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Objective:To investigate the clinical characteristics of choledocholithiasis com-bined with periampullary diverticulum and influencing factor for difficult cannulation of endoscopic retrograde cholangiopancreatography (ERCP).Methods:The retrospective case-control study was conducted. The clinical data of 1 920 patients who underwent ERCP for choledocholithiasis in 15 medical centers, including the First Hospital of Lanzhou University, et al, from July 2015 to December 2017 were collected. There were 915 males and 1 005 females, aged (63±16)years. Of 1 920 patients, there were 228 cases with periampullary diverticulum and 1 692 cases without periampullary diverticulum. Observation indicators: (1) clinical characteristics of patients with choledocholithiasis; (2) intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis; (3) influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range) or M( Q1, Q3), and com-parison between groups was conducted using the Wilcoxon rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Logistic regression model was used for univariate and multivariate analyses. Results:(1) Clinical characteristics of patients with choledocholithiasis. Age, body mass index, cases with complications as chronic obstructive pulmonary disease, diameter of common bile duct, cases with diameter of common bile duct as <8 mm, 8?12 mm, >12 mm, diameter of stone, cases with number of stones as single and multiple were (69±12)years, (23.3±3.0)kg/m 2, 16, (14±4)mm, 11, 95, 122, (12±4)mm, 89, 139 in patients with choledocholithiasis combined with periampullary diverticulum, versus (62±16)years, (23.8±2.8)kg/m 2, 67, (12±4)mm, 159, 892, 641, (10±4)mm, 817, 875 in patients with choledocholithiasis not combined with periampullary diver-ticulum, showing significant differences in the above indicators between the two groups ( t=?7.55, 2.45, χ2=4.54, t=?4.92, Z=4.66, t=?7.31, χ2=6.90, P<0.05). (2) Intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis. The balloon expansion diameter, cases with intraoperative bleeding, cases with hemorrhage management of submucosal injection, hemostatic clip, spray hemostasis, electrocoagulation hemostasis and other treatment, cases with endoscopic plastic stent placement, cases with endoscopic nasal bile duct drainage, cases with mechanical lithotripsy, cases with stone complete clearing, cases with difficult cannulation, cases with delayed intubation, cases undergoing >5 times of cannulation attempts, cannulation time, X-ray exposure time, operation time were 10.0(range, 8.5?12.0)mm, 56, 6, 5, 43, 1, 1, 52, 177, 67, 201, 74, 38, 74, (7.4±3.1)minutes, (6±3)minutes, (46±19)minutes in patients with choledocholithiasis combined with periampullary diverticulum, versus 9.0(range, 8.0?11.0)mm, 243, 35, 14, 109, 73, 12, 230, 1 457, 167, 1 565, 395, 171, 395, (6.6±2.9)minutes, (6±5)minutes, (41±17)minutes in patients with choledocholithiasis not combined with periampullary diverticulum, showing significant differences in the above indicators between the two groups ( Z=6.31, χ2=15.90, 26.02, 13.61, 11.40, 71.51, 5.12, 9.04, 8.92, 9.04, t=?3.89, 2.67, ?3.61, P<0.05). (3) Influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Results of multivariate analysis showed total bilirubin >30 umol/L, number of stones >1, combined with periampullary diverticulum were indepen-dent risk factors for difficult cannulation in patients with periampullary diverticulum who underwent ERCP for choledocholithiasis ( odds ratio=1.31, 1.48, 1.44, 95% confidence interval as 1.06?1.61, 1.20?1.84, 1.06?1.95, P<0.05). Results of further analysis showed that, of 1 920 patients undergoing ERCP for choledocholithiasis, the incidence of postoperative pancreatitis was 17.271%(81/469) and 8.132%(118/1 451) in the 469 cases with difficult cannulation and 1 451 cases without difficult cannula-tion, respectively, showing a significant difference between them ( χ2=31.86, P<0.05). In the 1 692 patients with choledocholithiasis not combined with periampullary diverticulum, the incidence of postopera-tive pancreatitis was 17.722%(70/395) and 8.250%(107/1 297) in 395 cases with difficult cannula-tion and 1 297 cases without difficult cannulation, respectively, showing a significant difference between them ( χ2=29.00, P<0.05). In the 228 patients with choledocholithiasis combined with peri-ampullary diverticulum, the incidence of postoperative pancreatitis was 14.865%(11/74) and 7.143%(11/154) in 74 cases with difficult cannulation and 154 cases without difficult cannulation, respectively, showing no significant difference between them ( χ2=3.42, P>0.05). Conclusions:Compared with patients with choledocholithiasis not combined with periampullary divertioulum, periampullary divertioulum often occurs in choledocholithiasis patients of elderly and low body mass index. The proportion of chronic obstructive pulmonary disease is high in choledocholithiasis patients with periampullary diverticulum, and the diameter of stone is large, the number of stone is more in these patients. Combined with periampullary diverticulum will increase the difficult of cannulation and the ratio of patient with mechanical lithotripsy, and reduce the ratio of patient with stone complete clearing without increasing postoperative complications of choledocholithiasis patients undergoing ERCP. Total bilirubin >30 μmol/L, number of stones >1, combined with periampullary diverticulum are independent risk factors for difficult cannulation in patients of periampullary diverticulum who underwent ERCP for choledocholithiasis.
