INTRODUCTION

Traditionally, endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach to biliary drainage[1,2]. However, the procedure fails in up to 10% of patients, especially owing to anatomic variations, malignant duodenal obstructions and previous surgeries[3,4]. For these cases, percutaneous transhepatic biliary drainage (PTBD) or surgery has been used, despite the high morbidity and not negligible mortality caused by these procedures[5,6].

More recently, endosonography-guided biliary drainage (EUS-BD) has emerged as an effective alternative, with the potential to provide the least invasive and lowest risk therapeutic modality for biliary access and drainage[7,8]. A recent meta-analysis has reported technical and clinical success of 90% and 94%,respectively[9].

We aimed to evaluate the role of different EUS-BD techniques in case of ERCP failure, and to propose a systematic routine for EUS-BD according to the feasible access routes to the biliary tree.

MATERIALS AND METHODS

Study design

This was a retrospective study with prospective data collection about the role of EUS-BD conducted at two tertiary-referral centers. Between February 2010 and December 2016, 3528 ERCPs were performed at these centers. Eligible cases included patients older than 18 years with unresectable biliopancreatic neoplasia, and patients with benign conditions referred to EUS-BD when access to the biliary tree and internal biliary drainage by ERCP were not possible. ERCP failure was considered when biliary cannulation could not be achieved even after advanced techniques (cannulation in addition to a pancreatic guidewire or stent, needle-knife access papillotomy over a pancreatic stent, cannulation through a duodenal stent, and back-loading of the duodenoscope over a duodenal guidewire to pass a luminal stricture).Exclusion criteria were an international normalized ratio (INR) ＞ 1.5 or platelet count ＜ 50000/μL, ascites around the puncture area, absence of an adequate acoustic window for hepatic or choledochal puncture,total gastrectomy, and patient refusal. After EUS-BD,four follow-up visits were scheduled for each patient during the first 90 d, or until their death. The study was approved by the Institutional Review Board (Approval No. 2.191.319), and all patients gave written informed consent for ERCP and EUS-BD before enrollment.

Technical aspects

All EUS-BD procedures were performed by the same experienced endoscopist with Fujinon (FujiFilm Corporation, Nishiazabu 2-chome Minato, Ku, Tokyo)duodenoscopes (ED-530XT) and curvilinear array echoendoscopes (EG530UT2) coupled to SU-7000 or SU-8000 ultrasound units. The sequential EUSBD procedures proposed for all patients were as follows: first, transhepatic puncture with a 19 gauge aspiration needle (EUSN-19 T, Cook, Winston Sallen,NC, United States) was tried. The EUS-RV technique was successful when the guidewire could be passed through the papilla and seized in the second portion of the duodenum. In case of papillary benign disease or absence of duodenal stenosis, retrograde treatment with a duodenoscope or echoendoscope was performed.An anterograde approach was attempted when tumoral duodenal in filtration or duodenal stenosis did not allow the capture of the guidewire in the duodenum. If the anterograde approach failed, Endosonography-guided hepatogastrostomy (EUS-HG) was the next alternative.In case of failure of the intrahepatic puncture due to unfavorable anatomy, cirrhosis or difficulty in maintaining the adequate position of the guidewire,patients were submitted to endosonography-guided choledocoduodenostomy (EUS-CD). If all approaches for EUS-BD were unsuccessful, patients were submitted to PTBD. Duodenal self-expandable metallic stents(SEMS) were used in all stenoses obstructing access to the papilla.

The procedures were always performed with the patient in the left lateral decubitus position, under deep sedation with the assistance of an anesthesiologist.After the procedure, patients were monitored for two hours, and intravenous antibiotics (ciprofloxacin and metronidazole) were given for 7 d.

In our experience, the transhepatic approach allows us to choose among three EUS-BD techniques according to the recovery or not of the guidewire,i.e., the EUS-RV, EUS-ASI and EUS-HG techniques.Our group has adopted a systematic EUS-BD routine starting with the transhepatic access to initially perform the EUS-RV or EUS-ASI technique. This approach offers a good acoustic window for puncture of the biliary tree, a straight and easier to work position of the echoendoscope, a better positioning of the guidewire,and a lower chance of bleeding or choleperitoneum,with both complications amenable to tamponade by the liver parenchyma[19,23]. In our study, beginning with the transhepatic approach, the overall technical success was 83%, and the clinical success (intention-to-treat) was 75%, similar to literature results[23]. On the other hand,the transduodenal approach permits an easier execution of only the EUS-CD or, although more laborious and time-consuming, the EUS-RV. In the failure of this approach, the transhepatic approach should be the rescue therapy.

