BACKGROUND:Delayed bleeding is a serious complication of endoscopic papillectomy (EP). The aim of this study was to evaluate the efficacy of preventing delayed bleeding of clip after EP. METHODS:Consecutive patients diagnosed with ampullary benign tumors who received EP from January 1st 2013 to December 31st 2024 were analyzed retrospectively. EP was performed with the snare polypectomy technique. Biliary duct stent and pancreatic duct stent were routinely placed. The resection site is closed completely by clips. RESULTS:Fifty major papilla benign tumors patients with a mean age of 55.9 ± 10.7 years were found. All of the lesions were En bloc removed in a single endoscopic procedure. The pancreatic duct stents and biliary duct stents were successfully placed in 47 (94%) and 49 patients (98%), respectively. Two patients had positive horizontal margin, 35 patients had negative horizontal margin, and in 13 patients, horizontal margin was compromised by cautery effect. None of the patients had vertical positive margin, 39 patients had vertical negative margin, and in 11 patients, vertical margin was compromised by cautery effect. Post-EP bleeding was observed in 2 patients (4%), which was classified as mild. Post-EP hyperamylasemia was observed in 13 patients (26%), and post-EP pancreatitis was observed in 7 patients (14%), 6 were mild pancreatitis and 1 was severe pancreatitis. Intraoperative perforation occurred in 1 patient, which was clamped with hemostatic clips. No cholangitis was observed. The mean follow-up duration was 378.1 ± 305.7 days. Histologically confirmed recurrence at the resection site was detected in 6 patients (12%). CONCLUSIONS:This study demonstrated that preventive closure of the resection site by clips was technically feasible and effective in preventing delayed bleeding after EP, without increasing the risk of postprocedure pancreatitis and cholangitis.

Background/Objectives: Malignant biliary stricture (MBS) remains difficult to diagnose accurately despite digital single-operator cholangioscopy (DSOC). We developed a deep learning (DL)-based computer-aided detection (CADe) and diagnosis (CADx) system for DSOC-based MBS assessment. Methods: This retrospective multicenter study included 149 patients from one center for model development and internal validation and 25 patients from two independent centers for external evaluation. CADe used a You Only Look Once version 11 (YOLOv11) architecture to localize irregular mucosa, abnormal vasculature, and nodular protrusions defined by the Carlos Robles-Medranda and Mendoza criteria. CADx used a Residual Network-18 classifier with gradient-weighted class activation mapping for interpretability. Results: CADe achieved a mean average precision at 50% intersection-over-union of 91.2%, with a precision of 92.0% and recall of 87.0%. CADx achieved a frame-level area under the receiver operating characteristic curve (AUC) of 0.960 in internal validation and 0.843 in external validation. External frame-level sensitivity was 52.0% and specificity was 95.2%. For the patient-level external endpoint, sensitivity was 85.7%, specificity was 94.4%, accuracy was 92.0%, and AUC was 0.881. Conclusions: The two-stage system combines localization of predefined cholangioscopic features with interpretable diagnostic classification. The small external cohort and marked reduction in frame-level sensitivity preclude firm conclusions regarding generalizability; prospective multicenter and live-procedure evaluation is required.

ObjectivesSynchronous adenomas of the major and minor duodenal papilla are seldom reported. The aim of this study was to describe the characteristics of synchronous major and minor papilla adenomas and to evaluate the safety and efficacy of endoscopic papillectomy (EP) for the management of the disease.MethodsConsecutive patients who underwent endoscopy for synchronous major and minor papilla adenomas from January 1, 2013 to August 31, 2023 were analyzed retrospectively. Patients’ characteristics, clinical manifestations, laboratory, imaging and endoscopic findings were collected.ResultsThe nine patients with synchronous major and minor papilla adenomas had an average age of 50.78 ± 10.70 years. The diameter of major and minor papilla adenomas was 12.11 ± 3.41 mm and 6.11 ± 1.05 mm, respectively. Most major papilla adenomas had R0 horizontal margins (n = 8), while R0 vertical margins were achieved in all patients. While minor papilla adenomas were resected with both R0 horizontal and vertical margins in all patients. Post‐EP bleeding was observed in one patient, which was classified as mild. Post‐EP hyperamylasemia and pancreatitis was observed in two and four patients, respectively; the latter consisted of three with mild pancreatitis and one with severe pancreatitis. No perforation was observed. The mean follow‐up duration was 9.22 ± 5.99 months. Histologically confirmed recurrence at the resection site was detected in one patient at 3 months after the procedure.ConclusionsSynchronous major and minor papilla adenomas may not be as rare as previously speculated. EP may be an effective and safe alternative modality for their management.