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Objective:To investigate the drainage efficacy of different types of plastic stents in endoscopic ultrasound (EUS)-guided transgastric drainage for pancreatic pseudocysts.Methods:Clinical data of patients with pancreatic pseudocyst who underwent EUS-guided transgastric drainage in the surgical endoscopic center of the First Hospital of Lanzhou University from March 2014 to December 2020 were retrospectively analyzed. Patients were divided into the 10 F double plastic stents group and the 7 F double plastic stents group. The drainage efficacy, complications and long-term outcomes of the two groups were compared.Results:A total of 29 patients were included, 11 in the 10 F double plastic stents group and 18 others in the 7 F double plastic stents group. The operation time of the two groups was 48.2±8.0 min and 34.7±5.8 min, respectively, showing significant difference ( t=5.24, P<0.001). There was no significant difference in the incidence of postoperative complications such as abdominal pain [18.2% (2/11) VS 5.6% (1/18)], fever [9.1% (1/11) VS 11.1% (2/18)] or bleeding (both none) between the two groups (all P>0.05). Two months after the operation, abdominal CT scan showed that the complete disappearance rates of cysts cavity in the 10 F and 7 F groups were 90.9% (10/11) and 88.9% (16/18), respectively, with no significant difference ( P=1.00). Conclusion:There are similar drainage effect and postoperative complications rates between the 7 F and the 10 F plastic stent in EUS-guided transgastric drainage for pancreatic pseudocysts. However, operation with the 7 F stent is more convenient for a shorter time, which is worth of clinical promotion.
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Objective To explore the value of preoperative LAR combined with AFP in evaluating the prognosis of patients with HCC. Methods We retrospectively analyzed the clinical data of 106 patients with HCC. Kaplan-Meier method was used to draw the survival curve. Univariate analysis was used to analyze possible variables affecting LAR. Cox risk regression model was used to evaluate the clinical value of preoperative LAR and AFP on the prognosis of HCC patients. Results The DFS and OS of the high LAR group and the high AFP group were shorter than those of the low LAR group and the low AFP group (P < 0.05). LAR≥4.58, AFP≥400μg/L and T3-T4 were independent risk factors affecting DFS and OS of HCC patients (P < 0.05). Postoperative interventional surgery was an independent factor influencing OS prolongation (P < 0.05). The DFS and OS were the shortest in the high LAR and high AFP group, and the DFS and OS were the longest in the low LAR and low AFP group (P < 0.05). Conclusion Preoperative LAR and AFP are independent poor prognostic factors of HCC. Preoperative LAR combined with AFP has a certain value in judging the prognosis of HCC patients.
