无痛性慢性胰腺炎的治疗及疗效

目的探究成人无腹痛慢性胰腺炎（CP）的治疗方法及其疗效。方法总结近10年CP患者临床资料,分析成人无痛性CP患者治疗措施及疗效。结果成人无痛性CP共56例,成功随访的46例（82．1％）中,男31例,女15例,年龄（51．6±14．5）岁,随访时间（34．5±27．1）个月。（1）CP胰管结石、胰管改变者26例：内镜介入治疗14例,外科手术治疗7例,两者联合治疗3例,保守治疗2例。（2）CP影像学表现为胰腺或腺周占位的18例：均外科手术治疗。以上两组患糖尿病和腹泻症状者均无减少,部分患者一般情况有改善;各1例患者死于胰腺癌。1例胰管结石患者取石术后结石复发。（3）CP胰管改变合并胰腺囊肿者2例：内镜与外科治疗各1例,后者手术后出现胃出血及肝硬化、黄疸,原因不明。结论内镜与外科治疗无痛性CP胰管结石疗效相近,而影像学表现为胰腺或腺周占位的CP则以外科手术为首选,单纯胰管改变患者治疗尚需观察。各种治疗仅可改善部分无痛性CP患者的一般情况;并应加强对无痛性CP患者的随访和定期复查。     

慢性胰腺炎继发胆总管狭窄诊治进展

胆总管狭窄（common bile duct stricture,CBDS）为慢性胰腺炎（CP）的常见并发症,可导致肝功能异常、胆管炎等,严重时可进展为胆汁性肝硬化,内镜介入和开腹手术为主要治疗方式.内镜介入目前已成为临床一线治疗手段,手术主要适用于无法排除肿瘤和内镜治疗失败的患者.本文从CP继发CBDS的临床特征、自然病程、治疗方案选择及临床疗效等方面做一综述.     

内镜超声检查对胆总管无扩张伴可疑胆总管结石的诊断价值

目的 探讨胆总管无扩张伴可疑胆总管结石患者（CBDS）行超声内镜检查（EUS）的价值.方法 对33例经多次腹部B超检查诊断胆囊结石,胆总管直径〈8 mm,未发现CBDS但有急性胰腺炎、阻塞性黄疸或反复胆绞痛等病史之一的患者行EUS,并与手术或ERCP结果进行比较.结果 33例患者行EUS,20例发现CBDS.经进一步手术或ERCP,该20例患者中有16例证实有CBDS.EUS对本组病例CBDS诊断的灵敏度为100%,特异度为76.5%,阳性预测价值为80%,阴性预测价值为100%.结论 对胆总管无扩张但有可疑CBDS者行EUS检查有较高的临床价值.     

慢性胰腺炎胆胰管狭窄的支架治疗

慢性胰腺炎为各种因素所致的胰腺反复发作性或持续性炎性病变，导致胰腺腺泡和胰岛组织萎缩、胰腺纤维化等，进而引起胰腺内外分泌功能不足。酒精是最常见的致病原因。CP患者常伴有胰管和（或）胆管狭窄和梗阻，引起管内液体引流不畅，管内压力升高，常引起腹痛等症状。胆总管梗阻还可以导致胆汁淤积、黄疸和胆管炎。外科手术虽然对CP及其并发症的治疗有较好的疗效，     

慢性胰腺炎内镜治疗的前瞻性研究

目的前瞻性研究内镜治疗慢性胰腺炎（CP）的长期疗效。方法根据M—ANNHEIM分类系统的CP诊断标准,将纳入的CP患者进行内镜治疗,包括内镜下行十二指肠乳头括约肌切开或胰管括约肌切开、胰管取石、胰管狭窄扩张、胰管支架放置,对患者治疗前后急性胰腺炎发作次数、腹痛、体重、内外分泌功能、胰管最大直径的变化情况进行分析。结果2006年1月1日至2007年12月31日共入选107例诊断明确的CP患者,男74例,女33例,平均年龄41．2岁,成功随访105例,失访2例,平均随访时间为15（3～27）个月,其中有4例转外科手术治疗,余101例患者腹痛完全缓解和部分缓解的分别有70例和19例,腹痛缓解率为88．1％（89／101）;内镜治疗前后糖尿病患者数均为10例,脂肪泻患者数分别为10例和3例;内镜治疗后有56．4％（57／101）的患者体重增加,平均增加4kg;内镜治疗前后胰管直径无显著变化,胰管直径的变化和内镜疗效无明显联系。结论内镜治疗可缓解CP的腹痛症状,增加患者体重。     

