肝门胆管癌的外科手术治疗

回顾性分析我院2000-07-2005-07经肝门胆管癌手术治疗的62例患者临床资料和随访结果,总结肝门胆管癌的手术治疗体会.62例手术切除患者中行根治性切除(R0)22例,非根治性切除28例(R1,R2).根治性切除中位生存期34个月,1、3和5年生存率分别为92.0%、40.0%和18.0% ;非根治性切除中位生存期16个月,1、3和5生存率分别为83.0%、22.0%和0.另12例未完成病灶切除,9例行经肿瘤切开放置Y管内支架引流,3例行胆囊桥式肝管一十二指肠吻合,中位生存期10个月,1、3和5年生存率分别为15.0%、0和0.手术切除是治疗肝门胆管癌的有效治疗方法,根治性切除能明显改善预后.     

内镜下置入金属支架治疗恶性胆道梗阻

对于失去手术机会的恶性胆道梗阻患者,通过放置金属支架,常能有效地消除黄疸,缓解患者皮肤瘙痒,改善肝功能,提高生活质量,延长生存期。自2004年2月~2007年2月,我们采用经内镜放置胆道金属支架,进行姑息性治疗恶性胆道梗阻32例患者,效果满意,现报告如下。1资料与方法1.1临床资料     

胆道恶性梗阻的内镜治疗现状

胆道恶性梗阻包括原发性胆管腺癌所致胆道梗阻以及胆囊癌、肝细胞癌、壶腹部癌、胰头癌及其它转移癌对肝胆管的侵犯。约70％～90％的患者合并梗阻性黄疸，易并发胆道感染等并发症，病情凶险，预后差。多数患者明确诊断后已失去外科手术机会，有文献统计仅10％～15%的胰腺癌和胆管癌患者有Whipple手术适应证，且手术疗效差，患者5年生存率均约5％～8％。     

关于肝门部胆管癌外科治疗的几点认识

肝门部胆管癌是胆道外科的难题之一，目前仍以手术治疗为主要手段。对肿瘤侵犯范围和可切除性作出正确的判断，选择合理的治疗方法，严格掌握手术切除范围及预防手术并发症，是使手术取得良好治疗效果的重要保证。现结合临床经验，对肝门部胆管癌的外科治疗谈几点体会。     

经内镜胆道金属支架引流术治疗恶性胆道梗阻的价值

目的回顾786例经内镜胆道金属支架引流术,探讨其治疗价值。方法在结合临床、影像学资料及尽可能获得的病理基础上确立恶性胆道梗阻,直接或在经内镜鼻胆管引流术（ENBD）、经内镜塑料内支架引流术（ERBD）过渡引流确定引流效果后行经内镜金属支架引流术（EMBE）,与姑息性手术及ERBD进行对照研究。结果一次操作成功率99.5%,减黄有效率为：满意68.4%,一般27.5%,无效4.1%;其中低位梗阻减黄有效率（满意＋一般）达96.6%,高位梗阻减黄有效率82.4%,支架平均通畅期289天,平均生存期310天,并发症率6.7%,死亡率1.2%。结论在严格掌握适应证的基础上,EMBE是安全有效解除恶性胆道梗阻的方法,对中晚期胆道肿瘤患者基本可替代姑息性胆道手术治疗。     

肝门部胆管癌49例临床治疗效果分析

目的:探讨影响肝门部胆管癌治疗效果的相关因素。方法:回顾分析49例肝门部胆管癌手术病例临床资料并进行统计分析。结果:49例患者中,实行根治性切除、姑息性手术及各种引流手术的患者平均术后生存时间分别为19.50月、8.79月及5.44月;而AJCC TNM分期Ⅰ期及Ⅱ期、Ⅲ期、Ⅳ期(Ⅳa期及Ⅳb期)患者平均术后生存时间分别为23.50月、9.37月及2.90月;术前日血清总胆红素水平>300μmol/L组及≤300μmol/L组的患者平均术后生存时间分别为3.62月及14.74月;术后1周血清总胆红素水平>40μmol/L组、20~40μmol/L组及<20μmol/L组患者平均术后生存时间分别为5.68月、11.59月及22.17月。结论:肿瘤分期及手术根治程度是影响肝门部胆管癌疗效的主要影响因素,术前血清总胆红素水平及术后近期胆红素下降程度有望作为判断肿瘤远期疗效的指标之一。     

