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Ren LK, Cai ZY, Ran X, Yang NH, Li XZ, Liu H, Wu CW, Zeng WY, Han M. Evaluating the efficacy of endoscopic sphincterotomy on biliary-type sphincter of Oddi dysfunction: A retrospective clinical trial. World J Clin Cases 2021; 9:9835-9846. [PMID: 34877322 PMCID: PMC8610902 DOI: 10.12998/wjcc.v9.i32.9835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/18/2021] [Accepted: 09/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although endoscopic sphincterotomy (EST) has a positive therapeutic effect on biliary-type sphincter of Oddi dysfunction (SOD), some patients still have little relief after EST, which implies that other functional abdominal pain may also be present with biliary-type SOD and interfere with the diagnosis and treatment of it.
AIM To retrospectively assess EST as a treatment for biliary-type SOD and analyze the importance of functional gastrointestinal disorder (FGID) in guiding endoscopic treatment of SOD.
METHODS Clinical data of 79 patients with biliary-type SOD (type I and type II) treated with EST at Affiliated Hospital of Guizhou Medical University from January 2014 to January 2019 were retrospectively collected to evaluate the clinical therapeutic effect of EST. The significance of relationship between FGID and biliary-type SOD was analyzed.
RESULTS Seventy-nine patients with biliary-type SOD received EST, including 29 type 1 patients and 50 type 2 patients. The verbal rating scale-5 (VRS-5) scores before EST were all 3 or 4 points, and the scores decreased after EST; the difference was statistically significant (P < 0.05). After EST, the serum indexes of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and total bilirubin in biliary-type SOD were significantly lower than before (P < 0.05). After EST, 67 (84.8%) and 8 (10.1%) of the 79 patients with biliary-type SOD had obviously effective (VRS-5 = 0 points) and effective treatment (VRS-5 = 1-2 points), with an overall effectiveness rate of 94.9% (75/79). There was no difference in VRS-5 scores between biliary-type SOD patients with or without FGID before EST (P > 0.05). Of 12 biliary-type SOD (with FGID) patients, 11 had abdominal pain after EST; of 67 biliary-type SOD (without FGID) patients, 0 had abdominal pain after EST. The difference was statistically significant (P <0.05). The 11 biliary-type SOD (with FGID) patients with recurrence of symptoms, the recurrence time was about half a year after the EST, and the symptoms were significantly relieved after regular medical treatment. There were 4 cases of post-endoscopic retrograde cholangiopancreatography pancreatitis (5.1%), and no cholangitis, bleeding or perforation occurred. Patients were followed up for 1 year to 5 years after EST, with an average follow-up time of 2.34 years, and there were no long-term adverse events such as sphincter of Oddi restenosis or cholangitis caused by intestinal bile reflux during the follow-up.
CONCLUSION EST is a safe and effective treatment for SOD. For patients with type I and II SOD combined with FGID, single EST or medical treatment has limited efficacy. It is recommended that EST and medicine be combined to improve the cure rate of such patients.
