| Part I.Clinical characteristics of patients with chronic pancreatitis undergoing endoscopic retrograde pancreatography and analysis of risk factors for failure of main pancreatic duct drainageObjective: Chronic pancreatitis(CP)can exhibit characteristic pathological changes such as pancreatic duct stenosis and pancreatic duct stones.Endoscopic treatment can alleviate pancreatic duct obstruction caused by pancreatic duct stones,improve pancreatic duct stenosis,achieve pancreatic duct decompression,and alleviate pancreatic pain.The aim of this study is to analyze the clinical characteristics of patients undergoing first-time endoscopic retrograde pancreatography(ERP)CP and explore the risk factors for failure of endoscopic retrograde main pancreatic duct drainage.Methods: This study reviewed and collected the clinical characteristics of CP patients who underwent ERP for the first time in our center from January 2015 to December 2016,including the patient’s date of birth,gender,height,weight,course of disease information,key events related to CP in the total course of disease,etiology related information,main laboratory and imaging examination results,endoscopic intervention records,postoperative complications,etc.,to analyze the success rate of pancreatography and postoperative complications,Logistic regression model was used to explore the risk factors for failure of main pancreatic duct drainage in CP patients.Result:1.In the end,550 CP patients who underwent ERP for the first time were included in the study,of which 439 patients were successfully drained directly through the main pancreatic duct,and 111 patients failed to be drained through the main pancreatic duct.The reasons for the failure of drainage through the main pancreatic duct include: 37 patients with failed main pancreatic duct angiography;45 cases underwent successful main pancreatography,but the treatment accessory was unable to reach the treatment site due to significant stenosis of the ventral pancreatic duct;15 cases underwent successful main pancreatography,but the treatment attachment was unable to reach the treatment site due to significant distortion of the ventral pancreatic duct;14 cases underwent successful main pancreatography,with successful development of the ventral pancreatic duct and no development of the proximal pancreatic duct.Among the patients who failed to drain the main pancreatic duct,28 successfully attempted to drain the accessory pancreatic duct,1successfully underwent accessory pancreatography,but the treatment attachment could not reach the treatment site,21 failed accessory pancreatography,and 61 cases were not described in the report as attempting accessory pancreatic duct intubation.The overall success rate of drainage was 84.9%(467/550),and the success rate of main pancreatic duct drainage was 79.8%(439/550).2.Clinical characteristics of 550 CP patients: Male 67.3%,median age of onset 39.7(27.6,51.1)years,median age of CP diagnosis 46.3(33.1,54.2)years,median age at ERP47.1(33.5,55.2)years,median time between first onset and ERP 2.9(0.5,8.6)years,median time between diagnosis and ERP 2.1(1.2,6.9)months,and 52 cases(9.5%)of adolescent onset.The median BMI is 21.0(18.9,23.2)kg/m2.254 patients(46.2%)had a history of smoking and 234 patients(42.5%)had a history of drinking alcohol.In terms of etiology,162 cases(29.5%)were ACP patients,365 cases(66.4%)were ICP patients,23cases(4.2%)were anatomically abnormal,including 14 cases(2.5%)of completeness pancreas division.In terms of initial symptoms,there were 225 cases(40.9%)of AP onset,199 cases(36.2%)of recurrent abdominal pain,2 cases(0.4%)of persistent abdominal pain,61 cases(11.1%)of diabetes,31 cases(5.6%)of steatorrhea,and 32 cases(5.8%)of other onset modes.In terms of abdominal pain types,there were 169 cases(30.7%)of RAP type pain,197 cases(35.8%)of RP type pain,118 cases(21.5%)of RAP+RP type pain,8cases(1.5%)of CP type pain,and 58 cases(10.5%)of painless patients.Four cases(0.7%)had a history of severe acute pancreatitis.149 patients(27.1%)had diabetes and 113patients(20.5%)had steatorrhea.In terms of CP complications,there were 18 cases(3.3%)of pancreatic portal hypertension,14 cases(2.5%)of common bile duct stenosis,and 93cases(16.9%)of pancreatic pseudocysts.70 cases(12.7%)were complicated with pancreatic pseudocysts during ERP.There were 431 patients(78.4%)with pre-ERP lithotripsy.In the ERP operation,308 cases(56.0%)of trainees participated in the operation,533 cases(96.9%)of papillary type were observed under endoscopy,and 17cases(3.1%)of other types were observed.The opening morphology of the main nipple showed villous type in 467 cases(84.9%),granular type in 53 cases(9.6%),split type in 21cases(3.8%),and other types in 9 cases(1.6%).22 cases(4.0%)had diverticula around the main nipple.Endoscopic sphincter preincision was performed in 10 cases(1.8%).3.355 cases(66.1%)of 537 patients with pancreatic duct stones were completely cleared,125 cases(23.3%)were partially cleared,57 cases(10.6%)failed to clear,and 