Routine for EUS-BD approaches

Endosonography-guided rendez-vous: When the duodenoscope could reach the major papilla, EUS-RV was tried and a curvilinear echoendoscope was used to obtain biliary access. The tip of the echoendoscope was positioned in the gastric fundus to access the intrahepatic bile duct. A 19 gauge EUS aspiration needle was used to puncture the bile duct close to the hepatic hilum, and to insert a large-caliber guidewire to deploy the stent. After fl uoroscopic con firmation of the needle inside the bile duct, the guidewire was inserted through the obstruction and passed to the duodenum. Once the guidewire crossed the papilla, the guidewire was retrieved with a biopsy forceps or snare. Next, a metal stent was deployed by means of the over-the-wire technique[10].

The main objectives of the study were to evaluate the success rates of endosonography (EUS)-guided biliary drainage techniques after ERCP failure for the management of biliary obstruction, and to propose a rational approach based on the access to the biliary tree and feasibility to recover the guidewire.

Endosonography-guided hepatogastrostomy:EUS-HG was tried after failure of the EUS-RV and EUS-anterograde stent insertion (EUS-ASI) techniques, in those cases whose hepatic puncture was successful but the guidewire could not be passed through the papilla.The dilated intrahepatic bile duct was punctured, and the guidewire was placed through the stenosis. The tract was dilated with a 6 Fr cystostome, and a fully covered metal stent was deployed, with care taken to leave more than 3 cm of the stent in the gastric lumen to avoid food obstruction.

针对全省还有4万多平方公里的水土流失面积尚未治理的现状，去年12月，省政府批复《山西省水土保持规划（2016-2030年）》，对未来一个阶段水土保持工作作了整体部署，将逐步解决发展不平衡不充分的问题；今年以来，又启动实施了“两山七河”生态修复，推动水土流失治理进入新的历史阶段。

Endosonography-guided Choledocoduodenostomy:In patients for whom a transhepatic approach was not feasible, EUS-CD was performed with the identification of the extrahepatic bile duct from the duodenal bulb.Once the insertion of the guidewire into the bile duct was confirmed by cholangiography, the tract was dilated with a 6 Fr cystostome, and a fully covered selfexpandable metal stent was inserted.

Technical and clinical success

Technical success was de fined as adequate positioning of the stent as shown by endoscopic and fl uoroscopic images. Clinical success was de fined as a decrease of at least 50% in serum total bilirubin levels.

扶贫资金是贫困群众的“救命钱”“保命钱”和减贫脱贫的“助推剂”，对加快贫困地区发展、改善扶贫对象基本生产生活条件发挥着重要作用。但近年来财政扶贫资金管理使用方面的“痼疾”仍存，资金使用效益仍有待提高，监管任务依然艰巨。本文简要阐述了加强扶贫资金监管的重要意义，分析了当前广西抓好扶贫资金监管问题整改的做法，并提出下一步加强扶贫资金监管的对策建议。

Statistical analysis

A linear model was adjusted for the calculation of the technical success prevalence ratios, generalized by Poisson distribution and by the linking logarithmic function using the Proc Genmod of SAS 9.3 software (SAS Institute Inc., Cary NC, United States) to determine whether the different approaches had any impact on efficacy, compared to the EUS-RV technique (P ＞ 0.05).

RESULTS

Patient demographics and technical aspects

研究区域位于辽宁省鞍山市千山山脉西北脚下，全国较为典型的深凹露天铁矿，已有百年的开采历史。2017年6月，按照矿山和选矿厂位置，依地形围绕矿区在毗邻城区方向5 km2范围内，设置11个样点，分别标记为S1～S11，具体布点如图1。采用五点取样法采样，每个样点均采集0～20 cm表层土壤，去除土壤中动植物残体、石子等杂物，充分混匀后取1 kg左右装入自封袋，编号，密封带回实验室后风干，用四分法选取土样并经粉碎研磨，过100目筛备用。