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Affiliation(s)
- Li-Kun Ren
- Department of General Surgery, The Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang 550025, Guizhou Province, China
| | - Zhi-Yuan Cai
- Department of General Surgery, The Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang 550025, Guizhou Province, China
| | - Xun Ran
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Neng-Hong Yang
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Xing-Zhi Li
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Hao Liu
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Chang-Wei Wu
- Department of General Surgery, The First People’s Hospital of Bijie City, Bijie 551700, Guizhou Province, China
| | - Wen-Ying Zeng
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Min Han
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
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Miyatani H, Mashima H, Sekine M, Matsumoto S. Clinical course of biliary-type sphincter of Oddi dysfunction: endoscopic sphincterotomy and functional dyspepsia as affecting factors. Ther Adv Gastrointest Endosc 2019; 12:2631774519867184. [PMID: 31448369 PMCID: PMC6693024 DOI: 10.1177/2631774519867184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The objective of this study was to clarify the effectiveness of treatment selection for biliary-type sphincter of Oddi dysfunction by severe pain frequency and the risk factors for recurrence including the history of functional gastrointestinal disorder. PATIENTS AND METHODS Thirty-six sphincter of Oddi dysfunction patients who were confirmed endoscopic retrograde cholangiopancreatography enrolled in this study. Endoscopic sphincterotomy was performed for type I and manometry-confirmed type II sphincter of Oddi dysfunction patients with severe pain (⩾2 times/year; endoscopic sphincterotomy group). Others were treated medically (non-endoscopic sphincterotomy group). RESULTS The short-term effectiveness rate of endoscopic sphincterotomy was 91%. The final remission rates of the endoscopic sphincterotomy and non-endoscopic sphincterotomy groups were 86% and 100%, respectively. Symptoms relapsed after endoscopic sphincterotomy in 32% of patients. Patients in the endoscopic sphincterotomy and non-endoscopic sphincterotomy groups had or developed functional dyspepsia in 41% and 14%, irritable bowel syndrome in 5% and 14%, and gastroesophageal reflux disorder in 14% and 0%, respectively. History or new onset of functional dyspepsia was related to recurrence on multivariate analysis. The frequency of occurrence of post-endoscopic retrograde cholangiopancreatography pancreatitis and post-endoscopic retrograde cholangiopancreatography cholangitis was high in both groups. Two new occurrences of bile duct stone cases were observed in each group. CONCLUSION According to the treatment criteria, endoscopic and medical treatment for biliary-type sphincter of Oddi dysfunction has high effectiveness, but recurrences are common. Recurrences may be related to new onset or a history of functional dyspepsia.
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Affiliation(s)
- Hiroyuki Miyatani
- Department of Gastroenterology, Jichi Medical
University Saitama Medical Center, Saitama, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Jichi Medical
University Saitama Medical Center, Saitama, Japan
| | - Masanari Sekine
- Department of Gastroenterology, Jichi Medical
University Saitama Medical Center, Saitama, Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Jichi Medical
University Saitama Medical Center, Saitama, Japan
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Domagk D, Oppong KW, Aabakken L, Czakó L, Gyökeres T, Manes G, Meier P, Poley JW, Ponchon T, Tringali A, Bellisario C, Minozzi S, Senore C, Bennett C, Bretthauer M, Hassan C, Kaminski MF, Dinis-Ribeiro M, Rees CJ, Spada C, Valori R, Bisschops R, Rutter MD. Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018; 50:1116-1127. [PMID: 30340220 DOI: 10.1055/a-0749-8767] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2: Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3: Bile duct cannulation rate (key performance measure, at least 90 %); 4: Tissue sampling during EUS (key performance measure, at least 85 %); 5: Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6: Bile duct stone extraction (key performance measure, at least 90 %); 7: Post-ERCP pancreatitis (key performance measure, less than 10 %). 8: Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.
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Affiliation(s)
- Dirk Domagk
- Department of Medicine I, Josephs Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany
| | - Kofi W Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle, United Kingdom
| | - Lars Aabakken
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Oslo University Hospital, Oslo Norway
| | - Laszlo Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tibor Gyökeres
- Department of Gastroenterology, Medical Center Hungarian Defence Forces, Budapest, Hungary
| | - Gianpiero Manes
- Department of Gastroenterology, ASST Rhodense, Rho, and Garbagnate Milanese Hospitals, Milan, Italy
| | - Peter Meier
- Med. Klinik II, DIAKOVERE Henriettenstift, Klinik für Enterologie, Hannover, Germany
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Thierry Ponchon
- Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Catholic University, Rome, Italy.,CERTT, Center for Endoscopic Research, Therapeutics and Training - Catholic University, Rome, Italy
| | | | - Silvia Minozzi
- Department of Medicine I, Josephs Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany
| | - Carlo Senore
- CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Cathy Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn, Dublin, Ireland
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Gastroenterological Oncology and Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.,Department of Health Management and Health Economics, University of Oslo, Norway
