Objective To evaluate whether small endoscopic sphincterotomy (EST) plus balloon dilation (EPBD) can replace endoscopic sphincterotomy (EST) alone for patients with common bile duct (CBD) stones.Methods From May 2008 to April 2011,462 patients with CBD stones were randomly divided into two groups.The success rate of complete stone removal after the first session,the rate of using mechanical lithotripsy (ML),the short-term complications,the procedure time and fluo roscopy time were compared between the two groups.Results Overall ductal clearance did not differ between the two groups (96.5％ vs 93.5％,P＞0.05).The complication rates at 24 hours were 6.9％ for the small EST plus EPBD group and 11.7％ for the EST group (P＞0.05).However,the rate of complete stone removal after the first session using small EST plus EPBD was significantly higher than EST alone (86.2％ vs 70.4％,P＜0.05).ML was required significantly more often in the EST group when compared with the small EST plus EPBD group (34.8％ vs 12.1％,P＜0.05).The total procedure time and total fluoroscopy time in the small EST plus EPBD group were significantly shorter than the EST group [(38.6±15.5) min vs (47.1±20.2) min,P＜0.05 and (17.3± 7.0) min vs (26.5±10.8) min,P＜0.05].Conclusions Compared with EST,small EST plus EPBD was safe and more efficacious for bile duct stones.In the future,small EST plus EPBD probably can replace EST to be the first treatment of choice for bile duct stones.

Objective To evaluate the efficacy and safety of small endoscopic sphincterotomy (EST) plus large balloon dilataion (EPLBD) for removal of common bile duct (CBD) stones larger than 12mm.Methods From June 2009 to December 2011,a total of 198 patients with CBD stones were randomly divided into two groups to receive EPLBD (n =100) or EST only (n =98).The rate of complete stone removal after the first session,the overall success rate of stone removal,the rate of using mechanical lithotripsy (ML),the rate of post procedure complication,procedure time and fluoroscopy time were compared between the two groups.Results The rate of complete stone removal after the first session in EPLBD group (89.0％) was significantly higher than that in EST group (71.4％,P ＜ 0.05).ML was required significantly more often in EST group (35.7％) compared to EPLBD group (12.0％,P ＜0.05).Total procedure time and total fluoroscopy time in EPLBD group (39.3 ± 15.8 min and 14.2 ±5.2 min) were significantly shorter than those of EST group (48.4 ± 19.3 min and 24.2 ±9.4 min,P ＜0.05).There was no significant difference between two groups in overall success rate of stone removal (97.0％ in EPLBD vs.93.9％in EST group,P ＞ 0.05) and the complications rate (8.0％ in EPLBD vs.13.3％ in ESTgroup,P ＞0.05).Conclusion EPLBD is as safe and effective as EST for common bile duct stones,larger than 12mm,and is more efficient in terms of procedure time,use of ML and success rate of stone removal.

Objective To investigate the efficacy of prophylactic pancreatic stent placement and nonsteroidal antiinflammatory drugs( NSAIDs) for the prevention of post?endoscopic retrograde cholangiopan?creatography(ERCP) pancreatitis(PEP). Methods A total of 623 patients with high risk factors for PEP were treated with prophylactic pancreatic stent placement ( 145 patients, group A) or rectal NSAIDs( 478 pa?tients, group B) for PEP prevention by using the propensity score matching( PSM) analysis. Incidence of PEP, moderate and severe PEP were investigated. According to risk factors of PEP, indications of prophy?lactic pancreatic stent placement were analysed. Results Of 623 patients with high risk factors, 145 pairs were generated after PSM.Pancreatitis occurred in 32 patients,10 (6?9%) in group A and 22 (15?2%) in group B( P<0?05 ) . Moderate?to?severe pancreatitis developed in 5 ( 3?4%) patients in group A and 14 (9?7%) patients in group B(P<0?05).Risk factors of post?ERCP PEP were cannulation attempts duration longer than 10 minutes, precut sphincterotomy, more than one pancreatic guidewire passages and history of ampullectomy. Conclusion Although the NSAIDs represent an easy, inexpensive treatment, prophylactic pancreatic stent placement is still a better prevention strategy for PEP.Prophylactic pancreatic stents should be recommended to those with risk factors including cannulation attempts duration longer than 10 minutes, precut sphincterotomy, more than one pancreatic guidewire passages and ampullectomy.

