经内镜逆行胰胆管造影术诊治肝移植术后吻合口离断并胆瘘1例

肝移植术后吻合口离断合并胆瘘较少见,可通过胆道重建或经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）进行治疗,但二者难度均较大。本文报道1例肝移植术后吻合口离断并胆瘘,通过ERCP分阶段予鼻胆管、支架引流联合治疗,成功治愈。     

腹腔镜单纯胆囊切除术后胆道并发症的内镜治疗

目的探讨十二指肠镜治疗腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）后胆道并发症的效果。方法胆管结石先行内镜下胆总管Oddi括约肌切开术（endoscopic sphincterotomy,EST）或内镜下乳头气囊扩张术（endosco picpapillary balloon dilatation,EPBD）后取石,胆总管上段狭窄行胆道扩张加支架置入术,胆漏、胆管横断者行内镜下鼻胆管引流术（endoscopic nasobiliary drainage,ENBD）或内镜下胆管内塑料支架引流术（endoscopic retrograde biliary drainage,ERBD）治疗。结果69例中,胆总管结石53例（76.7%）,胆总管上段部分狭窄11例（15.9%）,胆管横断2例（2.9%）,胆漏3例（4.3%）。53例胆总管结石患者49例行EST后取石,4例因乳头较小行EPBD后取石。11例胆总管部分狭窄行胆道扩张术后放置内支架引流治疗,3个月后5例拔管造影未见明显狭窄结束治疗,6例狭窄未能完全解除者,再行胆管扩张及重新放置塑料内支架,均于9个月内恢复。2例胆管横断患者行ENBD后开腹手术治疗。3例胆漏患者用医用胶注射封堵漏口后行ENBD或ERBD后症状明显减轻,一周后缓解。结论LC后胆道并发症应早期行ERCP以明确诊断;十二指肠镜对LC后并发症的处理是一种好方法,优于其它检查和治疗。     

微创治疗胆道非吻合口狭窄的价值

目的评估微创方法治疗肝移植术后胆道非吻合口狭窄（NABS）的价值。方法回顾性分析13例肝移植术后NABS患者的临床资料,比较不同类型NABS患者经内镜下逆行胰胆管途径（ERCP途径）及经皮肝穿刺胆管途径（PTCD途径）的微创治疗效果,并总结NABS患者再次肝移植的手术指征。结果4例行PTCD途径治疗,效果不佳,后期3例改ERCP途径治疗。8例微创治疗后有效,有效率8／13;余5例改手术治疗,其中再次肝移植4例、胆肠吻合1例。Ⅰ型（围肝门部狭窄）、Ⅱ型（肝门部＋肝内胆管狭窄）、Ⅲ型（肝内胆管多发狭窄）NABS患者微创治疗有效率分别为3／4、4／7、1／2。II型及Ⅲ型患者近一半（4／9）需再次肝移植,合并肝动脉狭窄的NABS患者再次肝移植率高达2／3。结论微创方法是治疗NABS的首选方案,主要依靠ERCP实施,PTCD疗效欠佳。根据胆管造影显现的狭窄类型,Ⅰ型患者微创治疗效果最佳。微创治疗无效的Ⅱ型及Ⅲ型患者,尤其是合并肝动脉狭窄者,应及时转手术治疗,以免错失手术机会。     

内镜下塑料胆管支架引流与鼻胆管引流治疗巨大胆总管结石的对比观察

ERCP是目前治疗胆总管结石的首选方法，然而对于部分结石巨大或病情复杂不能长时间接受内镜治疗者，采取内镜下塑料胆管支架引流术（endoscopic retrograde biliary drainage，ERBD）或内镜下鼻胆管引流术（endoscopic nasobiliary drainage，ENBD），不仅操作时间短，并发症少，手术风险小，而且ERBD可使结石缩小，有利于后续治疗。     