胆道支架置入术治疗胆道恶性梗阻

目的:评价胆道支架置入术治疗胆道恶性梗阻的价值.方法:135例胆道恶性梗阻患者,应用经皮肝穿胆道造影及支架置入技术,其中87例合并动脉内化疗或化疗栓塞术,48例单纯应用支架置入术.结果:单支置入128例,双支置入7例.支架置入术成功率为99.3%(成功植入142支/首次预计植入143支).黄疸完全缓解率86.7%(117/135),总有效率97.8%(132/135).6个月、12个月及24个月生存率分别为71.1%(96/135)、43.7%(59/135)及11.9%(16/135),联合抗肿瘤治疗与单纯支架治疗12个月生存率分别为:54.0%(47/87)及25.0%(12/48),统计学处理有显著性差异(X2=10.59,P＜0.001).支架再狭窄或阻塞21例,经皮穿刺外引流或支架内再置入支架治疗,黄疸再次消失.结论:胆道支架置入术减黄疗效肯定,与抗肿瘤治疗联合应用可提高患者生存率.     

肝门部胆管恶性间质瘤一例

患者女 ,37岁。因进行性尿黄伴巩膜黄染、皮肤瘙痒半月余于 2 0 0 1年 12月 17日入院。体检 :皮肤、巩膜明显黄染 ,血清总胆红素 2 19μｍｏｌ/Ｌ ,直接胆红素 172 μｍｏｌ/Ｌ ,ＡＦＰ、ＣＥＡ正常 ,ＣＡ19 9334Ｕ/ｍｌ,乙肝病毒标志物均为阴性。腹部Ｂ超提示 :胆总管占位病变 ,肝内胆管扩张 ,胆囊炎 ,胆石症。ＣＴ显示右上腹十二指肠后外方区域见占位性病变 ,约3ｃｍ× 3ｃｍ× 6 .5ｃｍ ,边缘清楚 ,密度均等。提示 :肝门部占位性病变 ,肝内胆管扩张 ,胆囊结石。ＭＲＩ及ＭＲＣＰ显示肝内胆管扩张 ,肝门部胆管中断 ,肝门区可见软组织肿块…     

胆管支架和(或)引流术治疗恶性胆管梗阻30天内死亡原因分析

目的 分析胆管支架和（或）引流术治疗恶性胆管梗阻３０ｄ内死亡原因及手术有关的近期并发症,探讨更有效的临床治疗方法及手术适应证。方法 １０７例恶性胆管梗阻者实行经皮经肝穿刺担管支架和（或）引流术,术后３０ｄ内共死亡１２例,其中原发性肝癌４例,肝门淋巴结转移瘤３例,胆管癌５例,死亡率为１１．２％。结果 １２例恶性胆管梗阻者,９例放置胆管支架,其中５例同时置引流管;３例仅置胆管引流管。手术后１０例胆管梗     

内支架联合适形放疗治疗恶性胆管梗阻的临床研究

目的探讨内支架联合适形放疗治疗恶性胆管梗阻的疗效。方法自1999年2月至2004年2月我院收治61例恶性胆管梗阻的患者,综合组34例行内支架联合适形放疗,并与同期单纯内支架置入27例对照组进行对比。结果综合组与对照组平均生存时间分别为(353±20)天和(176±12)天(P<0.01),中位生存期分别为(350±29)天和(170±17)天(P<0.01)有显著性差异。结论内支架联合适形放疗是治疗恶性胆管梗阻的有效方法。     

胆道支架放置术治疗恶性胆道梗阻的临床应用

目的：探讨胆道支架放置术治疗恶性胆道梗阻性黄疸的疗效和安全性。方法：恶性梗阻性黄疸病人24例，均采用胆道支架放置术的治疗方法，分别观察血清胆红素下降程度，手术并发症，并随访病人生存期和胆道支架维持通畅时间。结果：所有病人在治疗过程中均安全，胆道支架放置术疗效显著，黄疸消除率为70．8％，平均支架维持通畅时间为8．6个月，半年和一年生存率为62．5％和16．7％。结论：胆道支架放置术在治疗恶性梗阻性黄疸有较好疗效，使用安全。     