BACKGROUND AND AIMDelayed bleeding after endoscopic sphincterotomy (ES) is a serious adverse event of endoscopic retrograde cholangiopancreatography. The aim of this study is to evaluate the effect of prevent delayed bleeding of hemostatic clip (Sureclip) after ES.METHODSConsecutive patients diagnosed with common bile duct stones with a high risk of delayed bleeding who received ES from January 1, 2013, to July 31, 2022, were analyzed retrospectively. A 1:1 propensity score-matching analysis and logistic regression analysis were used. The patients were allocated into the hemostatic clip and control groups. The rate of delayed bleeding, hyperamylasemia, pancreatitis, and hemostatic clip closing the bile duct or pancreatic duct by mistake were compared between the 2 groups.RESULTSOverall, 161 and 232 patients were allocated to the control and hemostatic clip groups, respectively, propensity score matching created 120 matched pairs. The rate of delayed bleeding was significantly lower in the hemostatic clip group than in the control group (1.67% vs. 7.5%, P=0.031). After adjusting for confounding factors, logistic regression showed hemostatic clip was associated with decreased odds of delayed bleeding (0.134, 95% CI: 0.025-0.719). No case of hemostatic clip closing the bile duct or pancreatic duct by mistake occurred in the hemostatic clip group. No significant differences were observed in postoperative hyperamylasemia and pancreatitis between the 2 groups.CONCLUSIONSThis study indicated that the prophylactic application of a hemostatic clip is associated with a significantly reduced rate of delayed bleeding after ES in high-risk patients. This approach did not increase the risk of adverse event.

[Voir la version anglaise de l’article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.221387][1] Un homme de 61 ans a souffert d’une pancréatite aiguë, 5 ans auparavant. Une tomodensitométrie (TDM) de son abdomen avait révélé la présence d’une masse kystique dans la deuxième partie du duod

A 61-year-old man had acute pancreatitis 5 years previously. Computed tomography (CT) of the abdomen showed a cystic mass at the second part of the duodenum. Surgery was suggested, but the patient declined. Over the subsequent 5 years, he had 4 additional episodes of acute pancreatitis before

