Fiberoptic duodenoscopy, retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy

Fiberoptic duodenoscopy, retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy are: 1. Obstructive jaundice. 2. Suspected biliary calculi and hepatic bile duct stenosis. 3. Suspected ampullary abdomen, pancreatic cyst, chronic pancreatitis, biliary tract tumor or metastatic adenocarcinoma in the pancreas. 4. Postoperative biliary or gallbladder syndrome. 5. Symptomatic duodenal papillary diverticulum. 6. X-ray examination or endoscopy for suspected gastric or duodenal external compression. Treatment of diseases: pancreaticobiliary tract abnormal syndrome Indication 1. Obstructive jaundice. 2. Suspected biliary calculi and hepatic bile duct stenosis. 3. Suspected ampullary abdomen, pancreatic cyst, chronic pancreatitis, biliary tract tumor or metastatic adenocarcinoma in the pancreas. 4. Postoperative biliary or gallbladder syndrome. 5. Symptomatic duodenal papillary diverticulum. 6. X-ray examination or endoscopy for suspected gastric or duodenal external compression. Contraindications 1. Acute pancreatitis or acute exacerbation of chronic pancreatitis. 2. Acute gastritis, acute biliary infection. 3. Allergic to iodine, some people who can not use anti-cholestasis drugs. 4. Cardiopulmonary dysfunction, frequent angina pectoris; esophageal or cardiac stenosis, endoscopy can not pass. 5. After the common bile duct jejunostomy, the endoscope could not be delivered to the anastomosis. 6. Poor general condition, intolerable examination; mental illness or disturbance of consciousness; or severe spinal deformity. [relative contraindications] 1. Throat and respiratory diseases such as pharyngitis, bronchitis, tuberculosis, emphysema. 2. Recessive coronary heart disease, medication should be taken before the examination. 3. Hypertension, who is more stable after controlling blood pressure. 4. Heavier esophageal varices. 5. Hepatitis B surface antigen (hbsag) positive. Preoperative preparation 1. Spare equipment: 1 side-view duodenoscopy, Pilot ii type subtotal gastrectomy can be used for front-view gastroscope. 2 PVC catheter, inner diameter 1mm, outer diameter 1.6mm, tip has 3 scales, each scale 5mm, metal wire is inserted into the middle of the catheter from the end to increase the hardness of the catheter, easy to intubate. Connect the tee fitting to the end of the tube. 3 cold light source, suction device, biopsy forceps. 4 x-ray machine with CCTV. 2. Disinfection of the instrument: The speculum biopsy catheter was repeatedly aspirated with 0.5% chlorhexidine solution for 3 minutes, and the catheter was immersed in 75% alcohol for more than half an hour. Rinse with sterile saline before use. For hbsag-positive patients, it is best to use a special mirror, which is disinfected with ethylene oxide gas or soaked in 2% glutaraldehyde for 20 minutes. 3. Contrast agent: 60% diatrizoate; 50% sodium. The concentration of the contrast agent can be diluted to 25% to 30% with sterile physiological saline, and heated to 37 ° C before the contrast to reduce the stimulation of the pancreatic duct epithelium. 4. Patient preparation: 1 Make a good explanation and get cooperation. 2 angiography timing 10 days after the onset of cholangitis, elderly patients with chronic illness should be examined 3 weeks after the onset. 3 Antibiotics were applied two days before the angiography. 4 blood test routine blood test, blood, urine amylase; iodine allergy test. 5 fasting, water, and smoking 6 to 8 hours before surgery. 6 Check the front emptying and urinating. 7 mentally nervous, 20 to 30 minutes before the examination, subcutaneous injection of stability 10mg; hiccups or vomiting can be injected Atokou 0.5mg or 654-2 10mg; inferior intravenous hypertonic glucose. 8 15 to 20 minutes before the test, take 5 to 5 ml of the foaming agent; use 2% dicaine or 4% lidocaine for topical anesthesia of the throat and throat spray for 3 times. 9 loose neckline and belt. Surgical procedure 1. Position: Take the left semi-prone position. Check the device for faults and check the patient's condition; turn on the power; the assistant holds the lens in the right hand, and the examiner stands on the right side of the patient. 2. Into the mirror: 1 The patient's head is tilted back, and the mouth is bitten by the mouth. The surgeon takes the left hand holding the duodenoscope to the objective lens about 20cm, and slowly inserts the mirror with the right hand. When passing through the throat, the patient is swallowed and sent to the esophagus and then examined. 2 In the direct vision, slowly enter the mirror, can be inflated when inserted about 45cm, so that the stomach cavity is opened, in order to observe the gastric mucosa. 3 After the lens is placed in the stomach cavity, it can be observed and attracted. If the objective lens is affected by the adhesion of the mucus, it can be inflated or filled with water. If there is a lot of liquid in the stomach, it can be sucked out, and it should be intermittently attracted to avoid aspiration caused by aspiration of the gastric mucosa. 4 first find the stomach angle, through the antrum to the pylorus, and then insert the duodenal bulb and descending. 3. Find the nipple: After the speculum passes through the pylorus, turn the mirror clockwise by 90°, and the duodenum can be seen. Then adjust the angle button up, continue to enter the mirror over the upper curve, reach the duodenal descending and see the ring fold. At this point, turn the mirror body counterclockwise to find the duodenal papilla. The nipple is often located in the medial side of the duodenal descending, typically at a depth of 80 cm. Find the main point of the nipple: first find the 12 intestine side bulge in the duodenal descending part, the nipple is usually located at the anal side of the nipple, that is, under the wrinkle of the wrap; or you can find the mouth side of the small band first, along the band The nipple can be found on the ditch; sometimes a small polypoid bulge is found in the upper part of the duodenal descending part, which is a secondary nipple. The nipple can often be found on the anal side 2 to 3 cm; in addition, the nipple surface often has a reddish-red oval bulge, and some It looks like a mildly smashed appearance. If you see a bile overflow, you can confirm it. The shape of the nipple can be nipple type, hemispherical type, flat type, and rare stalactite type, scorpion hat type, lobulated shape, and groove shape. 