Comparison of plastic and self-expandable metal stents in the palliative treatment of malignant biliary obstruction:a meta-analysis

Stent-placement-is-one-of-the-main-methods-in-the-pal-iative-treatment-of-malignant-biliary-obstruc-tion,-including-plastic-and-self-expandable-metal-stents.-The-comparison-of-stent-patency-between-self-expandable-metal-and-plastic-stents-in-pal-iation-of-malignant-biliary-obstruction-is-meaningful.-We-carried-out-a-meta-analysis-to-summarize-current-evidence-for-clinical-ef-icacy-of-self-expandable-metal-and-plastic-stents-in-the-treatment-of-malignant-biliary-obstruc-tion.-Methods:A-comprehensive-search-of-several-databases-including-CNKI,-Wanfang-Data,-Sino-MED.-A-fixed-ef-ects-or-random-ef-ects-model-was-used-to-pool-data-of-al-study-endpoint.-Sensitivity-analysis-was-also-performed.-Results:Eight-randomized-clinical-trials-were-identified,-including-633-patients.-These-results-suggested-that-the-self-expandable-metal-stents-were-associated-with-a-significantly-longer-stent-patency-(OR=8.15;95%CI:2.80-23.76;I2=85%).-No-publication-bias-was-observed.-Conclusion:Self-expanding-metal-stents-have-a-longer-patency-than-plastic-stents-and-of-er-adequate-pal-iation-in-patients-with-malignant-biliary-obstruction.     

Comparison of intraluminal radiofrequency ablation and stents vs. stents alone in the management of malignant biliary obstruction

Purpose: To retrospectively evaluate the added benefit of adding intraluminal radiofrequency ablation (RFA) to biliary metal stent placement for patients with malignant biliary obstruction (MBO).

Methods: From November 2013 to December 2015, 89 patients with MBO who had undergone percutaneous intraluminal RFA and stent placement (RFA-stent group, n?=?50) or stent placement only (stent group, n?=?39) were included. Outcomes were compared according to the type of tumour: cholangiocarcinoma or non-cholangiocarcinoma.

Results: Primary and secondary stent patency (PSP, SSP) were significantly higher for the RFA-stent group than the stent group (PSP: 7.0?months vs. 5.0?months, p?=?0.006; SSP: 10.0?months vs. 5.6?months, p?p?=?0.068). In subgroup analysis, RFA-stent showed significant PSP benefits compared to stent alone in patients with cholangiocarcinoma (7.4?months vs. 4.3?months; p?=?0.009), but with comparable outcomes in patients with non-cholangiocarcinoma (6.3?months vs. 5.2?months; p?=?0.266). The SSP was improved in both subgroups (cholangiocarcinoma, 12.6?months vs. 5.0?months, p?p?=?0.013). Technical success and clinical success were not significantly different between the two groups. The rate of complication was higher for the RFA-stent group, but tolerable when compared to the stent group.

Conclusions: Although survival was comparable between the groups, RFA-stent confers therapeutic benefits to patients with MBO in terms of stent patency compared to stent placement alone, especially in those with cholangiocarcinoma.     

The use of self-expandable metal stents in the palliation of malignant bowel obstruction

Palliation of malignant gastrointestinal obstruction is a major aspect of oncology. We assessed the efficacy of stents in the palliation of gastric outlet, duodenal and colonic obstruction. We undertook a retrospective study of 35 consecutive patients who were referred for stent insertion with palliative intent from June, 1999 to March, 2003. Thirty-two stents were successfully placed in 30 patients. Technical success rate was 86% (30/35 patients). Of the patients who had successful insertion, 83% had complete relief of symptoms. In 1 patient the stent failed to expand. There was no procedure related mortality. Median survival was 1.6 months (range, 0-14.8). The conclusion was that self-expandable metal stents provide an effective method of palliation in malignant gastrointestinal obstruction, with high clinical and technical success rates and low complication rates.     

