内镜胆道内支架引流治疗伴肝脏转移的胰头癌16例

目的:评价伴肝脏转移的胰头癌患者内镜胆道内支架引流治疗的临床意义.方法:门诊就诊和转院的胰头癌伴有肝脏转移患者,如具有严重的梗阻性黄疸则符合内镜逆行胆胰管造影救治指征,然后按照知情同意的原则进入治疗研究计划.均应用内镜胆道内支架引流技术,包括金属内支架和塑料支架.治疗出院后随访观察至患者死亡.结果:16例患者进入治疗研究,其中伴有腹膜后淋巴结转移5例.均采用内镜胆道支架引流术,其中应用胆道金属支架12例,胆道塑料支架4例,胰管内支架6例.治疗后1 wk时梗阻性黄疸缓解率100%,精神状况明显好转75.0%(12/16),食欲改善25.0%(4/16),睡眠改善37.5%(6/16).治疗后的患者最短生存期为9d,最长生存期为134 d,平均81.4 d±50.2 d.随访数据表明治疗有意义的97%,治疗效果满意的11例.结论:对于伴有肝脏转移的胰头癌患者,内镜胆道内支架引流技术不仅能解除梗阻性黄疸,而且可以一定程度的改善生存质量,具有一定的临床应用价值.     

经内镜内支架置入术治疗中晚期胰腺癌

本文介绍了胆、胰、十二指肠内镜支架治疗技术及其在胰腺癌治疗中缓解症状、提高生活质量和延长生存期的作用,对临床工作具有指导意义。     

内镜下置入金属支架治疗中晚期胰头癌引起的胆道梗阻

胰头癌患死亡的主要原因是胆道梗阻所致的并发症，早期解除梗阻有利于延长生命。外科冶疗仍是目前惟一有效的治疗方法，但其手术切除率低（10％～20％）：，并发症多，创伤大，病死率高，远期疗效差。对手术不能切除的中晚期胰头癌引起的胆道梗阻，我科采用经内镜置放胆道金属支架对其进行姑息性治疗，效果满意，现报告如下。     

金属和塑料支架置入治疗胰头癌伴阻塞性黄疸的疗效分析

目的分析比较金属与塑料胆管支架治疗胰头癌伴阻塞性黄疸的疗效。方法40例胰头癌伴阻塞性黄疸患者随机分为2组,内镜下分别置入金属支架和塑料支架。观察术前和术后患者发热、腹痛、腹胀、黄疸、WBC、血淀粉酶、总胆红素(TB)、直接胆红素(DB)、ALT、AST、γ-GT、AKP的变化。结果所有患者支架置入成功,术后1个月及6个月X线复查,提示支架仍保持原位及良好的扩张状态。术后发热、腹痛、腹胀、黄疸发生率明显降低(P<0.05),WBC、TB、DB、ALT和AST也明显降低(P<0.05)。金属支架组发热、黄疸的发生率显著低于塑料支架组(P<0.05),血胆红素、AKP、ALT水平也较塑料支架组显著降低(P<0.05)。但金属支架组术后3h血淀粉酶升高较塑料支架组明显(P<0.05)。随访6月患者未出现死亡。结论胆管支架能有效治疗胰腺癌伴阻塞性黄疸,金属支架的疗效显著优于塑料支架,但其术后发生胰腺炎的风险增高。     

金属和塑料支架置入治疗胰头癌伴阻塞性黄疸的疗效分析

目的 分析比较金属与塑料胆管支架治疗胰头癌伴阻塞性黄疸的疗效.方法 40例胰头癌伴阻塞性黄疸患者随机分为2组,内镜下分别置入金属支架和塑料支架.观察术前和术后患者发热、腹痛、腹胀、黄疸、WBC、血淀粉酶、总胆红素(TB)、直接胆红素(DB)、ALT、AST、γ-GT、AKP的变化.结果 所有患者支架置入成功,术后1个月及6个月X线复查,提示支架仍保持原位及良好的扩张状态.术后发热、腹痛、腹胀、黄疸发生率明显降低(P＜0.05),WBC、TB、DB、ALT和AST也明显降低(P＜0.05).金属支架组发热、黄疸的发生率显著低于塑料支架组(P＜0.05),血胆红素、AKP、ALT水平也较塑料支架组显著降低(P＜0.05).但金属支架组术后3 h血淀粉酶升高较塑料支架组明显(P＜0.05).随访6月患者未出现死亡.结论 胆管支架能有效治疗胰腺癌伴阻塞性黄疸,金属支架的疗效显著优于塑料支架,但其术后发生胰腺炎的风险增高.     

