原发性肝癌伴胆管癌栓导致阻塞性黄疸的诊治

目的；探讨原发性肝癌继发胆管癌栓引起阻塞性黄疸（阻黄）的临床表现，诊断，治疗及手术方式与预后的关系。方法：回顾分析我院收治的11例阻黄患者的临床资料。结果：患者的临床症状不典型，入院后按常规均行化验及B超，CT、ERCP，MRCP，PTC等检查，并分别行肝原发癌灶切除，胆管癌栓清除，T管引流，肝动脉插管埋泵等手术治疗，术前诊断符合率为45.5%。术后对症化疗，患者预后与术式有关，行切除肝内原发肿瘤 胆道癌栓清除术者预后较好，行单纯癌栓清除术者预后较差。结论：原发性肝癌继发胆管癌栓引起阻黄术前不易诊断，应选择多种检查手段。包括术中B超，纤维胆道镜等检查，力求确诊，尽可能切除原发性肝内癌灶以提高疗效。     

原发性肝癌伴胆管癌栓致阻塞性黄疸的外科治疗

目的探讨原发性肝癌伴胆管癌栓致阻塞性黄疸的外科手术治疗及其治疗效果。方法回顾性对15例原发性肝癌伴胆管癌栓致阻塞性黄疸行外科手术治疗的总结和分析。结果行左半肝切除 胆总管切开取癌栓术5例,行肿瘤切除 胆总管切开取癌栓术7例,行胆总管切开取癌栓 肝总动脉结扎3例,术后随访2年,平均生存时间为14.5个月,最长存活23个月。结论外科治疗明显提高了患者生活质量,延长了生存时间。     

肝癌合并胆管癌栓致梗阻性黄疸的外科治疗

原发性肝癌 (ＨＣＣ)主要是肝细胞癌 ,发生黄疸的机会少见。ＨＣＣ合并胆管癌栓所致的梗阻性黄疸在临床上虽不常见 ,也非罕见 ,文献报道ＨＣＣ合并胆管癌栓的发病率不一 ,约 1%～ 4 %。一般认为小肝癌 (≤ 5ｃｍ)较少发生胆管癌栓 ,当癌体增大时 ,其发生胆管癌栓的机会也随之增大。我科 1996～2 0 0 1年 5年期间共收治了 5 16例ＨＣＣ患者 ,经手术证实 9例 (1.9% )癌栓阻塞胆总管致梗阻性黄疸 ,1例癌栓阻塞右肝管 ,1例癌栓阻塞左肝管。以往认为侵入胆管的ＨＣＣ是晚期肝癌的一种特殊表现类型 ,当患者出现黄疸时已属晚期 ,多持消极态度和内科…     

肝癌伴胆管癌栓致梗阻性黄疸的诊断和治疗

原发性肝癌常侵犯门静脉、肝静脉形成癌栓,而肝癌伴胆管癌栓致梗阻性黄疸者临床上较少见。以往此类病人均被认为是晚期,多持消极态度。目前认为该病经积极手术治疗,可望改善病人症状,延长生存期。我院1996年1月至2 0 0 2年10月共收治该病12例,现报告如下。临床资料1.一般资料:本组男10例,女2例。年龄31～78岁,平均5 5 8岁。占我院同期手术治疗原发性肝癌的2 34% (12 / 493)。病程15～2 70d。其中右上腹疼痛不适11例,皮肤瘙痒4例,大便陶土色2例,乏力、纳差、消瘦、肝脏肿大5例,本组均有不同程度的黄疸。9例病人有乙型肝炎感染病史。2 .实验…     

原发性肝癌并发胆管癌栓的手术治疗：附13例报告

笔者回顾性分析14年间手术治疗的13例原发性肝癌伴有胆管癌栓患者的临床资料。全组病例术前均有黄疸，总胆红素水平在54～574 mol/L，平均251 mol/L。B超术前确诊肝癌伴有胆管癌栓7例，CT术前确诊肝癌伴有胆管癌栓9例。 13例均行手术治疗，其中11例行肝切除+胆管癌栓取除，包括右半肝切除2例，右半肝不规则切除2例，左半肝切除3例，左外叶切除2例，肝方叶切除1例，肝中叶切除1例;2例仅行胆总管切开取癌栓，T管引流。术后1年内死亡2例。行肝切除者，术后生存时间为6个月~5年9个月。中位生存时间为15个月;未切肝者2例，分别生存11个月和17个月。提示对原发性肝癌伴胆管癌栓者应积极手术治疗，仍有可能获得较好的效果。     