A 44-year-old man presented to the gastroenterology department with a 1-month history of heartburn. Physical examination revealed clubbing of the fingers and toes (Figure A, B), abnormal thickening of the palms and feet, and swelling of the knee and ankle joints (Figure B). Onset of these noted physical signs occurred from a very young age, and they were aggravated progressively and plateaued in adulthood. Laboratory studies showed no abnormalities. Upper gastrointestinal endoscopy showed a grossly enlarged appearance of the major and minor papilla without other abnormalities (Figure C). Biopsies were performed and confirmed this to be tubular adenoma. Colonoscopy revealed a 1.5-cm pedunculated polyp in the sigmoid colon that was histologically confirmed to be tubulovillous adenoma with high-grade dysplasia (Figure D). Small-bowel capsule endoscopy showed no abnormalities. All adenomatous lesions were completely resected endoscopically, with negative margins. A diagnosis of hypertrophic osteoarthropathy was suspected based on abnormal physical findings. Subsequently, a series of examinations was performed to make a definite diagnosis and clarify the etiology. Plain radiographs of the hands and knees demonstrated bilateral symmetrical periosteal reaction (Figure E, F). Echocardiography revealed a patent foramen ovale (2 mm). Findings from chest computed tomography and arterial blood gas analysis were normal. Considering that the patient had no known secondary etiology for hypertrophic osteoarthropathy, a diagnosis of primary hypertrophic osteoarthropathy (PHO) was suspected. The subsequent enzyme-linked immunosorbent assay analyses revealed that the concentration of serum prostaglandin E2 (PGE2) was 69.29 pg/mL (reference range, 28.7-308.2 pg/mL) and the concentration of urinary PGE2 was 585.1 ng/mmol Cr (reference range, 36.4-85.5 ng/mmol Cr). Heterozygous HPGD mutation of c.1A>G (ENST00000296522: p.Met1Val, the start codon was mutated from ATG to GTG) was identified by whole genome sequencing. The patient was ultimately diagnosed as having PHO. Follow-up esophagogastroduodenoscopy at 3 and 6 months showed no abnormalities, but endoscopy at 9 months revealed a recurrent lesion at the ampullary region. Targeted biopsy confirmed low-grade intraepithelial neoplasia, with no evidence of adenoma. Follow-up colonoscopy at 9 months showed no abnormalities. Considering that the disturbed PGE2 catabolism may result in the manifestations, the patient was started on celecoxib therapy (200mg qd) with plans for repeated esophagogastroduodenoscopy 3 months later and colonoscopy 1 year later. An inherited disease that is characterized by digital clubbing, periostosis, and pachydermia, PHO is caused by abnormalities in PGE2 metabolism.1Wang Q. Li Y.H. Lin G.L. et al.Primary hypertrophic osteoarthropathy related gastrointestinal complication has distinctive clinical and pathological characteristics: two cases report and review of the literature.Orphanet J Rare Dis. 2019; 14: 297https://doi.org/10.1186/s13023-019-1264-5Crossref PubMed Scopus (10) Google Scholar HPGD or SLCO2A1 gene mutations are known to be related to PHO, which could markedly elevate the circulating PGE2 level.2Uppal S. Diggle C.P. Carr I.M. et al.Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy.Nat Genet. 2008; 40: 789-793https://doi.org/10.1038/ng.153Crossref PubMed Scopus (212) Google Scholar,3Zhang Z. Xia W. He J. et al.Exome sequencing identifies SLCO2A1 mutations as a cause of primary hypertrophic osteoarthropathy.Am J Hum Genet. 2012; 90: 125-132https://doi.org/10.1016/j.ajhg.2011.11.019Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar Theoretically, this could increase the risk of gastrointestinal adenomas; however, this is rarely reported. We hope that this case may serve as a reminder to clinicians that a screening gastrointestinal endoscopy is recommended for patients with PHO.

The fundamental treatment for acute cholecystitis is surgical cholecystectomy, especially laparoscopic cholecystectomy. Some high-risk surgical patients need gallbladder drainage. The traditional drainage method is percutaneous transhepatic gallbladder drainage. However, in recent years, two endoscopic approaches, including endoscopic transpapillary gallbladder drainage and endoscopic ultrasound-guided gallbladder drainage, have developed rapidly and have advantages in long-term outcomes. In this article, the authors discuss the historical development, technical characteristics, comparison between methods , adverse events and long-term outcomes of the two endoscopic drainage methods through literature review.

目的:探讨在新型冠状病毒肺炎(简称新冠肺炎;WHO定名COVID-19)疫情下,如何正确规范处理中重度胆道感染、梗阻性黄疸.方法:分析新冠肺炎疫情期间(2020年2月1日—2020年4月30日),湖北医药学院附属东风医院ERCP治疗的8例胆总管结石伴中重度胆道感染及2例中重度梗阻性黄疸患者的资料,评估疫情期间内镜逆行胰胆管造影术(ERCP)在胆道外科中的安全性和防护流程的有效性.在进行ERCP治疗时采集内镜镜身拭子进行新型冠状病毒核酸检测,对比术前咽拭子新型冠状病毒核酸检测.结果:10例ERCP治疗过程顺利,患者恢复良好,医护人员无感染病例发生.内镜镜身拭子检测新型冠状病毒核酸与常规咽拭子检测无显著差异.制定的防护操作流程达到预期效果.结论:在新型冠状病毒肺炎疫情期间,在严格遵循防护规范基础上ERCP在胆道外科中的治疗是安全的,医护人员感染风险可有效控制.在进行ERCP治疗时采集内镜镜身拭子的方法可行.