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Objective:To investigate the risk factors for common bile duct calculi recurrence and application value of its prediction model after endoscopic retrograde cholangiopancreato-graphy (ERCP) .Methods:The retrospective cohort study was conducted. The clinicopatholo-gical data of 506 patients with common bile duct calculi who were admitted to the First Hospital of Lanzhou University from January 2015 to December 2017 for ERCP routine treatment were collected. There were 251 males and 255 females, aged (59±15)years. Patients received ERCP for common bile duct calculi. Observation indicators: (1) clinicopathological data of patients with common bile duct calculi; (2) risk factors for common bile duct calculi recurrence after ERCP; (3) establishment of prediction model for common bile duct calculi recurrence after ERCP. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Univariate and multivariate analysis were conducted using the COX proportional hazard model. The prediction model for the recurrence of common bile duct stones after ERCP was established according to the coefficient of regression equation. The receiver operating characteristic curve(ROC) was drawed for efficiency evaluation with area under curve (AUC). Results:(1) Clinicopathological data of patients with common bile duct calculi: 104 of 506 patients with common bile duct calculi had recurrence and 402 had no recurrence. There were significant differences in the age, hyperlipidemia, common bile duct diameter, distal bile duct stricture, the number of calculi, gallbladder status, history of biliary tract surgery, endoscopic spinecterotomy, postoperative drainage mode between patients with and without recurrence ( Z=?2.844, χ2=6.243, Z=?2.897, χ2=11.631, 4.617, 16.589, 18.679, 2.070, 50.274, P<0.05). (2) Risk factors for common bile duct calculi recurrence after ERCP: Results of univariate analysis showed that age, time of first attack, hyperlipidemia, common bile duct diameter, distal bile duct stricture, the number of calculi, the maximum calculi diameter, gallbladder status, history of biliary tract surgery and postoperative biliary drainage mode were related factors for common bile duct calculi recurrence after ERCP ( hazard ratio=1.656, 2.179, 1.712, 1.657, 2.497, 1.509, 1.971, 2.635, 3.649,95% confidence interval as 1.113?2.463, 1.135?4.184, 1.122?2.644, 1.030?2.663, 1.501?4.154, 1.025?2.220, 1.122?3.464, 1.645?4.221, 1.575?8.456, P<0.05). Results of multivariate analysis showed that time of first attack <30 days, hyperlipidemia, distal bile duct stricture, history of biliary tract surgery and postoperative biliary drainage mode as cholangiopancreatic stent were independent risk factors for common bile duct calculi recurrence after ERCP ( hazard ratio=2.332, 1.676, 2.088, 2.566, 3.712, 95% confidence interval as 1.089?4.998, 1.060?2.649, 1.189?3.668, 1.456?4.521, 1.296?10.635, P<0.05). (3) Establishment of prediction model for common bile duct calculi recurrence after ERCP: based on multivariate analysis, indicators including time of first attack <30 days, hyperlipidemia, distal bile duct stricture, history of biliary tract surgery and postoperative biliary drainage mode as cholangiopancreatic stent were included into the coefficient of regression equation, and the prediction model for common bile duct calculi recurrence after ERCP was established: ln[(λ(t))/(λ 0(t))]=0.847×time of first attack+0.516×hyperlipidemia+0.736×distal bile duct stricture+0.942×history of biliary tract surgery+1.312×cholangiopancreatic stent. The perfor-mance evaluation showed that the AUC of ROC of prediction model was 0.757 (95% confidence interval as 0.713?0.811, P<0.05), and the optimal cut-off value was 1.41, the sensitivity and specificity were 69.2% and 72.9% respectively. Conclusions:The time of first attack <30 days, hyperlipidemia, distal bile duct stricture, history of biliary tract surgery and postoperative biliary drainage mode as cholangiopancreatic stent are independent risk factors for common bile duct calculi recurrence after ERCP. Patients with evaluation score >1.41 in prediction model were at high risk for common bile duct calculi recurrence after ERCP.
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Objective:To investigate the predictive value of high-sensitive C-reactive protein (hs-CRP) for early hematoma enlargement in patients with primary intracerebral hemorrhage.Methods:Patients with intracerebral hemorrhage admitted to the Department of Neurosurgery, the First Affiliated Hospital of Zhengzhou University from January 2014 to January 2019 were enrolled retrospectively. The patients were sent to hospital within 6 h after onset, and the diagnosis of cerebral hemorrhage was confirmed by head CT. The head CT was reexamined within 24 h after the first head CT. Hematoma enlargement was defined as hematoma volume increase >6 ml or relative volume increase >33%. Multivariate logistic regression analysis was used to investigate the independent risk factors for influencing early hematoma enlargement. Receiver operating characteristic (ROC) curve was used to evaluate the predictive ability of hs-CRP for hematoma enlargement. Results:A total of 154 patients with intracerebral hemorrhage were included, including 99 males (64.3%), aged 58.7±11.1 years. The median baseline Glasgow Coma Scale score was 13. The time from onset to first CT scan was 2.92±1.35 h. The time from the first CT to the second one was 16.05±4.40 h. The baseline volume of hematoma was 21.82±11.08 ml. Among them, 27 patients (17.5%) had hematoma that broke into the ventricle, 40 (26.0%) had hematoma enlargement. The average hs-CRP level at admission in the enlarged hematoma group was significantly higher than that in the non-enlarged hematoma group (11.56±3.72 mg/L vs. 9.51±4.31 ml; t=-2.669, P=0.008). Multivariate logistic regression analysis showed that hs-CRP at admission (odds ratio [ OR] 1.123, 95% confidence interval [ CI] 1.017-1.241; P=0.022), irregular hematoma shape ( OR 4.160, 95% CI 1.714-10.098; P=0.002) and the time from onset to the first CT scan ( OR 0.510, 95% CI 0.323-0.803; P=0.004) were significantly correlated with hematoma enlargement. Pearson correlation analysis showed that hs-CRP was positively correlated with baseline hematoma volume ( r=0.237, P=0.003). ROC curve analysis showed that the area under the curve of hs-CRP predicting hematoma enlargement was 0.678 (95% CI 0.584-0.772). The optimal cut-off value was 10.55 mg/L. The sensitivity and specificity for predicting hematoma enlargement were 86.9% and 60.0%, respectively. Conclusion:For patients with hs-CRP ≥10.55 mg/L at admission, irregular hematoma shape, and the time from admission to the first CT scan <3 h, should be focused the management and be alert to the occurrence of early hematoma enlargement.
