胰头癌伴恶性梗阻性黄疸患者胆汁细菌检出的临床分析

目的 了解恶性梗阻性黄疸患者胆汁菌群分布情况,探讨影响恶性梗阻性黄疸患者胆汁细菌培养阳性的相关因素.方法 对2007年10月-2008年10月入住复旦大学附属华山医院外科的65例恶性梗阻性黄疸患者病例资料进行回顾性分析.对可能影响恶性梗阻性黄疸患者胆汁细菌检出的相关风险因素包括:年龄、胆道手术史、皮肤巩膜黄染时间、血清谷丙转氨酶水平、总胆红素水平、CA19-9水平、肿瘤大小、梗阻部位、有无胆道感染临床表现及APACHEⅡ评分进行单因素和多因素分析.结果 送检65例胆汁标本,培养结果阳性25例(38.5％),其中革兰阴性菌21株(占72.4％),革兰阳性菌6株(占20.7％),真菌2株(6.9％).单因素分析显示可能影响恶性梗阻性黄疸患者胆汁细菌培养阳性率的相关因素是:年龄、胆道手术史、胆道梗阻部位、胆道感染症状和APACHEⅡ评分.多因素分析显示:年龄、胆道手术史、胆道梗阻部位和APACHEⅡ评分是独立的危险因素.结论 年龄、胆道手术史、胆道梗阻部位和APACHEⅡ评分是恶性梗阻性黄疸患者胆汁细菌培养阳性的独立危险因素.     

胆道支架治疗恶性梗阻性黄疸早期疗效及其影响因素

目的探讨胆道支架用于治疗恶性梗阻性黄疸(MOJ)的早期疗效及其影响因素。方法回顾性分析接受经皮肝穿胆管引流(PTCD)+胆道支架植入治疗的232例MOJ患者的临床资料,判断术后早期疗效,并采用单因素分析和Logistic回归分析其影响因素。结果 232例均成功实施PTCD+胆道支架植入术,并置管引流,术后早期疗效显著149例、有效36例、无效47例,总有效率79.74%(185/232)。肿瘤类型、梗阻水平、梗阻长度、肝功能Child-Pugh分级、腹腔积液、肝内病变、远处转移、肿瘤最大径、术前血小板计数(PLT)、CA125水平和术后胆道感染是影响早期疗效的重要因素(P均0.05);肝功能Child-Pugh分级、术前PLT、CA125水平和术后胆道感染是影响早期疗效的独立危险因素(P均0.05)。结论胆道支架植入术在改善MOJ患者肝功能、减黄方面具有一定价值;肝功能Child-Pugh分级、术前PLT、CA125水平和术后胆道感染是影响术后早期疗效的独立危险因素。     

术前减黄治疗对梗阻性黄疸患者CA19-9的影响

目的 探讨术前减黄治疗对梗阻性黄疸患者CA19-9和TBil的影响,为梗阻性黄疸患者的鉴别诊断提供依据.方法 回顾性分析2005年7月至2008年7月成都军区总医院收治的32例梗阻性黄疸患者的临床资料.分析17例恶性胆道梗阻性黄疸患者(恶性梗阻组)和15例良性胆道梗阻性黄疸患者(良性梗阻组)通过PTBD进行减黄治疗前后的CAl9-9和TBil的变化情况.采用t检验分析数据.结果 经减黄治疗后,恶性梗阻组患者的TBil由(27l±74)μmol/L下降到(144±33)μmol/L,治疗前后比较差异有统计学意义(t=6.52,P<0.05);CA19-9由(277±114)U/ml下降到(264±98) U/ml,治疗前后比较差异无统计学意义(t=0.34,P>0.05).良性梗阻组患者的TBil和CA19-9均下降明显,分别由(245±67)μmol/L下降到(135±43)μmol/L和(239±103)U/ml下降到(117±84)U/ml,两种指标治疗前后比较差异有统计学意义(t=5.30,3.54,P<0.05).结论 对梗阻性黄疸患者术前进行减黄治疗,动态观察血清CA19-9变化情况,有利于梗阻性黄疸患者的鉴别诊断.     

