Preoperative biliary drainagein hilar cholangiocarcinoma:Whenandhow?简

Hilar cholangiocarcinoma is a tumor of the extrahepatic bile duct involving the left main hepatic duct, the right main hepatic duct, or their confluence. Biliary drainage in hilar cholangiocarcinoma is sometimes clinically challenging because of complexities associated with the level of biliary obstruction. This may result in some adverse events, especially acute cholangitis. Hence the decision on the indication and methods of biliary drainage in patients with hilar cholangiocarcinoma should be carefully evaluated. This review focuses on the optimal method and duration of preoperative biliary drainage (PBD) in resectable hilar cholangiocarcinoma. Under certain special indications such as right lobectomy for Bismuth type IIIA or IV hilar cholangiocarcinoma, or preoperative portal vein embolization with chemoradiation therapy, PBD should be strongly recommended. Generally, selective biliary drainage is enough before surgery, however, in the cases of development of cholangitis after unilateral drainage or slow resolving hyperbilirubinemia, total biliary drainage may be considered. Although the optimal preoperative bilirubin level is still a matter of debate, the shortest possible duration of PBD is recommended. Endoscopic nasobiliary drainage seems to be the most appropriate method of PBD in terms of minimizing the risks of tract seeding and inflammatory reactions.     

Clinical usefulness of a treatment algorithm for pancreatic pseudocysts

BACKGROUND: Endoscopic procedures have become a first-line approach to the treatment of pancreatic pseudocysts. OBJECTIVE: Our purpose was to determine the results of a therapeutic algorithm including EUS-assisted drainage, transpapillary drainage, and conventional endoscopic drainage in terms of (1) feasibility and efficacy of the endoscopic procedure and (2) morbidity. DESIGN: Prospective study with a treatment algorithm drawn up before the endoscopic procedure, including either conventional endoscopic transmural drainage (CTMD), conventional transpapillary drainage (CTPD), or EUS-guided transmural drainage (EUS-GTD). PATIENTS: A total of 50 patients, including 15 women and 35 men with a mean age of 51 years, were included in this prospective study. RESULTS: The mean size of the pseudocysts was 8.2 cm (range 3-12 cm). A total of 29 pseudocysts did not bulge into the digestive wall (58%); 24 (48%) neither bulged nor communicated with the pancreatic duct. EUS-GTD was performed on 28 patients (56%), CTMD on 13 patients (26%), and CTPD on 8 patients (16%), and endoscopic procedures failed in 1 patient. Technical feasibility was 98% (49/50), and clinical success was achieved in 90% of the cases and disappearance of the pseudocysts in 96% of the cases without significant differences among the 3 groups. The morbidity rate was 18% (9 cases). Five superinfections occurred in the EUS-GTD group and 1 in the CTMD group. One death occurred from late bleeding in the CTMD group. LIMITATION: Randomization of patients in this prospective study was not possible because of the different characteristics of the pseudocysts. CONCLUSION: With this algorithm, clinical success was achieved in 45 (90%) of the cases and disappearance of the pseudocysts in 48 (96%) of the cases with a reasonable morbidity rate. In half of the cases, EUS is required for treating pancreatic pseudocyst.     

Endoscopic management of acute calculous cholangitis

Acute cholangitis is associated with significant morbidity and mortality. Endoscopic drainage procedures have been shown to be a safe and effective mode of treatment in acute cholangitis. As there is paucity of large series on endoscopic management of acute cholangitis, a study was performed to evaluate safety and efficiency of endoscopic biliary decompression in acute cholangitis. The study included 89 consecutive patients (mean age 55 ± 15 years; range 35–70 years; 50 males) with acute cholangitis requiring biliary drainage. Main presenting features were upper abdominal pain (84%), fever with chills (90%) and jaundice (74%). Altered sensorium, hypotension, features of peritonitis and acute renal failure were present in 15, 11, 18 and 5%, respectively. Endoscopic procedures performed were endoscopic sphincterotomy (ES) with stone extraction (n= 40); ES with endoscopic nasobiliary drainage (ENBD; n= 30); ENBD without ES (n= 8); and ES with stent placement (n= 11). Of the 89 patients, 85 (95%) responded within 48–72 h. Endoscopic common duct clearance could be achieved in 58 of 78 (74%) patients, whereas in 11 patients undergoing stent placement, stone extraction was not attempted. Complications included post-sphincterotomy bleed (n= 2), retroduodenal perforation (n= 1) and acute pancreatitis (n= 1) with an overall complication rate of 4.4%. All the complications were seen in patients undergoing ES with stone extraction. Mortality was 3.3%. In conclusion, endoscopic biliary drainage is a safe and effective mode of treatment for acute cholangitis. Endoscopic nasobiliary drainage or stent placement is safer than ES in acute cholangitis as an initial step.     

