鼻胆引流管改制高位悬挂超长胆管支架预防十二指肠胆管反流的疗效（含视频）

目的：评估鼻胆引流管改制高位悬挂超长胆管塑料支架,预防十二指肠胆管反流的临床疗效。方法：本研究采用自身前后对照方法,纳入2014年2月至2016年5月因肝外胆管狭窄在北京大学第三医院行一次或多次普通支架（包括胆管塑料支架或金属支架）后堵塞的患者18例,之后置入高位悬挂超长胆管塑料支架。置入后随访至2017年6月30日,将高位悬挂超长胆管支架与患者最后一次普通支架的通畅时间进行比较,并记录超长支架并发症发生率。结果：纳入的18例患者中 1例患者失访,17例纳入分析。9例为胆管恶性狭窄,8例为良性狭窄。17例患者超长胆管塑料支架平均通畅时间为210 d,相比普通支架139 d明显延长（P=0.015）。恶性狭窄患者3例曾置入金属支架,此3例患者超长胆管塑料支架和金属支架的通畅时间分别为278 d和205 d,差异无统计学意义(P=1.000),余6例患者高位悬挂超长胆管支架和普通塑料支架通畅时间分别为156 d和65 d（P=0.049）。良性狭窄患者超长支架通畅时间为254 d,明显比普通塑料支架143 d延长（P=0.025）。仅有1例患者出现术后轻度胰腺炎,无其他严重并发症发生。结论：鼻胆引流管改制高位悬挂超长胆管塑料支架,有效延长支架保持通畅的时间,且不增加术后并发症的发生率,值得临床推广。     

内镜下光动力治疗在不可切除肝门部胆管癌梗阻性黄疸治疗中的作用研究

目的　探讨内镜下光动力治疗（photodynamic therapy, PDT）联合胆管支架置入在不可切除肝门部胆管癌梗阻性黄疸中的临床疗效。方法　回顾性分析2020年1月至2023年1月中科大附一院（40例）和铜陵市人民医院（3例）收治的共43例不可切除肝门部胆管癌发生梗阻性黄疸的患者临床资料,支架组（n=23）单纯置入胆管支架,联合组（n=20）行PDT联合胆管支架置入。对比两组患者的胆红素下降程度、支架通畅期、术后卡氏行为评分、并发症发生情况及预后情况。采用Cox回归分析患者生存期的影响因素。结果　支架组和联合组一般资料比较差异无统计学意义（P>0.05）。术后联合组的支架通畅时间为204.53 d（95%CI：143.75~265.32 d）,长于支架组的138.36 d（95%CI：95.38~181.34 d）,差异无统计学意义（P=0.091）。支架组和联合组术后1周中位胆红素下降值分别为30.10 μmol/L和9.40 μmol/L,差异无统计学意义（Z=-0.243,P=0.808）。支架组和联合组术后1个月［（69.09±12.69）分和（73.16±13.36）分,t=-0.999,P=0.324］和3个月卡氏行为评分［（67.14±9.94）分和（70.67±10.33）分,t=-0.935,P=0.358］差异无统计学意义。联合组的总体生存期为267.38 d（95%CI：186.93~347.83 d）,显著长于支架组的140.41 d（95%CI：97.38~183.45 d）（P=0.017）。Cox回归多因素分析显示,PDT联合胆管支架置入（HR=0.457,95%CI：0.212~0.986,P=0.046）是患者生存期的独立保护因素。结论　内镜下PDT联合胆管支架置入可有效缓解不可切除肝门部胆管癌的梗阻性黄疸,改善患者的生活质量,延长患者的生存时间。     