术前减黄治疗对梗阻性黄疸患者CA19-9的影响

目的 探讨术前减黄治疗对梗阻性黄疸患者CA19-9和TBil的影响,为梗阻性黄疸患者的鉴别诊断提供依据.方法 回顾性分析2005年7月至2008年7月成都军区总医院收治的32例梗阻性黄疸患者的临床资料.分析17例恶性胆道梗阻性黄疸患者(恶性梗阻组)和15例良性胆道梗阻性黄疸患者(良性梗阻组)通过PTBD进行减黄治疗前后的CAl9-9和TBil的变化情况.采用t检验分析数据.结果 经减黄治疗后,恶性梗阻组患者的TBil由(27l±74)μmol/L下降到(144±33)μmol/L,治疗前后比较差异有统计学意义(t=6.52,P<0.05);CA19-9由(277±114)U/ml下降到(264±98) U/ml,治疗前后比较差异无统计学意义(t=0.34,P>0.05).良性梗阻组患者的TBil和CA19-9均下降明显,分别由(245±67)μmol/L下降到(135±43)μmol/L和(239±103)U/ml下降到(117±84)U/ml,两种指标治疗前后比较差异有统计学意义(t=5.30,3.54,P<0.05).结论 对梗阻性黄疸患者术前进行减黄治疗,动态观察血清CA19-9变化情况,有利于梗阻性黄疸患者的鉴别诊断.     

术前减黄治疗对梗阻性黄疸患者CA19-9的影响

目的 探讨术前减黄治疗对梗阻性黄疸患者CA19-9和TBil的影响,为梗阻性黄疸患者的鉴别诊断提供依据.方法 回顾性分析2005年7月至2008年7月成都军区总医院收治的32例梗阻性黄疸患者的临床资料.分析17例恶性胆道梗阻性黄疸患者(恶性梗阻组)和15例良性胆道梗阻性黄疸患者(良性梗阻组)通过PTBD进行减黄治疗前后的CAl9-9和TBil的变化情况.采用t检验分析数据.结果 经减黄治疗后,恶性梗阻组患者的TBil由(27l±74)μmol/L下降到(144±33)μmol/L,治疗前后比较差异有统计学意义(t=6.52,P<0.05);CA19-9由(277±114)U/ml下降到(264±98) U/ml,治疗前后比较差异无统计学意义(t=0.34,P>0.05).良性梗阻组患者的TBil和CA19-9均下降明显,分别由(245±67)μmol/L下降到(135±43)μmol/L和(239±103)U/ml下降到(117±84)U/ml,两种指标治疗前后比较差异有统计学意义(t=5.30,3.54,P<0.05).结论 对梗阻性黄疸患者术前进行减黄治疗,动态观察血清CA19-9变化情况,有利于梗阻性黄疸患者的鉴别诊断.     

梗阻性黄疽的介入治疗

自1952年Carter和Saypol用腰穿针完成首例经皮经肝穿刺胆道引流术（PTCD）至今已50余年，梗阻性黄疸的介入治疗无论在操作技术、器械及医生的临床经验等方面都有了长足的进步，临床应用也日趋广泛，尤其在恶性肿瘤所引起的黄疸病人中，胆道介入治疗更成为首选方案。其适应证：（1）以降低手术风险为目的的术前胆道减压和减黄，（2）不能手术根治的恶性胆道梗阻的姑息治疗；[第一段]     

经皮肝穿刺胆管引流术联合支架植入术治疗恶性梗阻性黄疸

目的评价经皮肝穿刺胆管引流术（PTBD）联合支架植入术与单纯PTBD姑息治疗恶性梗阻性黄疸的近、远期疗效。方法回顾性分析60例恶性梗阻性黄疸患者经两种姑息介入治疗后的临床资料,对其中30例行PTBD＋支架植入（A组）,30例单纯行PTBD（B组）,分析两组治疗术后的总胆红素（TBIL）、直接胆红素（DBIL）、并发症、引流道通畅时间及生存期。结果术后1周,A、B两组TBIL分别下降（174.81±49.13）μmol/L、（95.23±42.33）μmol/L（P=0.02）,DBIL分别下降（96.01±36.51）μmol/L、（58.16±31.21）μmol/L（P=0.03）;术后1个月TBIL分别下降（284.25±112.53）μmol/L、（276.42±125.47）μmol/L（P=0.09）,DBIL分别下降（152.06±41.32）μmol/L、（147.06±43.83）μmol/L（P=0.13）。A组总体并发症发生率（11/30,36.67%）明显低于B组（27/30,90.00%）,差异有统计学意义（χ2=18.37,P〈0.05）。A、B组胆管中位通畅时间（162.5天vs 78.5天）,患者中位生存期（203.5天vs 126.0天）差异均有统计学意义（P均〈0.01）。结论PTBD联合支架植入术可较单纯PTBD更有效地提高恶性梗阻性黄疸患者的生活质量,延长其生存期。     