Objective:To evaluate the clinical efficacy and safety of SpyGlass-guided laser lithotripsy for large common bile duct (CBD) stones with diameter>2 cm.Methods:From August 2015 to August 2018, a total of 157 patients with large CBD stones at the First Affiliated Hospital of Shandong First Medical University who met the inclusion criteria were randomly divided into SpyGlass group ( n=78, underwent SpyGlass-guided laser lithotripsy) and laparoscopic common bile duct exploration (LCBDE) group ( n=79, underwent LCBDE) by using random numbers. Non-inferiority test was used for rates of one-time stone removal and total stone removal, and the non-inferiority margin was set to 10%. The transform rate, incidence of short-term complications, hospital stay, and quality of life (assessed by the gastrointestinal quality of life index) were compared between the two groups. Results:The total success rates of stone clearance were 92.3% (72/78) and 96.2% (76/79) in the SpyGlass group and LCBDE group, respectively ( P=0.023), with valid non-inferiority hypothesis. The one-time stone removal rates were 83.3% (65/78) and 96.2% (76/79), respectively ( P=0.124), with invalid non-inferiority hypothesis. There were no significant differences in the incidence of transform [7.7% (6/78) VS 3.8% (3/79), P=0.294] or short-term complications [5.1% (4/78) VS 10.1% (8/79), P=0.246] between the two groups. Compared with the LCBDE group, the SpyGlass group had a shorter hospital stay (5.65±0.94 d VS 8.84±1.54 d, P=0.001) and higher scores of gastrointestinal quality of life index (1 month after operation: 99.85±4.36 VS 91.51±5.47, P=0.001; 3 months after operation: 131.24±3.32 VS 112.32±7.77, P=0.001). Conclusion:For large CBD stones, the efficacy of SpyGlass-guided laser lithotripsy is not inferior to LCBDE, and it is less invasive. In the future, SpyGlass-guided laser lithotripsy could be an important option for the treatment of large CBD stones.

Objective:To establish a predictive model of moderate to severe pain in patients with hepatocellular carcinoma (HCC) undergoing transcatheter arterial chemoembolization (TACE).Methods:264 patients with HCC who underwent TACE operation in Southern Medical University from January 2017 to April 2018 were selected as the modeling set. The pain was assessed by numeric rating scales. The patients were divided into pain group ( n=96) and non-pain group ( n=168) according to whether moderate to severe pain occurred within 24 hours after the operation. Binary Logistic regression analysis were performed for variables that were statistically significant in the univariate analyses. The predictive nomogram was constructed and the internal validation was performed. In addition, 87 patients with HCC who underwent TACE operation from January 2020 to June 2020 were selected as the validation set for external validation. Results:In the modeling set, 96 patients (36.36%) had moderate to severe pain within 24 hours after TACE operation in 264 patients with HCC, and the dosage of morphine intramuscularly injected within 24 hours was 1015 mg, with an average of 10.57 mg per patient. Multivariate Logistic regression analysis showed that preoperative pain, the distance between the tumor and capsule ≤2 cm, high prothrombin activity, dosage of lipiodol>10 ml, and several thromboembolic tumors were independent risk factors for moderate to severe pain after TACE ( P<0.05). Age>50 was the protective factor of moderate to severe pain after TACE ( P<0.05). The area under ROC curve was 0.799 (95% CI: 0.745-0.853) in the modeling set. The area under Roc curve for internal validation and external validation were 0.780 and 0.788, respectively. The calibration curves showed satisfactory agreements between the model predicted probability and the actually observed probability. Conclusion:The predictive model of moderate to severe pain after TACE was established in this study has good differentiation and accuracy, it has certain guiding significance for predicting the high-risk group of moderate to severe pain after TACE operation and formulating the targeted prevention strategy.