ObjectiveTo investigate the value of nasobiliary cholangiography in the diagnosis of residual common bile duct stones after endoscopic retrograde cholangiopancreatography (ERCP) and the risk factors for residual stones. MethodsA retrospective analysis was performed for the clinical data of the patients who underwent ERCP and nasobiliary cholangiography after endoscopic nasobiliary drainage in Peking University First Hospital from January 1, 2018 to December 31, 2019. The chi-square test was used for comparison of categorical data between groups, and a logistic regression analysis was used to investigate independent risk factors for residual stones. ResultsA total of 366 patients underwent ERCP and nasobiliary cholangiography and 27 patients were suspected to have residual stones, among whom 25 had residual stones confirmed by ERCP. The rate of residual stones after ERCP was 6.8% (25/366), and nasobiliary cholangiography had a positive predictive value of 92.6% (25/27) in predicting residual common bile duct stones. The univariate analysis showed that there were significant differences between the two groups in multiple stones, common bile duct diameter ≥1.5 cm, and mechanical lithotripsy (χ2=5014, 7.651, and 9.670, all P＜0.05). The multivariate logistic regression analysis showed that multiple stones (odds ratio ［OR］=2713, 95% confidence interval ［CI］: 1.002-7.345, P=0.049) and mechanical lithotripsy (OR=9.183, 95% CI: 2.347-35.925, P=0.001) were independent risk factors for residual stones. ConclusionPost-ERCP nasobiliary cholangiography is an effective method to detect residual common bile duct stones. Multiple stones and mechanical lithotripsy during ERCP are independent risk factors for residual stones.

Abstract The incidence of pancreatic cancer has been rising worldwide, and its clinical diagnosis and treatment remain a great challenge. To present the update and improvements in the clinical diagnosis and treatment of pancreatic cancer in recent years, Chinese Pancreatic Association, the Chinese Society of Surgery, Chinese Medical Association revised the Guidelines for the Diagnosis and Treatment of Pancreatic Cancer in China (2014) after reviewing evidence-based and problem-oriented literature published during 2015–2021, mainly focusing on highlight issues regarding diagnosis and surgical treatment of pancreatic cancer, conversion strategies for locally advanced pancreatic cancer, treatment of pancreatic cancer with oligo metastasis, adjuvant and neoadjuvant therapy, standardized processing of surgical specimens and evaluation of surgical margin status, systemic treatment for unresectable pancreatic cancer, genetic testing, as well as postoperative follow up of patients with pancreatic cancer. Forty recommendation items were finally proposed based on the above issues, and the quality of evidence and strength of recommendations were graded using the Grades of Recommendation, Assessment, Development, and Evaluation system. This guideline aims to standardize the clinical diagnosis and therapy, especially surgical treatment of pancreatic cancer in China, and further improve the prognosis of patients with pancreatic cancer.

Objective To observe and analyze the duodenal papilla diseases associated with recurrent choledocholithiasis. Methods A total of 614 patients with choledocholithiasis who had been treated with endoscopic retrograde cholangiopancreatography and without endoscopy or surgery of duodenal papilla were analyzed retrospectively from January 1, 2018 to June 30, 2020 in our hospital. Results Twenty patients with common bile duct stone extraction were studied as recurrent choledocholithiasis group, and 20 patients without biliary surgery or intervention were as initial choledocholithiasis group matched according to the age and gender. The number of patients with each duodenal papilla diseases in recurrent group were more than those in initial group. Parapapillary diverticulum was 9 vs. 5, long nipple 10 vs. 4, duodenal papillitis 2 vs. 0, atrophic papillitis 4 vs. 1 in both groups without statistically significant differences. There were more patients with duodenal papilla diseases in recurrent group than those in initial group. Normal nipple was 3 cases in recurrent group and 12 cases in initial group (P=0.008) with statistically significant difference. Conclusions More patients with recurrent choledocholithiasis had duodenal papilla disease and further studies are required for the mechanism of duoneal papilla disease associated with choledocholithiasis.