Endosonography-guided rendez-vous

The EUS-guided transhepatic approach was tried in all patients (Figure 1). In 18/24 (75%) cases, puncture of the bile duct was possible, but the passage of the guidewire through the papilla occurred only in 12 (50%)cases. The guidewire could be recovered in 5/7 cases,and the passage of the stent was performed by means of an EUS-RV technique (Figure 2). The complication rate for these cases was 28% (2/7), consisting of an intracavitary hemorrhage and a choleperitoneum, both managed conservatively. In 5 other cases the guidewire could not be recovered in the duodenum owing to duodenal stenosis (3) or papillary infiltration (2). For these cases, an EUS-ASI technique was the next option.In 6 other cases, the guidewire did not cross the papilla,and was positioned in the proximal common bile duct(4), and in the right lobe (1) and left lobe of the liver (1).For these cases, an EUS-HG was the next alternative.The remaining 6 patients for whom transhepatic approaches were not possible underwent EUS-CD.

我国的法院调解包括人民法院对受理的第一审、第二审和再审民事案件，在答辩期满后裁判作出前的调解，以及征得当事人各方同意而在答辩期满前进行的调解。通过法院调解来“息事宁人”自然是当事人的一种权利，而“有权利，就有救济方法”，这体现在为有瑕疵的生效调解书提供的再审渠道。但是2012年民事诉讼法关于再审制度的修改并未在实质上触及调解书的部分，不仅没能使原先调解书再审的模糊规则得到改观，还留下了其与新的通常再审制度在关系上的困惑。笔者认为，理清这一系列启动调解书再审的问题，必须立足于法院调解的属性，因为属性才是阐释制度的应然规则和观察运行的实然状态的基石。

EUS-guided anterograde stent insertion

Even after passage of the guidewire in the secondduodenal portion, the recovery of the guidewire was not possible in 5 patients due to malignant duodenal stenosis (3) or papillary infiltration (2). For these cases, anterograde deployment of the biliary SEMS was performed (Figure 3). After passage of the biliary SEMS, a duodenal SEMS was delivered in 3 patients

with neoplastic duodenal stenosis. The overall technical success was 100%.

Endosonography-guided hepatogastrostomy

EUS-HG through transhepatic puncture was tried in 6 patients in whom the guidewire was positioned in the common bile duct (4), right lobe (1) and left lobe of the liver (1) (Figure 4). In 5/6 (83.3%) cases, an uneventful passage of the biliary SEMS was possible.For a single patient with recurrent liver metastasis from colon cancer after hepatectomy, the introduction of the transhepatic guidewire was impossible. The technical success rate was 83.3%, with one patient developing a pneumoperitoneum after the procedure.

Endosonography-guided choledochoduodenostomy

The insertion of the biliary stent through the duodenal puncture was tried in 6 patients as a rescue EUS-guided procedure for biliary drainage (Figure 5). All of these cases presented malignancies (Table 1). The correct positioning of the guidewire was achieved in 5/6(83.3%), and one case was referred to PTBD. There was no complication.

Technical and clinical success

The overall technical success for EUS-BD was 83.3%(20/24). There was no significant difference among the various techniques (P = 0.81). Prior to EUS-BD, the mean levels of serum total and direct bilirubin were 13.3 mg/dL (5-29.9) and 9.1 (3-20.4) mg/dL, respectively.Ten days after EUS-BD, the mean levels were 2.3(1.3-33) mg/dL, and 1.7 (0.6-22) mg/dL, respectively.The overall clinical success of EUS-BD was 75%.

Complications

2 Fogel EL, Sherman S, Devereaux BM, Lehman GA. Therapeutic biliary endoscopy. Endoscopy 2001; 33: 31-38 [PMID: 11204985 DOI: 10.1055/s-2001-11186]

DISCUSSION

Patients were submitted to EUS-guided rendez-vous (7), EUS-guided anterograde stent insertion (5), EUS-guided hepaticogastrostomy (6), and EUSCD (6). Success rates did not differ among the various EUS-BD technique.Overall, technical and clinical success rates were 83.3% and 75%, respectively.The technical success for each technique was 71.4%, 100%, 83.3%, and 83.3%, respectively (P = 0.81). Complications occurred in 3 (12.5%) patients.All of these cases were managed conservatively, but one patient died after a rescue percutaneous transhepatic biliary drainage. Regarding particular EUSBD techniques, there is a scarcity of comparative studies, and a consensus about the best technique has not been established.