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。     

塑料胆管支架置入方式对不可切除肝门部胆管癌伴梗阻性黄疸治疗效果的影响

目的　对比塑料胆管支架3种末端开口留置方式在解除不可切除肝门部胆管癌梗阻性黄疸方面的临床应用效果。方法　回顾性分析2014年4月—2020年12月在中国医学科学院肿瘤医院内镜科行塑料胆管支架置入减黄治疗的不可切肝门部除胆管癌患者61例，其中胆管支架末端开口胃内留置18例（胃内留置组），十二指肠乳头留置31例（十二指肠乳头留置组），十二指肠水平部留置12例（十二指肠水平部留置组）。对随访2周发热率、围手术期死亡率、术后90 d支架梗阻率、支架中位通畅时间进行分析。结果　胃内留置组、十二指肠乳头留置组和十二指肠水平部留置组3组患者术后2周内发热率比较［66.7%（12/18），58.1%（18/31）和16.7%（2/12），χ2=7.30，P=0.026］差异有统计学意义，围手术期死亡率［0（0/16），3.2%（1/31）和0（0/10），χ2=1.09，P=1.000］、术后90 d内支架梗阻率［52.9%（9/17），48.3%（14/29）和40.0%（4/10），χ2=1.91，P=0.589］和支架中位通畅时间（66.0 d，91.5 d和94.0 d，Z=4.96，P=0.084）比较差异无统计学意义。结论　与胆管支架末端开口胃内留置和十二指肠乳头留置比较，十二指肠水平部留置术后2周发热率低，但支架中位通畅时间、术后90 d支架梗阻率及围手术期死亡率相似。支架末端开口留置于十二指肠水平部可作为首选置入方式。     

全覆膜金属支架与塑料支架在不可切除的远端胆道 恶性梗阻中的应用对比研究

目的探讨经内镜逆行胆胰管造影术（endoscopic retrograde cholangiopancreatography,ERCP）下胆道全覆膜金属支架及塑料支架置入治疗远端胆道恶性梗阻性黄疸的有效性及安全性。方法回顾性分析并总结2012年11月—2018年12月收治的52例接受ERCP下全覆膜金属支架（WallFlex）置入和40例胆道塑料支架置入治疗不可切除的恶性梗阻性黄疸患者的操作成功率、临床成功率、通畅时间、堵塞率、再干预次数、总费用等临床资料。结果ERCP 操作成功率两组均为100.0%（92/92）,金属支架组和塑料支架组临床成功率分别为94.2%（49/52）和75.0%（30/40）（χ2 =6.89,P<0.01）。两组生存时间比较,差异无统计学意义（6.5个月比7.2个月, χ2=0.25,P>0.05）。金属支架组中位通畅时间较塑料支架组明显延长（182.0 d 比 84.0 d,P<0.01）。两组胰腺炎（χ2 =0.2,P>0.05）及胆管炎发生率(χ2 =0.2,P>0.05）比较差异无统计学意义。金属支架组发生堵塞的概率要明显少于塑料支架组 [7.8%（4/51）比 25.0%（10/40）, χ2 =5.25,P<0.05],在再次干预次数方面,金属支架组要明显少于塑料支架组（0.06 次比 0.38次,t=2.91,P<0.01）。塑料支架组和金属支架组在总费用上比较差异无统计学意义（42 956.1元比 44 851.5元,t=1.84,P=0.07）。结论ERCP下全覆膜金属支架置入对于不可切除的远端胆道恶性梗阻患者是一种安全、有效、经济的治疗方法,在通畅时间及再次干预次数等方面要明显优于塑料支架。     

内镜支架引流治疗肝细胞肝癌所致肝门部胆管恶性梗阻的疗效分析

目的　评估无法手术切除的肝细胞肝癌所致肝门部胆管恶性梗阻患者的内镜支架引流疗效。方法　回顾性分析2012年1月—2019年1月在海军军医大学第三附属医院因无法手术切除的肝细胞肝癌导致肝门部胆管恶性梗阻而行内镜支架引流的106例患者的临床资料。根据置入支架类型的不同，分为金属支架组（30例）和塑料支架组（76例）。观察指标包括临床成功率、并发症发生率、支架通畅期及总体生存时间。采用多因素Cox回归模型分析患者支架通畅期和总体生存时间的独立预测因素。结果　患者的总体临床成功率为67.9%（72/106），术后胆管炎发生率为29.2%（31/106）。金属支架组与塑料支架组的临床成功率分别为93.3%（28/30）和57.9%（44/76） （χ2=12.40，P<0.001），术后胆管炎发生率分别为13.3%（4/30）和35.5% （27/76）（χ2=5.12，P=0.024）。中位支架通畅期为5.2（95%CI：3.7~6.0）个月，中位总体生存时间为3.0（95%CI：2.5~3.7）个月。多因素Cox回归分析显示肝脏引流体积<30%是支架通畅期的独立预测因素（HR=2.12， 95%CI：1.01~4.46，P=0.048）。BismuthⅣ型（HR=2.06， 95%CI：1.12~3.77，P=0.020）、Child⁃Pugh C级（HR=4.09， 95%CI：2.00~8.39，P<0.001）、塑料支架（HR=1.87，95%CI：1.21~2.90，P=0.005）是总体生存时间的独立预测因素。结论　肝细胞肝癌一旦累及肝门部胆管预后不良。与塑料支架相比，金属支架引流在临床成功率、术后胆管炎发生率方面均具有一定优势。肝脏引流体积<30%是支架通畅期的独立预测因素，而Bismuth Ⅳ型、Child⁃Pugh C级、塑料支架为总体生存时间的独立预测因素。     