ERCP检查在胆囊切除术后阻塞性黄疸诊断中的应用

３６例胆管切除术后阻塞性黄疸患者行ＥＲＣＰ检查、结果显示：胆总管结石９例，肝内外胆管结石１５例，医源性胆管损伤５例，毛细胆管性肝炎３例，胰头肿瘤１例，十二指肠乳头肿瘤２例。文章还论述了ＥＲＣＰ检查在阻塞性黄疸诊断中的优点及其局限性。     

阻塞性黄疸术后黄疸加重的原因分析

黄疸是肝胆系疾病的一个突出表现。阻塞性黄疸病人经手术减黄后胆红素呈进行性下降而顺利恢复,这在动物实验及临床实践中均已得到证实。但在临床上少数病人术后黄疸没有下降反而逐渐加深,其原因较复杂,与诸多因素有关。除常见的残余     

原发性肝癌合并胆管癌栓的诊治进展

以往多认为原发性肝癌合并胆管癌栓已属晚期,治疗棘手,预后差.但随着外科手术方式的完善和技术水平的提高,影像学诊断技术的成熟,对胆管癌栓形成机制、病理学特征及临床分型有了更多的认知,患者术后的生存时间得以提高,生活质量得以改善.原发性肝癌合并胆管癌栓在普外科中的诊疗有了较大的进展.     

Neurofibroma of the common bile duct: a rare cause of obstructive jaundice

Neurofibroma of the common bile duct is extremely rare. Fewer than 20 cases have been reported in the literature. We report a case of neurofibroma in a 47-year-old female presented with obstructive jaundice. Preoperative imaging failed to diagnose the case. The patient was treated with en-bloc excision of the extrahepatic biliary tree and Roux-en-Y hepaticojejunostomy.     

Eosinophilic cholangitis with obstructive jaundice mimicking bile duct carcinoma

A 55-year-old male who presented with obstructive jaundice and radiographically documented extrahepatic biliary tract obstruction is reported. Eosinophilic infiltration of the gallbladder, common bile duct, intrahepatic bile ducts, and bone marrow was observed. Eosinophilic cholangitis, a rare inflammatory condition that clinically resembles a biliary malignancy, should be taken into consideration in the differential diagnosis in the evaluation of presumed neoplasm of the bile ducts.     

医源性胆管损伤内镜治疗

伴随腹腔镜胆囊切除术的普遍开展,医源性胆管损伤的发生率越来越高。微创时代胆管损伤及狭窄应采用综合治疗方案,即胆管损伤-胆道重建（留置通道）-胆道镜检查及治疗-及时发现问题必要时再次手术。     

An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction

Background Endoscopic sphincterotomy and stone extraction are standard procedures for the removal of bile duct stones. Stone recurrence can, however, occur in up to 25% of cases. Risk factors have been poorly defined, but are believed to be related to bile stasis. This study investigated whether an angulated common bile duct (CBD) that may predispose to bile stasis influences symptomatic stone recurrence after successful endoscopic therapy. Methods This study included 232 consecutive patients (mean age, 64.1 years; 86 men) who had undergone therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones. Data from the follow-up period (36 ± 17 months) were obtained from medical records and patient questioning. Common bile duct angulation and diameter were measured from the cholangiogram after stone removal. Results Symptomatic bile duct stones recurred in 16% of the patients (36/232). Three independent risk factors were identified by multivariate analysis: an angulated CBD (angle, ≤145°; relative risk [RR], 5.2; 95% confidence interval [CI], 2.2–12.5; p = 0.0002), a dilated CBD (diameter, ≥13 mm; RR, 2.6; 95% CI, 1.2–5.7; p = 0.017), and a previous open cholecystectomy (RR, 2.7; 95% CI, 1.3–5.9; p = 0.0117). Gender, age, urgency of procedure, or a periampullary diverticulum did not influence the recurrence rate. Conclusions Angulation of the CBD (≤145°) on endoscopic cholangiography, a dilated CBD, and a previous open cholecystectomy are independent risk factors for symptomatic recurrence of bile duct stones. The findings support the role of bile stasis in stone recurrence. Further studies using these data prospectively to identify high-risk patients are warranted. Part of this work was presented at the Digestive Disease Week in New Orleans, 16–20 May 2004, and published in abstract form in Gastrointestinal Endoscopy 2004;59: AB197     

Conversion of percutaneous transhepatic cholangiodrainage to internal drainage in obstructive jaundice

Conversion of percutaneous transhepatic cholangiodrainage to an internal drainage is safe and effective in rerouting bile back to the intestinal tract in obstructive jaundice without major operative procedure. The method consists of insertion of a drainage tube with several side holes beyond the bile duct stricture. Usually, a single lumen tube is used. However, double lumen tube is preferred when the amount of bile discharge is excessive. This simple technique is found to be useful in the management of obstructive jaundice not only for preoperative decompression of biliary tree but also for the inoperable lesions.     

