腹腔镜胆囊切除术前利用256层螺旋CT血管成像技术评估胆囊动脉

目的经过256层螺旋CT血管成像技术察看胆囊癌、胆囊炎时胆囊动脉显示状况、能否影响胆囊动脉起源,并测量胆囊动脉管径及横截面积。方法选取在我院行上腹增强扫描检查并提示胆囊癌、胆囊炎及胆囊未见异常患者的影像资料,观察并记录各组资料胆囊动脉显示率、显示评分、起源,并测量胆囊动脉直径及横截面积。结果胆囊炎组91例,胆囊动脉显示率96.7%(88/91),其中胆囊动脉起源变异13例(14.8%),88例患者中,显示评分1分19例、2分69例;胆囊癌30例,胆囊动脉显示率96.7%(29/30),其中胆囊动脉起源变异5例(17.2%),29例患者中,显示评分1分3例、2分26例;胆囊正常组100例,胆囊动脉显示率94.0%(94/100),其中胆囊动脉变异16例(17%),94例患者中,显示评分1分58例、2分36例。各组间进行统计分析,胆囊动脉显示率及起源变异无统计学意义(P0.05),胆囊动脉显示评分有统计学意义(P0.05);对各组胆囊动脉直径及横截面积的测量:胆囊炎症组98支,直径平均(1.99±0.39)mm,横截面积平均(3.30±1.25)mm2,胆囊癌组30支,直径平均(2.44±0.69)mm,横截面积平均(5.11±3.46)mm2,胆囊正常组101支,直径平均(1.78±0.30)mm,横截面积平均(2.59±0.83)mm2,各组间比较,有显著差异(P0.05)。结论胆囊合并胆囊炎及胆囊癌时256层螺旋CT可以很好的评估胆囊动脉,能够作为腹腔镜胆囊切除术的术前检查。     

128层螺旋CT血管成像对胆囊动脉的研究

目的：探讨128层CT血管成像（CTA）对胆囊动脉的正常解剖及其变异的显示能力.方法：107例患者采用128层螺旋CT行胆囊动脉成像,并行多平面重组（MPR）、薄层最大密度投影（SMIP）、全体积最大密度投影（VMIP）和容积再现（VR）成像,观察胆囊动脉的起源、支数、走行及其与胆囊三角之间的解剖关系.结果：103例（96.3%）CTA能显示胆囊动脉（n=128）及其起源,起源于正常肝右动脉105支（82.0%）,变异肝右动脉8支（6.3%）,其它动脉15支（11.7%）;单支胆囊动脉78例（75.7%）,双支胆囊动脉25例（24.3%）,共同起源于正常肝右动脉20例（80%）.98例（95.1%）MPR、SMIP图像能清晰地显示胆囊动脉与胆囊三角之间的解剖关系,1支胆囊动脉走行于胆囊三角内55例（56.1%）,1支胆囊动脉走行于胆囊三角外18例（18.4%）,1支胆囊动脉走行于胆囊三角内而另外1支走行于胆囊三角外18例（18.4%）.103例横轴面CT、MPR和SMIP图像均能显示胆囊动脉,VMIP图像能显示胆囊动脉92支（71.9%）,VR图像仅能显示胆囊动脉59支（46.1%）.结论：CTA能清晰地显示胆囊动脉的起源、支数、走行及其与胆囊三角之间的解剖关系,为临床外科提供解剖学依据.     

口服枸橼酸铁铵在MRCP评价胆囊切除术后残余胆囊管显像中的价值

目的:探讨口服枸椽酸铁铵对MRCP评价胆囊切除术后残余胆囊管显像的价值。方法:采用呼吸导航3DFSE T2WI及单次屏气2D厚层FSE T2WI对55例胆囊切除术后患者进行检查,其中27例口服枸椽酸铁铵,28例空腹检查,比较2组患者残余胆囊管显示效果及胃十二指肠伪影情况。结果:27例口服枸椽酸铁铵3D MRCP残余胆囊管显示率为96.3%(26/27),2D MRCP为92.6%(25/27),均出现胃十二指肠伪影2例(7.4%)。28例空腹组3D MRCP残余胆囊管显示率为85.7%(24/28),2D MRCP为46.4%(13/28),均出现胃十二指肠伪影27例(96.4%)。结论:口服枸椽酸铁铵可明显消除胃液影响,明显提高MRCP对胆囊切除术后残余胆囊管的显示率及图像质量。     