彩色多普勒超声引导经皮经肝穿刺胆道引流术治疗梗阻性黄疸

经皮经肝穿刺胆道引流术（percutaneous transhepatic bile duct drainage,PTBD）是解决胆道梗阻的有效途径。过去多在X线引导下穿刺,随着超声影像学的发展,超声引导PTBD更加安全、方便和实用。2007年2月～2011年2月,我们应用彩色多普勒超声引导PTBD治疗梗阻性黄疸115例,效果较好,报道如下。     

PTCD并胆道支架治疗恶性梗阻性黄疸临床观察

目的 研究PTCD（经皮经肝胆管引流术）并胆道支架置入术对恶性梗阻性黄疸的治疗效果.方法 对19例行PTCD并胆道支架置入术的恶性梗阻性黄疸患者行回顾性分析.结果 技术成功率100％,术前血清总胆红素（228.9±30.2）μmol/L,术后2周时,血清总胆红素分别下降到（167.4 ±42.1）μmol/L （P＜0.05）.8例出现并发症,其中胆道出血2例,胆管炎4例,支架阻塞1例,胆汁漏1例,经治疗好均好转.结论 PTCD并胆道支架置入术是一种安全、有效的姑息治疗梗阻性黄疸的方法.     

恶性梗阻性黄疸介入治疗

目的 回顾性分析恶性梗阻性黄疸患者的介入治疗方法及近期疗效。方法62例患者,其中肝癌7例,胆囊癌10例,胆管癌15例,胰腺癌17例,肝门部转移癌13例。43例行内外引流,19例放置了胆道支架。结果 黄疸消退明显55例,不明显7例。内外引流者血清总胆红素由（450.12±113.51）μmol/L降至（240.25±107.81）L（1周）-（90.91±101.72）μmol/L（2周）。胆道内支架置入者由（410.53±98.13）μmol/L降至（270.23±115.64）μmol/L（1周）-（105.43±97.85）μmol/L（2周）。内外引流与内支架置入疗效无明显差别,早期并发症29例,死亡7例。结论 介入治疗恶性梗阻性黄疸方法简单、安全、疗效肯定。     

Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center

BACKGROUND: Iatrogenic factors became the leading mechanisms of severe cholangitis in a referral center. PATIENTS AND METHODS: The records of the 58 patients treated for severe cholangitis between 1996 and May 2004 (inclusive) were evaluated. RESULTS: The most frequent underlying diseases were periampullary tumors and mid-bile duct carcinomas (22), followed by proximal cholangiocarcinomas (14). The triggering mechanism was an incomplete endoscopic retrograde cholangiopancreatography (ERCP) in 32 patients, incomplete or inappropriate percutaneous transhepatic biliary drainage (PTBD) in 6, apparently successful ERCP and stenting in 1, and percutaneous transhepatic cholangiography in 1. PTBD was the treatment of choice (38). Mortality was 29% (17/58); the major causes were refractory sepsis (8) and incomplete biliary drainage (advanced tumor, technical failure, or hemobilia) (8). CONCLUSIONS: In this series composed predominantly of patients referred after development of sepsis, ERCP and PTBD complications were the leading mechanisms of severe cholangitis. Nonoperative biliary manipulations are invasive procedures with potentially fatal complications. The decisions to perform such procedures and periprocedural management are responsibilities of an experienced multidisciplinary team.     

Pre-operative percutaneous transhepatic biliary drainage: the results of a controlled trial

The operative mortality for biliary tract obstruction due to malignancy is high. In 1981 a controlled clinical trial of pre-operative percutaneous drainage was started at the Royal Postgraduate Medical School. At the time of percutaneous transhepatic cholangiography patients were randomized either to laparotomy or to pre-operative percutaneous transhepatic biliary drainage ( PTBD ) followed by laparotomy. Only patients with malignant biliary tract obstruction and serum bilirubin greater than 100 mumol/l were included. Seventy patients entered the trial, and five were withdrawn. Of the 65 remaining, 31 underwent laparotomy and 34 had pre-operative PTBD followed by laparotomy. The median duration of drainage was 18 days and during this time the median bilirubin fell from 305 to 115 mumol/l. Five patients required early surgery for complications of PTBD and two died within 30 days of surgery. The mortality for laparotomy was 19 per cent (6/31) compared with 32 per cent (11/34) for drainage plus laparotomy. This trial highlights the hazards of PTBD in high risk patients and has failed to demonstrate a reduction in mortality with the use of pre-operative PTBD .     