经皮置管负压冲洗联合内镜引流治疗重症急性胰腺炎合并胰腺坏死组织感染

目的 观察经皮置管负压冲洗联合内镜引流(PCD+ NPI+ ED)治疗重症急性胰腺炎(SAP)合并胰腺坏死组织感染(IPN)的临床效果.方法 回顾2011年7月至2012年7月经PCD+ NPI+ED联合技术治疗的17例合并IPN的SAP患者的临床资料,分析临床治疗过程及预后.结果 17例患者IPN确诊距发病时间为(26.9 ±7.9)d.13例革兰阴性菌感染,3例革兰阳性菌感染,1例侵袭性真菌感染.首次PCD+ NPI治疗距发病时间为(34.8±11.6)d.B超引导下置管1例,CT引导下置管8例,B超和CT联合引导下置管8例,每例患者平均所置负压冲洗引流管为(3.5±1.2)根.首次ED治疗距首次PCD+ NPI时间为(26.7 ±9.6)d,每例患者平均ED治疗(2.1 ±0.9)次.2例中转剖腹手术引流,距确诊IPN时间分别为24d和56 d.17例患者均无PCD+ NPI置管相关并发症发生,第1例患者在ED治疗过程中发生出血,ED治疗后2例并发十二指肠瘘,1例并发高位空肠瘘,1例并发降结肠瘘,2例腹腔出血.无新发脏器功能障碍和脓毒血症.1例在PCD+ NPI+ ED联合治疗前即并发多器官功能不全和脓毒血症,虽中转剖腹手术引流仍无法有效控制脓毒血症而病死.结论 PCD+ NPI+ ED联合技术可使IPN患者避免剖腹手术引流,减少并发症发生,改善患者预后.     

鼻胆囊引流管辅助下行腹腔镜胆囊次全切除术的临床体会

目的总结慢性萎缩性胆囊炎患者在鼻胆囊引流管(ENGBD)引导下施行腹腔镜胆囊次全切除术(LSC)的经验。方法收集2007年1月-2016年12月在武警重庆市总队医院肝胆外科、成都中医药大学附属医院普通外科和重庆市中医院普通外科收治的慢性萎缩性胆囊炎合并继发性胆总管结石患者124例,回顾分析其临床资料。所有病例均采用经内镜逆行胰胆管造影(ERCP)、括约肌切开后取石,术中置入ENGBD者分配入试验组(A组,n=47)、置入鼻胆引流管(ENBD)者分配入对照组(B组,n=77)。2组均于ERCP后施行腹腔镜胆囊切除术(LC)或腹腔镜胆囊次全切除术(LSC),困难病例则中转开腹实施胆囊切除术。计量资料2组间比较采用t检验;计数资料2组间比较采用χ~2检验。结果 A组在ENGBD的引导下,较B组更易完成LSC术(53.2%vs 20.8%),中转开腹实施胆囊切除术的比例也大为降低(4.3%vs 35.1%)。B组可能因胆囊与周围器官之间形成内瘘(包括Mirizzi综合征)、意外胆囊癌、胆囊管汇合异常等复杂情况,NEGBD难以成功置入,使得手术中发生肝动脉/肝静脉损伤,又因担心胆管损伤而被迫中转开腹。结论慢性萎缩性胆囊炎合并继发性胆总管结石时,于ERCP后置入ENGBD有助于LSC的顺利实施,可有效降低中转开腹比例。     