总而言之，受到诸如患者因素、检验仪器以及操作等多种原因所影响，这就使得医学检验分析前会出现一定的误差，对此这除了要求患者在检验前严格依据医生指示外，规范并提升检验操作同样重要。

Overall, the therapeutic success of EUS-BD ranges from 73% to 100%[15-19]. However, there is no con- sensus about the best EUS-BD technique[9]. Regarding particular EUS-BD techniques, there is a scarcity of comparative studies. Ogura et al[20] compared EUS-HG and EUS-CD for patients with jaundice and duodenal obstruction. Patients submitted to the transhepatic approach exhibited a longer patency of the biliary stent than those submitted to the transduodenal approach.In addition, the EUS-CD technique revealed a higher rate of complications, especially reflux cholangitis(OR = 10.285; 95%CI: 1.686-62.733; P = 0.012).Artifon et al[21] also evaluated the two techniques in a randomized clinical trial. There was no significant difference in effectiveness or safety between the two procedures. Technical and clinical success, as well as complications rates were 96%, 91%, and 20% for EUSHG, respectively, and 91%, 77% and 12.5% for EUSCD, respectively.

In an attempt to demonstrate the value of EUSRV as the initial therapeutic option for biliary drainage in ERCP failure, Iwashita et al[22] performed the procedure using the transduodenal approach and using the transhepatic approach after failure of the transcholedochal approach. The authors concluded that EUS-RV is an effective and safe procedure, as also observed in our own experience. However, in contrast to the cited study, we began EUS-BD by the transhepatic approach, leaving the transduodenal approach only for the rescue option in the failure of the transhepatic approach.

由于Bartter综合征表型变异较大，可从无症状生存到严重生长落后[1]，且涉及多个致病基因，各突变类型表型相互重合[2,3]，个别病例甚至存在双基因突变[4,5]，故临床鉴别诊断较为困难。在本研究中，我们采用高通量捕获测序技术结合多重连接探针扩增技术(multiplex ligation-dependent probe amplification，MLPA)，PCR-Sanger测序明确了基因突变类型确诊了1例Ⅲ型BS家系，并在此基础上完成了产前诊断。

Nevertheless, despite the good results of EUS-BD when using the transhepatic approach, the literature still mentions some concern about the risk of complications with the intrahepatic access[18,20,24]. The needle must traverse the peritoneal cavity, a procedure that might increase the risk of pneumo- and choleperitoneum.This complication occurred in one of our patients and was managed conservatively. Another issue is the movement of the stomach and liver during breathing and peristalsis, which might induce stent migration,trauma to the bilioenteric tract, and bile leakage. Finally,small-caliber intrahepatic ducts may not accommodate wider 8-mm to 10-mm metal stents, possibly predisposing to pneumoperitoneum and bile leakage due to incomplete sealing of the bilioenteric fistula[25,26].For this reason, our goal during EUS-BD by means of the transhepatic approach is to obtain an intrahepatic duct of larger caliber as close as possible to the hepatic hilum.

In all of our cases in which the guidewire could not be reached in the duodenum due to stenosis or papillary infiltration, EUS-ASI succeeded without complications.The good performance and low complications rate of the EUS-ASI technique has been demonstrated in the literature[27].

On the other hand, if the patient has only a dilated biliary tree where the hepatic puncture is feasible but the guidewire could not reach the papilla, EUSHG should be the next option. The greatest limitation in patients undergoing EUS-HG is the access to the right intrahepatic biliary tract and the progression of the guidewire to the common bile duct or its passage through the duodenal papilla. However, many authors justify selective drainage of the left intrahepatic biliary tract compared to the extrahepatic approach[7,28,29]. Both approaches have been shown to be effective and to involve low complications rates[21,26].

Nonetheless, EUS-BD by transhepatic approach may not be possible in some cases, depending on the patient anatomy[19,30]. We observed EUS-RV failure due to the impossibility of puncturing the liver or the inability to maintain the stability of the guidewire, and the difficulty to seize the guidewire in the duodenal lumen. In such cases, an extrahepatic approach must be adopted. The transcholedochal approach has the bene fit of being feasible in patients whose papilla cannot be reached and has the advantage of being close to the duodenum[7,31,32]. In the current study, the technical success rates were the same (83.3%) for EUS-HG and EUS-CD, in agreement with published series[20,21]. Except for a pneumoperitoneum in the intrahepatic group, no difference in major complications was found between EUS-HG and EUS-CD (16.6% vs 0%; P = 0.81).

