A case report on choledochoduodenal fistula: how to suspect this unusual entity?

A choledochoduodenal fistula is an abnormal connection between the common bile duct and the duodenum, which are associated with a history of problems in the common bile duct. It has appeared in 0.74% of patients submitted for biliary tract surgery. The most frequent symptoms of non-obstructive enteric biliary fistulas are: epigastric pain, cholangitis (80.91%), jaundice (54,.26%), fever (50.69%), nausea and/or vomiting (10.30%), abdominal distension (0.39%), asymptomatic (0.11%), and diarrhea (0.11%). Diagnostic imaging methods provide the data of greatest interest in revealing the presence of air in the bile duct. This method, as well as barium reflux under the biliary tree in contrasted studies and in ERCP, reveal the fistulous tract and its location. Neither the prevalence, nor the clinical characteristics that pertain to its presentation, are well known among our population. Possible treatments for this illness include conservative treatment with medication, endoscopic sphincterotomy, and surgical therapy.

Colangitis aguda secundaria a hidatidosis biliar resuelta por colangiopancreatografía retrógrada endoscópica. Reporte de un caso / Acute cholangitis secondary to biliary hydatidosis resolved by endoscopic retrograde cholangiopancreatography. Reporte of a case

Introducción. La hidatidosis biliar es la complicación más frecuente de la hidatidosis hepática. La colangiopancreatografía retrógrada endoscópica desempeña un papel clave en el tratamiento. Caso clínico. Femenina de 57 años acude por dolor abdominal, vómito, diarrea, leucocitosis, hiperbilirrubinemia, en colangioresonancia magnética presenta vía biliar dilatada, defecto de señal en tercio proximal y distal. La colangiopancreatografía retrógrada endoscópica evidencia presencia de cuerpo extraño de aspecto de membranas, vía biliar dilatada, se extrae quistes de aspecto parasitario. Conclusión. El tratamiento de elección es quirúrgico y farmacológico, la colangiopancreatografía retrógrada endoscópica antes de la cirugía, asegura la extracción del material hidatídico y trata la obstrucción biliar, identifica el trayecto fistuloso y facilita su cierre mediante colocación de prótesis y esfinterotomía, por lo que constituye un tratamiento no quirúrgico efectivo y con margen amplio de seguridad.

Introduction: Biliary hydatid disease is the most common complication of hepatic hydatid disease. Endoscopic retrograde cholangiopancreatography plays a key role in treatment. Clinical case: A 57-year-old female presented with abdominal pain, vomiting, diarrhea, leukocytosis, mixed hyperbilirubinemia, and magnetic resonance cholangiography showed a dilated bile duct and a signal defect in the proximal and distal third. Endoscopic retrograde cholangiopancreatography shows the presence of a foreign body with a membrane appearance, a dilated bile duct, and cysts with a parasitic appearance. Conclusion: The treatment of choice is surgical and pharmacological, endoscopic retrograde cholangiopancreatography before surgery ensures the extraction of hydatid material and treats biliary obstruction, identifies the fistulous tract and facilitates its closure by placing a prosthesis and sphincterotomy, which is why it constitutes a Effective non-surgical treatment with a wide margin of safety.

Procedimiento endoscópico-percutáneo de rendezvous para el manejo de vía biliar difícil: experiencia en un centro endoscópico de Lima-Perú / Endoscopic-percutaneous rendezvous procedure for the management of difficult biliary tract: experience in an endoscopic center in Lima-Peru

RESUMEN Objetivos: El acceso biliar refractario a las técnicas convencionales de canulación es un escenario clínico desafiante para la mayoría de endoscopistas, la técnica de rendezvous endoscópico-percutáneo es una óptima alternativa con altas tasas de éxito y bajas tasas de complicaciones en manos expertas, sin embargo, su uso rutinario en Occidente principalmente Latinoamérica es aún limitado. El objetivo de nuestro estudio fue evaluar la factibilidad, eficacia y seguridad del rendezvous endoscópico-percutáneo en el manejo de la vía biliar difícil en un centro endoscópico en Perú. Materiales y métodos: Estudio descriptivo - tipo serie de casos que incluyó 21 pacientes, con diagnóstico de vía biliar difícil, todos tratados mediante rendezvous endoscópico-percutáneo entre Julio 2017 a Julio 2020. Se evaluó: edad, género, número de colangiopancreatografias retrógradas endoscópicas fallidas previas, hallazgos endoscópicos asociados, tasa de canulación exitosa, tasa de resolución exitosa de coledocolitiasis difícil, eventos adversos y mortalidad relacionada con el procedimiento. Resultados: La tasa de canulación exitosa fue del 100% (21/21). Se presentaron 12 casos (57,1%) de coledocolitiasis difícil de los cuales se obtuvo una tasa de resolución exitosa del 91,6% (11/12). La tasa global de eventos adversos fue de 4,7% (1/21), la cual fue un caso de hemorragia digestiva post-esfinteroplastía que fue resuelta exitosamente solo por vía endoscópica. Conclusiones: El rendezvous endoscópico-percutáneo realizado por manos expertas es factible, seguro y clínicamente efectivo para el manejo de la vía biliar difícil en Latinoamérica.