ERCP在胆道外科治疗中的应用

目的探讨ERCP在胆道外科治疗中的应用价值。方法回顾性分析近3年（2003年1月至2006年1月间）胆道术后残余结石及再生结石行乳头括约肌切开取石122例,腹腔镜胆囊切除术（LC）术后胆瘘行鼻胆管引流（ENBD）13例,原位肝移植术后胆管狭窄行胆管球囊扩张,放置胆管内支架或鼻胆管引流6例。结果122例胆道术后残余结石及再生结石患者经十二指肠镜胆道造影（ERC）成功率95.9%,取石成功率91.5%,其中有5例经2次操作取尽结石。13例胆瘘患者经鼻胆管引流2～3周后,胆瘘处均闭合,无严重并发症发生。6例胆管狭窄患者经ERC胆道介入（球囊扩张、ENBD或内支架）均治愈。结论ERCP在胆道外科治疗中具有重要应用价值,是术后残余结石或再生结石、术后胆瘘及术后胆管狭窄的有效介入方法。     

Ⅳ型肝门部胆管癌内镜治疗支架选择分析

目的 探究Bismuth分型Ⅳ型肝门部胆管癌内镜治疗支架的选择方法及经验。方法 回顾性分析2010年9月—2018年9月在兰州大学第一医院普外科就诊并接受经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography, ERCP）治疗的65例Ⅳ型肝门部胆管癌患者临床资料。按照内镜引流方式不同分为3组:经内镜胆道内支架放置术（endoscopic retrograde biliary drainage,ERBD）组38例、ERBD+内镜下胆道金属支架置入 (endoscopic metal biliary endoprosthesis, EMBE)组23例、EMBE组4例;根据胆道造影方式不同分为造影剂组(n=26)、空气造影组（n=22）及无胆道造影组(n=17）。比较术后急性胆管炎发生率、总胆红素显著下降率及住院期间死亡率等指标。结果 3种引流方式相比,ERBD组、ERBD+EMBE组和EMBE组的急性胆管炎发生率分别为23.7%（9/38）、52.2%（12/23）和75.0%（3/4）,差异有统计学意义（χ2=7.499,P=0.006）。3组住院期间死亡率分别为5.3%（2/38）、13.0%（3/23）和50.0%（2/4）,差异有统计学意义（χ2=7.729,P=0.021）;两两比较,ERBD组和EMBE组之间差异有统计学意义（χ2=8.406,P=0.004）。3种造影方式相比,造影剂组、空气造影组和无胆道造影组的急性胆管炎发生率分别为57.7%（15/26）、27.3%（6/22）和17.6%（3/17）,差异有统计学意义（χ2=8.407,P=0.015）;两两比较,造影剂组和无胆道造影组之间差异有统计学意义（P=0.012）。结论 对于Ⅳ型肝门部胆管癌,胆道双塑料支架置入能显著降低患者术后急性胆管炎发生率及住院期间死亡率,可作为首选支架方案;术中造影剂的使用会增加术后急性胆管炎发生率,应慎用造影剂。     

肝移植术后胆道吻合口狭窄内镜处理策略

目的探讨肝移植术后胆道吻合口狭窄的内镜处理和操作技巧。方法分析第二军医大学附属东方肝胆外科医院内镜科2003年12月至2006年12月经十二指肠镜治疗的228例肝移植患者临床资料。结果肝移植术后胆道并发症患者中,合并或单纯胆道吻合口病变者187例,占82.0%,其中175例成功进行了内镜下治疗,成功率93.6%。187例有胆道吻合口病变的患者中,吻合口狭窄149例(79.7%),其中成功进行内镜下逆行胰胆管造影(ERCP)治疗者145例,成功率为97.3%。结论肝移植后胆道并发症患者中,合并或单纯胆道吻合口狭窄者占绝大多数,ERCP是诊断和治疗肝移植术后胆道并发症的首选方法之一。行ERCP时导丝及其他附件通过胆道吻合口狭窄的操作技巧是治疗成功的关键。     

