| 抄録 |
There are many potential difficult situations in pancreaticobiliary endoscopy where tips or tricks may help overcome issues. The most notable however are the following; access to the CBD or PD, large CBD stones, hilar strictures and altered anatomy ERCP. Duct access can be difficult even for experts and there are a variety of accessories and methods to facilitate entry. The data does support the use of wireguided techniques to help primary cannulation and avoid the requirement of needle knife. Needle knife does however have support in clinical studies and maybe safer than persistence of the standard techniques. The most important factor in access is familiarity and speed to avoid prolonged and recurrent cannulation efforts that will increase complications. There is also controversy between methods of sphincter disruption for stone extraction particularly between the east and west. Balloon dilatation is rarely performed in the west in preference for sphincterotomy and further clarification is required through clinical research.Large CBD stones have traditionally been treated with intra-ductal lithotripsy but ampullary balloon dilatation now seems to simplify large stone removal. CBD perforation remains a risk and careful patient selection is required. In those who are not suitable for balloon dilatation intra-ductal stone lithiasis is needed with baskets, laser or EHL methods. Multi-stenting with plastic stents or even fully covered metal stents can also be used in the short term with good success. Hilar strictures are mainly malignant from either primary or metastatic disease. There are many controversies when managing these strictures including endoscopic versus percutaneous approaches and unilateral versus bilateral stenting. The new large cell stent designs allow for easier bilateral stent insertion and this may be the preferred technique with emerging endoscopic tumour ablation methods such as PDT and radiofrequency ablation. Finally, altered anatomy ERCP is evolving from a Billroth 1 or 2 situations to some form of choledocho-jejunostomy. These anatomical variations are commonly seen in obesity surgery and liver transplant patients. With the evolution of device assisted enteroscopy access is now easier and pancreatico-biliary therapeutics is feasible. Accessories for such work are still lacking but ever evolving allowing for better therapeutic capabilities. |