ABSTRACT Objectives: Biliary access refractory to conventional cannulation techniques is a challenging clinical scenario for most endoscopists. The endoscopic-percutaneous rendezvous technique is an optimal alternative with high success rates and low complication rates in expert hands, however its routine use in the West, mainly in Latin America, is still limited. The aim of our study was to evaluate the feasibility, efficacy and safety of endoscopic-percutaneous rendezvous in the management of difficult biliary tract in an endoscopic center in Peru. Materials and methods: Descriptive study - case series type that included 21 patients, with diagnosis of difficult bile duct, all treated by endoscopic-percutaneous rendezvous between July 2017 to July 2020. We evaluated: age, gender, number of previous failed endoscopic retrograde cholangiopancreatography, associated endoscopic findings, rate of successful cannulation, rate of successful resolution of difficult choledocholithiasis, adverse events and procedure-related mortality. Results: The rate of successful cannulation was 100% (21/21). There were 12 cases (57.1%) of difficult choledocholithiasis of which there was a successful resolution rate of 91.6% (11/12). The overall adverse event rate was 4.7% (1/21), which was one case of post-sphincteroplasty gastrointestinal bleeding that was successfully resolved endoscopically only. Conclusions: Endoscopic-percutaneous rendezvous performed by expert hands is feasible, safe and clinically effective for the management of the difficult bile duct in Latin America.

Seis meses de entrenamiento en Colangiografía Endoscópica Retrograda en centro formador de alto volumen ¿es suficiente? Experiencia inicial en un hospital de la Araucanía

Introducción: La colangiopancreatografía endoscópica retrógrada (CPRE) es un procedimiento terapéutico para diversas patologías biliopancreáticas. Existen diversos centros de formación con una variedad de tiempos de práctica para la realización de CPRE. Objetivo: Evaluar resultados iniciales post entrenamiento en endoscopia terapéutica en el Instituto Chileno-Japonés del Hospital San Borja Arriarán, analizando 150 CPRE consecutivas, describiendo aspectos técnicos, morbilidad y mortalidad, realizadas entre noviembre de 2017 a enero de 2019 por un único operador en un hospital de la Araucanía. Método: Análisis retrospectivo del registro prospectivo de los 150 primeros casos consecutivos de CPRE realizados en el hospital San José de Victoria (HSJV). Se midieron variables clínicas, técnicas y de laboratorio. Se utilizó estadística descriptiva con medidas de tendencia central, dispersión y tendencia extrema. Resultados: Serie de 150 pacientes sometidos a CPRE: Edad promedio 60,1 años, mediana de 65 y edades extremas 16-98 años. Sexo femenino 69,3%. Indicaciones CPRE: 67,3% coledocolitiasis sin colangitis, 16,7% colangitis aguda, 6% estenosis de vía biliar benigna, 3.3% tumor periampular. Todos apoyados por anestesista, 50,7% propofol y 49.3% anestesia general. Tasa de canulación biliar 96,7%. Precorte 19,3%. Complicaciones reportadas alcanzaron el 4,67%, sin mortalidad por el procedimiento en la serie. Conclusiones: Los resultados de esta serie muestran que la formación obtenida por el profesional logró los estándares sugeridos para un procedimiento efectivo y seguro, destacando una tasa de canulación del 96,7%, siendo superior a lo que las guías internacionales describen como exitosa. La morbilidad asociada a CPER es comparable a cifras nacionales e internacionales.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure for various biliopancreatic pathologies. There are different training centers with a variety of practice times for performing ERCP. Objective: This study aims to evaluate the initial post-training results in therapeutic endoscopy at the Chilean-Japanese Institute of San Borja Arriarán Hospital, analyzing 150 consecutive ERCP procedures performed between November 2017 and January 2019 by a single operator at a hospital in La Araucanía, describing technical aspects, morbidity, and mortality. Method: Retrospective analysis of the prospective registry of the first 150 consecutive ERCP cases performed at the San José de Victoria Hospital (HSJV). Clinical, technical and laboratory variables were measured. Descriptive statistics were produced with measures of central tendency, dispersion and extreme tendency. Results: Series of 150 patients undergoing ERCP: mean age 60.1 years, median 65 and extreme ages 16-98 years. Female sex 69.3%. ERCP indications: 67.3% choledocholithiasis without cholangitis, 16.7% acute cholangitis, 6% benign bile duct stenosis, 3.3% periampullary tumor. All supported by an anesthetist, 50.7% propofol and 49.3% general anesthesia. Biliary cannulation rate 96.7%. Precut 19.3%. Reported complications reached 4.67%, with no mortality from the procedure in the series. Conclusions: The results of this series show that the training obtained by the professional improves the standards proposed for an effective and safe procedure, highlighting a cannulation rate of 96.7%, higher than what international guidelines describe as successful. The morbidity associated with ERCP in our series is comparable to national and international figures.