胰管内支架置入术联合化瘀清胰汤治疗慢性胰腺炎15例

[目的]观察内镜下胰管内支架置入术联合化瘀清胰汤治疗慢性胰腺炎（CP）的临床疗效。[方法]40例CP患者随机分为A组（12例）采用西医综合治疗;B组（13例）在西医综合治疗的基础上给予化瘀清胰汤,口服或鼻饲;C组（15例）在B组治疗的基础上行内窥镜逆行胆囊-胰腺造影（ERCP）术、胰管内支架置入术,疗程为7 d,观察3组患者治疗后临床症状、体征缓解时间及生化指标恢复正常时间,并随访半年。[结果]手术成功率100%,C组腹痛腹胀、恶心呕吐、脂肪泻3项症状积分显著优于A、B组,3组相比,C组总有效率（86.7%）明显高于A、B组（58.3%、76.9%）（P〈0.05）。随访结果显示,C组患者体质量均有一定程度增加,治疗后随访体质量指数（BMI）（平均27.5±14.8）较治疗前（平均21.3±2.5）明显提高（P〈0.05）。[结论]内镜下胰管内支架置入术联合清胰化瘀汤治疗CP,较单纯西医综合治疗与单纯中西医结合内科治疗疗效更好,更安全、可靠。     

内镜乳头括约肌小切开联合气囊扩张术6例临床分析

我院自 1997年 6月至 1998年 12月,对 6例胆总管残留结石和胆总管蛔虫嵌顿患者采用小切口内镜乳头括约肌切开术（ EST）联合乳头球囊扩张术（ EPBD）治疗取得满意疗效,现报道如下。 　　一、资料与方法 　　1．一般资料：本组 6例,男 4例,女 2例;年龄 18～ 72岁,平均 52岁。术前经 B超、内镜逆行胰胆管造影术（ ERCP）及实验室检查诊断为胆总管结石 4例,胆总管蛔虫常规取虫致蛔虫嵌顿 2例。 6例中 2例并发重症急性胆管炎 (ACST), 5例伴黄疸, 3例有胆囊切除或胆道手术史,胆总管结石直径在 1.5 cm以下,术前准备同常规 EST…     

经内镜及外科手术治疗肝外胆管结石的疗效比较

目的探讨经内镜治疗肝外胆管结石的价值。方法将２００例肝外胆管结石患者分为内镜治疗组（内镜组）及外科手术组（手术组）各１００例,内镜组首先完成经内镜胆胰管造影,诊断确立后即时行十二指肠乳头切开术及胆管取石术;手术组确诊后根据病情选择不同术式,行开腹手术。结果内镜组治愈率为９８％,手术组为９０％（Ｐ＜０．０１）;黄疸消退时间内镜组为（３．０５±０．１２）天,手术组为（７．８３±０．３２）天（Ｐ＜０．０１）;残余结石发生率内镜组为２％,手术组为１０％（Ｐ＜０．０１）;住院时间内镜组为（４．６２±０．１７）天,手术组为（２３．５９±２．７６）天（Ｐ＜０．０１）。结论经内镜治疗肝外胆管结石的疗效明显优于手术疗效,是一种安全可靠的治疗方法。     