经胃联合经皮内镜治疗感染性胰腺坏死的疗效分析

目的　评价经胃联合经皮内镜治疗感染性胰腺坏死（infected pancreatic necrosis,IPN）的疗效。方法　回顾性分析2015年8月—2020年8月在南京鼓楼医院消化内科重症监护室接受经胃联合经皮内镜治疗的19例IPN患者的临床资料,分析其临床疗效及手术相关并发症的发生情况。结果　每例患者内镜腔内引流术（endoscopic transmural drainage, ETD）治疗（1.1±0.3）次。在ETD术中,9例患者置入双腔固定支架,2例患者置入金属覆膜支架,7例置入双猪尾塑料支架,1例仅置入鼻囊肿引流管。19例患者均在首次经皮穿刺引流术（percutaneous catheter drainage, PCD）中置入12~14 F引流管进行引流,每人置管（1.8±1.2）根,其中3例患者后续更换为双套管持续引流,1例患者后续经皮置入金属覆膜支架进行引流。穿刺引流液培养结果为11例革兰阴性杆菌及革兰阳性球菌,4例革兰阳性球菌,1例革兰阳性杆菌,3例革兰阴性杆菌。19例患者中4例同时合并真菌感染。每例患者清创（3.1±1.8）次,其中2例行经皮内镜坏死组织清除术联合内镜坏死组织清除术治疗。每例患者总操作（6.1±2.4）次。术后出现出血1例（5.3%）,经内镜治疗后成功止血,无消化道瘘、穿孔、胰瘘等严重并发症发生。1例死亡,原因为脓毒血症,其余18例经治疗后IPN明显吸收。19例患者均未转为开腹手术。结论　经胃联合经皮内镜治疗IPN安全有效。     

床旁经皮经肝胆囊穿刺引流术在高龄急性化脓性胆囊炎患者中的应用价值

目的评价床旁B超引导下经皮经肝胆囊穿刺引流术(PTGD)对高龄急性化脓性胆囊炎患者的应用价值。方法回顾性分析2010年8月～2011年3月接受治疗的25例高龄急性化脓性胆囊炎患者的临床资料。结果 25例均置管成功。1例87岁女性患者PTGD术后7天死于多器官功能衰竭。其余24例在行PTGD术后2周～2月间择期行腹腔镜胆囊切除术,其中中转开腹3例,胆囊切除术后均未死亡。结论 PTGD治疗高龄化脓性胆囊炎是一项安全、有效、简便的方法。     

中心静脉导管腹腔引流治疗顽固性腹水36例分析

目的探讨采用腹腔穿刺置入中心静脉导管治疗顽固性腹水的疗效。方法选择2010年7月至2011年3月本科室经补充白蛋白及各种利尿剂治疗无效的肝硬化顽固性腹水患者36例,进行腹腔置管放液治疗,第1次放腹水一般不超过800ml,此后每日放腹水量1500～2000ml,联合输注人血白蛋白10g／d。口服螺内酯400mg／d,呋塞米160mg／d,联合内科综合治疗。结果观察治疗12d后的腹水消退情况、超声检查结果、尿量、稳定时间,治疗3d后患者腹胀均得到缓解,12d后显效17例（47．2％）,有效15例（41．7％）,无效4例（11．1％）,总有效率达88．9％。结论中心静脉导管置入腹腔后,减少了穿刺次数,减少了肝肾综合征的发生,中心静脉导管腹腔持续引流操作简便,不良反应少,有利于顽固性腹水的治疗。     

Initial experience of transnasal endoscopic biliary drainage without conscious sedation for the treatment of acute cholangitis (with video)

