Risk Prediction for Early Biliary Infection after Percutaneous Transhepatic Biliary Stent Placement in Malignant Biliary Obstruction

PurposeTo establish a nomogram for predicting the occurrence of early biliary infection (EBI) after percutaneous transhepatic biliary stent (PTBS) placement in malignant biliary obstruction (MBO).Materials and MethodsIn this multicenter study, patients treated with PTBS for MBO were allocated to a training cohort or a validation cohort. The independent risk factors for EBI selected by multivariate analyses in the training cohort were used to develop a predictive nomogram. An artificial neural network was applied to assess the importance of these factors in predicting EBI. The predictive accuracy of this nomogram was determined by concordance index (c-index) and a calibration plot, both internally and externally.ResultsA total of 243 patients (training cohort: n = 182; validation cohort: n = 61) were included in this study. The independent risk factors were length of obstruction (odds ratio [OR], 1.061; 95% confidence interval [CI], 1.013–1.111; P = .012), diabetes (OR, 5.070; 95% CI, 1.917–13.412; P = .001), location of obstruction (OR, 2.283; 95% CI, 1.012–5.149; P = .047), and previous surgical or endoscopic intervention (OR, 3.968; 95% CI, 1.709–9.217; P = .001), which were selected into the nomogram. The c-index values showed good predictive performance in the training and validation cohorts (0.792 and 0.802, respectively). The optimum cutoff value of risk was 0.25.ConclusionsThe nomogram can facilitate the early and accurate prediction of EBI in patients with MBO who underwent PTBS. Patients with high risk (> 0.25) should be administered more effective prophylactic antibiotics and undergo closer monitoring.     

经皮经肝胆道支架治疗恶性胆道梗阻的临床分析

目的探讨胆道恶性梗阻时经皮经肝穿刺胆道镍钛记忆合金支架置入术及其临床疗效。方法18例恶性胆道梗阻患者,采用二步法在X线透视定位下共置入支架20枚。支架放置成功后,经长鞘管注入造影剂,及时了解支架膨胀情况及通畅性,最后放置外引流管。支架选用南京微创医学科技有限公司生产的镍钛记忆合金支架。术后观察病人黄疸变化情况,肝功能及血清淀粉酶变化,随访3~11个月。结果18例均一次性置入成功。支架置入后1周,血清总胆红素(STB)下降66.27%,丙氨酸氨基转移酶(ALT)下降57.83%,天门冬氨酸氨基转移酶(AST)下降62.21%,r-谷氨酰转肽酶(r-GT)下降44.74%,血清碱性磷酸酶(ALP)下降47.57%。早期并发症包括高淀粉酶血症、急性腹膜炎、胆道出血、胆漏等。晚期主要有支架移位或再狭窄。随访期间1例死于心、肺功能衰竭。结论经皮经肝穿刺胆道支架置入术治疗不能手术切除的恶性梗阻性黄疸,是一种姑息性治疗胆道恶性梗阻的有效方法。     

经皮穿肝经口腔双途径联合支架置入治疗胆管和十二指肠恶性梗阻

目的:探讨胆管和十二指肠恶性梗阻双途径联合支架置入介入治疗的方法和效果.方法:23 例胆管和十二指肠恶性梗阻,17例先经皮肝穿刺置入金属支架解除胆管梗阻,出现十二指肠梗阻后,再在X线透视下,经口腔置入记忆合金网状十二指肠内支架.6例因胆管与十二指肠恶性梗阻并存,先置入十二指肠内支架并同时置入胆管支架.测定术前、术后血清总胆红素水平及体重并进行t检验.结果:23例患者双途径联合支架置入成功后,术前、术后血清总胆红素水平及体重比较差异均有显著性意义(P＜0.05).十二指肠支架置入后,消化道梗阻症状迅即解除,当日即能进食,均无严重并发症发生.随访1～20个月进食情况均良好.结论:经皮肝穿经口腔双途径联合支架置入治疗胆管和十二指肠恶性梗阻是首选的有效治疗方法.     

