内镜下支架置入治疗老年晚期恶性胆管梗阻性黄疸的临床观察

目的 观察内镜下胆管内支架置入对老年晚期恶性梗阻性黄疸的引流效果.方法 回顾分析36例老年晚期恶性梗阻性黄疸患者的临床资料.结果 胆管内支架置入对老年恶性梗阻性黄疸患者有明显的短期减黄效果,且住院时间短,近期并发症少,但远期由于支架堵塞,有引起黄疸复发及胆管炎危险.结论 胆管内支架置入是一种安全有效的治疗老年晚期恶性胆管梗阻性黄疸的减黄方法,对于失去手术机会的晚期恶性胆管梗阻患者,在延长患者生存期,提高生活质量方面均具有十分重要的意义.     

晚期高位胆道恶性梗阻性黄疸ERCP、PTCD和手术治疗的对比性研究

目的探讨晚期高位胆道恶性梗阻性黄疸各种姑息减黄法的优劣,为临床推广作指导。方法选取86例山东省烟台毓璜顶医院收治的晚期高位恶性梗阻性黄疸患者,按治疗方式随机分为姑息性手术组、ERCP组和PTCD组,对比三组患者的术前术后治疗效果,同时对各组间的治疗效果进行比较。结果三组患者治疗后各项指标明显优于治疗前,差异具有统计学意义(P0.05)。PTCD治疗效果好于ERCP,治疗效果可靠。结论晚期高位胆道恶性梗阻性患者,各引流措施均可有效缓解梗阻,但PTCD操作方便,安全性好,具有更好的经济效益。     

经皮经肝胆道内支架置入术在恶性梗阻性黄疸中的应用

目的探讨经皮经肝胆道内支架置入术治疗恶性梗阻性黄疸的疗效。方法对18例恶性梗阻性黄疸患者行经皮、肝穿刺胆内支架置入治疗。结果 18例患者共成功置入支架20枚,术后梗阻胆道的通畅率100%,症状体征明显缓解,术后1周血清总胆红素水平较术前显著下降(P﹤0.05)。结论经皮肝穿刺胆道内支架置入术治疗恶性梗阻性黄疸可延长患者生存期,对失去外科手术机会的部分恶性梗阻性黄疸患者是一种较为理想的非手术方法。     

循证护理在PTCD及胆道内支架置入术治疗梗阻性黄疸病人中的应用

梗阻性黄疸多数由恶性肿瘤引起,最有效的治疗手段是外科肿瘤切除加胆肠吻合术,如肿瘤无法切除,行姑息性的胆肠吻合术也可有效的解除黄疸.但对于梗阻性黄疸患者,往往全身情况较差,肝功能明显异常,承受手术有一定难度.经皮肝穿刺胆道引流(PTCD)及胆道内支架置入术已成为恶性梗阻性黄疸的常用姑息性治疗手段.对于恶性梗阻性黄疽患者,预计无法进行外科手术根治或吻合,无法耐受手术以及梗阻部位不明确者,均可进行经皮肝胆道引流术及胆道内支架置入术.我科2005年7月～2007年9月运用循证护理的方法对245例阻塞性黄疸患者进行护理,效果良好,现报道如下.     

经内镜与经皮肝穿刺胆道金属支架置入治疗肝外胆管恶性梗阻的对比分析

【目的】探讨应用不同方式胆道金属支架置入治疗肝外胆管恶性梗阻的效果,为临床上选择更适当的方法治疗晚期恶性梗阻性黄疸提供依据。【方法】回顾性分析本院2009年1月至2013年1月经内镜胆道金属支架置入术（EMBD）治疗肝外胆管恶性梗阻患者80例（EMBD组）及经皮肝穿刺胆管造影（PTC）胆道金属支架置入术治疗肝外胆管恶性梗阻患者80例（PTC组）的临床资料。比较两组的手术成功率、术后并发症发生率、支架通畅时间及患者生存期。【结果】两组患者术后肝功能均有明显改善,两组之间比较总胆红素（TB）、碱性磷酸酶（ALP）及谷氨酰基转移酶（GGT）下降程度无显著性差异（P＞0．05）,PTC组的手术成功率高于 EMBD组,但并发症的发生率明显高于 EMBD组（P＜0．05）。两组病人术后支架通畅时间及生存期比较无显著性差异（P ＞0．05）。【结论】对于肝外胆道恶性梗阻患者可首选 EMBD,如手术失败可考虑经PTC途径行胆道支架置入。     