内镜超声治疗胰腺假性囊肿内引流支架的选择

目的　探讨内镜超声（endoscopic ultrasound,EUS）引导下经胃内引流术治疗胰腺假性囊肿时,不同型号塑料支架的引流效果。方法　对兰州大学第一医院外科内镜中心2014年3月—2020年12月所施行的EUS引导下经胃内引流治疗胰腺假性囊肿患者的相关临床资料进行回顾性分析,将患者分为置入“双猪尾”10 F双塑料支架组和置入“双猪尾”7 F双塑料支架组,比较这两组塑料支架的引流效果、并发症及远期疗效。结果　共纳入29例胰腺假性囊肿患者,其中10 F双塑料支架组11例,7 F双塑料支架组18例,两组手术操作时间分别为（48.2±8.0）min及（34.7±5.8）min,差异有统计学意义（t=5.24,P<0.001）。术后腹痛［18.2%（2/11）比5.6%（1/18）］、发热［9.1%（1/11）比11.1%（2/18）］及出血（均无）等并发症发生率,两组间对比差异均无统计学意义（P均>0.05）。2个月后复查CT,10 F双塑料支架组、7 F双塑料支架组嚢腔完全消失率分别为90.9%（10/11）和88.9%（16/18）,两组差异无统计学意义（P=1.00）。结论　对于符合EUS引导下经胃内引流术治疗胰腺假性囊肿标准的患者,7 F与10 F支架的引流效果及并发症发生率相当,但7 F支架具有手术操作便利、时间较短的优点,值得临床推广。     

金属支架置入联合鼻胆管引流对胆管癌患者ERCP术后胆管炎的预防作用

背景:晚期胆管癌患者在接受经内镜胆管金属支架置入术后容易发生胆管炎。目的:探讨经内镜胆管金属支架置入联合经内镜鼻胆管引流术对晚期胆管癌患者ERCP术后胆管炎的预防作用。方法:选取263例接受经内镜胆管金属支架置入术的晚期胆管癌患者,并分为仅置入胆管金属支架组(支架组)和置入胆管金属支架后留置鼻胆管引流组(引流组)。评估两组ERCP术后胆管炎发生率、并发症发生率以及术后住院时间。结果:与支架组相比,引流组术后胆管炎发生率显著降低(2.3%对10.8%,P=0.032),术后住院时间显著缩短[(4.68±1.43)d对(5.18±1.45)d,P=0.011],这一差异在肝门部胆管癌患者中尤为明显[术后胆管炎发生率:3.5%对15.0%,P=0.045;术后住院时间:(5.18±1.44)d对(5.68±1.39)d,P=0.033]。引流组术后3 h、24 h、72 h的C反应蛋白、白细胞计数、中性粒细胞百分比均显著低于支架组(P0.05)。两组并发症发生率无明显差异(P0.05)。结论:经内镜胆管金属支架置入联合经内镜鼻胆管引流术对预防晚期胆管癌患者ERCP术后胆管炎的发生是安全、有效的,尤其是对肝门部胆管癌患者。     