金属内支架姑息性治疗恶性梗阻性黄疸的临床应用(附53例报告)

目的:研究经皮胆道金属内支架植入术姑息性治疗恶性梗阻性黄疸的临床价值。材料和方法:53例恶性梗阻性黄疸患者在经皮胆道造影后进行了经皮胆道金属内支架植入术,共植入内支架58枚。结果:全组内支架植人的成功率98.1%(52/53);52例治疗前后血清总胆红素相差值为182±67μmol/L,P<0.005,其中总胆红素恢复正常或接近正常者39例;下降百分比750%者7例;25%～50%者3例;<5%者3例。全组30天病死率3.8%(2/53),早期并发症15.1%(8/53)。在平均随访6.9个月内,再阻塞率13.8%(4/29),4例均进行了再次介入治疗。结论:经皮金属内支架胆道植入术是姑息性治疗手术不能切除的恶性梗阻性黄疸有效方法。     

经皮肝穿胆道内支架置入术治疗恶性胆管梗阻

目的：探讨经皮肝穿胆道内支架置入术治疗恶性胆管梗阻的疗效及技术要点。方法：３５例恶性胆管梗阻采用经皮肝穿刺肝管胆道内支架置入术，其中胰头癌１３例，肝转移癌５例、肝门淋巴结转移压迫胆管７例、胆管癌１０例。结果：共置入３种４３枚金属内支架，其中８例采用双内支架，技术操作成功率１００％。术前血清总胆红素１７０．００～８６０．０ｕｍｏＩ／Ｌ，术后３１例降至１８．２～５３．６ｕｍｏＩ／Ｌ。半年以上生存率７７．１４％（２７／３５），１年以上生存率４８．５７％（１７／３５）。本组无严重并发症，轻度并发症未作特殊处理。结论：经皮肝穿胆道内支架置入术，是不能手术的恶性胆管梗阻安全、有效的治疗方法。配合动脉插管化疗可显著提高其疗效     

Percutaneous Unilateral Biliary Metallic Stent Placement in Patients with Malignant Obstruction of the Biliary Hila and Contralateral Portal Vein Steno-Occlusion

Objective

To investigate the outcomes of percutaneous unilateral metallic stent placement in patients with a malignant obstruction of the biliary hila and a contralateral portal vein steno-occlusion.

Materials and Methods

Sixty patients with a malignant hilar obstruction and unilobar portal vein steno-occlusion caused by tumor invasion or preoperative portal vein embolization were enrolled in this retrospective study from October 2010 to October 2013. All patients were treated with percutaneous placement of a biliary metallic stent, including expanded polytetrafluoroethylene (ePTFE)-covered stents in 27 patients and uncovered stents in 33 patients.

Results

A total of 70 stents were successfully placed in 60 patients. Procedural-related minor complications, including self-limiting hemobilia (n = 2) and cholangitis (n = 4) occurred in six (10%) patients. Acute cholecystitis occurred in two patients. Successful internal drainage was achieved in 54 (90%) of the 60 patients. According to a Kaplan-Meier analysis, median survival time was 210 days (95% confidence interval [CI], 135-284 days), and median stent patency time was 133 days (95% CI, 94-171 days). No significant difference in stent patency was observed between covered and uncovered stents (p = 0.646). Stent dysfunction occurred in 16 (29.6%) of 54 patients after a mean of 159 days (range, 65-321 days).

Conclusion

Unilateral placement of ePTFE-covered and uncovered stents in the hepatic lobe with a patent portal vein is a safe and effective method for palliative treatment of patients with a contralateral portal vein steno-occlusion caused by an advanced hilar malignancy or portal vein embolization. No significant difference in stent patency was detected between covered and uncovered metallic stents.     