经皮胆道支架置入治疗恶性梗阻性黄疸的护理探讨

经皮胆道支架置入治疗恶性梗阻性黄疸,具有创伤小,并发症少的特点,能迅速解除胆管癌、胰腺癌引起的恶性梗阻,减轻黄疸,改善黄疸引起的各种临床症状,提高患者的生存质量,是治疗梗阻性黄疸理想的非外科手术方法[1]。2004年1月-2005年12月,我院对21例恶性梗阻性黄疸患者采用经皮胆     

胆道内射频消融及支架治疗高位恶性梗阻性黄疸的护理

目的观察胆道内射频消融及支架治疗高位恶性梗阻性黄疸的临床疗效及护理。方法选取2012年2月~2014年10月我院诊治的高位恶性梗阻性黄疸患者30例为观察组,采用经皮肝穿胆道内射频消融联合胆道内支架置入方法。选择2009年1月~2010年12月我院诊治的高位恶性梗阻性黄疸患者30例为对照组,采用介入方法治疗。比较两组治疗后的临床效果。结果两组治疗前血清胆红素水平比较无显著性差异(P0.05),治疗后7天,观察组血清胆红素水平明显低于对照组(P0.05),治疗后30天两组血清胆红素水平均继续下降,观察组较对照组明显(P0.05)。两组并发症发生率比较无显著性差异(P0.05);观察组1年内支架通畅29例(96.67%),明显高于对照组21例(70.0%),两组比较有显著性差异(P0.05)。结论胆道内射频消融及支架治疗高位恶性梗阻性黄疸疗效确切,可应用于临床。     

恶性梗阻性黄疸的综合介入治疗探讨

恶性梗阻性黄疸临床上并不少见,内科治疗常难以奏效,而局部或远处的多发性转移性肿瘤常使外科手术无法进行.恶性胆道梗阻所致的继发性感染和肝功能衰竭是导致患者死亡的重要原因[1].寻求对恶性梗阻标本兼治的有效方法仍然是临床迫切需要解决的问题.作者自2001年10月～2003年5月对21例恶性梗阻性黄疸,采用经皮肝穿胆道内支架植入联合局部动脉化疗栓塞治疗,取得了明显效果,现报告如下.     

ERBD治疗难以切除的恶性胆道梗阻

目的探讨内镜下逆行胆道内引流术(ERBD)对难以切除的恶性胆道梗阻的姑息性治疗作用.方法通过十二指肠镜对41例由7种晚期恶性肿瘤引起的梗阻性黄疸患者,施行逆行胆道内支架植入术,全部获成功.结果38例患者血清总胆红素降至正常,另3例下降约50%.结论ERBD能有效控制恶性胆道梗阻患者的黄疸,是临床上一种可供选择的微创方法.     

胆管癌并阻塞性黄疸9例立体定向适形放疗体会

胆管癌确诊时大多已属晚期,常合并较严重的梗阻性黄疸。解除梗阻性黄疸及其肝损伤和全身影响为治疗的关键〔1〕。急诊减黄手段多为有创或微创治疗,如:各种胆管的内外引流手术、经皮肝穿刺胆道引流术(PTCD)、胆道支架等,可对部分患者起到快速减黄的目的,但持续时间短,易出现感染、出血等并发症,对原发肿瘤无作用,甚至继发转移。我院2003年以来对不能手术的胆管癌并梗阻性黄疸9例患者实施急诊立体定向适形放疗(3D-CRT)治疗,取得较好效果。     

Diagnosis and treatment of biliary obstruction caused by portal cavernoma

While hemorrhagic complications of portal cavernoma are frequent, compression of the bile ducts by portal cavernoma is uncommon and treatment is still a matter for debate. We report here six new cases in order to describe: (a) the clinical, biological, and morphological features of this condition, and (b) the long-term results of a combined endoscopic and surgical treatment. The median age of patients at the time of diagnosis was 36.5 years. The circumstances of diagnosis were acute cholangitis (n=3), asymptomatic biological cholestasis (n=1), pruritus, jaundice and asthenia (n=1) and jaundice alone (n=1). Portal cavernoma and bile duct dilatation were confirmed by abdominal ultrasonography with pulsed color doppler and endoscopic retrograde cholangiography (ERC). Gallstones were found in four patients. Following stenting of the bile duct, there was a good outcome in two patients. In four patients, after failure of prolonged endoscopic treatment, second-line surgical portal-systemic shunting allowed removal of the biliary stent, and no recurrence of disease. In conclusion, biliary involvement in portal cavernoma is now a well-recognized entity, and our results suggest that combined endoscopic and surgical treatment could be required.     

