difficult bile duct stones.Furthermore,EPLBD without EST was recently introduced as its simplified alternative technique.Thus,we systematically searched PubMed,Medline,the Cochrane Library and EMBASE,and analyzed all gathered data of EPLBD with and without EST,respectively,by using a single standardized definition,reviewing relevant literatures,published between 2003and June 2013,where it was performed with largediameter balloons(12-20 mm).The outcomes,including the initial success rate,the rate of needs for EML,and the overall success rate,and adverse events were assessed in each and compared between both of two procedures:"EPLBD with EST"and"EPLBD without EST".A total of 2511 procedures from 30 published articles were included in EPLBD with EST,while a total of413 procedures from 3 published articles were included in EPLBD without EST.In the results of outcomes,the overall success rate was 96.5%in EPLBD with EST and97.2%in EPLBD without EST,showing no significant difference between both of them.The initial success rate(84.0%vs 76.2%,P<0.001)and the success rate of EPLBD without EML(83.2%vs 76.7%,P=0.001)was significantly higher,while the rate of use of EML was significantly lower(14.1%vs 21.6%,P<0.001),in EPLBD with EST.The rate of overall adverse events,pancreatitis,bleeding,perforation,other adverse events,surgery for adverse events,and fatal adverse events were 8.3%,2.4%,3.6%,0.6%,1.7%,0.2%and 0.2%in EPLBD with EST and 7.0%,3.9%,1.9%,0.5%,0.7%,0%and 0%in EPLBD without EST,respectively,showing no significant difference between both of them.In conclusion,recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events,when performed under appropriate guidelines.
基金Supported by A Grant of the Korea Healthcare technology R&D Project, Ministry for Health, Welfare and Family Affairs,Republic of Korea (A091047)
文摘AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS: There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047). CONCLUSION: Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.
基金Supported by Technology Foundation for Selected Overseas Chinese Scholar,Zhejiang Province,No.188020-710903/016
文摘AIM: To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (≥ 10 mm).
文摘AIM:To evaluate the efficacy and safety of endoscopic sphincterotomy(EST) + endoscopic papillary large balloon dilation(EPLBD)vs isolated EST.METHODS:We conducted a retrospective single center study over two years,from February 2010 to January 2012.Patients with large(≥ 10 mm),single or multiple bile duct stones(BDS),submitted to endoscopic retrograde cholangio-pancreatography(ERCP) were included.Patients in Group A underwent papillary large balloon dilation after limited sphincterotomy(EST+EPLBD),using a through-the-scope balloon catheter gradually inflated to 12-18 mm according to the size of the largest stone and the maximal diameter of the distal bile duct on the cholangiogram.Patients in Group B(control group) underwent isolated sphincterotomy.Stones were removed using a retrieval balloon catheter and/or a dormia basket.When necessary,mechanical lithotripsy was performed.Complete clearance of the bile duct was documented with a balloon catheter cholangiogram at the end of the procedure.In case of residual lithiasis,a double pigtail plastic stent was placed and a second ERCP was planned within 4-6 wk.Some patients were sent for extracorporeal lithotripsy prior to subsequent ERCP.Outcomes of EST+EPLBD(Group A) vs isolated EST(Group B) were compared regarding efficacy(complete stone clearance,number of therapeutic sessions,mechanical and/or extracorporeal lithotripsy,biliary stent placement) and safety(frequency,type and grade of complications).Statistical analysis was performed using χ 2 or Fisher’s exact tests for the analysis of categorical parameters and Student’s t test for continuous variables.A P-value of less than 0.05 was considered statistically significant.RESULTS:One hundred and eleven patients were included,68(61.3%) in Group A and 43(38.7%) in Group B.The mean diameter of the stones was similar in the two groups(16.8 ± 4.4 and 16.0 ± 6.7 in Groups A and B,respectively).Forty-eight(70.6%) patients in Group A and 21(48.8%) in Group B had multiple BDS(P = 0.005).Overall,balloon dilation was performed up to 12 mm in 10(14.7%) patients,13.5 mm in 17(25.0%),15 mm in 33(48.6%),16.5 mm in 2(2.9%) and 18 mm in 6(8.8%) patients,taking into account the diameter of the largest stone and that of the bile duct.Complete stone clearance was achieved in sixty-five(95.6%) patients in Group A vs 30(69.8%) patients in Group B,and was attained within the first therapeutic session in 82.4% of patients in Group A vs 44.2% in Group B(P 【 0.001).Patients submitted to EST+EPLBD underwent fewer therapeutic sessions(1.1 ± 0.3 vs 1.8 ± 1.1,P 【 0.001),and fewer required mechanical(14.7% vs 37.2%,P = 0.007) or extracorporeal(0 vs 18.6%,P 【 0.001) lithotripsy,as well as biliary stenting(17.6% vs 60.5%,P 【 0.001).The rate of complications was not significantly different between the two groups.CONCLUSION:EST+EPLBD is a safe and effective technique for treatment of difficult BDS,leading to high rates of complete stone clearance and reducing the need for lithotripsy and biliary stenting.
文摘Radiologists first described the removal of bile duct stones using balloon dilation in the early 1980s.Recently,there has been renewed interest in endoscopic balloon dilation with a small balloon to avoid the complications of endoscopic sphincterotomy(EST)in young patients undergoing laparoscopic cholecystectomy.However,there is a disparity in using endoscopic balloon papillary dilation(EPBD)between the East and the West,depending on the origin of the studies.In the early 2000s,EST followed by endoscopic balloon dilation with a large balloon was introduced to treat large or difficult biliary stones.Endoscopic balloon dilation with a large balloon has generally been recognized as an effective and safe method,unlike EPBD.However,fatal complications have occurred in patients with endoscopic papillary large balloon dilation(EPLBD).The safety of endoscopic balloon dilation is still a debatable issue.Moreover,guidelines of indications and techniques have not been established in performing endoscopic balloon dilation with a small balloon or a large balloon.In this article,we discuss the issue of conventional and large balloon endoscopic dilation.We also suggest the indications and optimal techniques of EPBD and EPLBD.