A 31 year-old-man presented with a 1-week history of persistent upper abdominal pain. Physical examination showed tenderness at the epigastric area, without rebound tenderness. A computed tomography scan of the abdomen showed antrum irregular thicken and a needle-type radiopaque foreign body penetrated into the pancreatic head (A). We presumed that this patient ingested a needle that penetrated the gastric antrum and migrated into the pancreatic body. We attempted to extract the foreign body endoscopically to avoid undergoing a laparotomy. A gastroscope was then performed, no foreign body was visible in the lumen, but a suspicious sinus tract was found at the antrum (B). We used a biopsy forceps try to reach the foreign body through the sinus tract with X-ray guided (C), a 26 mm-long corroded needle wasfinally extracted without causing any esophageal injury (D).The patient's pain relieved after operation.

目的 探讨胆管空肠Roux-en-Y吻合联合腹膜下空肠盲袢固定标记法在肝胆管结石病术后及其伴随的胆管狭窄治疗中的价值.方法 回顾性分析2009年1月至2017年12月在北京大学第一医院接受胆管空肠Roux-en-Y吻合联合腹膜下空肠盲袢固定标记术的113例肝胆管结石病病人的临床资料.并对术后经肠袢胆道镜治疗肝内胆管结石和狭窄的情况进行总结.结果 113例病人全部完成胆肠吻合及盲袢固定标记术并在术后行胆道镜检查,其中79例行胆道镜取石治疗;49例行胆道镜下球囊扩张肝内胆管狭窄,7例发现有术后近期吻合口狭窄而行球囊扩张,71例证实结石取净或狭窄缓解后结束治疗.16例在治疗结束后因肝内胆管结石复发而在局麻下打开空肠盲袢,其中15例顺利完成再次治疗.结论 空肠盲袢固定标记法便于在胆管空肠Roux-en-Y吻合后进一步治疗肝内胆管结石及狭窄,并使多数复发病例避免了再次开放手术,对于易复发的肝胆管结石病是一种可供选择的治疗方法.

Introduction: Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (CBDE) (LCBDE), or laparoscopic transcystic CBDE (LTCBDE). However, the comparative long-term prognosis of these methods in terms of adverse outcomes remains uncertain. Methods: In an ambispective, multicenter, observational, open cohort study, patients with cholecystocholedocholithiasis underwent one of three treatments (EST+laparoscopic cholecystectomy (LC), LCBDE+LC, and LTCBDE+LC).The primary outcome was adverse outcomes. Results: At a median follow-up period of 2.72 years among 2708 patients, the adverse outcome rate is 9.3%. Compared with LCBDE and LTCBDE groups, EST group displayed an increased risk for adverse outcomes (HR 1.25, 95% CI 0.93-1.69, P=0.146; HR 1.77, 95% CI 1.30-2.43, P<0.001) and stone-related outcomes (HR 1.43, 95% CI 0.99-2.06, P=0.054; HR 4.36, 95% CI 2.71-7.02, P<0.001) in the unadjusted Cox model. After adjustment in the multivariable analysis, EST group still displayed an increased risk of adverse outcomes (HR 1.43, 95% CI 1.05-1.95, P=0.021; HR 1.87, 95% CI 1.35-2.59, P<0.001) and stone-related outcomes (HR 1.64, 95% CI 1.13-2.37, P=0.010; HR 4.88, 95% CI 2.99-7.97, P<0.001). Compared with LTCBDE group, LCBDE group displayed an increased risk for a stone-related outcome in both the unadjusted Cox model (HR 3.05, 95% CI 1.89-4.90, P<0.001) and the adjusted multivariable analysis (HR 2.98, 95% CI 1.83-4.86, P <0.001). Conclusion: Compared with EST, the laparoscopic technique was associated with a lower risk of adverse outcomes and stone-related outcomes after adjustment for confounding factors. In laparoscopic techniques, the risk of stone-related outcomes after LTCBDE is reduced 66.4% than LCBDE. Clinical Trial Registration: CREST Choles ClinicalTrials.gov number, NCT02554097. Funding Statement: The author(s) disclose receipt of the following financial support for the research, authorship, and/or publication of this article: this program is sponsored by Capital Health Research and Special Development (No. 2016-1-1111), National Key Technologies R&D Program (No. 2015BAI13B09), and Beijing Municipal Administration of Hospitals Incubator Program (No. PX2016001 and No. PX2019004). Declaration of Interests: The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethics Approval Statement: Ethical approval was obtained at all participating centers.