BACKGROUND: Endoscopic biliary drainage has been established as providing effective treatment for acute obstructive jaundice and cholangitis. A recently developed ultrathin transnasal videoendoscope is less invasive, even for patients who were critically ill, and can be performed without conscious sedation. OBJECTIVE: To evaluate the clinical efficacy and safety of biliary drainage (BD) by using transnasal videoendoscopy (TNE) without conscious sedation. DESIGN: Case series. SETTING: This procedure was performed at Tokyo Medical University Hospital. PATIENTS: Three patients with bile-duct stones and acute cholangitis and with a previous biliary endoscopic sphincterotomy (ES) were included in this study. INTERVENTION: All patients underwent BD by using a front-viewing TNE. Two 5F stents were placed into the bile duct across the major papilla. MAIN OUTCOME MEASUREMENT: The efficacy and safety of the TNE technique. RESULTS: Transnasal insertion of a TNE endoscope was feasible in all patients, without epistaxis. TNE BD was achieved in all patients. Abdominal pain, fever, and jaundice improved 24 hours after the procedure in all patients. Despite the absence of intravenous conscious sedation, all patients would agree to undergo the procedure again, if necessary. LIMITATIONS: Maneuverability of the TNE endoscope; limited to patients with a previous ES. CONCLUSIONS: In this small series, unsedated TNE can be used to successfully drain the biliary system in patients with a previous ES. Additional studies to validate this hypothesis are needed.     

内镜胆管引流术治疗胆瘘的临床价值

目的　探讨内镜胆管引流术治疗胆瘘的有效性和安全性。方法　回顾性分析2002年11月—2022年11月在解放军总医院第一医学中心诊治的连续性409例胆瘘患者的临床资料，最终纳入53例内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography， ERCP）下行胆管引流术的胆瘘患者，分析患者的一般情况、手术操作情况、治疗结局和不良事件等。将患者分为支架引流组（n=46）与鼻胆管引流组（n=7），比较两组术中特点、手术结果以及手术时间。结果　53例患者中，男36例、女17例，年龄（52.2±12.7）岁，其中58.5%（31/53）的患者继发于胆囊切除术。其临床成功率为83.0%（44/53），手术时间为27.0（13.5，33.5） min，治疗1（1，2） 次，治愈时间89 （47，161） d。ERCP治疗轻度胆瘘相较于重度胆瘘成功率较高［96.4%（27/28）比 68.0% （17/25）， χ2=7.57， P=0.006］。跨瘘口引流相较于非跨瘘口引流治疗胆瘘的成功率更高［91.7% （33/36） 比64.7% （11/17）， χ2=5.95， P=0.015］，而使用较大口径（≥10 Fr）与较小口径（<10 Fr）的支架治疗胆瘘的成功率相近［81.8% （27/33）比84.6%（11/13）， χ2=0.05， P=0.822］。18.9%（10/53）的患者出现不良事件，其中胰腺炎6例、出血2例、胆管炎1例，死亡1例。除1例死亡外，其余9例不良事件均为轻度，且经保守治疗后好转。鼻胆管引流组和胆管支架引流组在临床成功率［6/7比82.6%（38/46）， χ2=0.04，P=0.838］、中位手术时间（28.0 min 比 23.0 min， Z=0.38， P=0.774）方面差异无统计学意义。结论　内镜胆管引流术治疗胆瘘是安全有效的。鼻胆管和胆管支架引流的临床疗效相似，ERCP治疗轻度胆瘘以及跨瘘口引流可能具有更高的临床成功率。     

Comparative study of biliary trace elements and clinical phenotypes in Wilson’s disease

AIM: To further explore the etiological mechanism of Wilson’s disease (WD) by comparing the changes of biliary trace elements and its clinical phenotype.METHODS: WD patients with different types and conditions (n = 20), non-WD patients with chronic liver damage (n = 22), and healthy volunteers (n = 10; used as controls) were studied. Biliary samples were taken by duodenal drainage. Atom absorption spectrophotometer was used to assay the copper and zinc content of each sample.RESULTS: In WD, the copper content and copper/zinc ratio of biliary juice were evidently lower than those of non-WD patients with chronic liver damage and of healthy controls (F = 14.76, 25.4; 14.92, 26.2 respectively; P < 0.01), while the biliary zinc level had no significant difference from the two non-WD control groups (P > 0.05). There were significant differences in biliary copper excretion among patients with different types and conditions (F = 3.75, P < 0.05; F = 6.20, P < 0.01).CONCLUSION: Copper excretion by liver and the biliary system decreases obviously in WD, which plays a key role in the phenotypic copper retention, and the biliary copper retention is closely related with the severity of hepatic injury and illness.