恶性梗阻性黄疸内镜下逆行胰胆管造影引流术后疗效观察

目的探讨恶性梗阻性黄疸经内镜下逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)引流术后的疗效。方法 60例恶性肿瘤引起的梗阻性黄疸患者,通过ERCP术置入胆管支架,观察插管成功率、肝功能变化及并发症发生情况。结果 60例患者中57例插管成功,成功率为95.0%(57/60)。57例插管成功的患者中9例胆管内放置金属支架,2例行单纯鼻胆管引流,3例行塑料内支架+鼻胆管引流,其余43例行8.5~10F塑料内支架引流术。术后患者黄疸及皮肤瘙痒等表现减轻或消失。术后1周,患者丙氨酸转移酶(ALT)、天冬氨酸转移酶(AST)、血清总胆红素(TBIL)、直接胆红素(DBIL)、碱性磷酸酶(ALP)、r-谷氨酰基转移酶(GGT)均显著降低(P0.05)。9例行胆管金属支架置入的患者中,1例于术后5个月发生支架阻塞,行胆泥清理并置入塑料支架后金属支架引流通畅。1例单纯鼻胆管引流患者20 d后获得外科手术治疗机会,另1例经鼻胆管引流1个月后肝功能恢复正常,得以行外科根治性手术治疗,43例行胆管塑料支架置入的患者中,8例于术后1~4周出现TBIL水平再次上升,行ERCP检查明确为支架移位或阻塞,给予更换支架,其中有1例更换为金属支架,3例置入塑料双支架。结论通过ERCP术放置胆管引流治疗恶性梗阻性黄疸,对于患者黄疸等症状的改善及生存质量的提高具有确切疗效。     

经内镜放置胆管金属支架联合鼻胆管引流治疗恶性胆管梗阻

目的探讨经内镜放置胆管金属支架联合鼻胆管引流对恶性胆管梗阻的治疗效果。方法 115例失去手术机会的恶性胆管梗阻患者行经内镜逆行胰胆管造影下放置胆管支架,其中48例行胆管塑料支架引流术,30例行胆管金属支架引流术,37例行胆管金属支架联合鼻胆管引流术;分析各组引流效果、成功率、早期并发症和胆管再堵塞发生情况。结果塑料支架组、金属支架组及金属支架联合鼻胆管组的谷丙转氨酶(ALT)、总胆红素(TBIL)、直接胆红素(DBIL)和碱性磷酸酶(AKP)在手术后均有明显降低(P0.05);手术后1周金属支架联合鼻胆管组的TBIL和DBIL明显低于塑料支架组、金属支架组(P0.05),塑料支架组和金属支架组相比,差异无统计学意义(P0.05);术后3个月内金属支架组和金属支架联合鼻胆管组再堵塞的发生率明显低于塑料支架组(P0.05),金属支架组和金属支架联合鼻胆管组相比,差异无统计学意义(P0.05);塑料支架组的手术成功率与金属支架组及金属支架联合鼻胆管组相比,差异无统计学意义(P0.05),塑料支架组的早期并发症发生率明显高于金属支架联合鼻胆管组,差异有统计学意义(P0.05)。结论经内镜逆行胰胆管造影下放置胆管金属支架联合鼻胆管对于恶性胆管梗阻有确切的引流效果。     

经皮经肝穿刺胆管引流治疗内镜难治性恶性胆道梗阻

目的探讨经皮经肝穿刺胆管引流术(PTBD)对梗阻性黄疸的介入治疗的意义。方法23例梗阻性黄疸患者,男14例,女9例,年龄61～88岁,平均(72.6±10.9)岁,其中胆管癌10例(术后5例),胰头癌3例,胃癌术后7例,十二指肠乳头癌2例,肝癌1例,不宜行十二脂肠镜逆行胰胆管造影(ERCP)或ERCP失败,经皮肝穿刺放置引流管或内支架。结果全部PTBD成功,其中外引流6例,内外引流13例(3例左右胆管双引流),金属内支架4例。引流术前血清总胆红素(321.6±132.1)μmol/L,引流术后1周血清总胆红素(88.6±10.1)μmol/L,较前明显下降(P<0.05),直接胆红素从(252.3±36.3)μmol/L降至(53.3±9.4)μmol/L(P<0.05)。结论PTBD对梗阻性黄疸是一种安全、有效的治疗方法。     