急诊腹腔镜手术治疗胆总管结石合并轻、中度急性胆管炎的疗效

目的:探讨腹腔镜胆总管探查取石术(common bile duct exploration,CBDE)联合胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆总管结石(common bile duct stones,C B D S)合并轻、中度急性胆管炎的安全性及有效性.方法:对2009-01/2012-12收治的37例胆囊结石伴CBDS合并轻、中度急性胆管炎患者行腹腔镜CBDE联合LC.除外有重度急性胆管炎、上腹部手术史、严重心肺及其他影响全麻或手术等疾病的患者.常规四孔法完成经胆总管切开的腹腔镜CBDE、T管引流及LC.根据术前MRCP了解结石大小、数量和位置,用推挤、冲吸及胆道镜等方法取石,病情不稳定者,不行术中胆道镜取石.所有患者均不行术中胆道造影.Winslow孔处常规放置腹腔引流管.有胆道残余结石者,术后8 wk行胆道镜取石.结果:37例胆囊结石伴CBDS合并轻、中度急性胆管炎患者,均顺利完成腹腔镜CBDE及LC.手术时间105.54 min±6.30 min;胆总管直径12.86 mm±0.58 mm;单发CBDS 14例(37.8%),多发CBDS 23例(62.2%);术后胆囊病理结果,急性胆囊炎9例(24.32%),慢性胆囊炎28例(75.68%);术后住院天数为11.27 d±0.82 d;总住院天数16.41 d±1.03 d.腹腔镜CBDE术后胆管炎症状及体征明显缓解,实验室检查结果改善.无中转开腹、术后腹腔出血、胆道损伤、手术死亡及伤口感染.术后胆漏4例,经保守治疗治愈.术后胆道残余结石4例,术后经T管窦道胆道镜取净结石.结论:对部分CBDS合并轻、中度急性胆管炎患者,腹腔镜CBDE及LC治疗是安全、有效及可行的.     

慢性胰腺炎的外科治疗及术式选择

目的 分析慢性胰腺炎（CP）外科治疗效果,探讨如何合理选择手术方式.方法 回顾性分析2007年1月至2011年12月哈尔滨医科大学第一附属医院手术治疗的54例CP患者的病例资料.结果 本组54例CP患者均行手术治疗,其中8例行单纯减压引流术（Partington术）;13例行切除术,包括7例胰十二指肠切除术（PD）、4例胰体尾部联合脾切除术、1例胰体尾部切除术（DP）及1例胰十二指肠联合胰体尾部切除术;12例行切除＋减压引流术,包括7例Beger术及5例Frey术;21例行其他手术（15例胰腺假性囊肿空肠吻合术,4例剖腹探查、胰腺组织活检术及2例胃空肠吻合、胆总管空肠吻合术）.术后病理证实4例CP已合并癌变.12例出现各种术后并发症,均经非手术治疗而治愈,无院内死亡病例.44例（81.5％）获得随访,随访时间2～ 67个月.42例术前明显腹痛者中36例（85.7％）获得持续缓解;术后新发糖尿病1例,无新发脂肪泻病例.结论 对于具备外科手术指征的CP患者,应以最大程度地保留胰腺内、外分泌功能为目的,遵循个体化治疗原则,合理选择手术方式,同时要兼顾手术的安全性及有效性.     

Endoscopic stenting for common bile duct stenoses in chronic pancreatitis: results and impact on long-term outcome.

OBJECTIVES: The overall incidence of common bile duct strictures due to chronic pancreatitis is reported to be approximately 10-30%. It remains a challenging problem for gastroenterologists and surgeons. The exact role of endoscopic stenting has not yet been clearly defined. DESIGN AND METHODS: Thirty-nine patients with chronic pancreatitis and symptomatic common bile duct stenoses underwent endoscopic stenting and were studied retrospectively. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stents in the long term. RESULTS: Indications for endoscopic stenting were symptomatic cholestasis, jaundice or cholangitis. The initial serum bilirubin was 8.3 mg/dl and the diameter of the common bile duct was 14.2 mm before stenting. Within 3-7 days of stenting, all patients presented improvement of jaundice and cholestasis. After a median stenting time of 9 months (range 1-144 months), 46% of the patients demonstrated regression of the stricture and clinical improvement, 26% required further stenting, and 28% were referred to surgery. Five patients received a self-expandable metal Wallstent. Thirty-one per cent demonstrated complete clinical recovery of the stricture as well as 10.2% a complete, radiologically verified stricture regression in a median follow-up of 58 months. CONCLUSIONS: There seems to be a therapeutic benefit for short-term endoscopic treatment but medium-term and long-term outcome remains questionable. Endoscopic stenting should be applied as an initial therapy before surgery, but it can be the definitive approach for older and morbid patients or cases with complete stricture regression after stent removal. Overall, it should not be considered as a routine procedure for symptomatic cases.     