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Due to the need of the diagnosis and minimally invasive treatment of biliary tract diseases, peroral choledochoscopy has recently become an important method for the diagnosis and treatment of biliary tract diseases, which helps to avoid some invasive and unnecessary surgical procedures. This article introduces the clinical advantages of SpyGlassTM DS Direct Visualization System and its indications and possible complications in biliary duct diseases. SpyGlassTM DS provides endoscopic imaging of the biliary tree and can perform biopsy under direct view, and thus it plays an important role in the diagnosis and treatment of biliary tract diseases. In particular, it can improve the diagnostic accuracy of biliary stricture with unknown nature and the surgical success rate and stone clearance rate of complex bile duct stones, with similar incidence rates of complications as conventional endoscopic retrograde cholangiopancreatography. SpyGlassTM DS is a safe and effective procedure and supplements the standard endoscopic diagnosis and treatment.
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Objective:To determine a better treatment and endoscopic stent for type Ⅳ hilar cholangiocarcinoma.Methods:Clinical data of 65 patients diagnosed with type Ⅳ hilar cholangiocarcinoma at Department of General Surgery, the First Hospital of Lanzhou University from September 2010 to September 2018 were retrospectively analyzed. According to different endoscopic drainage methods, the patients were divided into three groups, endoscopic retrograde biliary drainage (ERBD) group (n=38), ERBD + endoscopic metal biliary endoprosthesis (EMBE) group (n=23) and EMBE group (n=4). According to different contrast methods, patients were divided into the contrast media group (n=26), air contrast group (n=22) and non-contrast group (n=17). Incidence of postoperative acute cholangitis, incidence of bilirubin levels decline and in-hospital mortality were analyzed.Results:The incidences of acute cholangitis in ERBD group, ERBD+ EMBE group and EMBE group were 23.7% (9/38), 52.2% (12/23) and 75.0% (3/4), respectively, with significant differences ( χ2=7.499, P=0.006). The in-hospital mortalities of the above three groups were 5.3% (2/38), 13.0% (3/23) and 50.0% (2/4), respectively, with significant differences ( χ2=7.729, P=0.021). For pairwise comparisons, there was significant difference in in-hospital mortalities between ERBD group and EMBE group ( χ2=8.406, P=0.004). The incidences of acute cholangitis were 57.7% (15/26), 27.3% (6/22) and 17.6% (3/17), respectively, in the contrast media group, the air contrast group and the non-contrast group, with significant difference ( χ2=8.407, P=0.015). For pairwise comparisons, there was significant difference in acute cholangitis incidence between the contrast media group and the non-contrast group ( P=0.012). Conclusion:For type Ⅳ hilar cholangiocarcinoma, biliary double plastic stent implantation can significantly reduce the incidence of postoperative acute cholangitis and the mortality during hospitalization, which can be used as the preferred stent scheme. Additionally, intraoperative contrast agents may increase the incidence of postoperative acute cholangitis which should be used with caution.
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Objective To determine the best endoscopic treatment for acute obstructive suppurative cholangitis (AOSC).Methods Data of 93 patients who were diagnosed as having AOSC in endoscopic center in the last three years were retrospectively analyzed.All patients were divided into three groups according to the different treatment methods:ENBD group,ENBD+ERBD group and double ERBD group.Postoperative temperature,bilirubin levels and mortality were compared.Results For patients with high level obstruction,incidence of fever in ENBD+ERBD group and double ERBD group were significantly higher than that of ENBD group (1/18 VS 4/10,P ＜ 0.05;0 VS 4/10,P ＜ 0.05).There were no significant differences in incidence of fever(1/18 VS 0) or bilirubin level decrease (17/18 VS 14/15) between ENBD+ERBD group and double ERBD group.For high level obstruction,if the patient had biliary imaging with contrast medium during operation,they would have higher incidence of high fever[(4/10 VS 3.45％ (1/28)] and mortality(3/11 VS 0),lower declining rate of bilirubin level [10/14 VS 96.55％(28/29)] than those without.Conclusion Both left and right hepatic ducts drainage should be recommended for high level biliary obstruction.During the operation,contrast medium should be limited to minimum dose,and should be avoided in high level obstruction cases.Air biliary imaging could be used when necessary.