内镜技术在肝外胆汁淤积性黄疸患者中的临床应用分析

目的探讨经内镜逆行胰胆管造影（ERCP）胆管引流术对各种良恶性肝外胆汁淤积疾病的治疗效果。方法 139例肝外胆汁淤积患者先行ERCP检查,确定胆管狭窄梗阻病变部位和性质后,再选择以下治疗方法：内镜下乳头肌切开术（EST）、内镜下乳头括约肌气囊扩张术（EPBD）、内镜下鼻胆管引流（ENBD）、内镜下塑料胆道支架引流（ERBD）和内镜下金属胆道支架引流（EBMSD）。结果针对良性胆管狭窄行EST、EPBD、ENBD及ERBD共59例,主要见于胆总管结石、胆管炎、胆管乳头狭窄和肝移植术后胆道并发症;针对恶性胆管狭窄行ENBD 14例,ERBD 6例,行EBMSD 26例,主要见于胰头癌、胆管癌、壶腹癌、原发性肝癌及肝门与肝内转移压迫胆管,所有病例均在引流后TB il及DB il等肝功能指标明显下降;术后两组分别有10、6例出现血淀粉酶一过性增高。结论经内镜下ERCP治疗技术在肝外胆汁淤积患者中的应用是安全有效的,对各种良恶性病变引起的胆管狭窄梗阻起了一定的治疗作用。     

肝内胆管结石并急性重症胆管炎的内镜治疗

内镜下鼻胆管引流术（endoscopic naso biliary drainage,ENBD）或内镜下塑料支架引流术（endoscopic retrograde biliary drainage,ERBD）治疗急性重症胆管炎（acute and severecholecystitis,ACST）效果满意,但对肝内胆管结石并急性重症胆管炎的治疗临床报道极少。我院1993年10月至2008年5月问,经ENBD或ERBD治疗肝内胆管结石并ACST患者22例,疗效满意,现报道如下。     

ERCP在手术后胆漏中的诊治作用

目的探讨ERCP对肝胆术后胆漏诊断及治疗作用。方法对2003年1月至2008年12月接受ERCP诊治的120例肝胆术后胆漏患者进行回顾性分析。结果120例胆漏患者中,诊断肝外胆漏（Ⅰ型）71例、肝内胆管漏（Ⅱ型）39例、胆囊管漏（Ⅲ型）10例。其中76例行内镜下鼻胆管引流术（ENBD）,35例行胆管内支架引流术（ERBD）,3例行ERBD＋ENBD,2例单纯行经内镜乳头括约肌切开术（EST）,1例放置可回收金属支架行金属支架引流（EMBE）,3例内镜治疗失败。共完整随访98例,占81．7％（98／120）,其中有效治愈胆漏85例,有效治愈率为86．7％（85／98）,平均胆漏愈合时问为（18．2±7．0）d。各型胆漏中,Ⅲ型胆漏有效治愈率最高,为100．0％,且该型胆漏愈合时间最短,为（8．2±3．5）d;在Ⅰ型和Ⅱ型胆漏中,对应非肝移植术后胆漏有效治愈率明显高于肝移植术后（P〈0．01）,且愈合时间明显变短（P〈0．01）。结论ERCP是诊治肝胆术后胆漏的一种安全、有效的手段,具有重要的临床价值,可作为肝胆术后胆漏诊治的首选方法,对于Ⅲ型胆漏治疗效果尤佳。     

Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures (RBES)

With the recent availability of removable esophageal stents, endoscopic stenting has been utilized to treat refractory benign esophageal strictures (RBES). The objective of this study was to review the feasibility and effectiveness of removable esophageal stents to treat RBES. Patients who received removable esophageal stents for the treatment of RBES at the institution between 2004–2010 using its stent implantation logs and endoscopic database were retrospectively identified. Patient demographics, stricture etiology and location, stent and procedure characteristics, and clinical outcomes were obtained. Twenty‐five patients with a mean age of 70 (72% male) underwent initial stent placement; 24 were successful. Overall clinical success was achieved in five of the 19 patients (26%) ultimately undergoing stent removal. RBES etiologies included anastomotic (13), radiation (5), peptic (3), chemotherapy (1), scleroderma (1), and unknown (2). Alimaxx‐E (Merit‐Endotek, South Jordan, UT, USA) stents were placed in 20 patients and Polyflex (Boston Scientific, Natick, MA, USA) stents were used in five patients. Immediate complications included failed deployment (1) and chest pain (7). Five patients died prior to stent removal. Stent migration was found in 53% (10/19) of patients who underwent stent removal: nine required additional therapy and one had symptom resolution. Out of the nine patients without stent migration, five required additional therapy and four had symptom resolution. Although placement of removable esophageal stents for RBES is technically feasible, it is frequently complicated by stent migration and chest pain. In addition, few patients achieved long‐term stricture resolution after initial stenting. In this study, most patients ultimately required repeated stenting and/or dilations to maintain relief of dysphagia.     