Comparison of duodenal stent placement with surgical gastrojejunostomy for palliation in patients with duodenal obstructions caused by pancreaticobiliary malignancies

BACKGROUND AND STUDY AIMS: Palliative treatment for duodenal stenosis with an enteral stent is effective in enhancing the quality of life of patients with duodenal obstruction. There have been no thorough comparisons of duodenal stent placement with standard surgical gastrojejunostomy. The present study evaluated the outcome of duodenal stent placement and surgical gastrojejunostomy for palliation of duodenal stenosis caused by pancreaticobiliary malignancies. PATIENTS AND METHODS: Medical records for patients who underwent palliative enteral stenting during the past 9 years were retrospectively reviewed, and the patients' clinical outcome was compared with that in patients who underwent open surgical gastrojejunostomy during the same period. Patients who underwent prophylactic gastrojejunostomy were excluded from the study. RESULTS: Twenty patients (11 men, nine women; mean age 71.8 years) with pancreaticobiliary malignancy underwent palliative enteral stenting (stent group). Nineteen patients (12 men, seven women; mean age 68.7 years) with pancreaticobiliary malignancies underwent surgical gastrojejunostomy (bypass group). In the stent group, the diagnoses were 12 pancreatic cancers, six gallbladder cancers, one bile duct cancer, and one ampullary cancer. In the bypass group, the diagnoses were 14 pancreatic cancers and five gallbladder cancers. There were no significant differences between the two groups with regard to clinical background. Both procedures were successful. There were no differences between the two groups with regard to the technical or clinical success rates, patient survival, possibility of discharge, need for parenteral nutrition, or incidence of complications. However, the time from the procedure to resumption of food intake was shorter in the stent group than in the bypass group (1 day vs. 9 days; P < 0.0001). Improvement in the performance score after the procedure was observed more frequently in the stent group (65 % vs. 26.3 %; P < 0.05). In terms of the median hospital stay from the time of the procedure to the time of initial discharge home (12 patients vs. nine patients), there was no statistical difference (15 days vs. 30 days) due to the small size of the sample. There was no procedure-related mortality in either group. CONCLUSIONS: Palliative stent placement was more beneficial than surgical gastrojejunostomy in enhancing the quality of life of patients with duodenal obstruction due to pancreaticobiliary malignancies.     

两种微创引流手术治疗恶性肿瘤引起的梗阻性黄疸效果的Meta分析

目的采用循证医学的方法评价经内镜逆行性胰胆管造影术(ERCP)和经皮肝穿刺胆道引流术(PTCD)治疗恶性梗阻性黄疸的临床效果。方法通过计算机检索有关ERCP或PTCD治疗恶性梗阻性黄疸的随机对照试验(RCT),检索时限为从建库起至2020年8月。两名评价者独立评价纳入文献的质量并提取资料,用RevMan 5.3软件进行Meta分析。结果共纳入8篇RCT研究,共736例患者。Meta分析结果显示:对于低位胆道梗阻者,两组手术成功率无显著差异(P=0.70),对于高位胆道梗阻者,ERCP组手术成功率低于PTCD组(P=0.0007),ERCP组总手术成功率低于PTCD组(P=0.008)。ERCP组治疗低位胆道梗阻者的临床疗效优于PTCD组(P=0.0001),而治疗高位胆道梗阻者的临床疗效低于PTCD组(P=0.005),两组总临床疗效无显著差异(P=0.81)。两组总并发症发生率无显著差异(P=0.60)。结论两种治疗方式均对恶性梗阻性黄疸有显著的临床疗效,但PTCD治疗有更高的手术成功率。     

Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study

BACKGROUND AND STUDY AIMS: Gastric outlet obstruction is a late event in the natural history of biliopancreatic tumours. Metallic self-expanding stents inserted under endoscopic and fluoroscopic guidance can be used for palliation. The aim of this study was to evaluate the feasibility, efficacy, and complications of endoscopic duodenal stenting in patients with malignant gastric outlet obstruction. PATIENTS AND METHODS: Between August 1998 and November 2001, 63 patients (31 women, 32 men; mean age 73 +/- 12) presenting with clinical symptoms of duodenal obstruction underwent endoscopic stenting with large metallic prostheses. Complications and clinical outcome were assessed both retrospectively and prospectively. RESULTS: Of the patients, 58 needed one duodenal stent and two overlapping stents were required in five patients. Stenting was immediately successful in 60/63 patients (95%). At the time of the duodenal procedure, 25 previously inserted biliary stents were still patent; biliary stenting was attempted during the same procedure in 18 patients; and 20 patients had no biliary stricture. There was no procedure-related mortality. There were complications in 30 % of patients: 13 stent obstructions, 4 stent migrations and 2 duodenal perforations (treated surgically). For 44 patients (70%) there were no minor or major digestive problem during their remaining lifetime. An exclusively peroral diet was possible in 58 patients (92%), but was considered satisfactory (solid or soft) in 46/63 patients (73%). Of the patients, 53 (84 %) died between 1 and 64 weeks after the duodenal stenting (median survival 7 weeks).CONCLUSIONS: Endoscopic stenting for the palliation of malignant gastric outlet obstruction is feasible and well-tolerated in most patients. Most dysfunctions can be managed endoscopically.     

十二指肠镜在处理胆囊切除术后胆道并发症中的应用价值

目的：探讨十二指肠镜在处理胆囊切除术后胆道并发症中的作用。方法：1997年1月－2001年6月对胆囊切除术后出现腹痛和黄患者行ERCP，明确为胆道并发症者285例，胆囊切除术后行ERCP的平均时间为95d。结果：285例胆道并发症者中，胆道残余结石217例，209例结石排出，胆总管部分狭窄47例，随访1年，35例取得满意效果。胆总管完全横断19例，12例行ENBD，待黄疸减退后全部行外科手术，胆漏2例，EST和ENBD治疗后2天体温下降症状减轻，避免再次外科手术。结论：胆囊切除术后临床怀疑有胆道并发症，应尽早行ERCP检查，十二指肠镜对胆道残余结石和胆漏的疗效确切，对胆管部分狭窄的患者应首选十二指肠镜内支架治疗。     

“一站式”冠状动脉搭桥及颈动脉支架植入术的初步尝试

目的:尝试应用冠状动脉搭桥术及颈动脉支架植入术"一站式"治疗冠心病合并严重颈内动脉狭窄。方法:选择复旦大学附属中山医院2例冠心病合并严重颈动脉狭窄的男性患者,给予其"一站式"冠状动脉搭桥术及颈动脉支架植入术,分析相应的围手术期治疗、手术方式及术后相关情况。结果:术后患者心功能改善。术后6个月颈动脉CTA提示支架通畅,患者无晕厥、黑朦症状。结论:"一站式"冠状动脉搭桥术及颈动脉支架植入术对冠心病合并颈动脉狭窄患者是较好的选择,但需要在杂交手术室进行,且对术者技术要求较高。     

金属支架姑息性治疗160例恶性梗阻性黄疸的临床观察

目的 探讨胆道金属支架(EMBS)植入术治疗恶性梗阻性黄疸的临床价值.方法 160例行EMBS植入术的恶性梗阻性黄疸患者为支架组,以30例同样失去手术机会但因经济条件所限经皮经肝穿刺胆道引流(PTCD)外引流治疗者为PTCD组.回顾性研究其支架通畅率、胆红素下降情况及并发症的发生情况.随访间期为3个月,Kaplan-Meier(1og-rank test)生存期分析比较支架组与PTCD组术后生存期差异.结果 2组患者厌食、皮肤瘙痒、尿色深染等症状较前均有不同程度改善;支架组总胆红素水平和直接胆红素水平治疗前[(218.78±2.29)、(128.82±2.40)μmoL/L]、治疗后7 d[(134.90±2.34)、(81.28 ±2.34)μmoL/L]、14 d[(83.18±2.40)、(51.29±2.45)μmol/L]、21 d[(40.74±2.29)、(25.70±2.40)μmol/L]比较均有不同程度的下降(P均=0.000),PTCD组总胆红素水平和直接胆红素水平治疗前[(223.57±2.58)、(127.60±2.59)μmoL/L]、治疗后7 d[(145.68±2.57)、(79.78±2.70)μmoL/L]、14 d[(87.57 ±2.58)、(58.36±2.46)μmol/L]、21d[(38.65±2.20)μmol/L,(29.46±2.20)μmoL/L]比较均有不同程度的下降(P均=0.000);但2组同期胆红素值的比较差异均无统计学意义(P均>0.05).支架组34例术后发生并发症,发生率为20.62%,有9例发生两种或两种以上并发症.PTCD组18例患者出现并发症,发生率为60.00%.支架组失访14例,136例患者死亡,支架组中位生存时间214 d;PTCD组无失访,30例患者均死亡,中位生存时间为75.5 d,生存期分析表明支架组生存时间较PTCD组长(P=0.000).结论 EMBS植入术治疗恶性梗阻性黄疸效果显著,相比PTCD外引流,支架内引流并发症少、恢复快,提高患者生存质量、延长生存期,是恶性梗阻性黄疸的一种理想的姑息性治疗方法.     