Analysis of symptoms and management modalities of endometriosis in a tertiary care hospital

Background: Endometriosis is a progressive disease characterized by the growth and placement of endometrial tissue outside the uterine cavity. Endometriosis affects 10-15% of all women of reproductive age and 70% of women with chronic pelvic pain. We have aimed to study the demographic factors, symptoms and management of endometriosis. Certain risk factors are discussed which may be helpful in early diagnosis of the same.Methods: A one year hospital based retrospective study involving detailed medical records of patients presenting with endometriosis between 1st November 2022 and 31st October 2023.Results: Majority of cases of endometriosis were found in the reproductive age group. Several patients presented with multiple symptoms, of which common ones were pelvic pain, dysmenorrhea, dyspareunia and infertility. Management modalities include medical management using GnRH agonist like injection leuprolide and surgical management techniques involving laparoscopy and laparotomy depending upon the extent of involvement. The most common site of endometriosis was found to be the ovary, while other peroperative findings included distorted anatomy and a concomitant infective focus owing to pelvic inflammatory diseases.Conclusions: Endometriosis can decrease quality of life due to severe pain, fatigue, infertility. No preventative measures have yet been found. But early diagnosis and management may be extremely helpful in improving the quality of life.

Duplicación del colédoco asociado a unión biliopancreática anómala: Reporte de caso / Common bile duct duplication associated with anomalous biliopancreatic junction: A case report

Introducción. La duplicación del colédoco es una anomalía congénita poco frecuente. En la mayoría de los casos este defecto se asocia a cálculos en la vía biliar, unión pancreatobiliar anómala, pancreatitis, cáncer gástrico o colangiocarcinoma. Por esta razón, el diagnóstico y el tratamiento temprano son importantes para evitar las complicaciones descritas a futuro. Métodos. Se presenta el caso de una paciente de 30 años, con antecedente de pancreatitis aguda, con cuadro de dolor abdominal crónico, a quien se le realizaron varios estudios imagenológicos sin claro diagnóstico. Fue llevada a manejo quirúrgico en donde se documentó duplicación del colédoco tipo II con unión pancreatobiliar anómala. Resultados. Se hizo reconstrucción de las vías biliares y hepatico-yeyunostomía, con adecuada evolución postoperatoria y reporte final de patología sin evidencia de tumor. Conclusión. El diagnóstico se hace mediante ecografía endoscópica biliopancreática, colangiorresonancia o colangiopancreatografía retrógrada endoscópica. El tratamiento depende de si está asociado o no a la presencia de unión biliopancreática anómala o cáncer. Si el paciente no presenta patología neoplásica, el tratamiento quirúrgico recomendado es la resección del conducto con reconstrucción de las vías biliares.

Introduction. Double common bile duct is an extremely rare congenital anomaly. This anomaly may be associated with bile duct stones, anomalous biliopancreatic junction, pancreatitis, bile duct cancer, or gastric cancers. Thus, early diagnosis and treatment is important to avoid complications. Clinical case. We report a rare case of double common bile duct associated with an anomalous biliopancreatic junction in a 30-year-old female, with prior history of acute pancreatitis, who presented with chronic abdominal pain. She underwent several imaging studies, without clear diagnosis. She was taken to surgical management where duplication of the type II common bile duct was documented with anomalous pancreatobiliary junction. Results. Reconstruction of the bile ducts and hepatico-jejunostomy were performed, with adequate postoperative evolution and final pathology report without evidence of tumor. Conclusion. Diagnosis is usually performed by an endoscopic ultrasound, magnetic resonance cholangiopancrea-tography, or endoscopic retrograde cholangiopancreatography. Treatment depends on the presence of anomalus biliopancreatic junction or concomitant cancer. In cases without associated malignancy, resection of bile duct and biliary reconstruction is the recommended surgical treatment.