胰头癌电子束CT与病理对照

胰腺癌发病率呈明显上升趋势,死亡率已居恶性肿瘤的第五位。在过去20年中我国胰腺癌发病率增长约6倍。胰腺癌是消化系统中较难早期诊断的肿瘤,临床发现时往往已届中晚期。我们使用电子束CT研究胰腺癌的形态学改变并与病理进行对照,目的在于探讨胰腺癌的CT表现的病理基础,更加深入认识胰腺癌的CT征象,提高胰腺癌早期诊断的准确性。 1 材料和方法 1.1 材料 1995-09/1999-03经EBCT检查病理证实的胰头癌31例。其中手术切除16例,经手术探查未能切除15例。采用美国Imatron公司的C-150型电子束CT扫描设备。     

经内镜射频消融和置入内支架联合治疗不能切除的胆胰肿瘤

目的探讨经内镜射频消融和置入内支架的联合治疗在延长不能切除的胆胰肿瘤患者胆道通畅期中的作用。方法共58例患者采用联合治疗：6例十二指肠乳头癌先作内镜下乳头局部切除，而后对残留病灶作射频消融；52例经ERCP测出肿瘤狭窄段的范围，对狭窄段作射频消融，然后置入相匹配的金属内支架。收集同期52例单放金属内支架者作为对照组。结果在联合治疗组中，3例治疗后2个月内因胆道严重感染、全身衰竭死亡，余55例胆道平均通畅期为9．2个月，平均存活期为16个月。其中48例再次梗阻后再次内镜下治疗，28例单作射频消融和20例射频消融加再置入内支架，通畅期又平均延长5．1个月。而单放内支架组胆道通畅期为6．1个月，平均存活期为13个月。结论射频消融能阻止肿瘤的局部增长，从而延长内支架的通畅期和患者的存活期。     

超声内镜在中晚期胰腺癌治疗中的应用进展

随着内镜技术的发展,EUS已逐渐从简单的诊断工具进展为介入、微创的治疗方法,给晚期胰腺癌的治疗带来了新的方向。本文就当前EUS介入技术在晚期胰腺癌治疗中的应用进展做一综述。     

奥曲肽联合ERCP＋留置内支架对胰头癌治疗效果的临床分析

目的 探讨奥曲肽联合ERCP＋留置内支架治疗胰头癌并阻塞性黄疸患者的临床价值.方法 收集2006年1月至2011年12月武汉市中心医院消化内科收治的99例并发阻塞性黄疸的胰头癌患者,采用随机、平行对照的方法分为治疗组及对照组.对照组51例患者仅采用ERCP及留置内支架减黄治疗,治疗组48例患者在内镜治疗的同时给予奥曲肽0.1 mg皮下注射,每日2次,连续治疗90d以上,直至病死.观察治疗前后患者血胆红素水平的变化;恶心、呕吐、腹痛、腹泻、纳差等症状的改善情况;治疗发生的并发症及患者的生存时间.结果 对照组患者治疗后6例再次出现黄疸,考虑支架阻塞,其中3例再次行内支架植入后黄疸消退,3例未再次行支架置入.其余45例及所有治疗组患者的血胆红素均下降至基本正常（低于正常值的2倍）.治疗前两组患者恶心、呕吐、腹痛、腹泻、纳差的发生率差异均无统计学意义,治疗后两组患者上述症状的发生率均较治疗前明显下降,且治疗组的下降显著优于对照组,差异均有统计学意义（P值均＜0.05）.对照组有3例术后发生急性胰腺炎,治疗后缓解.治疗组无1例术后发生胰腺炎,但有3例注射部位发生皮肤疼痛,经更换注射部位后疼痛缓解.对照组患者平均生存时间为（7.3±5.3）个月,治疗组为（14.4±8.7）个月,差异有统计学意义（P＜0.05）.结论 奥曲肽联合ERCP＋留置内支架治疗胰头癌并阻塞性黄疸患者能明显改善患者生存质量,延长患者的生存时间.     

胰头癌胆管支架置入后十二指肠狭窄的介入治疗

消化道狭窄或梗阻多以恶性肿瘤压迫、浸润所致。由于肿瘤性病变引起梗阻时往往已是病程晚期，外科手术创伤大，失去根治手术的机会。消化道介入治疗是近年发展起来的微创治疗新技术，成为胃肠道狭窄或梗阻的首选方法。我科于2005年1月及12月对1例胰腺癌患者分别实施经内镜胆道支架置入及经内镜十二指肠球囊扩张及支架置入术。对同一患者，在胆道支架置入术后再行十二指肠球囊扩张及支架置入术的情况较少见。现报告如下。     

Conformable covered versus uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction: A randomized prospective study