经皮经肝穿刺胆道引流术治疗阻塞性黄疸

目的探讨施行兼有内引流及外引流效果的PTCD,对阻塞性黄疸的治疗效果。方法回顾性地总结分析近3年来我院所做的32例该类PTCD的临床资料。结果共施行该型引流术32例,其中30例病人减黄效果明显,对其他临床不适也有较好的缓解作用。随访病人最长生存期为15个月。结论施行兼具内/外引流效果的胆道引流术,对不宜手术的恶性阻塞性黄疸病人是较好的选择,同时也可为其他的非手术综合治疗创造机会。     

超声引导下经皮经肝胆道穿刺置管引流术在恶性阻塞性黄疸中的应用

目的探讨B超引导下经皮经肝穿刺胆道引流(PTBD)治疗胰胆系肿瘤所致恶性阻塞性黄疸的优缺点。方法恶性阻塞性黄疸疾病24例,均采用B超引导的PTBD术治疗。结果所有病例PTBD术1次穿刺成功,无显著并发症发生,患者黄疸迅速缓解消退。结论B超引导下行PTBD术是一种比较安全、简便、经济的治疗恶性阻塞性黄疸的方法。     

Preoperative management of hilar cholangiocarcinoma

From both the therapeutic and diagnostic viewpoints, percutaneous transhepatic biliary drainage (PTBD) is crucial for the preoperative management of hilar cholangiocarcinoma. The direct anterior approach under fluoroscopic guidance is the most advantageous form of PTBD. Despite some advantages, endoscopic retrograde biliary drainage is contraindicated for preoperative biliary decompression. Pertinent multiple catheterizations using PTBD result in an accurate diagnosis of cancer extent, and produce effective relief of jaundice, as well as preventing the development of cholangitis. This, in turn, permits a rational surgical strategy and improved postoperative recovery. Preoperative staging of hilar cholangiocarcinoma is achieved by tube cholangiography through the PTBD catheter and by percutaneous transhepatic cholangioscopy. Angiography and percutaneous transhepatic portography are also recommended to diagneous extramural invasion of cancer. Prevention of posthepatectomy liver failure is the greatest challenge in the treatment of this disease. A multifactorial approach that combines several elements may provide sufficient data for determing the safe limits of surgery and for predicting posthepatectomy liver failure. Preoperative percutaneous transhepatic portal vein embolization (PTPE) is an effective method for preventing this intractable complication.     

Percutaneous Transhepatic Biliary Drainage in the Management of Post-surgical Biliary Leaks

The aim of this study was to evaluate the efficacy of percutaneous transhepatic biliary drainage (PTBD) in the treatment of post-surgical biliary leaks and its efficacy in restoring the integrity of bile ducts. One hundred and fifty-seven patients with a post-surgical biliary leak were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to laparoscopic procedures in 114 patients, while 43 patients had postoperative leak following open surgery. Percutaneous transhepatic biliary drainage was performed with an 8- to 10-F catheter, with the side holes positioned proximal to the site of extravasation to divert bile flow away from the leak site. The established biliary leaks at the site of origin were diagnosed at an average of 7 days (range 2–150 days) after surgery. In all cases, percutaneous access to the biliary tree was achieved. In 62 patients, biliary leak completely healed after drainage for 10–50 days (mean, 28 days) while 89 patients underwent surgical reconstruction subsequently. PTBD is a feasible, effective, and safe procedure for the treatment of post-surgical biliary leaks. It is therefore a reliable alternative to surgically repair smaller biliary leaks, while in patients with large defects, it helps prepare patients for surgical reconstruction.     