Perforación colónica por endoprótesis biliar impactada / Colonic perforation due to impacted biliary stent

Introducción. La colocación de endoprótesis biliares es cada día más frecuente por ser actualmente una de las mejores opciones para el tratamiento de patologías de la vía biliar. La migración de las endoprótesis es una de las complicaciones que puede ocurrir en hasta un 10,8 % de los pacientes, pero en muy raras ocasiones llegan a causar una perforación intestinal. Caso clínico. Se trata de una paciente de 61 años, a quien cinco años atrás se le realizó una colangiopancreatografía retrógrada endoscópica por coledocolitiasis. Consultó por presentar dolor abdominal, y al examen físico se encontraron abdomen agudo y plastrón en fosa ilíaca izquierda a la palpación. La tomografía computarizada informó un cuerpo extraño a nivel del colon descendente, con perforación del mismo. Se realizó laparotomía exploratoria y colostomía por perforación del colon sigmoides secundaria a prótesis biliar migrada. Resultados. La paciente evolucionó favorablemente y a los seis meses se realizó el cierre de la colostomía, sin complicaciones. Conclusión. Los pacientes a quienes se les colocan prótesis biliares requieren un seguimiento adecuado para evitar complicaciones que, aunque raras, pueden ocurrir, como la migración intestinal con perforación. El tratamiento de dichas complicaciones se hace por vía endoscópica, laparoscópica o laparotomía en caso de complicación severa.

Introduction. Endoscopic placement of biliary stents is becoming more common every day, as it is currently one of the best options for the treatment of bile duct pathologies. One of the complications that can occur is the migration of the endoprostheses in up to 10.8% of patients, which in very rare cases can cause intestinal perforation. Clinical case. This is a 61-year-old female patient, who underwent endoscopic retrograde cholangiopancreatography five years ago for choledocholithiasis. She consulted due to abdominal pain, with a physical examination that upon palpation documented an acute abdomen and a palpable plastron in the left iliac fossa. The computed tomography revealed a foreign body at the level of the descending colon, with perforation. Exploratory laparotomy and colostomy were performed due to perforation of the sigmoid colon secondary to migrated biliary prosthesis. Results. The patient progressed favorably and six months later the colostomy was closed without complications. Conclusions. Patients who receive biliary stents require adequate follow-up to avoid complications that, although rare, may occur, such as intestinal migration with intestinal perforation. The treatment of these complications can be endoscopic, laparoscopic or laparotomy in case of severe complication.

Clinical Efficacy of Abdominal Ultrasound-guided Endoscopic Retrograde Appendicitis Therapy for Acute Uncomplicated Appendicitis / 昆明医科大学学报

Objective To compare the clinical efficacy of abdominal ultrasound-guided endoscopic retrograde appendicitis therapy(ERAT)with laparoscopic appendectomy(LA)for acute uncomplicated appendicitis using propensity score matching.Methods The clinical data of 441 patients with acute uncomplicated appendicitis admitted to the Third People's Hospital of Yunnan Province from March 2020 to April 2023 were collected.The cases were classified based on the differences in surgical method and divided into the ERAT group(n = 30)and LA group(n = 411).The clinical efficacy of patients was compared between the two groups after reducing confounding bias by propensity score matching(PSM).Results After PSM,a total of 30 pairs of patients in the two groups were successfully matched,and the baseline data of the two groups met the requirements for comparability.At 24 hours after the operation,the ERAT group exhibited lower white blood cells,neutrophil counts,and C-reactive protein levels compared to the LA group,and these differences were statistically significant(P<0.05).There was no significant difference in the operation time and total effective rate between the ERAT group and the LA group(P>0.05).However,the ERAT group had lower intraoperative blood loss and shorter pain relief time compared to the LA group,and these differences were statistically significant(P<0.05).Conclusion Abdominal ultrasound-guided endoscopic retrograde appendicitis treatment is an effective,safe,and feasible technique with good prospects for the treatment of acute uncomplicated appendicitis.

The effect of simple topical and intravenous general anesthesia on the occurrence of pancreatitis after ERCP surgery:a retrospective analysis / 临床外科杂志