4. Intubation: After finding the nipple, the patient takes the left semi-prone position and adjusts the angle knob of the lens body so that the nipple is at the center of the field of view. Intravenous injection of 10 mg of anisodamine, or 20 mg of sputum, or 20 ml of 25% glucose solution, 654-2 10 mg to reduce the peristalsis and secretion of duodenum, easy to intubate. Distinguish the nipple opening, which can be fluffy, granular, split, longitudinal and single-hole hardened. Place the nipple opening in the center of the field of view, insert a nylon catheter from the opening, and determine the position of the cannula under fluoroscopy. If the nipple is not seen, the tube is blindly intubated, and the mucosa of the nipple is completely damaged, making the intubation difficult. Selective intubation of the pancreatic duct and bile duct: Because of the different ways in which the common bile duct and the pancreatic duct lead to the nipple opening, it often causes difficulty in selective angiography. The common bile duct and pancreatic duct confluence have 85% of the common pipeline, and the length is about 1 to 10 mm. At this time, if the pancreatic duct and the bile duct are simultaneously displayed in the clinic, the intubation should not be too deep, and one or two scales may be inserted. Generally, when the contrast agent is injected for the first time, the depth of the catheter should not be less than 5 mm. If the common length of the pancreas and bile duct is greater than 5 mm, the two tubes are simultaneously developed. If the bile duct is not developed, you can withdraw 2mm and inject the contrast agent. If it is still not developed, the catheter can be withdrawn and re-intubated from below the nipple. At this point, the contrast agent is injected and the bile duct is likely to be developed. For selective pancreatography, the catheter should be inserted vertically from the front into the nipple opening, often showing the pancreatic duct. If selective cholangiography is required, the catheter should be inserted from the underside of the nipple in the direction of the crease of the mouth, and the bile duct is easily displayed by the lifter of the lens and the catheter is lifted up while the cannula is lifted. The intubation direction of the selective pancreatic duct cholangiography is about 30°. The bile and pancreatic ducts are respectively opened to a nipple, and the bile duct is often located above the opening of the pancreatic duct. If the two tubes are respectively opened to the respective nipples, the nipples of the bile duct opening are often slightly higher than the nipples of the pancreatic duct opening. During the whole intubation process, it should not be too deep or too strong to avoid damage to the pancreas and bile duct mucosa. 5. Contrast, film: After the catheter is inserted into the nipple opening, the drug can be photographed under the monitoring of the TV screen. However, it should be noted that: 1 discharge air bubbles inside the duct. Fill the catheter with the contrast agent before the intubation, and close the catheter tee joint to prevent the injection of bubbles to form a false stone shadow. 2 slowly injecting warmed 30% diatrizoate through the catheter, the injection rate is preferably 0.2-0.6 ml per second, and the pressure should not be too large, so as to avoid the contrast agent causing excessive filling of the pancreatic duct and the contrast agent entering the pancreatic parenchyma. Causes pancreatic bubble development. The pressure of pancreatic ductography is preferably 882.631098.54pa (90110mmh 2o). Between 784.56 and 980.67pa (80 to 100 mmh2o) is appropriate for cholangiography. If there is no pressure measuring device, the pancreatic duct or bile duct can be displayed on the TV screen to control the injection pressure. The amount of contrast agent depends on the degree of expansion of the gallbladder and pancreatic duct. Pancreatic duct development requires about 2 to 5 ml, cholangiography requires 20 to 50 ml; filling gallbladder requires 50 to 80 ml. Conservatives for pancreatic cysts should not be too much, because if there is an obstruction, it can cause poisoning and death. 3 adjust the position and film. The left lateral position allows the contrast agent to fill the distal end of the pancreatic duct, and then changes to the prone position or supine position, so that the pancreatic duct can be clearly displayed. After the bile duct is filled, the head should be changed to a low-foot high prone position (15°-20°), so that the upper bile duct and the left and right hepatic bile duct branches are filled, and sometimes the position needs to be rotated left and right to obtain a satisfactory image. In addition, it is necessary to observe the lower part of the common bile duct in the conventional standing position. If the gallbladder is full, the concealed stones in the gallbladder can often be displayed by standing and local compression. In the process of contrast agent filling the pancreas and bile duct, the film should be taken at the same time, at least two filling phases should be selected, and different body position films should be selected to better display the lesions. In the case of no obstruction of the pancreatic duct, the contrast agent may preferably be emptied within 10 to 20 seconds, and may be emptied within 3 to 4 minutes, and the residence time in the biliary tract is longer. If the contrast agent in the pancreatic duct has not been emptied after 15 to 20 minutes, the contrast agent in the bile duct failed to empty within 30 to 60 minutes, indicating obstructive lesions in the pancreas and bile duct. Therefore, when suspected and obstructed, 15, 30 and 60 minutes of x-ray film should be taken to observe the contrast of the contrast agent. In order to further understand the gallbladder contraction function, or to make the gallbladder neck and gallbladder clear, after the gallbladder is developed, Into the fat meal, after 30 minutes and 60 minutes respectively. It is called functional endoscopic retrograde cholangiopancreatography. After the examination, the mirror was retracted to the gastric cavity, and the pylorus, sinus, small curved side of the stomach, large curved side, fundus, cardia and esophagus were observed in turn. If a lesion is found, it is also necessary to take a photo, biopsy or brush to send a pathological examination.