经皮经肝穿刺胆管引流治疗内镜难治性恶性胆道梗阻

目的探讨经皮经肝穿刺胆管引流术(PTBD)对梗阻性黄疸的介入治疗的意义。方法23例梗阻性黄疸患者,男14例,女9例,年龄61～88岁,平均(72.6±10.9)岁,其中胆管癌10例(术后5例),胰头癌3例,胃癌术后7例,十二指肠乳头癌2例,肝癌1例,不宜行十二脂肠镜逆行胰胆管造影(ERCP)或ERCP失败,经皮肝穿刺放置引流管或内支架。结果全部PTBD成功,其中外引流6例,内外引流13例(3例左右胆管双引流),金属内支架4例。引流术前血清总胆红素(321.6±132.1)μmol/L,引流术后1周血清总胆红素(88.6±10.1)μmol/L,较前明显下降(P<0.05),直接胆红素从(252.3±36.3)μmol/L降至(53.3±9.4)μmol/L(P<0.05)。结论PTBD对梗阻性黄疸是一种安全、有效的治疗方法。     

Treatment of malignant biliary obstruction by combined percutaneous transhepatic biliary drainage with local tumor treatment

AIM: To evaluate the utility of local tumor therapy combined with percutaneous transhepatic biliary drainage (PTBD) for malignant obstructive biliary disease. METHODS: A total of 233 patients with malignant biliary obstruction were treated in our hospital with PTBD by placement of metallic stents and/or plastic tubes. After PTBD, 49 patients accepted brachytherapy or extra-radiation therapy or arterial infusion chemotherapy. The patients were followed up with clinical and radiographic evaluation. The survival and stent patency rate were calculated by Kaplan-Meier survival analysis. RESULTS: Twenty-two patients underwent chemotherapy (11 cases of hepatic carcinoma, 7 cases of pancreatic carcinoma, 4 cases of metastatic lymphadenopathy), and 14 patients received radiotherapy (10 cases of cholan-giocarcinoma, 4 cases of pancreatic carcinoma), and 13 patients accepted brachytherapy (7 cases of cholangio-carcinoma, 3 cases of pancreatic carcinoma, 4 cases of metastatic lymphadenopathy). The survival rate of the local tumor treatment group at 1, 3, 6, and 12 months was 97.96%, 95.92%, 89.80%, and 32.59% respectively, longer than that of the non treatment group. The patency rate at 1, 3, 6, and 12 months was 97.96%, 93.86%, 80.93%, and 56.52% respectively. The difference of patency rate was not significant between treatment group and non treatment group. CONCLUSION: Our results suggest that local tumor therapy could prolong the survival time of patients with malignant biliary obstruction, and may improve stent patency.     

恶性胆道梗阻经皮胆道引流或支架置入术后感染的病原学特征

目的 探讨恶性胆道梗阻(MBO)患者经皮胆道引流或支架置入术后感染的病原学特征。方法 收集2016年1月—2020年12月在苏州大学附属第一医院介入科接受介入治疗后存在或怀疑胆道感染、送检胆汁培养和/或无同期血培养的MBO患者的临床资料。从病原学培养的阳性率、菌群分布、血培养与胆汁培养的一致性、主要致病菌的耐药率方面进行分析。结果 共纳入患者219例,胆汁病原学培养阳性105例(47.95%),其中革兰氏阴性菌、革兰氏阳性菌、真菌的构成比分别为64.89%、28.24%、6.87%。同期送检血培养者69例,阳性33例(47.82%)。血培养和胆汁培养同为阳性的患者25例,一致性分析结果显示,完全一致占36%(9/25),部分一致占20%(5/25),完全不一致占44%(11/25)。常见致病的革兰氏阴性菌为大肠埃希菌、肺炎克雷伯、阴沟肠杆菌,对其耐药率(<15%)较低的抗生素有头孢哌酮/舒巴坦、阿米卡星、亚胺培南。常见致病的革兰氏阳性菌为屎肠球菌、粪肠球菌,对其耐药率较低的抗生素有万古霉素、利奈唑胺、替考拉宁。结论 MBO患者经皮胆道引流或支架置入术后感染的常见致病菌为大肠埃希菌...     

Percutaneous transhepatic biliary drainage in patients with malignant biliary obstruction of the hepatic confluence.

Despite many studies on percutaneous transhepatic biliary drainage (PTBD), there are no satisfactory reports of PTBD for malignant obstruction of the hepatic confluence. In this study, the results of PTBD using the direct anterior approach under fluoroscopic guidance are described in 16 patients with malignant biliary obstruction of the hepatic confluence. A total of forty-two drainage catheters were placed in the 16 patients: one catheter was placed in three patients; two catheters in six; three catheters in four; four catheters in two; seven catheters in one. PTBD was successful in 100% of the cases with no mortality or critical complications, and the biliary decompression effect of PTBD was highly satisfactory. Nine patients underwent histologically curative hepatectomies. Two of the nine resected cases died of postoperative hepatic failure, but the postoperative course in the others was satisfactory. The authors stress that selective biliary drainage for each isolated segmental duct is mandatory for advanced malignant obstruction of the hepatic confluence.     