Treatment of complications of hepatic hydatid disease by ERCP

BACKGROUND: The aim of this study was to evaluate the effectiveness of endoscopic sphincterotomy for preoperative and postoperative complications of hepatic hydatid disease. METHODS: Nineteen patients underwent endoscopic treatment for complications of hepatic hydatid disease. Indications for ERCP in 5 patients treated before surgery (Group A) were obstructive jaundice in 1 and acute cholangitis in 4. In 14 patients treated after surgery (Group B), the indication was acute cholangitis in 6, obstructive jaundice 2, and persistent external drainage in 6 patients. OBSERVATIONS: In group A, ERCP detected hydatid vesicles within the bile duct. All patients underwent endoscopic sphincterotomy and clearance of the duct with no complications. The 6 patients in Group B with persistent external drainage had biliary fistulas that resolved after endoscopic treatment within 10 to 20 days. Among the 8 patients with postoperative obstructive jaundice or acute cholangitis, 7 had cyst remnants obstructing the bile duct and 1 had findings of sclerosing cholangitis. All underwent endoscopic sphincterotomy and clearance of the bile duct without complications. After treatment, all patients, with the exception of the one with sclerosing cholangitis, remained asymptomatic. CONCLUSION: Endoscopic sphincterotomy is a safe and effective treatment for biliary complications of hepatic hydatid disease.     

Advances of recurrent risk factors and management of choledocholithiasis

Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%–22%, and common bile duct stones (CBDS) accounts for 8%–20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.     

Therapeutic Endoscopic Balloon Dilatation of the Extrahepatic Biliary Ducts

Nine patients with extrahepatic obstructive biliary or pancreatic disease underwent therapeutic endoscopic balloon dilatation over a 24-month period. There were 10 obstructing lesions including common bile duct strictures (six patients), bilioenteric anastomotic strictures (two patients), ampullary stenosis (one patient) and an ampullary neoplasm (one patient). Endoscopic balloon dilatation was performed to relieve cholestasis (five patients), as treatment for cholangitis (one patient), as therapy for acute pancreatitis (one patient), to facilitate delivery of common bile duct stones (one patient), and to allow placement of a biliary endoprosthesis (one patient). The procedure was successful in seven of 12 attempts (58%) and was associated with one major complication (8.0%). Endoscopic balloon dilatation can be an effective palliative therapeutic procedure, with a wide spectrum of use, which may eliminate the need for surgery.     

Long-term outcome of endoscopic metallic stenting for benign biliary stenosis associated with chronic pancreatitis

AIM:Endoscopic metal stenting(EMS)offers goodresults in short to medium term follow-up for bile ductstenosis associated with chronic pancreatitis(CP);however,longer follow-up is needed to determine if EMShas the potential to become the treatment of first choice.METHODS:EMS was performed in eight patients withsevere common bile duct stenosis due to CP.After theresolution of cholestasis by endoscopic naso-biliarydrainage three patients were subjected to EMS while,the other five underwent EMS following plastic tubestenting.The patients were followed up for more than5 years through periodical laboratory tests and imagingtechniques.RESULTS:EMS was successfully performed in all thepatients.Two patients died due to causes unrelated tothe procedure:one with an acute myocardial infarctionand the other with maxillary carcinoma at 2.8 and 5.5years after EMS,respectively.One patient died withcholangitis because of EMS clogging 3.6 years after EMS.None of these three patients had showed symptoms ofcholestasis during the follow-up period.Two patientsdeveloped choledocholithiasis and two suffered fromduodenal ulcers due to dislodgement of the stentbetween 4.8 and 7.3 years after stenting;however,theywere successfully treated endoscopically.Thus,five ofeight patients are alive at present after a mean follow-upperiod of 7.4 years.CONCLUSION:EMS is evidently one of the very promising treatment options for bile duct stenosisassociated with CP,provided the patients are closelyfollowed up;thus setting a system for their promptmanagement on emergency is desirable.     

Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy

Endoscopic sphincterotomy is an accepted treatment for retained common bile duct stones, but there is little specific information available regarding its application in acute suppurative obstructive cholangitis with sepsis due to choledocholithiasis. Thirteen patients with this condition were referred to the authors for consideration of urgent endoscopic common bile duct decompression. All had been judged to be poor surgical candidates. Pus was released from the common bile duct by sphincterotomy within 24 hours of admission in all 13. Stones were removed endoscopically in 10 patients (77%) without complications. After endoscopic stone removal, symptoms, signs, and abnormal laboratory values returned to normal rapidly; follow-up endoscopic retrograde cholangiography did not show retained stones. Three patients whose large stones precluded endoscopic removal underwent operative choledocholithotomy. Urgent endoscopic sphincterotomy offers an important alternative in the treatment of acute suppurative obstructive cholangitis secondary to choledocholithiasis.     