Endoscopic radiofrequency ablation for malignant biliary obstruction

Cholangiocarcinoma and pancreatic cancer are the most common causes of malignant biliary obstruction. The majority of patients are diagnosed at a late stage when surgical resection is rarely possible. In these cases, palliative chemotherapy and radiotherapy provide only limited benefit and are associated with poor survival. Radiofrequency ablation (RFA) is a procedure for locoregional control of tumours, whereby a high-frequency alternating current turned into thermal energy causes coagulative necrosis of the tissue surrounding the catheter. The subsequent release of debris and tumour antigens by necrotic cells can stimulate local and systemic immunity. The development of endoluminal RFA catheters has led to the emergence of endoscopically delivered RFA, a treatment mainly used for malignant biliary strictures to prolong survival and/or stent patency. Other indications include recanalisation of occluded biliary stents and treatment of intraductal ampullary adenoma or benign biliary strictures. This article presents a comprehensive review of endobiliary RFA, mainly focusing on its use in patients with malignant biliary obstruction. The available data suggest that biliary RFA may be a promising modality, having positive impacts on survival and stent patency and boasting a reasonable safety profile. However, further studies with better characterised and stratified patient populations are needed before the method becomes accepted within routine clinical practice.     

恶性高位梗阻性黄疸的介入治疗

背景与目的:侵犯或压迫肝门部胆管的恶性肿瘤造成的胆道高位梗阻,因梗阻部位多位于胆总管上段、肝总管,左右叶肝管甚至互不相通,单侧PTBD引流只能局限于引流管头端所放置的单一分支肝管,部分病例PTBD术后黄疸没有明显减退,甚至短期内加重,导致病情进一步恶化。本研究探讨左右叶双侧PTBD结合内支架术治疗恶性高位梗阻性黄疸的疗效。方法:17例高位恶性梗阻性黄疸的患者(男性11例,女性6例,平均年龄63.4岁),行左、右叶双侧PTBD结合内支架治疗。置入2枚支架的15例;2例为一侧肝管至胆总管置入支架,另一侧留置引流管。15例PTBD术后行TAI/TACE或放疗。结果:全部患者PTBD手术成功。治疗后总胆红素明显下降,由(357.7±142.5)μmol/L降至(174.7±87.6)μmol/L。引流通畅中位时间8.9个月,全组生存中位时间11.2个月。结论:左右叶双侧PTBD结合内支架治疗高位恶性梗阻性黄疸近期疗效肯定,早期引流与多支引流同样重要。     

Efficacy and safety evaluation of paclitaxel-loaded metal stents in patients with malignant biliary obstructions

Paclitaxel-eluting covered metal stents (PECMSs) and metallic stents covered with a paclitaxel-incorporated membrane (MSCPMs) have been developed to increase stent patency by preventing tumor ingrowth. However, few studies have compared their efficacy and safety compared with conventional covered metal stents (CMSs). This study aimed to compare differences in efficacy and safety between PECMS/MSCPM and CMS by meta-analysis. A search of PubMed and Embase was conducted for randomized controlled trials of PECMS/MSCPM and CMS in patients with malignant biliary obstructions published between January 1966 and August 2017. A meta-analysis was performed to compare clinical outcomes and complications between stent types. A total of 221 patients from three studies were included. There were no significant differences between PECMS/MSCPM and CMS in stent patency duration (P = 0.128) or survival time (P = 0.363). Risk did not differ between PECMS/MSCPM and CMS for stent malfunction (hazard ratio [HR]: 1.13, 95% confidence interval [CI]: 0.63–2.02, P = 0.677 for all stent malfunction; HR: 1.39, 95% CI: 0.68–2.85, P = 0.362 for stent occlusion caused by tumor ingrowth; HR: 0.80, 95% CI: 0.34–1.91, P = 0.617 for stent occlusion caused by distal stent migration or sludge impaction), or complications (HR: 1.54, 95% CI: 0.70–3.39, P = 0.280 for all complications; HR: 0.42, 95% CI: 0.14–1.30, P = 0.131 for pancreatitis). The exception was cholangitis-like symptoms, the risk for which was higher in PECMS/MSCPM compared with CMS (HR: 3.93, 95% CI: 1.08–14.29, P = 0.038). Although PECMS/MSCPM may be associated with higher risk of cholangitis-like symptoms, the overall results were similar between PECMS/MSCPM and CMS. Further studies are warranted in larger populations of patients.