455cases(84.7%)were successfully drained.4.There were 28 cases(5.1%)of postoperative complications in ERP,including 12cases(2.2%)of postoperative pancreatitis,1 case(0.2%)of bleeding,and 15 cases(2.7%)of infection.24 cases(4.4%)had mild complications,4 cases(0.7%)had moderate complications,and no severe complications occurred.5.Risk factor analysis of 550 CP patients who underwent ERP for the first time attempting to intubate the main pancreatic duct due to failed main pancreatography.The age of onset(OR=1.016,95% CI 1.002-1.030,P=0.023)is an independent risk factor for failure of main pancreatic duct drainage in CP patients undergoing ERP for the first time,and the participation of trainees in the procedure(OR=0.429,95% CI 0.280-0.658,P<0.001)is an independent protective factor.Conclusion: Endoscopic therapy can be a reasonable treatment option for CP patients with pancreatic duct obstruction,with a high success rate and high safety of endoscopic drainage.Part I I.Study on the success rate and safety of endoscopic retrograde accessory pancreatography in chronic pancreatitisObjective: The main pancreatic duct endoscopic approach through the main duodenal papilla is generally considered to be the most common method for endoscopic treatment of CP.However,some patients with CP have failed to achieve deep pancreatic intubation through main papillary angiography due to pancreatic division,main pancreatic duct distortion,stenosis,or other reasons,and require endoscopic retrograde accessory pancreatography through the accessory papilla.The purpose of this study was to analyze the success rate and safety of accessory pancreatography.Methods: This study prospectively collected CP patients who underwent ERP for the first time in the Pancreatic Disease Special Area of Gastroenterology Department of Changhai Hospital,and counted the number of patients who received main and accessory pancreatography techniques,mainly analyzing the success rate and safety of accessory pancreatography techniques.Result: 1.Starting from September 15,2022 and ending on April 26,2023,this study collected a total of 100 CP patients who underwent ERP for the first time.The overall success rate of drainage was 84.0%(84/100),with 69 patients successfully drained through the main pancreatic duct angiography and 31 patients failing to drain through the main pancreatic duct.The reasons for the failure of drainage through the main pancreatic duct include: 13 patients failed to undergo main pancreatography;Seven cases underwent successful main pancreatography,but the treatment accessory was unable to reach the treatment site due to significant stenosis of the ventral pancreatic duct;Six cases underwent successful main pancreatography,but the treatment attachment was unable to reach the treatment site due to significant distortion of the ventral pancreatic duct.Five cases underwent successful main pancreatography,but the ventral pancreatic duct was successfully visualized,while the proximal pancreatic duct was not visualized.Among the patients with failed main pancreatic duct drainage mentioned above,15 patients successfully attempted accessory pancreatic duct drainage,and 16 patients failed accessory pancreatic duct pancreatography.The success rate of main pancreatic duct drainage was 69.0%(69/100),and the success rate of accessory pancreatic duct drainage was 48.4%(15/31).2.There was a statistical difference between CP patients with successful and failed endoscopic retrograde main pancreatic duct drainage in terms of completeness pancreatic division and anesthesia mode(P<0.05),but there was no statistical difference in other general conditions,etiology,course information,key events,and endoscopic treatment related information(P>0.05).3.There were 11 cases(11.0%)of postoperative complications after ERCP,including 8 cases(8.0%)of postoperative pancreatitis,1 case(1.0%)of perforation,and 2 cases(2.0%)of infection.Eleven cases(11.0%)had mild complications,and no moderate to severe complications occurred.There was no significant statistical difference(P>0.05)in the incidence and severity of complications after attempting secondary pancreatography compared to single primary pancreatography.Conclusion: Endoscopic retrograde accessory pancreatography plays an important role in the diagnosis and treatment of CP,and its technical success may be related to the degree of development of the accessory pancreatic duct.Attempting accessory pancreatography can improve the success rate of endoscopic drainage.The operation of the accessory pancreatic duct often increases the risk of complications after the failure of the main pancreatic duct drainage.In this study,the operation of the accessory pancreatic duct did not significantly increase the risk of complications.In ERP,patients with stenosis,distortion,compression,and interruption of the main pancreatic duct and failure of deep intubation through the main pancreatic duct should undergo endoscopic retrograde accessory pancreatography. |
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