Clinical Efficacy of Endoscopic Treatment for Benign Colorectal Stricture: Balloon Dilatation versus Stenting

Background/Aims

There has been a lack of research comparing balloon dilatation and self-expandable metal stent (SEMS) placement to determine which is better for long-term clinical outcomes in patients with benign colorectal strictures. We aimed to compare the clinical efficacy and complication rates of balloon dilatation and SEMS placement for benign colorectal strictures from a variety of causes.

Methods

Between January 1999 and January 2012, a total of 43 consecutive patients who underwent endoscopic treatment for benign colorectal stricture (balloon only in 29 patients, SEMS only in seven patients, and both procedures in seven patients) were retrospectively reviewed.

Results

Thirty-six patients underwent endoscopic balloon dilatation, representing 65 individual sessions, and 14 patients received a total of 17 SEMS placements. The initial clinical success rates were similar in both groups (balloon vs SEMS, 89.1% vs 87.5%). Although the reobstruction rates were similar in both groups (balloon vs SEMS, 54.4% vs. 57.1%), the duration of patency was significantly longer in the balloon dilatation group compared with the SEMS group (65.5±13.3 months vs. 2.0±0.6 months, p=0.031).

Conclusions

Endoscopic balloon dilatation is safe and effective as an initial treatment for benign colorectal stricture and as an alternative treatment for recurrent strictures.     

Value of two-phase dynamic multidetector computed tomography in differential diagnosis of post-inflammatory strictures from esophageal cancer

AIM: To characterize the computed tomography(CT) findings in patients with post-inflammatory esophageal strictures(corrosive and peptic) and reveal the optimal scanning phase protocols for distinguishing postinflammatory esophageal stricture and esophageal cancer.METHODS: Sixty-five patients with esophageal strictures of different etiology were included in this study: 24 patients with 27 histopathologically confirmed corrosive strictures, 10 patients with 12 peptic strictures and 31 patients with esophageal cancer were evaluated with a two-phase dynamic contrast-enhanced MDCT. Arterial and venous phases at 10 and 35 s after the attenuation of 200 HU were obtained at the descending aorta, with a delayed phase at 6-8 min after the start of injection of contrast media. For qualitative analysis, CT scans of benign strictures were reviewed for the presence/absence of the following features: "target sign", luminal mass, homogeneity of contrast medium uptake, concentric wall thickening, conically shapedsuprastenotic dilatation, smooth boundaries of stenosis and smooth mucous membrane at the transition to stenosis, which were compared with a control group of 31 patients who had esophageal cancer. The quantitative analysis included densitometric parameter acquisition using regions-of-interest measurement of the zone of stenosis and normal esophageal wall and the difference between those measurements(ΔCT) at all phases of bolus contrast enhancement. Esophageal wall thickening, length of esophageal wall thickening and size of the regional lymph nodes were also evaluated. RESULTS: The presence of a concentric esophageal wall, conically shaped suprastenotic dilatation, smooth upper and lower boundaries, "target sign" and smooth mucous membrane at the transition to stenosis were suggestive of a benign cause, with sensitivities of 92.31%, 87.17%, 94.87%, 76.92% and 82.05%, respectively, and specificities of 70.96%, 89.66%, 80.65%, 96.77% and 93.55%, respectively. The features that were most suggestive of a malignant cause were eccentric esophageal wall thickening, tuberous upper and lower boundaries of stenosis, absence of mucous membrane visualization, rupture of the mucous membrane at the upper boundary of stenosis, cup-shaped suprastenotic dilatation, luminal mass and enlarged regional lymph nodes with specificities of 92.31% 94.87%, 67.86%, 100%, 97.44%, 94.87% and 82.86%, respectively and sensitivities of 70.97%, 80.65%, 96.77%, 80.65%, 54.84%, 87.10% and 60%, respectively. The highest tumor attenuation occurred in the arterial phase(mean attenuation 74.13 ± 17.42 HU), and the mean attenuation difference between the tumor and the normal esophageal wall(mean ΔCT) in the arterial phase was 23.86 ± 19.31 HU. Here, 11.5 HU of ΔCT in the arterial phase was the cut-off value used to differentiate esophageal cancer from post-inflammatory stricture(P = 0.000). The highest attenuation of postinflammatory strictures occurred in the delayed phase(mean attenuation 71.66 ± 14.28 HU), and the mean ΔCT in delayed phase was 34.03 ± 15.94 HU. Here, 18.5 HU of ΔCT in delayed phase was the cut-off value used to differentiate post-inflammatory stricture from esophageal cancer(P 0.0001).CONCLUSION: The described imaging findings reveal high diagnostic significance in the differentiation of benign strictures from esophageal cancer.     