内镜下胆道支架置入术治疗恶性胆道梗阻122例

目的:探讨经内镜逆行胰胆管造影技术(ERCP)在恶性胆道梗阻中的应用.方法:收集2003-07/2007-12临床确诊为恶性胆道梗阻患者122例,均采用ERCP及留置内支架,比较手术前后血清总胆红素变化情况.结果:全组122例胆管恶性梗阻中,行ERCP操作138例次,置管成功128例次,操作成功率92.75%.消除黄疸总有效率96.88%,并发症发生率为7.97%.108例置管成功且治疗有效者全部跟踪随访,其中86例在随访期内死亡,存活期为7.14±5.13 mo,22例至今仍存活,全组生存中位时间7.2 mo.结论:胆道支架置入术治疗恶性梗阻性黄疸疗效确切,安全性高,能提高患者生活质量.     

经皮经肝胆管内外引流术治疗恶性胆道梗阻的疗效观察

目的观察并比较经皮经肝穿刺胆管内外引流术治疗ERCP难治性恶性胆道梗阻的远期疗效和并发症。方法回顾性分析1999年9月至2005年12月上海长海医院经皮经肝穿刺胆管内外引流术治疗ERCP难治性恶性胆道梗阻患者的资料,比较行胆管金属支架内引流术和导管外引流术术后黄疸消退时间、无黄疸生存期、需再次施行胆管穿刺引流术的例次数和并发症。共67例患者入选,其中,内引流组28例(男18例,女10例),平均年龄(63．4±11．3)岁;外引流组39例(男30例,女9例);平均年龄(61．5±13．2)岁。结果内引流组和外引流组术后黄疸明显消退率分别为85．71％和79．48％(P>0．05);皮肤巩膜黄染平均消退时间为(21．4±18．6)和(34．2±23．6)d(P< 0．05);术后平均无黄疸生存期为(5．4±3．7)和(2．6±2．1)个月(P<0．01);需再次施行胆管穿刺引流术分别为3例次和16例次(P<0．05);内引流组阻塞性黄疸合并胆道感染3例、肠梗阻2例,外引流组导管移位和脱落14例、导管堵塞5例、出血和胆漏各1例,并发症发生率两组差异有统计学意义(P<0．05)。结论经皮经肝穿刺金属支架内引流术较导管外引流术能更显著地缩短ERCP难治性胆管恶性梗阻患者黄疸消退时间、延长无黄疸生存期,减少重复介入次数和并发症。     

经皮肝穿刺胆道取石治疗胆总管结石患者影响引流持续时间的因素分析*

目的 探讨影响经皮肝穿刺胆道引流(PTBD)治疗胆总管结石(CBDS)患者引流持续时间的因素。方法 2019年4月～2021年3月我院收治的112例CBDS患者均接受PTBD治疗。收集临床资料,以PTBD平均引流时间加标准差之和为截断点,将患者分为PTBD 持续时间延长组和正常组,应用多因素Logistic回归分析影响引流延长的因素。结果 在112例CBDS患者中,109例(97.3%)患者成功取出结石,其中81例胆道引流时间短于17天,另28例超过17天;PTBD持续时间延长组血清总胆红素【(38.1±7.3)μmol/L对(24.2±6.2)μmol/L】、淀粉酶【(403.7±15.6)U/L对(92.7±13.2)U/L】 、ALP【(302.3±52.1)U/L对(180.7±50.2)U/L】、GGT【(176.6±16.7)U/L对(93.3±15.6)U/L】、C反应蛋白【(75.1±12.2)mg/L对(56.9±10.3)mg/L】和结石直径【(16.9±2.5)mm对(11.3±2.1)mm】等均显著高于PTBD持续时间正常组,差异有统计学意义(P＜0.05);多因素Logistic回归分析显示血清总胆红素(OR:4.092,95%CI:1.684～9.944)和淀粉酶水平(OR:3.277,95%CI:1.348～7.965)及结石直径(OR:3.651,95%CI:1.502～8.873)是影响CBDS患者PTBD持续时间的独立因素(P＜0.05)。结论 采用PTBD治疗CBDS患者成功率高,了解一些容易导致引流时间延长的因素有助于做好术前准备和术后管理。     