3D全胸腔镜不停跳房间隔缺损修补术CUSUM学习曲线分析*

目的探讨3D全胸腔镜不停跳房间隔缺损(ASD)修补术的学习曲线及安全性。方法 ASD患者206例,完成3D全胸腔镜ASD修补及三尖瓣成形术44例(腔镜组)。累积和(CUSUM)法确定3D胸腔镜ASD修补术的学习曲线。并与传统开胸手术(开胸组)行倾向性评分匹配(PSM),分析腔镜组学习期间手术的安全性。结果 CUSUM学习曲线显示手术失败率、手术时间、体外循环时间、术后并发症发生率分别在第34、21、29及39例患者后低于可接受水平。匹配后两组术前特征不存在系统差异。腔镜组体外循环时间长于开胸组(P=0.000);手术时间、呼吸机辅助时间、ICU住院时间、术后并发症及总住院费用两组比较差异无统计学意义(P0.05)。腔镜组术后引流量明显少于开胸组(P=0.000)。结论 3D胸腔镜不停跳ASD修补术使手术更简化,更安全,不增加术后并发症及住院费用,并能在39例后快速跨越学习曲线。     

经内镜逆行胰胆管造影术和经皮肝穿刺胆道引流术治疗恶性梗阻性黄疸的疗效对比

目的对比经内镜逆行胰胆管造影术(ERCP)和经皮肝穿刺胆道引流术(PTCD)治疗恶性梗阻性黄疸的临床疗效。方法回顾性分析湖北民族学院附属民大医院肝胆胰外科恶性梗阻性黄疸患者97例,其中ERCP组54例和PTCD组43例。对比两组患者临床疗效、术后并发症、舒适度评分、住院天数和费用。结果 (1)两组患者症状较术前改善,生化指标均下降,ERCP组和PTCD组黄疸总缓解率为77.78%和79.07%,高位梗阻黄疸缓解率为55.00%和89.29%,低位梗阻黄疸缓解率为91.18%和60.00%,差异有统计学意义(P0.05);(2)ERCP组和PTCD组术后并发症发生率为37.04%和16.28%,差异有统计学意义(P0.05);(3)ERCP组和PTCD组舒适度量表评分为(15.13±3.89)和(16.60±3.15)分,差异有统计学意义(P0.05);(4)ERCP组和PTCD组住院时间分别为(8.74±4.94)和(11.12±4.82)d,差异有统计学意义(P0.05),住院费用分别为(2.27±0.63)和(2.19±0.34)万元,差异无统计学意义(P0.05)。结论 ERCP和PTCD对恶性梗阻性黄疸的治疗均可获得满意的临床疗效,ERCP对低位梗阻患者治疗优于PTCD,PTCD对高位梗阻患者治疗优于ERCP。ERCP并发症高于PTCD,舒适评分优于PTCD且住院时间短,两者在费用上无明显差异。     

心理干预对经食管内镜直视记忆合金支架置入患者的影响

目的探讨减轻行食管支架置入术患者紧张焦虑情绪及术后并发症的有效性心理干预措施。方法选择住院择期实施内镜下食管支架置入术的患者70例,按入院先后顺序分为观察组和对照组,各35例,对照组给予常规护理及一般心理护理,观察组除采用常规护理外,对患者实施个性化心理干预,比较两组患者紧张、焦虑情况及术后并发症发生率。结果观察组患者紧张焦虑情况较对照组有明显缓解,两组比较差异有统计学意义（无焦虑22．85％比65．71％;χ2=13．17,P〈0．05）;观察组术后并发症发生率低于对照组,差异具有统计学意义（χ2分别为11．7,4．6,4．2;P〈0．05）。结论实施心理干预能有效减轻患者的心理压力,缓解患者的紧张、焦虑情绪,从而降低术后并发症的发生,提高患者的生存质量,提高其满意度。