内镜-X线联合小肠内支架置入术临床应用

目的 评价内镜-X线联合小肠支架置入术的临床应用。方法 小肠支架治疗12例良恶性狭窄患者，其中良性3例，恶性9例。结果 12例患者一次置入成功，获得良好近期疗效。结论 小肠支架置入术能够缓解胃十二指肠狭窄梗阻，方法安全有效，可望成为于术后的补充治疗。     

经尿道KTP激光治疗尿道狭窄与闭锁(附16例报告)

目的 探讨经尿道KTP激光(绿激光)术治疗尿道狭窄与闭锁的疗效。方法 使用新型KTP激光对16例尿道狭窄与闭锁患者进行经尿道汽化切除，对手术疗效及技术要点进行回顾性分析与总结。结果 手术全部成功，随访2～5个月，15例(94．7％)一次治愈，排尿通畅；1例术后2个月尿线变细行尿道扩张后治愈。结论 经尿道新型KTP激光治疗尿道狭窄与闭锁安全有效，手术操作简便，恢复快，并发症少。     

Liver histology in benign biliary stricture: Fibrosis to cirrhosis . . . and reversal?

Background: Secondary biliary cirrhosis is a potential complication of post‐cholecystectomy bile duct stricture (PCBDS). This study addresses the factors that determine the severity of pathological changes on liver biopsy and the correlation with long‐term outcome following repair. Methods: Liver biopsies obtained at surgery for repair of PCBDS in 71 patients were reviewed and pathological changes were scored from 0 to 3. Patients with fibrosis score 0–2 were categorized as the non‐cirrhotic group and those with score 3 (secondary biliary cirrhosis) were categorized as the cirrhotic group. Clinical and biochemical parameters, stricture type and outcome were analyzed by univariate and multivariate analysis for correlation with degree of fibrosis. Follow‐up liver biopsies (3–60 months) after stricture repair were obtained in five patients. Results: There were 58 patients in the non‐cirrhotic group and 13 in the cirrhotic group. On univariate analysis, portal hypertension and prolonged injury‐repair duration correlated with secondary biliary cirrhosis. Patients with a fair outcome in the cirrhotic group (4/13) had derangements in liver function tests but had patent biliary enteric anastomosis on evaluation. Of the five patients in whom liver biopsies were obtained at follow up, two had regression, two were static, and one had progression. Conclusion: All patients with PCBDS had varying degrees of fibrosis. Prolonged injury‐repair interval and portal hypertension were the important parameters correlating with secondary biliary cirrhosis. Early repair of biliary stricture is recommended to prevent liver fibrosis. A successful relief of biliary obstruction may halt and/or reverse pathological changes in the liver.     

Different pattern of risk factors for post-ERCP pancreatitis in patients with biliary stricture

Objective: To identify possible risk factors associated with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in biliary stricture (BS), common bile duct stone (CBDS) and unselected patients.

Materials and methods: Consecutive ERCP patients with native papilla from January 2010 to December 2014 in Xijing Hospital were eligible. Patient-related and procedure-related parameters were collected retrospectively. The primary outcome was PEP. Univariate and multivariate logistic regression were used for data analysis.