外科姑息性手术后经皮胆道内支架置入术治疗恶性梗阻性黄疸

有关文献统计大多数恶性胆道狭窄的患者失去了根治性手术机会 ,因而我们对 7例恶性胆道狭窄的患者行外科姑息性手术 ,并于术中留置Ｔ管或ＰＴＣＤ引流管 ,术后行胆管内支架置入术 ,配合肝动脉插管化疗和栓塞治疗可提高患者的生存期[1,2 ] 。现报告如下。1　资料与方法1.1　临床资料　本组 7例恶性胆道狭窄的患者 ,男 6例 ,女 1例。年龄 40～ 70岁 ,平均 5 9.2岁。阻塞部位 :胆总管 4例 ,肝管 3例。肿瘤部位 :胰头癌 2例 ,肝癌 1例 ,肝转移癌 1例 ,肝门淋巴结转移压迫胆总管 1例 ,胆管癌 2例。狭窄病变长 2 .0～ 7.0ｃｍ(图 2 ) ,平均 4.4ｃ…     

经皮肝穿刺胆道支架置入及引流术治疗梗阻性黄疸

目的 探讨梗阻性黄疸经皮肝穿刺胆道支架置入及引流术的治疗方法与疗效.方法 对44例胆道梗阻患者先行经皮肝穿刺胆道造影(PTC),如导丝不能越过阻塞段,则直接行外引流;如能越过阻塞段,则行支架置入或内外引流术.结果 44例患者中6例单纯外引流;7例单纯内外引流;2例仅行PTC胆道造影而未行胆道引流;29例置入支架32枚,其中19例行支架置入 外引流,10例单纯支架置入.在有完整随访资料的16例中,术后1周血清总胆红素从术前(351±142.4)μmol/L降至(143.5±97.6)μmol/L,13例血清总胆红素1个月降到正常或接近正常水平,3例血清总胆红素1个月无明显下降(＜50%).死亡9例,生存时间3～21个月,中位生存期6.8个月.结论 经皮肝穿刺胆道支架置入及引流术是治疗梗阻性黄疸的一种安全、有效的姑息性方法.     

Safety and Efficacy of Percutaneous Biliary Covered Stent Placement in Patients with Malignant Biliary Hilar Obstruction; Correlation with Liver Function

Purpose

To estimate the safety and efficacy of percutaneous ePTFE-covered biliary stent placement and the relationship between underlying liver function and stent patency in patients with malignant hilar obstruction.

Materials and Methods

From March 2012 to June 2015, 41 patients [22 females, 19 males; mean age 69.8 (range 34–94) years] with malignant biliary obstruction underwent percutaneous biliary stent placement (31 patients with unilateral, 10 patients with bilateral side-by-side). Cumulative patient survival and stent patency rate curves were derived using the Kaplan–Meier method. A Cox model was used to explore the relationship between liver function and patient survival, and also biliary stent patency. Pearson correlation coefficient was used to analyze the relationship between patient survival and stent patency.

Results

Technical success rate was 100 % and clinical success rate was 95 %. During follow-up, four complications occurred (two bilomas and two cases of acute cholecystitis) and were treated successfully with percutaneous drainage. No other complication occurred. Mean serum bilirubin level was 11.34 ± 7.35 mg/dL before drainage and 5.00 ± 4.83 mg/dL 2 weeks after stent placement. The median patent survival duration was 147 days (95 % CI, 69.6–224.4 days). The median stent patency duration was 101 days (95 % CI, 70.0–132.0 days). The cumulative stent patency rates at 1, 3, 6, and 12 months were 97, 57.6, 30.3, and 17.0 %, respectively. Child–Pugh score was correlated significantly with patient survival (P = 0.011) and stent patency (P = 0.007). MELD score was correlated significantly with stent patency (P = 0.044). There was a correlation between patient survival and stent patency (r = 0.778, P < 0.001).

Conclusion

Percutaneous placement of ePTFE-covered biliary stent was a safe and an effective method for malignant biliary obstruction. Underlying liver function seemed to be one of the important factors affecting patient survival and stent patency, and stent patency showed statistically significant correlation with patient survival.