As a whole, EUS-BD is a safer technique than PTBD and surgery, with complication rates ranging from 10%to 20%, although the severity of most cases is mild to moderate[10,13]. Our complication rate also agreed with that reported in other studies[10,13]. Three of our cases developed complications, representing an overall rate of 12.5%. All of these cases were managed conservatively,but a patient with intracavitary bleeding was submitted immediately to PTBD after EUS-BD failure, and died three days later.

2.2两组患儿肺功能水平恢复情况 实验组患者的FVC、FEV、PEF水平明显优于对照组,P<0.05表示统计学有意义。见表2。

Despite the small number of our patients, this study did not demonstrate any significant difference in technical success or complication rates among different techniques of EUS-BD, in agreement with other studies[19,23].

In summary, a rational algorithm for EUS-BD in case of obstructive biliary diseases and ERCP failure might begin with the transhepatic approach, followed by particular EUS-BD techniques based on the patient’s anatomy and feasibility to recover the guidewire.

ARTICLE HIGHLIGHTS

Research background

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach to biliary drainage, and, in the failure of the procedure, percutaneous transhepatic biliary drainage or surgery must be used. However,endosonography can guarantee the least invasive and lowest risk treatment for biliary drainage of these cases. This study presents the results of different techniques for endosonography-guided biliary drainage in case of ERCP failure.

Research motivation

In case of ERCP failure, patients must be submitted to surgery or percutaneous transhepatic biliary drainage at different places in the hospital and with a long delay in treatment, conditions which can increase the morbidity and risks for the patient. Endosonography-guided biliary drainage can be performed immediately after ERCP failure, decreasing the time and risk of de finitive treatment of the patient.

Research objectives

Endosonography-guided anterograde stent insertion: In the presence of neoplastic duodenal stenosis, when the guidewire could not be seized in the duodenum, the stent was placed in an anterograde way.Access to the intrahepatic bile duct was obtained using a 19 gauge aspiration needle. Once puncture of the bile duct was con firmed by fl uoroscopy, the guidewire was inserted through the duodenal major papilla and positioned in the second portion of the duodenum. At this point, a SEMS was inserted through the gastric wall across the papilla.

Research methods

In our experience, an alternative to ERCP failure for biliary drainage was necessary in 24 of 3538 (0.68%) cases. Elderly people with malignant biliary obstruction were the most common candidates for the procedure. The sequential endosonography-guided biliary drainage (EUS-BD) procedures proposed for all patients were transhepatic puncture in order to perform the EUS-guided rendez-vous technique. An anterograde approach was attempted when the capture of the guidewire in the duodenum was not possible. If the anterograde approach failed, EUS-guided Hepatogastrostomy was the next alternative. In case of failure of the intrahepatic puncture, patients were submitted to EUS-guided choledochoduodenostomy (EUS-CD).

Research results

In our experience, an alternative to ERCP failure for biliary drainage was necessary in 0.68% of the cases, a finding similar to the rate of 0.62% in the experience of Holt et al[11]. Elderly people with malignant biliary obstruction are the most common candidates for the procedure[11], which was the case in our study, with patients at a median age of 68 years and with malignancies representing 83% of the cases. Endosonography-guided biliary drainage has been an alternative therapy to PTBD and surgery in ERCP failure[8,12]. PTBD, despite its satisfactory results,has a complication rate of about 30%, and surgery,although regarded as the definitive treatment for biliary drainage, is associated with high morbidity and mortality, especially for cases with terminal neoplastic disease[11,13,14].

Research conclusions

A rational approach to EUS-guided biliary drainage in case of obstructive biliary disease and ERCP failure should begin with the transhepatic approach,followed by particular EUS-guided biliary drainage techniques based on the patient’s anatomy and feasibility to recover the guidewire in the duodenum.

Research perspectives

EUS-guided biliary drainage should be included in the therapeutic arsenal for the management of malignant biliary obstruction in case of ERCP failure, and should be the choice rather than surgery or percutaneous transhepatic biliary drainage.