BackgroundA conformable self-expandable metallic stent was developed to overcome the limitation of previous self-expandable metallic stents. The aim of this study was to evaluate outcomes after placement of conformable covered and uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction.MethodsA single-blind, randomized, parallel-group, prospective study were conducted in 4 medical centres between March 2009 and July 2012. 134 patients with unresectable malignant gastroduodenal obstruction were assigned to a covered double-layered (n = 66) or uncovered unfixed-cell braided (n = 68) stent placement group. Primary analysis was performed to compare re-intervention rates between two groups.Results120 patients were analysed (59 in the covered group and 61 in the uncovered group). Overall rates of re-intervention were not significantly different between the two groups: 13/59 (22.0%) in the covered group vs. 13/61 (21.3%) in the uncovered group, p = 0.999. Stent migration was more frequent in the covered group than in the uncovered group (p = 0.003). The tumour ingrowth rate was higher in the uncovered group than in the covered group (p = 0.016).ConclusionsThe rates of re-intervention did not significantly differ between the two stents. Conformable covered double-layered and uncovered unfixed-cell braided stents were associated with different patterns of stent malfunction.     

Surgical palliation of unresectable pancreatic head cancer in elderly patients

AIM： To determine if surgical biliary bypass would provide improved quality of residual life and safe palliation in elderly patients with unresectable pancreatic head cancer. METHODS： Nineteen patients, 65 years of age or older, were managed with surgical biliary bypass （Group A）. These patients were compared with 19 patients under 65 years of age who were managed with surgical biliary bypass （Group B）. In addition, the results for group A were compared with those obtained from 17 patients, 65 years of age or older （Group C）, who received percutaneous transhepatic biliary drainage to evaluate the quality of residual life. RESULTS： Five patients （26.0%） in Group A had complications, including one intraabdominal abscess, one pulmonary atelectasis, and three wound infections. One death （5.3%） occurred on postoperative day 3. With respect to morbidity, mortality, and postoperative hospitalization, no statistically significant difference was noted between Groups A and B. The number of readmissions and the rate of recurrent jaundice were lower in Group A than in Group C, to a statistically significant degree （P = 0.019, P = 0.029, respectively）. The median hospital-free survival period and the median overall survival were also significantly longer in Group A （P = 0.001 and P 〈 0.001, respectively）. CONCLUSION： Surgical palliation does not increase the morbidity or mortality rates, but it does increase the survival rate and improve the quality of life in elderly patients with unresectable pancreatic head ca n ce r.     

Recent developments in palliative chemotherapy for locally advanced and metastatic pancreas cancer

In spite of advances made in the management of the other more common cancers of the gastrointestinal tract,significant progress in the treatment of pancreatic cancer remains elusive.Nearly as many deaths occur from pancreatic cancer as are diagnosed each year reflecting the poor prognosis typically associated with this disease.Until recently,the only treatment with an impact on survival was surgery.In the palliative setting,gemcitabine(Gem) has been a standard treatment for advanced pancreatic cancer since ...     

A new approach to endoscopic treatment of tumors of the esophagogastric junction with individually designed self-expanding metal stents

The incidence of adenocarcinoma of the esophagogastric junction is constantly increasing. Curative treatment is no longer possible at the time of diagnosis in more than 50% of patients with esophageal carcinoma, and palliative treatment focusing on eliminating dysphagia is required. Endoscopic therapy with stent implantation is an established method of achieving this. It can be carried out quickly, with a low rate of early complications, and leads to fast symptomatic improvement, assessed using the dysphagia score. The relatively high rate of late complications such as stent migration, hemorrhage, and gastroesophageal mucosal prolapse has led to recent debate on the role of metal stents in palliative therapy. We present here a new type of stent design for transcardial application, which is intended to prevent bleeding due to mechanical mucosal lesions caused by the distal end of the stent extending into the stomach. The further intention of this case report is to force the discussion on individually designed nitinol stents in special anatomic conditions.     

Endoscopic biliary drainage in patients with cholangiocarcinoma – self-expanding metal versus polyethylene stents

Background: Endoscopic biliary drainage is the standard of care for patients with cholangiocarcinoma (CCA)-induced, obstructive jaundice. Self-expanding metal stents are supposed to be superior to polyethylene stents in terms of reduction of interventions and costs. So far, there are only few real-life data with respect to stent selection and survival in this patient cohort.

Methods: In this study, we retrospectively analyzed patients with CCA treated with endoscopic biliary drainage from 2000 to 2015 at Hannover Medical School, Germany. The aim of this study was to analyze whether metal stenting reduces the frequency of interventions and influences survival in a large, real-life cohort.