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Objective To summarize clinical experience on the diagnosis and management of pancreatic regional portal hypertension. Methods The clinical manifestations,diagnostic methods and therapeutic modalities of 40 cases of pancreatic regional portal hypertension were analyzed retrospectively.Results Male:female =26: 14.The average age was (40 ± 10)yrs.Among these patients,16 patients (40％) were accompanied by upper gastrointestinal bleeding and 20 patients (50％) by hypersplenism.There were 16 patients (40％) suffering from benign lesions and 6 patients (15％) from malignancy at pancreatic body and tail respectively,and 8 patients(20％ ) from severe necrotic pancreatitis accompanying pseudocyst and 10 patients (25％) from chronic pancreatitis. The average splenic venous pressure was (28.4±4.2) cm H2O(P ＜0.01 ).The average diameter and speed of splenic vein bloodflow by Doppler examination was ( 1.3 ± 0.2 ) cm ( P ＜ 0.01 ) and ( 9.3 ± 0.5 ) cm/s ( P ＜ 0.05 ).The follow-up rate was 100％.Splenectomy was effective for controlling gastrointestinal bleeding. Conclusions It is not difficult to diagnose pancreatic regional portal hypertension based on findings of US,CT and endoscopic examination,together with its clinical features. Therapy should be aimed at both regional portal hypertension and underlying diseases.
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ObjectiveTo evaluate the therapeutic effect of gastroesophageal devasculariztion on cirrhotic portal hypertensive bleeding.MethodsClinical data of 85 cirrhotic patients with portal hypertentsive bleeding undergoing gastroesophageal devascularization were retrospectively analyzed. Results The following-up rate was 78％. The 1-yr,3-yr and 5-yr survival rate was 95％, 88％and 82％respectively.There was significant difference in survival time after devascularization between patients of Child-Pugh A and Child-Pugh B.For the whole group the 1-yr,3-yr and 5-yr recurrent bleeding rate was 6％,16％ and 28％ and postoperative hepatic encephalopathy was 7％.ALT,AST and ALB recovered to pre-operative level on post-operative day 7.ConclusionsGastroesophageal devascularization was an effective therapy in treating portal hypertensive variceal bleeding.Liver function remains a significant factor influencing long term survival.
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ObjectiveTo systematically evaluate the therapeutic effect of gastroesophageal devascularization( GD),portasystemic shunt( PSS),devascularization plus portasystemic shunt ( GD + PSS) for the treatment of 4250 cirrhotic portal hypertension cases reported in Chinese literature. MethodsThe literatures about the effect of gastroesophageal devascularization,portasystemic shunt,devascularization plus portasystemic shunt on portal hypertension were collected from Wanfang databases, China National Knowledge Infrastructure(CNKI) from 1980 to 2011.RevMan 4.2 and SPSS 13.0 were used for data analysis. ResultsIn this study 17 reports were enrolled into the meta-analysis.The results of the mta-analysis showed that long term survival rate in the group of GD plus PSS was higher than that in group of GD [OR=1.73,95％CI (1.23,2.44),P ＜0.01].That in group of PSS was similar with the group of GD [ OR =0.87,95 ％ CI (0.63,1.20),P =0.40 ].That of group GD plus PSS was similar with the group of PSS [ OR =1.73,95％ CI (0.95,3.13),P =0.07 ].For recurrent variceal bleeding rate,that in group of PSS was lower than that in the group of GD[ OR =0.46,95％ CI (0.35,0.61 ),P ＜0.01 ].That in the group of GD plus PSS was lower than that in the group of GD [ OR =0.25,95％ CI (0.18,0.35),P ＜ 0.01 ].The group of GD plus PSS was similar to that of group of PSS [ OR =0.72,95％ CI ( 0.40,1.29 ),P =0.27 ].Encephalopathy rate was higher in the group of PSS than the group of GD [ OR =3.57,95％ CI (2.43,5.23 ),P ＜0.01 ].That in group of GD plus PSS was lower than that in the group of PSS[ OR =0.37,95％ CI (0.20,0.69),P ＜0.01 ],while that in GD plus PSS was similar to the group of GD[ OR =1.58,95％ CI (1.02,2.43),P =0.04 ].ConclusionsThe only significant factor influencing the long term result in Chinese patients with portal hypertension is preoperative liver function.The three types of operation have different benefits and disadvantages.