In conclusion,I would like to say that to be a professional translator has to manipulate the theoretical knowledge and the practical translating techniques.An excellent translation work can be

REFERENCES

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Three (12.5%) complications occurred in patients submitted to EUS-BD: a pneumoperitoneum, a choleperitoneum, and an intracavitary liver hemorrhage. All of them were a consequence of the liver puncture in the hilum and were treated conservatively (Table 1). The patient with liver hemorrhage died three days after the PTBD due to acute respiratory and renal failure.

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例如，在美术教学中，有关《艺术—生命与自然和谐交融》这一内容的授课当中，学生将接触到国内外许多优秀的艺术作品。目的是为了提高学生对生命与自然和谐的理解，增强学生对自然美的感知，并形成正确的人生价值。同时文化差异带来的不同美的表现力，不仅扩大了学生的知识面，它使学生能够逐步掌握学习中的感知和欣赏方法；最后，为了保持课堂的活跃性并反映学生的主体学习地位，教师还可以让学生欣赏某幅作品。如“孟特芳丹的回忆”，以提高学生的审美能力。

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玻璃瓶装的罐头，十分惹人注目，透明的瓶身，贴着美丽的图案与商标，摇动起来，里面的糖水黏黏的，看着就好吃。

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16 Khashab MA, Levy MJ, Itoi T, Artifon EL. EUS-guided biliary drainage. Gastrointest Endosc 2015; 82: 993-1001 [PMID:26384159 DOI: 10.1016/j.gie.2015.06.043]

17 Moole H, Bechtold ML, Forcione D, Puli SR. A meta-analysis and systematic review: Success of endoscopic ultrasound guided biliary stenting in patients with inoperable malignant biliary strictures and a failed ERCP. Medicine (Baltimore) 2017; 96: e5154 [PMID:28099327 DOI: 10.1097/MD.0000000000005154]

18 Park DH, Song TJ, Eum J, Moon SH, Lee SS, Seo DW, Lee SK,Kim MH. EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos). Gastrointest Endosc 2010; 71: 413-419 [PMID: 20152319 DOI: 10.1016/j.gie.2009.10.015]

19 Tyberg A, Desai AP, Kumta NA, Brown E, Gaidhane M, Sharaiha RZ, Kahaleh M. EUS-guided biliary drainage after failed ERCP:a novel algorithm individualized based on patient anatomy.Gastrointest Endosc 2016; 84: 941-946 [PMID: 27237786 DOI:10.1016/j.gie.2016.05.035]

已有研究表明,不同的微胶囊包裹工艺方法对微胶囊的性质会有较大的影响。朱红梅等人比较了4种物理方法对制备香草兰精油微胶囊的影响[6]; 贺龙通过制备3种甜橙微胶囊,研究不同工艺步骤对微胶囊的性能的影响[7]; Zasypkin等人研究了不同的改性淀粉用于挤压糖玻璃化包埋风味物质的影响[8]; Tackenberg等人采用麦芽糊精、蔗糖和水的混合物对风味油进行包埋,研究各组分对胶囊固体性质影响[9]。目前,虽然有较多论文研究了不同的微胶囊制备工艺对微胶囊的影响,但是针对挤压法的工艺研究较少。

20 Ogura T, Chiba Y, Masuda D, Kitano M, Sano T, Saori O,Yamamoto K, Imaoka H, Imoto A, Takeuchi T, Fukunishi S, Higuchi K. Comparison of the clinical impact of endoscopic ultrasoundguided choledochoduodenostomy and hepaticogastrostomy for bile duct obstruction with duodenal obstruction. Endoscopy 2016; 48:156-163 [PMID: 26382307 DOI: 10.1055/s-0034-1392859]

21 Artifon EL, Marson FP, Gaidhane M, Kahaleh M, Otoch JP.Hepaticogastrostomy or choledochoduodenostomy for distal malignant biliary obstruction after failed ERCP: is there any difference? Gastrointest Endosc 2015; 81: 950-959 [PMID:25500330 DOI: 10.1016/j.gie.2014.09.047]

22 Iwashita T, Yasuda I, Mukai T, Iwata K, Ando N, Doi S,Nakashima M, Uemura S, Mabuchi M, Shimizu M. EUS-guided rendezvous for difficult biliary cannulation using a standardized algorithm: a multicenter prospective pilot study (with videos).Gastrointest Endosc 2016; 83: 394-400 [PMID: 26089103 DOI:10.1016/j.gie.2015.04.043]

During the study period, it was not possible to cannulate the biliary tree in 24 of 3528 (0.68%) patients submitted to ERCP. Thirteen men and 11 women with a mean age of 67.8 years old were included in the study. The most common symptom was jaundice in 96% of the patients, followed by abdominal pain and acute biliary pancreatitis in 21% and 8.3% of cases,respectively. The demographics, reasons for ERCP failure, indications for EUS-BD, as well as technical and clinical success are listed in Table 1.