经内镜置入胆管内支架引流治疗良恶性胆管梗阻

目的 观察经内镜下胆管内引流术治疗良恶性胆管梗阻病人的效果.方法 经内镜下逆行胆管造影,根据胆管狭窄的情况放置不同的胆管支架.术后观察病人的黄疸、腹痛和发热等症状,并复查肝功能等.结果 36例良恶性胆管梗阻,塑料支架置入成功率为96.4%,金属支架成功率为100%,无支架术相关死亡者.结论 经内镜下逆行胆管内引流手术要求的条件低,创伤小,引流效果好,是治疗胆管梗阻的首选引流方法 ,值得进一步推广.     

原发性肝癌合并胆管梗阻的影像诊断与介入治疗

目的　探讨原发性肝癌合并胆管梗阻的影像诊断与介入治疗价值。方法　对 2 6例原发性肝癌合并胆管梗阻者进行回顾性分析 ,所有患者均行超声和CT检查 ,18例行MRI检查 ,11例行PTC检查 ,10例行ERCP检查 ,12例行胆道内支架置入术 ,2 2例经肝动脉化疗栓塞 (TACE)治疗。结果　 2 6例患者经超声、CT、MRI、PTC和ERCP等影像学检查后获得正确诊断。 12例患者分别置入了 4枚塑料内支架和 8枚金属支架 ,技术成功率为 10 0 % ,均有明显的减黄效果 ,患者术后 1周的血清胆红素水平由术前的 ( 2 96± 67) μmol/L降至 ( 10 4± 5 2 ) μmol/L(P <0 .0 5 )。 2 2例患者成功地进行了TACE治疗。结论　超声、CT、MRI和胆管造影检查对原发性肝癌合并胆管梗阻有较高的诊断价值 ,其相互补充有助于本病的正确诊断。胆道内支架置入术与TACE等介入治疗是其有效的治疗方法。     

67例肝门部胆管癌内镜下治疗的临床分析

目的 探讨肝门部胆管癌患者内镜下支架治疗的临床效果,为置人支架方式的选择提供依据.方法 选择67例肝门部胆管癌患者,根据磁共振胰胆管造影(MRCP)和逆行胰胆管造影(ERCP)对患者Bismuth分型进行比较.ERCP下胆管狭窄部分别置人金属和塑料支架,观察患者术前、术后临床表现及肝功能指标.随访1年观察患者生存情况.结果 MRCP与ERCP对患者Bismuth分型结果基本相似,仅对Ⅰ型与Ⅳ型判断略有偏差.所有患者中置入金属支架21例,双侧塑料支架10例,单侧塑料支架36例.术后1周腹痛、发热及消化不良症状的发生率较术前显著降低(P＜0.05),术后1个月黄疸发生率均较术前显著降低(P＜0.01).术后1个月血清总胆红素、直接胆红素、丙氨酸转氨酶、碱性磷酸酶和γ-谷氨酰转肽酶值均较术前显著降低(P＜0.05).ERCP术后1个月,单侧金属支架组与双侧塑料支架组患者血清总胆红素、直接胆红素及碱性磷酸酶值较单侧塑料支架组显著降低(P＜0.05),而金属支架组与双侧塑料支架组患者间肝功能差异无统计学意义(P＞0.05).结论 内镜下支架置入术能显著缓解肝门部胆管癌患者,尤其是出现阻塞性黄疸者的临床症状.     