| | - Mario Dinis-Ribeiro
- Servicio de Gastroenterologia, Instituto Portugues de Oncologia Francisco Gentil, Porto, Portugal
| | - Colin J Rees
- Northern Institute for Cancer Research, Newcastle University, Newcastle, United Kingdom
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Catholic University, Rome, Italy.,Digestive Endoscopy and Gastroenterology Unit, Poliambulanza Foundation, Brescia, Italy
| | - Roland Valori
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, United Kingdom
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology. University Hospital Leuven, Leuven, Belgium
| | - Matthew D Rutter
- Northern Institute for Cancer Research, Newcastle University, Newcastle, United Kingdom.,Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK
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4
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Domagk D, Oppong KW, Aabakken L, Czakó L, Gyökeres T, Manes G, Meier P, Poley JW, Ponchon T, Tringali A, Bellisario C, Minozzi S, Senore C, Bennett C, Bretthauer M, Hassan C, Kaminski MF, Dinis-Ribeiro M, Rees CJ, Spada C, Valori R, Bisschops R, Rutter MD. Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. United European Gastroenterol J 2018; 6:1448-1460. [PMID: 30574315 DOI: 10.1177/2050640618808157] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/24/2018] [Indexed: 02/06/2023] Open
Abstract
The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at centre and endoscopist level: 1 Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90%); 2 antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95%); 3 bile duct cannulation rate (key performance measure, at least 90%); 4 tissue sampling during EUS (key performance measure, at least 85%); 5 appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95%); 6 bile duct stone extraction (key performance measure, at least 90%); 7 post-ERCP pancreatitis (key performance measure, less than 10%); and 8 adequate documentation of EUS landmarks (minor performance measure, at least 90%). This present list of quality performance measures for ERCP and EUS recommended by the ESGE should not be considered to be exhaustive; it might be extended in future to address further clinical and scientific issues.
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Affiliation(s)
- Dirk Domagk
- Department of Medicine I, University of Muenster, Warendorf, Germany
| | - Kofi W Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Lars Aabakken
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Laszlo Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tibor Gyökeres
- Department of Gastroenterology, Medical Center Hungarian Defence Forces, Budapest, Hungary
| | - Gianpiero Manes
- Department of Gastroenterology, Garbagnate Milanese Hospitals, Milan, Italy
| | - Peter Meier
- Med. Klinik II, Klinik für Enterologie, Hannover, Germany
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, University Medical Center Rotterdam, The Netherlands
| | - Thierry Ponchon
- Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Andrea Tringali
- Digestive Endoscopy Unit, Catholic University, Rome, Italy.,Center for Endoscopic Research, Therapeutics and Training, Catholic University, Rome, Italy
| | | | - Silvia Minozzi
- Department of Medicine I, University of Muenster, Warendorf, Germany
| | - Carlo Senore
- CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Cathy Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Gastroenterological Oncology and Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Mario Dinis-Ribeiro
- Servicio de Gastroenterologia, Instituto Portugues de Oncologia Francisco Gentil, Porto, Portugal
| | - Colin J Rees
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK
| | - Cristiano Spada
- Digestive Endoscopy Unit, Catholic University, Rome, Italy.,Digestive Endoscopy and Gastroenterology Unit, Poliambulanza Foundation, Brescia, Italy
| | - Roland Valori
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
| | - Matthew D Rutter
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK.,Department of Gastroenterology, University Hospital of North Tees, Cleveland, UK
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5
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Miyatani H, Matsumoto S, Mashima H. Risk factors of post- endoscopic retrograde cholangiopancreatography pancreatitis in biliary type sphincter of Oddi dysfunction in Japanese patients. J Dig Dis 2017; 18:591-597. [PMID: 28898571 DOI: 10.1111/1751-2980.12541] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/14/2017] [Accepted: 09/08/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Suspected sphincter of Oddi dysfunction (SOD) is a well-known risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The indication of ERCP for suspected SOD patients was very low in Japan compared to other countries. Therefore, the risk of PEP may be different in Japanese SOD patients. The objective of this study was to evaluate the risk of PEP in suspected biliary type SOD in Japan. METHODS From December 1996 to January 2017, 72 patients were suspected as having biliary type SOD, by questionnaire, liver function tests, hepatobiliary scintigraphy, abdominal ultrasonography, upper gastrointestinal endoscopy, endoscopic ultrasonography and magnetic resonance cholangiopancreatography. Finally, 60 patients who underwent ERCP were included in this study, and the factors associated with PEP were evaluated. RESULTS The overall PEP rate was 23.3% (n = 14). Diagnostic ERCP alone for SOD did not increase the risk of PEP. The correlation of PEP incidence with pancreatic duct guidewire (PGW) technique and endoscopic sphincterotomy (EST) was indicated in univariate and multivariate analysis. Pancreatic stent placement was a risk in univariate analysis but not in multivariate analysis. CONCLUSIONS PGW technique and EST for biliary type SOD were important risk factors for PEP. Pancreatic stenting was ineffective for prevention of PEP.
