| Objectives: To investigate the application of the timing of transpancreatic sphincterotomy(TPS)in patients with guide wire entering the pancreatic duct during difficult ERCP biliary cannulation,the success rate of selective bile duct intubation,complication rate and influencing factors of TPS at different times were analyzed and compared.The safety and effectiveness of TPS implementation at different times were summarized,and the influencing factors of common postoperative complications in patients with ERCP difficult intubation whose guide wire went into the pancreatic duct were analyzed,in order to provide reference for clinical development of accurate surgical strategies.To summarize the safety and efficacy of TPS at different times,and analyze the influencing factors of common postoperative complications in patients with unintentional pancreatic duct cannulation during difficult ERCP biliary access,in order to provide reference for clinically formulating precise surgical strategies.Methods: The clinical data of patients who underwent ERCP in the Digestive Endoscopy Department of xx Hospital from January 2019 to November 2022 were retrospectively analyzed.A total of 510 patients with guide wire entering the pancreatic duct during difficult ERCP biliary cannulation were included.According to whether or not TPS was performed and the timing of TPS implementation,the included patients were divided into continuous attempt of conventional cannulation technique(328 cases),early TPS group(83 cases)and delayed TPS group(99 cases).Patients who had sphincterotomy immediately after guidewire running into pancreatic duct for the first time,during the cannulation time was 5-10 min were set as early TPS group.while patients who underwent TPS when the guide wire had repeatedly entered the pancreatic duct(≥ 2 times)or when the cannulation time was ≥ 10 min were set as delayed TPS group.Patients who continued to try conventional intubation technique even when the guidewire entered the pancreatic duct and intubation time ≥ 5min,were classified as the group that continued to try conventional intubation.The general data,procedure time,cannulation time,success rate of biliary cannulation and incidence of complications in each group were compared,and the risk factors of different complications were analyzed.Results:1.General information: A total of 510 patients with a guidewire mistakenly inserted into the pancreatic duct during difficult ERCP biliary cannulation were enrolled,including 245 males(48%)and 265 females(52%),with an average age of(55.7±16.0)years.The main indication for ERCP was choledocholithiasis in 330cases(64.7%),followed by benign common bile duct strictures in 85 cases(16.7%).There were no significant differences in gender,age,ERCP indications,hypertension,diabetes,coronary heart disease,hepatic insufficiency,preoperative jaundice,body mass index,history of cholecystectomy,duodenal papilla diverticulum,bile duct dilatation and other general clinical baseline data among the three groups(all P values>0.05).2.Intraoperative situation: The overall intubation success rate of the three groups was 93.7%(478/510),and the intubation success rate of the delayed TPS group was83.8%(83/99),which was significantly lower than the early TPS group and the group that continued to try conventional intubation technique(all P values <0.05).In the early TPS group,only one patient failed intubation,and the success rate of intubation was 98.8%(82/83),which was higher than that in the continued attempt at conventional intubation technique group(95.4%,313/328),but the difference was not statistically significant(P =0.271).The average operation time in the three groups was 31.0(24.0～46.0)minutes,and the average intubation time was 13.0(10.0～19.0)minutes.The operation time[50.0(40.5～67.0)min] and intubation time [23.0(17.5～28.0)min] of the delayed TPS group were significantly longer than those of the early TPS group and the continued attempt at conventional intubation group(both P<0.001).The operative time [28.0(23.0～32.0)min] and the intubation time [12.0(9.0～14.0)min] of the early TPS group were shorter than those in the continued attempt at conventional intubation group,but the differences were not statistically significant(all P values >0.05).3.Postoperative outcomes: In terms of complications after ERCP,the total complication rate of the three groups was 37.3%(190/510),and the total complication rate of the early TPS group was significantly lower than that of the delayed TPS group(30.1% vs.48.5%,P=0.012),but there was no statistically significant difference compared with the continued attempt at conventional intubation group(35.7%,117/328),and there was also no significant difference in the incidence of total complications between the latter two groups(P>0.05).The overall incidence of Post-ERCP pancreatitis(PEP)in the three groups was9.0%(46/510),and the incidence of PEP in the early TPS group was 1.2%(1/83),which was significantly lower than that in the delayed TPS group(P<0.001),the incidence of PEP in the latter group was significantly higher than that in the continued attempt at conventional intubation group(17.2% vs.8.5%,P=0.014).Although the incidence of PEP in the early TPS group was lower than that in the continued attempt at conventional intubation group(1.2% vs.8.5%),the difference was not statistically significant(P>0.05).All patients with postoperative PEP were mild,and the symptoms could be relieved after conservative medical treatment.The overall bleeding rate among the three groups was 31.2%(159/510),among which the early bleeding rate was 29.0%(148/510),and the delayed bleeding rate was5.5%(28/510).There was no significant difference in the incidence of overall bleeding,early bleeding and delayed bleeding among the three groups(all P values >0.05).Only one patient in the three groups developed biliary tract infection(0.2%,1/510),and there were no perforation or operation-related deaths in each group.4.The independent risk factors of PEP include female(OR=2.185,95%CI:1.068-4.467),hypertension(OR=4.161,95%CI: 1.340-12.919),intubation time(OR=1.135,95%CI : 1.096-1.175).5.The independent risk factors of overall bleeding(early bleeding and delayed bleeding)include hepatic insufficiency(OR=4.511,95%CI: 1.851-10.990),intubation time(OR=1.039,95%CI: 1.012-1.066),EST(OR=7.461,95%CI: 2.498-22.289)and ESBD(OR=2.056,95%CI:1.270-3.329).While successful intubation(OR=0.065,95%CI: 0.010-0.422)was the independent protective factor of overall bleeding after ERCP.Conclusions:1.In patients with unintentional pancreatic duct cannulation during difficult ERCP biliary access,early implementation of TPS shortens intubation time and operative time compared with continued attempt at conventional intubation technique and delayed TPS,thereby improving the success rate of selective biliary cannulation and reducing the incidence of complications,it may be an effective ways to solve the difficult cannulation dilemma in the future.2.In patients with unintentional pancreatic duct cannulation during difficult ERCP biliary access,compared with continued attempt at conventional intubation technique and early TPS,delayed the implementation of TPS prolongs intubation time and operation time,reduces the success rate of biliary intubation,and increases the incidence of complications,which should be paid attention to clinically.3.In patients with unintentional pancreatic duct cannulation during difficult ERCP biliary access,female,hypertension,and intubation time were independent risk factors for PEP.Hepatic insufficiency,intubation time,EST,and ESBD were independent risk factors for overall bleeding after ERCP,while intubation success was independent protective factor. |
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