放置金属支架姑息性解除恶性胆道梗阻57例

目的内镜法放置胆道支架,姑息性治疗胆管恶性梗阻的最大缺陷是支架的阻塞,造成阻塞的重要原因之一是通常的塑料支架口径较小,而放置可膨式金属支架使得内引流中口径达到1cm.方法我们从1994年4月-1996年5月放置膨胀式金属道支架治疗57例无法根治的恶性梗阻性黄疸患者,其中采用内镜法置管54例,经皮肝穿刺法3例.结果导丝定位后支架放置的成功率为95%,2例发生胆管炎,经保守治疗得以控制.术后两周内黄疸完全消退21例,明显减退23例,然而9例患者在平均147d 后由于引流失效出现晚期胆管炎.全组有23例术前采用鼻胆管和3例采用内置管临时性引流,临时性引流具有可预先了解引流效果和控制炎症的优点.结论对于无法切除的恶性胆道梗阻患者,放置金属胆道支架可有效解除黄疸,改善生活质量,但欲获得最佳疗效,需严格掌握置管指证.为获得持久的引流效果.肿瘤两端支架的长度不宜短于2cm;对肝门部胆管癌,Bismuth 分型对挑选合适的引流部位有较大的参考价值.     

胆管恶性梗阻的内镜治疗

目的研究经内镜下塑料支架和金属支架对胆管恶性梗阻的治疗效果。方法将我院2010年1月至2012年6月经ERCP确诊为胆管恶性梗阻的120例患者,分成金属支架引流术组（EMBE）（n=62）和塑料支架引流术组（ERBD）（n=58）,监测两组患者血清总胆红素、谷丙转氨酶、碱性磷酸酶、谷氨酰胺转肽酶、血清TNF-α等的变化,并统计分析两组患者并发症的发生率以及死亡率。结果两组插管成功率及并发症发生率为均无明显差异（P〉0.05）,无死亡病例。治疗1周后复查两组患者的肝功能各项指标,结果较治疗前有统计学差异（P〈0.05）。两组成功随访89例,随访率为74.16%（89/120）,12例ERBD患者发生支架阻塞,占30.77%（12/39）,该组中位生存期为5个月。6例EMBE患者发生支架阻塞,占12%（6/50）,该组中位生存期为9.3个月,两组比较P均〈0.05。结论从随访看,支架阻塞发生率和中位生存期EMBE组均优于ERBD组,但两组均能有效的建立胆管内引流,改善患者的肝功能,具有创伤小、痛苦少、恢复快、无体外留管、符合生理过程等优点。     

放置胆管支架治疗胆管梗阻131例临床分析

目的 探讨放置胆管支架治疗胆管梗阻性疾病的可行性和疗效.方法 回顾性分析解放军总医院消化疾病中心2006年4月至2007年2月对131例住院胆管梗阻性疾病患者行138例次放置胆管支架的诊治经过,分析其黄疸改善情况及并发症的发生率.结果 全部患者均成功放置了胆管支架,术后3d血清总胆红素、直接胆红素、碱性磷酸酶和γ-谷氨酰转移酶均明显下降,差异有统计学意义.主要并发症为胆管炎及胰腺炎.结论 放置胆管支架为治疗胆管梗阻性疾病的有效治疗方法,尤其是为失去手术机会的患者提供了重要的治疗方案.     

经内镜胆道支架置入治疗35例恶性梗阻性黄疸疗效分析

目的探讨经十二指肠镜逆行胰胆管造影（ER-CP）置入胆道内支架治疗恶性梗阻性黄疸的临床疗效。方法 35例恶性梗阻性黄疸的患者,均行ERCP（经内镜逆行胰胆管造影）术,根据情况置入不同规格支架,观察治疗效果和3个月、6个月生存率。结果 32例患者插管成功,插管成功率为91.43%,其中10例置入金属支架,22例置入塑料支架。术后并发急性胰腺炎2例（6.25%）,经治疗后痊愈。成功置入支架的32例患者术后黄疸逐渐消退,皮肤瘙痒等症状明显缓解或消失,血清总胆红素从（230.85±83.81）μmol/L下降到术后1周（121.88±52.27）μmol/L（P〈0.01）,支架组随访26例中总体3个月、6个月存活分别达到92.30%及76.92%。结论经十二指肠镜逆行胰胆管造影（ERCP）置入胆道内支架治疗恶性胆道梗阻疗效确切,对于解除恶性梗阻性黄疽、缓解症状、提高患者生存质量、延长生命具有较满意效果。     