经皮肝穿刺胆道内支架植入治疗恶性胆道梗阻64例

目的：总结经皮肝穿刺胆道内支架植入治疗恶性梗阻性黄疸的经验,探讨其临床疗效及价值。方法：64例患者均采用X线透视下经皮肝穿刺胆道内支架植入术治疗恶性梗阻性黄疽。根据梗阻部位的不同解剖决定放置支架的方式。结果：64例患者中,50例植入单支支架于肝总管或(和)胆总管,14例植入2支以上支架于总管和分支胆管,其中2例肝内胆管支架的桥接通过肝实质。58例患者2周内血清胆红素降低75％以上。结论：经皮肝穿刺刺内支架植入是治疗恶性胆道梗阻性的有效方法。     

Biliopancreatic and biliary leak after pancreatoduodenectomy treated by percutaneous transhepatic biliary drainage

BackgroundComplementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication.MethodsAll patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014–2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage.ResultsFollowing 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21–60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2).ConclusionAlthough drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy.     

三种非手术胆管引流方法治疗肝门部恶性胆道梗阻的疗效评估

目的探讨不同非手术胆管引流方法治疗肝门部恶性胆道梗阻（MHBO）的疗效和并发症发生率。方法245例MHBO患者分为3组,其中内镜治疗组86例、经皮治疗组104例、内镜与经皮联合组（联合治疗组）55例。245例患者中,BismuthⅠ型31例、Ⅱ型24例、Ⅲ型108例、Ⅳ型74例。对各组患者的临床资料进行回顾性分析,并对其中具有可比性的数据进行统计学处理。结果内镜治疗组、经皮治疗组和联合治疗组减黄有效率分别为82．4％（56／68,除外18例近期并发胆管炎行PTBD者）、72．1％（75／104）和89．1％（49／55）,其中Bismuth Ⅲ型患者减黄有效率分别为78．6％（22／28,除外7例近期并发胆管炎行PTBD者）、69．8％（30／43）和90．0％（27／30）,且Ⅲ型患者中双侧引流减黄有效率89．5％（34／38）明显优于单侧引流73．0％（46／63）。内镜治疗组近期并发胆管炎19例,发生率为22．1％（19／86）,明显高于经皮治疗组的5．8％（6／104）和联合治疗组的5．5％（3／55）（P均〈0．05）。Bismuth Ⅲ型及以上患者中,内镜、经皮及联合治疗组近期胆管炎发生率分别为33．3％（18／54）、6．6％（5／76）和5．8％（3／52）,内镜治疗组明显高于其他两组（P〈0．05）。结论对于不能手术的MHBO,内镜和（或）经皮方法减黄治疗有效,但内镜治疗胆管炎发生率高;Bismuth Ⅲ型及以上患者内镜与经皮联合治疗胆管炎并发症发生率低,减黄效果好。     

胆管内外引流治疗内镜难治性恶性胆道梗阻的对比研究

目的　比较经皮经肝穿刺胆管金属支架内引流术与导管外引流术治疗内镜难治性恶性胆道梗阻的疗效及并发症。方法　回顾性分析 1999年 9月至 2 0 0 2年 8月上海长海医院对内镜难治性恶性胆道梗阻患者施行经皮经肝穿刺胆管引流术的资料 ,比较两种引流术前后和引流术间肝功能的差异及并发症。共 2 7例患者 (2 9例次 )入选。其中 ,内引流组 13例 (13例次 ) ,男 9例 ,女 4例 ,平均年龄 6 2 5岁 ;外引流组 15例 (16例次 ) ,男 9例 ,女 6例 ,平均年龄 6 0 8岁。结果　术前 2～ 4d及术后5～ 7d血清总胆红素 (TB)在内引流组分别为 (2 79 19± 10 8 15 ) μmol/L和 (15 8 0 2± 99 97) μmol/L ,外引流组为 (2 6 1 0 9± 10 6 4 8) μmol/L和 (172 81± 10 6 4 8) μmol/L。血清直接胆红素 (DB)内引流组为(2 2 6 83± 84 0 3) μmol/L和 (132 5 7± 80 16 ) μmol/L ,外引流组为 (2 0 8 0 3± 95 0 3) μmol/L和 (14 2 6 1±83 74 ) μmol/L。术前两组间TB和DB差异无显著性 (P >0 0 5 ) ;术后两组TB和DB均较术前显著降低 (P <0 0 1) ;术后TB和DB降低幅值在内引流组显著高于外引流组 (P <0 0 5 )。内引流组 1例出现胆漏和肠梗阻 ,1例出血 ;外引流组 2例导管移位和脱落 ,1例导管堵塞 ,1例出血 ,1例胆漏     

Percutaneous transhepatic versus EUS-guided gallbladder drainage for malignant cystic duct obstruction

1. Download high-res image (282KB)
2. Download full-size image