Objective To investigate the effects of simple topical anesthesia and intravenous general anesthesia on the occurrence of pancreatitis after ERCP.Methods 400 Patients who underwent ERCP due to pancreaticobiliary duct disease in our hospital from January 2021 to March 2023 were selected and divided into two groups:Simple topical anesthesia group and intravenous general anesthesia group,200 cases in each group.The levels of venous pancreatic amylase and abdominal symptoms and signs were recorded in the two groups before operation and 3 h and 24 h after operation.The observation results were hyperamylaseemia and postoperative pancreatitis at 3 h and 24 h after operation.Results The incidence of postoperative pancreatitis after ERCP was higher in the superficial anesthesia group than in the intravenous general anesthesia group(7.5％and 2.0％,respectively;P＜0.05),there was statistical significance;The level of serum pancreatic amylase(198±216)U/L in intravenous general anesthesia group was significantly lower than that in superficial anesthesia group(379±327)U/L at 3h after surgery(P＜0.05).The level of serum pancreatic amylase(129±98)U/L in intravenous general anesthesia group was lower than that in superficial anesthesia group(187±156)at 24h after surgery(P＜0.05).The incidence of hyperamylasemia was 15.5％(31/200 cases)in the 3h postoperative intravenous general anesthesia group,lower than that in the simple surface anesthesia group(34.5％)(69/200 cases),and 5.5％(11/200 cases)in the 24h postoperative intravenous general anesthesia group,lower than that in the simple surface anesthesia group(19.0％)(38/200 cases)(P＜0.05).Conclusion Compared with simple surface anesthesia,intravenous general anesthesia can reduce the level of serum amylase after ERCP,and can reduce the occurrence of pancreatitis after ERCP.

Finite element analysis of anterograde and retrograde intramedullary nail for different areas of femoral shaft fractures / 中国组织工程研究

BACKGROUND:Intramedullary nail has achieved a good clinical result in the treatment of femoral shaft fractures,but some patients still have aseptic nonunion due to mechanical instability.The femur is the longest and largest bone in the human body,but there are few studies on whether the fracture of the femur has different biomechanical results in different areas and the influence of different inserting methods on the stability of fracture fragments in different areas. OBJECTIVE:To analyze the biomechanical characteristics of anterograde and retrograde intramedullary nails in the treatment of different areas of femoral shaft fractures,and to evaluate the best way of insertion to reduce the incidence of nonunion. METHODS:CT data of a healthy volunteer were selected to import into the software of Mimics 19.0 and Geomagic studio 2017 to extract and optimize the three-dimensional model of the right femur.The anterograde and retrograde intramedullary nail models were built with Solidworks 2017 software and assembled with femoral shaft fracture models at different fracture areas according to standard surgical techniques.The models were imported into Abaqus 2017 software in STEP format to set material attribute parameters,boundary conditions,load and submit calculation,and the results were viewed in the visualization module.Among them,the antegrade and retrograde intramedullary nails of the upper femoral shaft fracture were A1 and A2 models,B1 and B2 models in the middle segment,and C1 and C2 models in the lower segment. RESULTS AND CONCLUSION:(1)In models A1,B1 and C2,the overall stress distribution of the femur was more uniform,and the placement,the displacement and angle of the fracture site,and inversion angle of the proximal femoral bone fragment were smaller.(2)For the upper and middle femoral shaft fractures,the anterograde intramedullary nail has a better biomechanical effect.For lower femoral shaft fractures,a retrograde intramedullary nail is preferable.

Finite element analysis of three different minimally invasive fixation methods for distal tibial fractures with soft tissue injury / 中国组织工程研究

BACKGROUND:The treatment of distal tibial fractures with soft tissue injury has always been challenging,and the new retrograde tibial nailing is a new choice.Up to now,there were few reports on the biomechanical properties between the new retrograde tibial nailing,anterograde intramedullary nailing and supercutaneous locking plate. OBJECTIVE:To explore the biomechanical stability of new retrograde tibial nailing,antegrade intramedullary nailing and supercutaneous locking plate in the treatment of distal tibial fractures with soft tissue injury using finite element analysis so as to offer a scientific foundation for clinical application. METHODS:The finite element model of transverse distal tibia fracture was established by relevant software utilizing the CT data of the tibia from a 42-year-old healthy male.Retrograde tibial nailing,antegrade intramedullary nailing and supercutaneous locking plate finite element models were assembled under the principle of fracture fixation.Finally,meshing,applying loads,and data processing were accomplished with the ANSYS 2019 software.Moreover,the stress distribution and displacement of the tibia and internal fixation of each model were compared. RESULTS AND CONCLUSION:(1)The displacement of fracture end in the three groups increased with the increase of load.In all mode loads,the average displacement of the fracture end was the least in the retrograde tibial nailing group,followed by the supercutaneous locking plate group,and the highest in the antegrade intramedullary nailing group.At 800 N vertical load,the displacement difference of the fracture end was statistically significant(P<0.05).There was no statistical significance in other load modes.(2)Under different loads,the tibial stress in the three groups was the highest in the middle of the tibia,and gradually decreased to the proximal and distal ends.The stress distribution of the tibial shaft was the highest in the retrograde tibial nailing group,followed by the supercutaneous locking plate group,and the least in the antegrade intramedullary nailing group.(3)Under different loads,the stress of the tibial stress raiser in the three groups was significantly higher in the supercutaneous locking plate group than in the other two groups,with statistical significance(P<0.05).(4)Under different loads,the stress of the fixators in the three groups was the largest in the supercutaneous locking plate group,followed by the retrograde tibial nailing group,and the minimum in the antegrade intramedullary nailing group.There were significant differences in the stress of fixator stress raiser among the three groups under different loading modes(P<0.05).(5)It is indicated that all three fixation methods have the good anti-rotation ability and axial stability.Retrograde tibial nail shows better biomechanical stability.