经内镜胆道引流治疗胆道梗阻

目的：进一步提高经内镜胆道引流术的成功率。方法：总结1998年1月至2001年9月对320例胆道梗阻患者行十二指肠镜下各种胆道引流术的经验，其中鼻胆管引流术（ENBD）242例，胆道内置管引流术（ERBD）43例，胆道金属支架术（EMBE）35例。结果：305例得到成功引流，胆道梗阻症状缓解；失败15例。其中ENBD失败10例，经调整鼻胆管位置或重新置管获得成功；ERBD失败3例，2例选用合适长度的支架后引流成功，1例经努力仍未成功改用经皮肝穿刺胆道引流；EM-BE失败2例，其中1例金属支架未超出肿瘤狭窄段，经原金属支架再套入另一金属支架而成功，另1例支架放置1月又出现胆道阻塞，经原金属支架通道再放入塑料支架而恢复通畅引流。结论：经内镜引流治疗胆道梗阻疗效确切，及早分析内镜引流失败原因并采取相应的对策，绝大多数引流失败是可以避免或补救的。     

Intrahepatic biliary papilloma morphologically similar to biliary cystadenoma

A 37-year-old man presented complaining of epigastralgia. Abdominal ultrasonography revealed the presence of a papillary tumor (9 mm in diameter) in the cystic lesion (18 mm in diameter) in hepatic segment 4, which was accompanied by mild intrahepatic bile duct dilatation. Although abdominal computed tomography also showed the cystic lesion, it did not show papillary tumors inside the lesion. Endoscopic retrograde cholangiography showed the communication between the cystic lesion and the left hepatic duct. In addition, mucus was observed in the common bile duct. When transpapillary intraductal ultrasonography was performed through the left hepatic duct using a fine ultrasonic probe, a hyperechoic papillary and lobulated tumor was clearly shown in the cystic lesion. The wall of the cyst was smooth and there was no sign of tumor infiltration. Based on these findings, biliary cystadenoma was diagnosed and an extended left lobectomy was carried out. However, pathological findings postoperatively revealed that the lesion was a localized biliary papilloma, developing and extending to the intrahepatic duct. This case is rare and there have been no published reports describing a biliary papilloma morphologically similar to biliary cystadenoma.     

Early treatment of biliary lithiasis in biliary pancreatitis

Since 1982, 38 consecutive patients with biliary pancreatitis were treated prospectively in order to prevent recurrent migration of gallstones. Removal of the stones was achieved by "early surgery" i. e. within the first week after admission or by endoscopic sphincterotomy in patients with severe pancreatitis. Gallstones were visualized by ultrasonography in 31 patients (82 p. 100). Microlithiasis was present in 14 (37 p. 100) and was missed at ultrasonography in 7 patients. According to Ranson's prognostic signs, only 4 patients had 4 or more signs. These 4 patients and 2 additional patients aged more than 85 underwent urgent retrograde cholangiography and endoscopic sphincterotomy. No complications could be attributed to this technique. Among the 4 patients with severe pancreatitis, 3 developed an abscess which required delayed surgery without further complications. The 32 other patients underwent a biliary operation within the first week after admission. Common bile duct calculi were present in 14 patients being discovered by cholangioscopy in 6. One patient died after operation and one was reoperated on for a pseudocyst on day 40. No recurrent attack of pancreatitis was observed in either group. Our study suggests that slightly delayed biliary operation with cholangioscopy during the same hospitalization can be performed safety in patients with mild pancreatitis. In patients with severe attack and/or poor general condition, endoscopic sphincterotomy is a safe technique and deserves wider consideration in the management of severe acute pancreatitis for which delayed drainage of pancreatic necrosis may occasionally be required.     