继发性胆管结石漏诊原因的分析

我院1990年4月～1996年12月治疗胆囊结石行胆囊切除术后继发性胆管结石23例。均经手术治疗及ERCP镜下取名治愈。漏诊的主要原因为临床表现不典型、肝胆B超检查未发现、术中探查不仔细等、高度怀疑继发性明管结石患者术前行ERCP或行术中经胆囊管胆道造影可有效预防胆管结石的漏诊。     

Diagnostic significance of bile cytology in obstructive jaundice

Cytological examination of exfoliated cells in the bile or irrigated fluid from a percutaneous transhepatic choledochal drainage (PTCD) tube and other jaundice-reducing fistula was performed in 59 patients with obstructive jaundice. Malignant cells were found in 22 of 27 patients with choledochal cancer, 5 of 17 patients with pancreatic cancer, 3 of 6 patients with gallbladder cancer, and one of 5 patients with other malignancies. Exfoliated malignant cells were found at a higher rate in the washed fluid of the PTCD tube than in the pure bile aspirated from the PTCD tube. Half of the positive cases were diagnosed as such upon the first cytological examination, and the remaining in second or subsequent cytological examinations. The cytological appearance of cells in the washed fluid or bile reflected the type of cancer cells found by touch-smear of the lesion and also the histological type. This method requires no special technique and facilitates accurate diagnosis in patients with malignant lesion of the choledochal duct.     

十二指肠镜治疗胆总管结石583例疗效分析

目的总结583例经十二指肠镜治疗胆总管结石的经验。方法自2003年1月至2004年2月,经十二指肠镜治疗胆总管结石共583例,回顾性分析其治疗效果。结果经十二指肠镜EST 立即取石71.35%(416/583),结石直径0.5～2.5 cm。在1周内总排石率84.04%(490/583),在2周内总排石率94.17%(549/583),34例取石失败,其中25例结石病人放置了塑料内支架引流促排石治疗3个月,有8例(32%)病人结石溶解消失,14例病人结石直径明显缩小,再次行 ERCP 取石成功。EST 术后9.95%(58/583)发生切口部位出血,十二指肠穿孔2例(0.34%),高淀粉酶血症及急性胰腺炎发生率分别为12.18%和2.74%,无死亡病例,平均住院时间(13.65±6.37)d。结论十二指肠镜胆总管取石效果好、创伤小,术后恢复快。对于胆囊结石合并胆总管结石病人,经十二指肠镜取石后,为病人行腹腔镜下胆囊切除术创造了条件。放置塑料内支架对于治疗胆总管巨大结石有效。     

肝脏肿瘤动脉栓塞化疗术后胆管狭窄

目的 分析肝脏经导管动脉栓塞化疗(transcatheter arterial chemoembolization,TACE)术后胆管狭窄致梗阻性黄疸的外科治疗方法.方法 回顾性分析1994年6月至2010年3月在浙江省人民医院及上海交通大学医学院附属新华医院行肝脏TACE治疗后出现胆管狭窄的15例患者的临床资料.7例为原发性肝癌,5例为肝脏血管瘤,3例为转移性肝癌,原发疾病分别为结肠癌2例和胰腺癌1例.肝脏TACE后出现梗阻性黄疸的时间为5～16个月,中位时间为9个月.结果 15例胆管狭窄病例均出现不同程度的梗阻性黄疸,13例经外科手术或经皮肝穿刺胆管造影(percutaneous transhepatic cholangiography,PTC)+放置胆管支架,2例仅行经皮肝穿刺胆道引流(percutaneous transhepatic cholangial drainage,PTCD).术后梗阻性黄疸均获得明显缓解.5例肝血管瘤状况良好;2例原发性肝癌TACE后梗阻性黄疸随访2年,无胆管梗阻再发和肿瘤复发;其余8例随访3～18个月,均死于原发病恶化.结论手术或介入手段治疗肝脏TACE术后胆管狭窄致梗阻性黄疸可获得良好的治疗效果,应根据原发病和胆管梗阻的部位、范围决定治疗方式.