     

Comparative Study of Percutaneous Transhepatic Biliary Stent Placement with or without Iodine-125 Seeds for Treating Patients with Malignant Biliary Obstruction

Purpose

To prospectively evaluate safety and efficacy of biliary stent placement with iodine-125 (¹²⁵I) seeds in patients with malignant obstructive jaundice (MOJ).

Malignant Hilar Biliary Obstruction: Treatment by Means of Placement of a Newly Designed Y-Shaped Branched Covered Stent

Purpose

To evaluate the technical feasibility and clinical efficacy of placement of a newly designed Y-shaped branched covered stent for palliative treatment of malignant hilar biliary obstruction.

Methods

From June 2011 to September 2014, 34 consecutive patients with malignant hilar biliary obstruction underwent percutaneous placement of a Y-shaped branched covered stent for palliative treatment. Technical and clinical success, complications, cumulative patient survival, and stent patency were evaluated.

Results

Stent placement was technically successful in all patients. All patients showed adequate biliary drainage on the follow-up cholangiogram. Mean serum bilirubin level (10.9 mg/dl) decreased significantly 1 week (5.7 mg/dl) and 1 month (2.6 mg/dl) after stent placement (p < 0.01). Complications associated with the procedure included hemobilia (n = 3) and biloma (n = 1). During the mean follow-up period of 225 (range 12–820) days, nine patients (26.5 %) developed stent occlusion caused by tumor overgrowth (n = 8) and sludge (n = 1). Two of them underwent coaxial placement of a second stent with good results. The median survival time was 281 days and median primary stent patency was 337 days. There were no significant differences in the patient survival and stent patency rates in relation to age, sex, or Bismuth type.

Conclusion

Percutaneous placement of the Y-shaped branched covered stent seems to be technically feasible and clinically effective for palliative treatment of malignant hilar biliary obstruction.

     

金属内支撑架在缓解治疗恶性胆管梗阻中的应用

本文报道１１例胆管恶性梗阻经ＥＲＣＰ放置金属内置管引流。患者原发性胆管癌７例，转移性癌４例，采用Ｗａｌｌ ｓｔｅｎｔ １０例，Ｓｔｒｅｃｋｅｒ ｓｔｅｎｔ１例，导管周径７￣９Ｆ，长４￣９．３ｃｍ，引流效果满意。     

胆管内支架治疗肝门部胆管梗阻

目的 探讨肝门部胆管梗阻置入支架治疗梗阻性黄疸的可行性和操作方法.资料与方法 28例肝门部胆管梗阻患者经皮经肝穿刺,分别在左右肝管置入支架.经单侧穿刺5例,经左右肝分别穿刺23例.2枚支架并排放置21例,经第1枚支架网眼放置第2枚支架7例.结果 手术成功率100%,无与操作有关的严重的并发症发生,血胆红素术前(19.34±15.47) mg/dl,术后1周内下降为(9.75±8.21) mg/dl.生存期25～816天(平均213天).结论 通过介入手段置入胆管内支架是缓解肝门部梗阻引起的黄疸安全、有效的方法 .     

Intravascular Ultrasound–Guided Transcaval Cholangiography to Facilitate Percutaneous Biliary Drain Placement in a Nondilated System

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经皮肝穿刺胆道支架植入后再狭窄分析及介入治疗

目的探讨恶性胆道梗阻性黄疸经皮肝穿刺胆道支架置放术后支架再狭窄原因及介入治疗。方法20例胆道支架再狭窄患者,根据术后引流量及黄疸消退情况,于2周,1个月,2个月,3个月复查肝功、血、尿、粪及B超、CT、经引流管胆道造影,确认支架再狭窄性质、部位后,利用外置引流管途径行介入再通治疗。支架均为国产普通镍钛合金胆道支架,直径10mm,长度40~80mm。结果20例支架再狭窄中,9例为肿瘤浸润压迫所致,3例为支架上端成角致阻塞,4例为胆泥及食物残渣或陈旧性凝血块阻塞支架,2例为胆管炎性狭窄,2例为肉芽组织增生引起阻塞。全部再狭窄病例经引流管抽吸、药物灌注、冲洗、导管导丝疏通、球囊扩张、支架再植入予以复通,生存期超过6个月。结论经皮肝穿刺胆道支架植入术治疗恶性胆道梗阻,术后支架再狭窄率仍较高,应引起重视。     