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Affiliation(s)
- Hiroyuki Miyatani
- Department of Gastroenterology, Jichi Medical University, Saitama, Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Jichi Medical University, Saitama, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Jichi Medical University, Saitama, Japan
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Abstract
Sphincter of Oddi dysfunction (SOD) has long been a controversial topic, starting with whether it even exists, as a sphincterotomy-responsive entity to treat, for either: (1) post-cholecystectomy abdominal pain and/or (2) idiopathic recurrent acute pancreatitis (IRAP). Many of its aspects had required further research to better prove or refute its existence and to provide proper recommendations for physicians to diagnose and treat this condition. Fortunately, there has been major advancement in our knowledge in several areas over the past few years. New studies on challenging the classification, exploring alternative diagnostic methods, and quantifying the role of sphincterotomy in treatment of SOD for post-cholecystectomy pain and for IRAP were recently published, including a randomized trial in each of the two areas. The goal of this paper is to review recent literature on selected important questions and to summarize the results of major trials in this field.
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Yin HK, Wu HE, Li QX, Wang W, Ou WL, Xia HHX. Pancreatic Stenting Reduces Post-ERCP Pancreatitis and Biliary Sepsis in High-Risk Patients: A Randomized, Controlled Study. Gastroenterol Res Pract 2016; 2016:9687052. [PMID: 27057161 PMCID: PMC4789431 DOI: 10.1155/2016/9687052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/18/2016] [Accepted: 02/01/2016] [Indexed: 02/07/2023] Open
Abstract
Background. Endoscopic retrograde cholangiopancreatography (ERCP) is an established treatment modality for bile duct disorders, but patients have a risk of post-ERCP pancreatitis (PEP) and biliary sepsis. Aim. To evaluate the effectiveness and safety of pancreatic stent for prophylaxis of PEP and biliary sepsis in high-risk patients with complicating common bile duct (CBD) disorders. Methods. Two hundred and six patients with complicating confirmed or suspected CBD disorders were randomly assigned to receive ERCP with pancreatic stenting (experimental group) or without stenting (control group). Primary outcome measure was frequency of PEP, and secondary outcome measures included operative time, blood loss, postoperative recovery times, and other ERCP-associated morbidities. Results. Baseline age, sex, CBD etiology, concomitant medical/surgical conditions, cannulation difficulty, and ERCP success were comparable between the two groups (all P > 0.05). Compared to the control group, the experimental group had a significantly lower frequency of PEP (7.7% versus 17.7%, P < 0.05) and positive bile microbial culture (40.4% versus 62.7%, P < 0.05). However, the two groups were similar in operative time, blood loss, postoperative recovery times, and other ERCP-associated morbidities (all P > 0.05). Conclusions. Pancreatic stenting can reduce the occurrence of PEP and biliary sepsis in high-risk patients with complicating CBD disorders but does not increase other ERCP-associated morbidities. This trial is registered with the Chinese Clinical Trial Registry (registration identifier ChiCTR-OCH-14005134).
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Affiliation(s)
- He-Kun Yin
- Department of Gastroenterology, Jiangmen Central Hospital, Jiangmen, Guangdong, China
- *He-Kun Yin:
| | - Hai-En Wu
- Department of Gastroenterology, Jiangmen Central Hospital, Jiangmen, Guangdong, China
| | - Qi-Xiang Li
- Department of Gastroenterology, Jiangmen Central Hospital, Jiangmen, Guangdong, China
| | - Wei Wang
- Department of Gastroenterology, Jiangmen Central Hospital, Jiangmen, Guangdong, China
| | - Wei-Lin Ou
- Department of Gastroenterology, Jiangmen Central Hospital, Jiangmen, Guangdong, China
| | - Harry Hua-Xiang Xia
- Department of Gastroenterology, The First Hospital Affiliated to Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
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