23 Poincloux L, Rouquette O, Buc E, Privat J, Pezet D, Dapoigny M, Bommelaer G, Abergel A. Endoscopic ultrasound-guided biliary drainage after failed ERCP: cumulative experience of 101 procedures at a single center. Endoscopy 2015; 47: 794-801 [PMID:25961443 DOI: 10.1055/s-0034-1391988]

日常炊事能源调查结果如图2所示。其中秸秆的比例为48%，薪柴的比例为27%，煤气罐的比例为17%，沼气的比例为8%，秸秆和薪柴的比例高达75%，大量秸秆和薪柴的燃烧，势必会加重住宅内的空气污染，危害身体健康。

李方振等[33]对不同砾石含量的宽级配砾质土进行了一系列的三轴渗透试验。根据砾石含量不同，将宽级配砾质土的结构分成悬浮-密实、密实-骨架、骨架-空隙三种形式；渗透系数随砾石含量的增大，呈现出先略微减小后又逐渐增大、最后显著增大的变化规律，并认为宽级配砾质土的渗透系数与含水率、干密度均有较大的关系。

24 Park DH. Endoscopic ultrasonography-guided hepaticogastrostomy. Gastrointest Endosc Clin N Am 2012; 22: 271-280, ix[PMID: 22632949 DOI: 10.1016/j.giec.2012.04.009]

25 Chan SM, Teoh AY. Endoscopic ultrasound-guided biliary drainage: a review. Curr Treat Options Gastroenterol 2015; 13:171-184 [PMID: 25783788 DOI: 10.1007/s11938-015-0047-x]

26 Khashab MA, Messallam AA, Penas I, Nakai Y, Modayil RJ, De la Serna C, Hara K, El Zein M, Stavropoulos SN, Perez-Miranda M,Kumbhari V, Ngamruengphong S, Dhir VK, Park DH. International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs choledochoduodenostomy approaches. Endosc Int Open 2016; 4: E175-E181 [PMID:26878045 DOI: 10.1055/s-0041-109083]

27 Weilert F. Prospective evaluation of simplified algorithm for EUS-guided intra-hepatic biliary access and anterograde interventions for failed ERCP. Surg Endosc 2014; 28: 3193-3199 [PMID:24879144 DOI: 10.1007/s00464-014-3588-5]

28 Harbin WP, Mueller PR, Ferrucci JT Jr. Transhepatic cholangiography: complicatons and use patterns of the fine-needle technique: a multi-institutional survey. Radiology 1980; 135: 15-22[PMID: 6987704 DOI: 10.1148/radiology.135.1.6987704]

29 Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM,Yeaton P. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc 2006; 64: 52-59[PMID: 16813803 DOI: 10.1016/j.gie.2006.01.063]

30 Giovannini M, Dotti M, Bories E, Moutardier V, Pesenti C, Danisi C, Delpero JR. Hepaticogastrostomy by echo-endoscopy as a palliative treatment in a patient with metastatic biliary obstruction.Endoscopy 2003; 35: 1076-1078 [PMID: 14648424 DOI: 10.1055/s-2003-44596]

31 Isayama H, Nakai Y, Kawakubo K, Kawakami H, Itoi T, Yamamoto N, Kogure H, Koike K. The endoscopic ultrasonography-guided rendezvous technique for biliary cannulation: a technical review. J Hepatobiliary Pancreat Sci 2013; 20: 413-420 [PMID: 23179560 DOI: 10.1007/s00534-012-0577-8]

32 Kim YS, Gupta K, Mallery S, Li R, Kinney T, Freeman ML.Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center.A case series. Endoscopy 2010; 42: 496-502 [PMID: 20419625 DOI: 10.1055/s-0029-1244082]