目的 评价经内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)下放置全覆膜自膨式可回收金属支架(fully-covered self-expandable metal stents,FCSEMS)治疗肝移植术后胆管吻合口狭窄(anastomotic biliary strictures,ABSs)的效果.方法 采用回顾性横断面研究方法,收集2015年1月至2017年4月首都医科大学附属北京佑安医院行肝移植(166例次肝移植)术后(3～60个月)出现ABSs、并于北京大学第一医院外科内镜中心进行内镜下FCSEMS治疗的12例病人资料,统计手术成功率、临床缓解率和并发症发生率等,总结及评价FCSEMS治疗肝移植术后ABSs的安全性及有效性.结果 12例病人中,接受FCSEMS治疗14例次获得成功:其中2例病人术后经2次支架治疗.1例病人内镜插管失败,结合经皮肝穿刺胆管引流(percutaneous transhepatic biliary drainage,PTCD)穿刺通过导丝插管成功,手术成功率为92.8％(13/14);临床缓解率为100％;术后发生急性胰腺炎1例,高淀粉酶血症3例,手术并发症发生率为28.6％(4/14);12例病人支架取出顺利,均无支架脱落及支架移位;所有病人FCSEMS植入术后无严重的手术并发症及死亡发生.结论 肝移植术后ABSs采用FCSEMS治疗,安全性及有效性均较高,可作为目前肝移植术后ABSs的一线治疗方法.

Key points and difficulties of the treatment of post-operative residual stones by choledochoscopy are how to find the stone, how to solve the narrow, how to deal with the huge stones, how to remove the stones, how to determine the stones are taken clean , etc. At the same time, by learning the experi-ences and some choledochoscope application skills in special situations, such as percutaneous transhepatic choledochoscope and choledochoscope after choledochojejunostomy, surgeons may be able to improve endoscopic treatment of intrahepatic li-thiasis after operation.

肝内胆管结石的高残石率、高复发率、高再手术率迄今仍是胆道外科的难题,随着胆道镜技术的发展,胆道镜对肝内胆管结石诊治发挥了重要的作用,胆道镜通过T管窦道,经皮经肝以及胆肠吻合术后的经皮经肠襻途径,进入肝内胆管,结合球囊扩张、碎石等措施,取尽肝内胆管结石,弥补了单纯手术治疗的不足,给肝内胆管结石的治疗带来更多的选择.

Objective To clarify the role of Pyk2 in cell proliferation and apoptosis in Lovo rectal cancer cells in vitro.Methods Two sets of shRNA (short hairpin RNA which will be subsequently processed to siRNAs) expression plasmid vectors were used to transfect lovo cells separetely.The lovo cells and the cells transfecled with a non - targeting, negative shRNA expression plasmid were used as controls.The downregulation of the protein level and mRNA level was further confirmed by Western blotting and RT - PCR. The growth curve of lovo cells was studied by cell counting.The changes in apoptosis and cell cycle were derermined by flow cytometry. Results Cells transfected with one of the shRNA expression vectors obtained knockdown of pyk2,with a significantly lower apoptosis level.The number of cells in the S stage of cell cycle increased as cell count did.Conclusion Pyk2 elevates the apoptosis level of lovo cells and lowers their proliferation.