Preoperative percutaneous transhepatic internal drainage in obstructive jaundice: a randomized, controlled trial examining renal function

Thirty patients with obstructive jaundice with plasma bilirubin values greater than 200 mumol/L were randomized at the time of percutaneous transhepatic Cholangiography to undergo immediate or delayed surgery. The patients who had preoperative percutaneous transhepatic biliary drainage (PTBD) for 13.8 +/- 5.8 days had fewer surgical complications than did patients who underwent immediate surgery (p less than 0.02), although when the complications of PTBD were included this advantage was diminished. Immediate surgery caused greater deterioration of renal function as measured by plasma urea, plasma B 2-microglobulin, phosphate clearance, uric acid clearance, and maximal concentrating ability than occurred after PTBD or delayed surgery. The improvement in phosphate clearance that followed PTBD was sustained through delayed surgical treatment, indicating better tubular function in these patients. This article supports the concept that preoperative PTBD will reduce surgical morbidity and will result in less renal impairment than will immediate surgery. However, the morbidity rates of the PTBD procedure will preclude its wide use.     

可切除肝门部胆管癌术前胆道引流方式的选择

目的比较可切除肝门部胆管癌术前经皮肝穿刺胆道引流(PTBD)及经逆行胰胆管造影(ERCP)内支架引流两种减黄方式的治疗效果,探讨最佳的术前引流方式。方法对2004年1月—2011年1月期间58例可切除的肝门部胆管癌术前行PTBD(35例)或ERCP(23例)减黄的患者的临床资料进行比较分析,比较两组的操作成功率、并发症发生率、胆道感染发生率以及引流效果。结果两组患者术前一般资料无统计学差异,PTBD组的操作成功率达100%,而ERCP组为87%(P=0.057);PTBD组2例出现胆道出血;而ERCP组出现1例十二指肠穿孔,2例十二指肠乳头出血,4例急性胰腺炎。ERCP组胆道感染的发生率高于PTBD组(43%vs.17%,P=0.028);两组均能于开腹手术前达到有效减黄,但ERCP组需时长于PTBD组(7周vs.4.5周,P=0.035),且更换引流物次数更多(2.5次vs.1.2次,P=0.029)。ERCP组8例(34.8%)需转为PTBD处理,其胆道感染的发生率为75.0%,平均需要进行4次更换引流物,术前平均引流时间为8周。PTBD组2例(5.7%)因胆汁引流量大(超过2000mL/d)转为ERCP...     

Value of percutaneous transhepatic cholangioscopy (PTCS)

Since July 1975, percutaneous transhepatic biliary drainage (PTBD) has been performed in 533 cases, and since April 1977 we have developed percutaneous transhepatic cholangioscopy (PTCS) as a diagnostic and therapeutic endoscopical tool in 198 cases of malignant disease and 195 benign cases. After dilating the sinus tract of PTBD using a 15-Fr catheter about 2 weeks after PTBD, PTCS was carried out through the sinus tract. PTCS has diagnostic advantages: the lesion can be accurately diagnosed histologically and the extent of cancer in the biliary tract can be assessed by taking biopsy specimens before the operation. PTCS has been applied for cholangioscopic lithotripsy in 145 cases of gallstone disease. In 44 cases, the Nd-YAG laser and/or electrohydraulic shock wave has been used to break up the stones. The PTCS morbidity was 6% and mortality was 0.3%.     

Treatment Strategy for Mucin-producing Intrahepatic Cholangiocarcinoma: Value of Percutaneous Transhepatic Biliary Drainage and Cholangioscopy

Intrahepatic cholangiocarcinomas that secrete macroscopically excessive mucin into the biliary system are rare, and few of the previously reported cases have achieved a curative resection. We defined these tumors as “mucin-producing intrahepatic cholangiocarcinomas” and clarify the optimal preoperative and surgical management for them. Eleven patients with mucin-producing intrahepatic cholangiocarcinomas underwent surgical resection in our department. The clinical, radiologic, surgical, and pathologic findings were studied. The clinical presentation of the 11 patients included repeated abdominal pain, jaundice, and fever. Conventional cholangiographies, such as percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography, could not offer precise information about tumor location and extension because of abundant mucin in the biliary system. Using percutaneous transhepatic biliary drainage (PTBD) and percutaneous transhepatic cholangioscopy (PTCS), we were able to drain the mucin and determine precisely the cancer extension into intrahepatic segmental bile ducts. Based on these findings, various types of liver resection with or without extrahepatic bile duct resection were planned, and 10 patients obtained curative resection. The cumulative 5-year survival rate after curative resection was 78%. In patients with mucin-producing intrahepatic cholangiocarcinoma, PTBD and PTCS are important for evaluating the cancer extension. Rational surgery based on accurate preoperative diagnosis improved the prognosis of patients with this disease.