Results: Overall, 422 patients with CCA were included in this study. Indication for endoscopic biliary drainage was most often obstructive jaundice (n?=?397; 94.1%). Among these patients, 20 patients (5%) were initially treated with a metal stent and 38 (9.6%) received a metal stent in the subsequent course. Median number of interventions per month was 2.4-fold reduced following metal stenting. Patients first treated with a metal stent had a more advanced tumor stage and a significantly shorter median overall survival (mOS) compared to patients who received a metal stent subsequently (7.5 months vs. 15.2 months; p=.019). There was no difference in mOS for metal vs. polyethylene stenting following a propensity score match for the confounders curative resection and chemotherapy (13.2 vs. 13.7 months, p=.555).

Conclusions: Our data confirm that metal stenting reduces the frequency of interventions, but does not influence OS. Metal stenting should be considered specifically in younger patients who are suitable for chemotherapy.     

异位胰腺的内镜诊断与分析

目的：探讨异位胰腺的内镜下特征。方法：总结近8年经胃镜、EUS、病理、手术确诊的15例异位胰腺。结果：15例异位胰腺无特异症状，其症状依其所在部位而异。胃镜下异位胰腺多为隆起病变，形态大小差异很大，具有1～2个或多个胰管，开口于肿物顶端，易误诊为息肉、平滑肌瘤、胃癌等。EUS所见异位胰腺，可发生胃肠壁任何一层，如发生在黏膜下层，呈低、中或混合回声，发现腺管结构则更有意义。结论：应用内镜有助于及时确诊异位胰腺，有利于与消化道其他隆起病变相鉴别，并可行内镜下黏膜切除术。     

Endoscopic removal technique of migrated pancreatic plastic stents

Endoscopic pancreatic stenting (EPS) is used for various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been observed. Especially, proximal stent migration presents a more serious condition because of the possibility of pancreatic duct (PD) damage. However, the removal of proximally migrated stents is technically challenging because of the small PD diameter, the bended PD course, the presence of PD strictures, and the lack of suitable devices for stent removal. Thus, few cases of surgical intervention have been encountered. In this study, we review the endoscopic treatment of proximally migrated pancreatic plastic stents. We classify migrated stent conditions into four types according to stent and PD conditions. In Type A, the main pancreatic duct (MPD) has no stricture. In Type B, the stent is positioned across the stricture on the MPD. In Type C, the stent is positioned further away from the stricture on the MPD. The tip of the proximal stent is located in the MPD in types A thru C. In Type D, the tip of the proximal stent is located in a branch duct. We introduced the strategy of endoscopic removal technique of each type of migrated plastic stents.     

elderly patients with unresectable pancreatic headcancer

AIM: To determine if surgical biliary bypass would provide improved quality of residual life and safe palliation in elderly patients with unresectable pancreatic head cancer. METHODS: Nineteen patients, 65 years of age or older, were managed with surgical biliary bypass (Group A). These patients were compared with 19 patients under 65 years of age who were managed with surgical biliary bypass (Group B). In addition, the results for group A were compared with those obtained from 17 patients, 65 years of age or older (Group C), who received percutaneous transhepatic biliary drainage to evaluate the quality of residual life. RESULTS: Five patients (26.0%) in Group A had complications, including one intraabdominal abscess, one pulmonary atelectasis, and three wound infections. One death (5.3%) occurred on postoperative day 3. With respect to morbidity, mortality, and postoperative hospitalization, no statistically significant difference was noted between Groups A and B. The number of readmissions and the rate of recurrent jaundice were lower in Group A than in Group C, to a statistically significant degree ( P = 0.019, P = 0.029, respectively). The median hospital-free survival period and the median overall survival were also significantly longer in Group A ( P = 0.001 and P < 0.001, respectively). CONCLUSION: Surgical palliation does not increase the morbidity or mortality rates, but it does increase the survival rate and improve the quality of life in elderly patients with unresectable pancreatic head cancer.     

Endoscopic trans-anal resection for palliation of acutely obstructed rectal cancer in frail elderly patients

Obstructive carcinomas of the rectum in frail elderly patients who are not candidates for curative surgery have been traditionally treated by diverting loop colostomy. This is a retrospective evaluation of the outcome of endoscopic trans-anal resection (ETAR) for obstructed rectal cancer. Fifty-two patients with a mean age of 82 (range 76–90) years and severe concomitant disease underwent ETAR which was carried out without general anaesthesia with a 27-French two-way Iglesias resectoscope. Mean distance from the anal verge was 6 (range 4–12) cm. Obstruction was relieved in all patients with one resection, 30-day- mortality rate was 2% (myocardial infarction in a 90-year-old-patient), the 10% morbidity rate (5/52 patients) was not directly ETAR-related, and extraperitoneal rectal perforation in one patient (2%) was uneventful. In conclusion, ETAR offers good palliation in selected patients. Received: 5 April 1998 / Accepted in revised form: 9 January 1999