Duodenoscopic papillary sphincterotomy

Indication 1, common bile duct stones after resection of the gallbladder, including primary common bile duct stones, residual stones, recurrent common bile duct stones. Common bile duct stones that are not resected, but are not or are not intended for surgery. 2, gallstones, if not considered or can not be used for gallbladder resection, and the following conditions: (1) combined with bile duct stones for the treatment of common bile duct stones before laparoscopic cholecystectomy. (2) There is no stone in the common bile duct, but the common bile duct is dilated with ampullary ampulla. (3) Gallbladder stones combined with recurrent pancreatitis. 3, the dead mites in the biliary tract need to be removed. 4, biliary anastomosis after the common bile duct blind syndrome. 5, biliary acute pancreatitis. 6, ampullary tumor caused by bile duct obstruction, causing acute obstructive suppurative cholangitis (can also be used for incision, bile duct drainage). 7, Oddi sphincter dysfunction, pressure confirmed by the pressure increased significantly. Contraindications 1, the general condition is very poor, can not tolerate endoscopy (including heart, brain, kidney, liver, severe lung failure). 2, there are contraindications for ERCP examination. 3, severe coagulation mechanism disorder failed to correct. Those with portal hypertension should be cautious. 4, benign or malignant stenosis at the lower end of the common bile duct, the stenosis of the stenosis is diagnosed beyond the duodenal wall by ERCP, and the EST does not reach the therapeutic goal. Preoperative preparation Equipment preparation: including duodenoscope, high-frequency electric generator, nipple cutting knife, various guiding wires, stone basket and gravel. Surgical procedure 1, routine ERCP diagnosis, further confirmed lesions, if the bile duct intubation is not smooth, then in the cholangiography, the guide wire is placed in the common bile duct to guide the incision knife. 2. Select different cutting knives according to the nipple and opening condition. 3. According to the requirement of selective cholangiography intubation under the microscope, the incision knife is correctly inserted into the bile duct through the nipple. If the guiding wire is placed beforehand, it is more convenient to insert the incision knife along the guide wire. Contrast and X-ray were confirmed in the common bile duct. 4. Further adjust the cutting knife to make it in the best direction. If using the pusher electric knife, 2/3 of the cutting blade wire should be outside the nipple. If the electric knife is used, make 1/3 in the nipple. In addition, the direction of the wire is made to coincide with the direction to be cut (ie, the longitudinal direction of the nipple). The cutting current is mixed with a current, and the current intensity is between about 3 or 20-30W. When the electricity is energized for 1-2s, the spark appears, the tissue turns white, and the electric knife is gradually pushed or pulled out, so that the steel wire and the nipple mucosa are in light contact, and a certain strength is maintained, and the nipple sphincter is gradually cut. 5, the length of the cut is based on the length of the nipple side bulge, (generally about 1-1.5cm), or small and medium cut according to the size of the gallstone. 6, after EST, the smaller stone (<1.0cm), you can directly use the stone basket to remove the stone, if the stone is larger (about 2.0cm), you can insert the stone crusher, crush the large stone, and then use the stone basket Take out separately. If there are many stones in the common bile duct, especially in the case of small stones, the air can be used for the stone. 7. After the stones are removed, the cholangiography of the bile duct is applied to confirm whether the stones in the common bile duct are removed. 8. If there are more stones, the operation time is long or the patient is unwell and it is difficult to continue taking the stone, the nasal bile duct drainage can be performed first, and the stone is taken after 3-7 days. complication 1, bleeding: a small amount of oozing can be sprayed under the microscope, injection or high-frequency electrocoagulation to stop bleeding. When the arterial pulsation bleeding is difficult to control, the patient's general condition should be quickly adjusted, blood transfusion should be taken and surgical hemostasis should be taken decisively. 2, perforation: EST perforation, should be treated according to acute abdomen, fasting, effective gastrointestinal decompression, intravenous rehydration, systemic application of antibiotics and other conservative treatment, such as no effect that surgery. 3, acute pancreatitis: as usual. 4, biliary tract infections: fasting, gastrointestinal decompression, antibiotic treatment, if necessary, then nasal bile duct drainage to reduce intra-biliary pressure.

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