Biomechanical difference of different fixation methods in bone healing of distal tibial comminuted fractures analyzed by finite element method / 中国组织工程研究

BACKGROUND:The treatment of distal tibial comminuted fractures with soft tissue injury has always been challenging.The new retrograde tibial nailing and supercutaneous locking plate are important treatment methods,but their strain and stress shielding at the fracture end during different periods of fracture healing and different load conditions have not been reported. OBJECTIVE:To explore the biomechanical stability of retrograde tibial nailing and supercutaneous locking plate in different periods of fracture healing by finite element analysis to offer a scientific foundation for clinical application and rehabilitation exercise. METHODS:The finite element model of distal tibial comminuted fracture was established by utilizing the CT data of the tibia from a 40-year-old healthy male.Retrograde tibial nailing,supercutaneous locking plate,and callus models were assembled in accordance with the principle of fracture fixation.The finite element analysis was performed using ANSYS software to compare the displacement of the fracture end,the stress shielding of the tibia,the stress of the callus,and the stress distribution of the tibia and the fixation device during different periods of fracture healing. RESULTS AND CONCLUSION:(1)The relative displacement of the tibial fracture decreased gradually with the healing of the fracture,and the displacement decreased significantly after 3 months.At 0 and 1 months after operation,the vertical displacement and total displacement of the supercutaneous locking plate group were higher than those in the retrograde intramedullary nail group.The Z-axis displacement(horizontal medial and lateral displacement)of the two fixation methods was more obvious than the X-axis and Y-axis,and the Z-axis displacement of supercutaneous locking plate group was the most obvious.The maximum Z-axis displacement of the two fixation methods was located on the outside of the tibia,and the minimum displacement was located on the inside of the tibia.(2)The stress shielding rate at different periods of fracture healing gradually decreased with time.The stress shielding rate of the retrograde intramedullary nail was higher than that of the supercutaneous locking plate at different stages of fracture healing.After 3 months,the stress shielding rate of the supercutaneous locking plate was reduced to about 4%,and the stress shielding rate of the retrograde intramedullary nail was reduced to about 40%.(3)The stress of the stress concentration site of the callus in the two fixation methods increased with the increase of the load,and the stress of the callus in the supercutaneous locking plate group was always greater than that in the retrograde intramedullary nail group.The maximum stress distribution of the callus was approximately equally distributed among the two modes of fixation,both in the lateral portion of the tibia.(4)As the fracture healed,the maximum stress of the tibia in the two groups decreased gradually,and the stress in the supercutaneous locking plate group was always greater than that in the retrograde intramedullary nail group.The average stress of the maximum stress area of the tibia in the supercutaneous locking plate group under 1 500 N load was 285 MPa,while that in the retrograde intramedullary nail group was 26 MPa.(5)As the fracture healed,the stress of the fixation device in the two groups decreased gradually,and the stress in the supercutaneous locking plate group was significantly higher than that in the retrograde intramedullary nail group.After 3 months,the stress of the two fixation devices decreased significantly.(6)It is indicated that in the early stage of fracture healing,the strain on the fracture end in the retrograde intramedullary nail group is small,and the maximum stress of the tibia is moderate,allowing early loaded.The fractured ends in the supercutaneous locking plate group had too large strain and too large maximum stress of the tibia,which needed to be partially loaded under protection and could not be fully loaded.In the middle and late stages of fracture healing,the tibial retrograde intramedullary nail and the supercutaneous locking plate could be completely loaded,and the stress shielding rate of the supercutaneous locking plate was significantly lower than the tibial retrograde intramedullary nail.

Endoscopic retrograde cholangiopancreatography therapy of biliary and pancreatic diseases in children / 中国小儿急救医学

Endoscopic retrograde cholangiopancreatography（ERCP）is an important minimally invasive treatment method in adults with biliary and pancreatic diseases. With the development of endoscopic technology and the increasing understanding of pediatric biliary and pancreatic diseases，ERCP technology has gradually become an indispensable diagnostic and treatment method for pediatric patients with biliary and pancreatic diseases. This review mainly elaborated on the indications and surgical points of ERCP in pediatric biliary and pancreatic diseases，in order to promote the application and development of ERCP in children.