The finest branches of the biliary tree might induce biliary vascularization necessary for biliary regeneration

BACKGROUND/AIMS: The finer branches of the biliary tree play an important role in biliary regeneration. They are consistently escorted by microvessels. Defects in the vascularization of these structures could impair bile duct regeneration. Therefore, we investigated the pattern of the escorting microvessels during the development of bile duct loss in the human liver, using chronic rejection as a model. METHODS: The number of interlobular bile ducts, bile ductules and extraportal biliary cells with and without escorting microvessels and the expression of VEGF-A were studied in follow-up biopsies of 12 patients with chronic rejection and 16 control patients with acute rejection without progression to chronic rejection. RESULTS: The controls showed a proliferation of bile ductules at 1-week and 1-month. Proliferation of bile ductules without microvessels preceded proliferation of bile ductules with microvessels. Proliferation of the microvascular compartment followed biliary proliferation. This sequence of events was not observed in the chronic rejection group, in which all biliary structures decreased in time. VEGF-A expression was increased at 1-week and 1-month in both groups. CONCLUSIONS: An immediate proliferative response of the finer branches of the biliary tree followed by proliferation of the microvascular compartment after biliary injury seems to be a prerequisite for bile duct regeneration.     

Preoperative biliary drainage for biliary tract and ampullary carcinomas

We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for postdrainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.     

Adjuvant therapies using biliary stenting for malignant biliary obstruction

The aim of this study was to analyze the patency of expandable metallic stents in malignant biliary obstruction and to evaluate the efficacy of adjuvant therapy accompanied by biliary stenting. We analyzed 29 patients in whom bile duct stenting was performed for malignant biliary obstruction. Their types of disease were: hilar ductal carcinoma (n = 8), gallbladder carcinoma (n = 11), and pancreatic carcinoma (n = 10). Initially, 46 expandable metallic stents were placed in 29 patients. In 23 of the 29 patients, adjuvant therapy was administered. Seventeen patients underwent radiotherapy, and 16 patients received various systemic chemotherapies. In principle, hyperthermia was performed twice a week, simultaneously with radiotherapy. Patient survival and the probability of stent patency were calculated using actuarial life table analysis. There was no significant difference in stent patency among the patients according to type of disease. Hyperthermia did not influence the stent patency rate. The median stent patency time was significantly greater in the chemo-radiation group than in the no-adjuvant therapy group: 182 days versus 68 days, respectively (P = 0.017). Moreover, a significant increase was seen in the median survival time in the chemo-radiation group: 261 days versus 109 days (P = 0.0337). Complications occurred in 9 patients (31.0%). Stent occlusion occurred in 6 patients (20.7%), with all of these patients managed successfully using a transhepatically placed new expandable metallic stent, employing the stent-in-stent method. Stent migration occurred in 2 patients after radiotherapy. Adjuvant therapies such as radiotherapy and systemic chemotherapy, in combination with stent insertion, resulted in an increase in the patency period of expandable metallic stents and in increased patient survival time.     

The effect of biliary decompression on antibiotic biliary excretion

BACKGROUND/AIMS: Raised biliary pressure may affect antibiotic biliary excretion. We evaluated whether biliary decompression for patients with biliary obstruction could improve antibiotic biliary excretion. METHODOLOGY: Eight patients with common bile duct obstruction undergoing endoscopic nasobiliary drainage were evaluated. During endoscopic cannulation, biliary pressure above the obstruction and antibiotic concentrations in the bile and peripheral blood were determined 60 min after the intravenous antibiotic (panipenem) administration. RESULTS: Biliary pressure was initially elevated above normal in all the patients, but normalized after biliary drainage for 5 to 7 days. At the initial endoscopic retrograde cholangiopancreatography, the aspirated bile contained low or undetectable levels of the antibiotic, but the mean bile panipenem concentration and the mean bile/plasma ratio of panipenem concentrations significantly improved after biliary decompression. CONCLUSIONS: The results suggest an important role of biliary pressure in determining antibiotic transfer into the bile.