Results: Totally 3133 unselected patients were included. 695 (22.2%) had BS alone and 1893 (60.4%) had CBDS alone. PEP incidence was higher in BS group compared with CBDS group (6.8% vs. 3.8%, p?=?.001). Among patient-related factors, duodenal stenosis (OR, 2.74; 95%CI, 1.14–6.59) and hilar stricture (OR, 2.59; 95%CI, 1.41–4.77) were found to be independently associated with PEP in BS group. While female gender (OR, 2.11; 95%CI, 1.20–3.73) and normal total bilirubin (OR, 1.93; 95%CI, 1.13–3.32) were related to PEP in CBDS group. Among procedure-related factors, cannulation time ≥?5?min (OR, 2.38; 95%CI, 1.06–5.33) and precut (OR, 3.20; 95%CI, 1.35–7.59) was respectively the only independent risk factor for PEP in BS and CBDS group.

Conclusions: Patients with BS and CBDS had different patterns of patient-related and procedure-related risk factors for PEP. The prophylaxis of PEP may need to be individualized based on different indications.     

Endoscopic management of esophageal stenosis in children: New and traditional treatments

Post-esophageal atresia anastomotic strictures and postcorrosive esophagitis are the most frequent types of cicatricial esophageal stricture. Congenital esophageal stenosis has been reported to be a rare but typical disease in children; other pediatric conditions are peptic, eosinophilic esophagitis and dystrophic recessive epidermolysis bullosa strictures. The conservative treatment of esophageal stenosis and strictures(ES) rather than surgery is a well-known strategy for children. Before planning esophageal dilation, the esophageal morphology should be assessed in detail for its length, aspect, number and level, and different conservative strategies should be chosen accordingly. Endoscopic dilators and techniques that involve different adjuvant treatment strategies have been reported and depend on the stricture’s etiology, the availability of different tools and the operator’s experience and preferences. Balloon and semirigid dilators are the most frequently used tools. No high-quality studies have reported on the differences in the efficacies and rates of complications associated with these two types of dilators. There is no consensus in the literature regarding the frequency of dilations or the diameter that should be achieved. The use of adjuvant treatments has been reported in cases of recalcitrant stenosis or strictures with evidence of dysphagic symptoms. Corticosteroids(either systemically or locally injected), the local application of mitomycin C, diathermy and laser ES sectioning have been reported. Some authors have suggested that stenting can reduce both the number of dilations and the treatment length. In many cases, this strategy is effective when either metallic or plastic stents are utilized. Treatment complications, such esophageal perforations, can be conservatively managed, considering surgery only in cases with severe pleural cavity involvement. In cases of stricture relapse,even if such relapses occur following the execution of well-conducted conservative strategies, surgical stricture resection and anastomosis or esophageal substitution are the only remaining options.     

Long-term prognosis of patients with endoscopically treated postoperative bile duct stricture and bile duct stricture due to chronic pancreatitis

Aim:  To compare the outcome of endoscopic therapy for postoperative benign bile duct stricture and benign bile duct stricture due to chronic pancreatitis, including long-term prognosis.
Methods:  The subjects were 20 patients with postoperative benign bile duct stricture and 13 patients with bile duct stricture due to chronic pancreatitis who were 2 years or more after initial therapy. The patients underwent transpapillary drainage with tube exchange every 3 to 6 months until being free from the tube. Successful therapy was defined as a stent-free condition without hepatic disorder.
Results:  Endoscopic therapy was successful in 90% (18/20) of the patients with postoperative bile duct stricture. The stent was removed (stent free) in 100% (20/20) of the patients, but jaundice resolved in only 10% (2/20) of patients while biliary enzymes kept increasing. Restricture occurred in 5% (1/20) of the patients, but after repeat treatment the stent could be removed. In patients with bile duct stricture due to chronic pancreatitis the therapy was successful in only 7.7% (1/13) of the patients; the stent was retained in 92.3% (12/13) of the patients during a long period. Severe acute pancreatitis occurred in 3.0% (1/33) of the patients as an accidental symptom attributable to endoscopic retrograde cholangiopancreatography (ERCP); however, it remitted after conservative treatment.
Conclusion:  Our results further confirm the usefulness of endoscopic therapy for postoperative benign bile duct strictures and good long-term prognosis of the patients.