Prevention and treatment of post-endoscopic retrograde cholangiopancreatography complication in children / 中国小儿急救医学

Endoscopic retrograde cholangiopancreatography（ERCP）and related technologies are gradually being developed in pediatric biliary and pancreatic diseases.Clinicians should pay more attention to the prevention and treatment of postoperative complications.This review started with the operational methods of ERCP and its related technologies，elaborated on the possible complications，summarized the prevention and treatment methods，and aimed to provide reference for clinical doctors.

Standardize the management of ERCP complications and accelerate the widespread populari-zation of ERCP in China / 中华消化外科杂志

The process of endoscopic retrograde cholangiopancreatography (ERCP) is inva-sive, and its related treatments have a potential risk of complications, which poses certain obstacles to its safe promotion. Therefore, it is very important to standardize the management of ERCP compli-cations and promote the widespread development of ERCP in China. The authors interpret the back-ground, significance, and key issues that need to be paid attention to in the Guidelines for the management of complications of duodenal perforation associated with ERCP in China ( 2023 edition), in order to facilitate ERCP physicians to better grasp and apply the guidelines, provide guidance and reference for the standardized management of ERCP related complications of duodenal perforation, and promote the popularization and widespread development of ERCP in China.

Analysis of the risk factors for biliary infection after endoscopic retrograde cholangiopancreatography for malignant biliary obstruction / 中华肝胆外科杂志

Objective:To analyze the risk factors of biliary infection after endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant biliary obstruction.Methods:Clinical data of 160 patients with malignant biliary obstruction admitted to the Affiliated People's Hospital of Ningbo Univer-sity from June 2017 to June 2022 were retrospectively analyzed, including 89 males and 71 females, aged (65.1±8.0) (range, 41-78) years old. Patients were divided into two groups according to the occurrence of biliary infection within 30 days after ERCP: infected group ( n=30) and uninfected group ( n=130). Multivariate logistic regression was used to identify the risk factors of postoperative biliary infection. Results:The incidence of biliary infection after ERCP was 18.8% (30/160) in the patients with malignant biliary obstruction. A total of 43 strains of pathogenic bacteria were detected, including 34 Gram-negative strains and nine Gram-positive strains. The most common pathogenic bacterium was Escherichia coli. Multivariate analysis showed patients with diabetes mellitus ( OR=2.356, 95% CI: 1.587-5.441, P=0.001), sphincter dysfunction ( OR=2.651, 95% CI: 1.854-6.225, P=0.005), preoperative albumin <35 g/L ( OR=3.225, 95% CI: 2.041-5.689, P=0.002), preoperative hemoglobin <110 g/L ( OR=3.424, 95% CI: 2.115-6.333, P=0.003) suffered a higher risk of biliary infection after ERCP. Conclusion:Diabetes mellitus, sphincter dysfunction, lower levels of preoperative albumin and hemoglobin are independent risk factors for biliary infection after ERCP in patients with malignant biliary obstruction.

Comparative analysis of LC+ LCBDE and LC+ ERCP/EST for acute biliary pancreatitis / 中华肝胆外科杂志

Objective:To juxtapose laparoscopic cholecystectomy combined with common bile duct exploration and stone extraction (LC+ LCBDE) against endoscopic retrograde cholangiopancreatography/sphincterotomy with laparoscopic cholecystectomy (LC+ ERCP/EST) in the therapeutic context of acute biliary pancreatitis.Methods:The clinical data of patients with acute biliary pancreatitis in Department of Hepatobiliary Surgery, Datong Third People's Hospital from January 2017 to January 2021 were retrospectively analyzed. A total of 44 patients were inrolled, including 23 males and 21 females, with the age of (60.6±11.7) years. Based on different treatment approaches, the patients were divided into the LC+ LCBDE group ( n=33) and the LC+ ERCP group ( n=11, LC+ ERCP/EST). Total bilirubin, direct bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood amylase, operation time, postoperative hospitalization stays, total hospitalization cost, postoperative anal exhaust time, and postoperative complications (bile leakage, fever, bleeding) were compared between the two groups. Results:There were no significant differences in preoperative total bilirubin, direct bilirubin, ALT, AST, and blood amylase between LC+ ERCP group and LC+ LCBDE groups (all P>0.05). In LC+ LCBDE group, operation time was 110.0 (96.3, 147.5) min, postoperative hospitalization time was 9.0 (7.5, 11.0) d, postoperative exhaust time was 2.0 (1.0, 2.0) d, and in LC+ LCBDE group, operation time was 60.0 (32.0, 65.0) min, postoperative hospitalization time was 7.0 (4.0, 8.0) d, postoperative exhaust time was 1.0 (1.0, 1.0) d. Comparisons with LC+ LCBDE group, LC+ ERCP group had shorter postoperative hospitalization stay and earlier postoperative exhaust time, the total hospitalization cost of LC+ LCBDE group was 23 829.3 (21 779.6, 27 221.9) yuan, which was higher than 36 894.8 (31 963.5, 41 172.2) yuan in LC+ ERCP group, and the differences were statistically significant (all P<0.05). Comparison of postoperative total bilirubin, direct bilirubin, ALT and AST between LC+ ERCP group and LC+ LCBDE group, with no significant difference(all P>0.05). No postoperative complications such as bile leakage, residual stones, fever and bleeding occurred in both groups. Conclusion:Compared with LC+ ERCP/EST, LC+ LCBDE in the treatment of acute biliary pancreatitis, although the operation time and hospital stay are longer, but the total hospitalization cost is less, there is no need for multiple operations, and it can be used as the first choice for acute biliary pancreatitis.