经皮肝穿刺胆道引流术介入治疗恶性胆道梗阻

目的探讨经皮肝穿刺胆道引流(PTCD)术和植入支架治疗恶性胆道梗阻的疗效及其并发症。方法75例恶性胆道梗阻的患者在DSA的引导下接受经皮肝穿刺胆道引流。结果37例单纯放了内外引流管,38例放置了胆道支架,其中9例为双支架,3例术后行经肝动脉化疗和/或栓塞。减黄总有效率达85.4%。支架阻塞5例。主要并发症:败血症3例,肝功能损害6例,肝动脉假性动脉瘤2例。结论PTCD术成功率高,减黄疗效好,是姑息性治疗恶性胆道梗阻安全、简单的治疗方法。     

开腹胆肠吻合与开腹胆道支架置入治疗恶性梗阻性黄疸的疗效观察

目的：探讨开腹胆肠吻合及开腹胆道支架置入在恶性梗阻性黄疸患者临床治疗中的应用价值及选择。方法：回顾分析71例不能根治切除的恶性梗阻性黄疸患者采用开腹胆肠吻合（n=44）及开腹置入记忆金属合金胆道内撑支架（n=27）治疗的情况。结果：所有患者均完成胆肠吻合或胆管末端支架置入达到内引流。术后胆红素均在术后第1周下降约100μmol/L;谷草转氨酶、谷丙转氨酶、碱性磷酸酶在术后第2周以后开始较术前明显下降（P〈0.05）。全组中位生存时间为22周,平均生存（31.69±33.24）周。全组死亡4例,死亡率5.63%。主要并发症有胆管炎12例,胆道出血5例,肝功能衰竭3例,多器官功能衰竭3例。结论：开腹胆肠吻合及开腹胆道支架置入均可有效解除恶性梗阻性黄疸患者胆道梗阻,改善肝功能;临床应根据患者的局部及全身情况选择不同的手术方式,提高安全及有效性,尽可能减少并发症的发生。     

恶性胆道梗阻的磁共振胰胆管成像表现与病理对照研究

目的研究恶性胆道梗阻的MR胰胆管成像表现、分型,并与病理对照。方法37例恶性胆道梗阻患者,常规T1WI、T2WI及脂肪抑制T2WI检查后,行MRCP检查。根据病变发生部位分型。并将每种类型的MRCP表现与病理组织学结果对照。结果37例患者,根据MRCP表现分成4种类型。其中I型3例,病理为肝内胆管细胞癌;II型7例,病理为胆管癌4例,胆囊癌3例;Ⅲ型14例,胆管癌4例,胆囊癌3例,胰头癌2例,壶腹癌3例,十二指肠癌2例;Ⅳ型13例,胆管癌6例,胰头癌4例,壶腹癌3例。结论恶性胆道梗阻有不同的MRCP表现,反映其病理组织学变化。     

Percutaneous Stent Placement as Treatment of Renal Vein Obstruction Due to Inferior Vena Caval Thrombosis

A patient who had undergone his third orthotopic liver transplantation nearly 9 years prior to presentation developed worsening hepatic and renal function, as well as severe bilateral lower extremity edema. Magnetic resonance imaging demonstrated vena caval thrombosis from the suprahepatic venous anastomosis to the infrarenal inferior vena cava, obstructing the renal veins. This was treated by percutaneous placement of metallic stents from the renal veins to the right atrium. At 16 months clinical follow-up, the patient continues to do well.