鼻胆管口鼻转换及固定新方法的设计与临床应用

为评价一套鼻胆管口鼻转换及固定的新方法——短鼻胆管导丝引出及单反α固定法的临床应用价值,选择2022年1—8月在同济大学附属东方医院拟行经内镜鼻胆管引流术的患者为研究对象,按照随机数字表法随机分为短鼻胆管导丝引出及单反α固定法组（观察组,n=145）和导丝套取及反a固定法组（对照组,n=71）,观察两组操作时间、一次操作成功率、不良事件、舒适度、满意度等指标差异。结果显示观察组操作时间低于对照组,差异具有统计学意义［102（91,117）s比136（127,145）s,Z=-9.639,P<0.001］;观察组鼻胆管口鼻转中一次操作成功率高于对照组［88.28%（128/145）比67.61%（48/71）,χ2=13.496］,鼻咽部刺激评分［1（1,2）分比2（1,2）分,Z=-4.457］和不良事件发生率［4.14%（6/145）比15.49%（11/71）,χ2=8.475］低于对照组,差异均有统计学意义（P<0.05）;观察组留置鼻胆管期间胆汁引流量［（179.45±81.54）mL比（142.89±55.69）mL,t=3.407］及护理满意度评分［（7.72±0.99）分比（6.06±1.07）分,t=11.337］高于对照组,舒适度评分［（3.00±1.01）分比（4.83±0.99）分,t=-12.642］及不良事件发生率［3.45%（5/145）比14.08%（10/71）,χ2=8.344］低于对照组,差异均有统计学意义（P<0.05）;观察组拔除鼻胆管的操作时间低于对照组,差异有统计学意义［（9.00±1.14）s比（11.93±1.36）s,t=-16.616,P<0.001］。由此可见,内镜下鼻胆管引流术后采取短鼻胆管导丝引出及单反α固定法进行鼻胆管口鼻转换及固定具有操作简单、刺激反应小、不良事件发生率低等优点,值得临床推广。     

超细推送系统金属支架在肝门胆管恶性狭窄中的应用

目的　探讨超细金属支架治疗肝门胆管恶性狭窄的可行性、有效性和安全性。方法　2014年1月—2021年6月在东方肝胆外科医院消化内科根据影像学或组织学和（或）细胞学诊断为Bismuth Ⅱ型以上肝门胆管恶性狭窄的30例患者,使用超细推送系统金属支架,采用同步并行置入法置入胆管双侧金属支架。分析其技术成功率、临床疗效及并发症发生率。结果　技术成功率为100.0%（30/30）,临床成功率为93.3%（28/30）,操作时间（55.7±20.7）min, 金属支架置入时间（28.3±18.2） min。早期不良事件包括轻度急性胰腺炎2例和胆管炎5例。支架半数通畅时间为243 d （95%CI： 186.6~299.4 d）,患者半数生存期为237 d （95%CI：149.0~325.0 d）。晚期胆管炎发生率为36.7% （11/30）。14例患者出现支架失效,其中5例接受内镜下再介入。双侧金属支架腔内再置入支架技术成功率为4/5,操作时间为（49.8±6.9）min。结论　内镜下同步并行放置双侧超细金属支架治疗肝门胆管恶性狭窄是安全、可行、有效的。 结果 技术成功率100%（30/30例）,临床成功率93.3%(28/30例),操作时间55.7±20.7分, 金属支架置入时间28.3±18.2分。早期不良事件包括轻度急性胰腺炎2例和胆管炎5例。支架中位通畅时间为243 d (95% CI 186.6-299.4 d),中位生存期为237 d (95% CI 149.0-325.0 d)。晚期胆管炎发生率为36.7% (11/30)。14例患者出现支架失效,其中5例受内镜下再介入。双侧金属支架腔内再置入支架技术成功率为80%（4/5）,操作时间为49.8±6.9分。 结论 内镜下同步并行放置双侧超细推送系统金属支架治疗肝门胆管恶性狭窄是安全、可行、有效的。     

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.     

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.     

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.     

高位胆道梗阻内镜下选择性胆管插管导丝引导方法探讨

目的探讨导丝引导技术在高位胆道梗阻内镜下选择性胆管插管中的应用价值。方法对344例经ERCP诊治的高位胆道梗阻患者,乳头部胆管插管成功后应用导丝直通法、导管导丝法、乳头切开刀法、导管导丝＋导丝弯曲法、导丝α及反α结袢法、导丝旋转法、导丝直通联合取石球囊法及多孔导向导管法等多种导丝引导方法进行选择性胆管深插管,使其通过胆管狭窄段,进入目标胆管。观察插管效果。结果336例高位胆道梗阻患者顺利完成超选择性目标胆管插管,随后完成相应内镜下治疗,总成功率为97．67％。所有患者在插管过程中无合并胆道出血及穿孔等病例。结论高位胆道梗阻内镜下选择性胆管插管中不同导丝引导方法可以提高微创诊疗成功率、缩短操作时间,减少患者痛苦、降低并发症的发生率。     

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.