Value of endoscopic retrograde cholangiopancreatography for the diagnosis and treatment of pediatric pancreaticobiliary maljunction / 中华消化内镜杂志

Objective:To investigate the safety and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis and treatment of pediatric pancreaticobiliary maljunction (PBM).Methods:Data of 40 pediatric patients under 14 with PBM diagnosed and treated by ERCP at Department of Gastroenterology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from November 2012 to September 2022 were collected. PBM types, ERCP-related diagnosis and treatment, adverse events and prognosis were retrospectively analyzed.Results:Nineteen cases were P-B type (joining of common bile duct with pancreatic duct), 17 were B-P type (joining of pancreatic duct with common bile duct), and 4 were complex type. Forty children with PBM underwent 50 ERCP-related operations, among which 48 procedures succeeded. One case failed during cannulation of ERCP, replaced by rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP) afterwards. There were no serious postoperative adverse events such as bleeding, perforation or death. Thirty-four patients (85%) were followed up successfully, among which 14 underwent further surgery and 20 continued conservative treatment.Conclusion:ERCP is the golden standard to diagnose pediatric PBM, and it is also safe and effective treatment for PBM.

Two-stage retrograde hybrid repair in the surgical treatment of acute aortic dissection complicated with distal malperfusion syndrome / 中国胸心血管外科临床杂志

@#Objective To evaluate the clinical efficacy of two-stage retrograde hybrid repair for acute aortic dissection involving the aortic arch complicated with distal malperfusion syndrome. Methods From May 2019 to December 2022, the patients presented with acute aortic dissection involving the aortic arch complicated with distal malperfusion syndrome treated in the Department of Cardiovascular Surgery of West China Hospital, Sichuan University were enrolled. After preoperative evaluation, all patients underwent priority emergency interventional surgery to improve distal malperfusion, and then underwent two-stage hybrid surgery to repair proximal aortic lesions. The perioperative clinical and imaging data were retrospectively analyzed. Results Five patients were collected, including 4 males and 1 female, with a median age of 58 years. The main manifestations were lower limb ischemia and renal insufficiency in 3 patients, and poor intestinal perfusion in 2 patients. All patients were given priority to interventional surgery to implant graft stents or bare stents and necessary branch artery intervention, and then successfully performed two-stage hybrid surgery, including type Ⅰhybrid surgery for 2 patients, type Ⅱ hybrid surgery for 1 patient and type Ⅲ hybrid surgery for the other 2 patients, with a success rate of 100.0%. All patients were discharged successfully, and the function of the organs with poor perfusion returned to normal. Only 1 patient recovered to grade 4 muscle strength of the diseased lower limbs upon discharge. No adverse events such as amputation, exploratory laparotomy and intestinal resection or long-term hemodialysis occurred. Conclusion The application of two-stage retrograde hybrid repair in the surgical treatment of acute aortic dissection involving the aortic arch complicated with distal malperfusion syndrome is safe and effective, and is helpful to improve the perioperative survival rate, and clinical outcomes of such patients.

Technical points of Retzius-sparing robot-assisted laparoscopic radical prostatectomy with retrograde release of the neurovascular bundle / 现代泌尿外科杂志

Retzius-sparing robot assisted radical prostatectomy (RS-RARP) can significantly improve the immediate urinary continence without increasing the positive rate of surgical margin.However, the learning curve is long, and fewer than 10% of the surgeons can master it.Therefore,we have optimized the procedures of RS-RARP, applying radical prostatectomy with retrograde release of neurovascular bundle to preserve it to the maximum extent.Urethral anastomosis can be performed with only one suture, which eliminates the need for Hem-o-lok and reduces subsequent complications.Our team routinely carries out this operation, and conlcudes that this surgical method can achieve good tumor control, good urinary continence, fast recovery of sexual function, few complications, and strong operability.This article details the key steps and operation experience of this technique.