Histological assessment of cholestasis

The microscopic identification of bile in sections of liver provides an important diagnostic challenge for the histopathologist, particularly in differentiating the many causes of intrahepatic cholestasis from mechanical bile duct obstruction. The pathologist's chief goal in evaluating the cholestatic liver is to distinguish intrahepatic cholestasis (seen in conditions such as drug hepatotoxicity, viral hepatitis, sepsis, or mutations affecting bile transporters) from large bile duct obstruction caused by conditions such as choledocholithiasis, pancreatic carcinoma, biliary stricture, or primary sclerosing cholangitis (PSC). This distinction carries major therapeutic and prognostic significance, because surgical, endoscopic,or radiologically guided intervention is likely to be undertaken if the pathologic features point to mechanical obstruction of the bile ducts. The histologic assessment of cholestasis, in broad terms, therefore, is a morphologic approach to distinguish between medical jaundice and surgical jaundice.     

Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents.

Twenty patients with chronic pancreatitis and signs of biliary obstruction were treated by endoscopic placement of self expandable metal mesh stents, and followed up prospectively. Eleven had been treated previously with plastic endoprostheses. All had persistent cholestasis, seven patients had jaundice, and three overt cholangitis. Endoscopic stent placement was successful in all cases. No early clinical complication was seen and cholestasis, jaundice or cholangitis rapidly resolved in all patients. Mean follow up was 33 months (range 24 to 42) and consisted of clinical evaluation, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 18 patients, successive ERCPs and cholangioscopies have shown that the metal mesh initially embeds in the bile duct wall and is rapidly covered by a continuous tissue by three months. The stent lumen remained patent and functional throughout the follow up period except in two patients who developed epithelial hyperplasia within the stent resulting in recurrent biliary obstruction, three and six months after placement. They were treated endoscopically with standard plastic stents with one of these patients ultimately requiring surgical drainage. No patient free of clinical or radiological signs of epithelial hyperplasia after six months developed obstruction later. This new treatment could become an effective alternative to surgical biliary diversion if further controlled follow up studies confirm the initial impression that self expandable metal mesh stents offer a low morbidity alternative for longterm biliary drainage in chronic pancreatitis without the inconvenience associated with plastic stents.     

Endoscopic treatment of primary sclerosing cholangitis.

BACKGROUND/AIMS: Dominant stricture of an extrahepatic bile duct is responsible for symptoms and an exacerbation of cholestasis in 15-20% of patients with primary sclerosing cholangitis. The aim of this study was to evaluate the efficacy and safety of endoscopic treatment in this selected patient group. METHODS: Retrospectively, we evaluated 16 patients who were treated endoscopically due to elevation of serum biochemical liver tests and symptoms which were attributable to dominant bile duct strictures during the period 1990 to 2003. Symptoms and biochemical liver tests were compared before and after treatment. RESULTS: Sixteen patients underwent a total of 58 therapeutic endoscopic retrograde cholangiopancreatographies (ERCP). Sixteen endoscopic sphincterotomies, 15 balloon dilatations, 6 bougie dilatations, 3 stone/sludge extractions and 8 stentings were performed. Endoscopic therapy was technically successful in all patients (100%). Biochemical liver tests were significantly improved when compared with pretreatment values (p<0.001). Patients have been followed-up without stents except for the patients who had cholangiocarcinoma and cirrhosis at the beginning. Procedure-related early complications occurred in 8.6% of therapeutic endoscopic biliary procedures. There was no mortality due to endoscopic treatment. Two patients whose stents were changed every two to three months had cholangitis due to stenting during 13 stent periods. Four patients whose stents were changed in seven to 10 days developed suppurative cholangitis (total 6 stent periods). CONCLUSIONS: Endoscopic therapy of symptomatic dominant strictures in primary sclerosing cholangitis is safe and effective. The cholangitis seen in long-term stenting seems to be solved by short-term stenting.