胆囊管变异与胆囊结石相关性的MRI研究

目的:利用磁共振胰胆管造影(M RCP)及常规M R I序列,探讨胆囊管变异与胆囊结石发生的相关性。方法:回顾性分析符合纳入标准的382例患者的MRI及临床资料,比较常见变异胆囊管与正常胆囊管患者胆囊结石患病率差异。胆囊管变异由两位影像医师根据MRI常规及2D-MRCP序列独立盲法诊断,胆囊结石经手术或MRI和B超检查共同证实。结果:正常胆囊管154例,胆囊管变异228例(变异率59.7%),其中胆囊管高位汇合20例,汇合于肝总管前或后壁130例,中间汇合24例,低位汇合16例,平行胆囊管20例,胆囊管低位汇合伴胆囊管平行走行11例,短胆囊管7例。变异胆囊管中,胆囊管低位汇合和胆囊管低位汇合伴胆囊管平行走行患者结石患病率(分别为68.8%、63.4%)较正常胆囊管患者差异有统计学意义(P=0.000、0.003),胆囊管高位汇合、汇合于肝总管前或后壁、中间汇合、平行汇合、短胆囊管患者胆囊结石患病率(分别为20.0%、26.9%、25.0%、40.0%、0)较正常胆囊管患者差异不具有统计学意义(P>0.05)。结论:胆囊管变异率较高,变异胆囊管中,胆囊管低位汇合、胆囊管低位汇合伴胆囊管平行走行是促进胆囊结石形成的危险因素。     

口服枸橼酸铁铵在胆囊管MRCP检查中的应用价值

目的：研究磁共振胰胆管成像显示胆囊管的最佳检查方法,并比较口服枸橼酸铁铵后胆囊管显示率的变化。分析胆囊管的显示在临床中的应用价值。方法：53例行常规MRCP检查者为正常对照组,69例检查前口服枸橼酸铁铵患者为实验组。另27例先常规行MRCP检查,再口服枸橼酸铁铵后做MRCP。在MRCP图像上,多角度、多方位观察胆囊管的显示情况,比较正常对照组与实验组胆囊管的显示率,比较口服枸橼酸铁铵前后胆囊管显示率的变化情况。结果：53例行常规MRCP检查的胆囊管显示率为71．7％（38／53）,69例口服枸橼酸铁铵后胆囊管的显示率为87．0％（60／69）。27例口服枸橼酸铁铵后做自身前后对照的病例中,服药前显示率为70．4％（19／27）,服药后显示率为88．9％（24／27）。在正常对照组与实验组间及口服枸橼酸铁铵前后做MRCP检查的病例中,服药后胆囊管的显示率明显提高,并具有显著统计学意义。结论：检查前口服枸橼酸铁铵在MRCP技术中的应用提高了正常胆囊管的显示,有利于胆囊切除术前常规了解胆囊管的正常解剖及变异,避免术中不必要的胆源性损伤及术后并发症的发生。     

胆囊管解剖及变异:磁共振胰胆管成像研究

目的 探讨采用磁共振胰胆管成像(MRCP)显示胆囊管的正常解剖及各种变异.方法 在149例MRCP图像上,多角度、多方位观察并测量胆囊管长度及管径,观察并统计胆囊管走行、汇入位置、汇入方向及各种解剖变异.结果 MRCP上胆囊管显示清晰合计122例(82%),长度为(20.83±8.92)mm,直径为(2.82±1.04)mm.70%呈管状走行,30%呈扭曲状走行.66%胆囊管在肝外胆管全长中1/3汇入胆总管,上1/3占31%,下1/3占3%.右侧汇入占74%,左侧占3%,前和后占23%.73%斜角汇入,15%螺旋状,12%平行状.胆囊管变异占20%,其中54%平行走行,17%低位汇入,17%中间汇入,4%长胆囊管,4%胆囊管囊肿,4%变异右肝管.结论 MRCP可以较好地显示胆囊管解剖及各种变异,在临床上具有重要的应用价值.     

高危急性胆囊炎采用经皮经肝胆囊穿刺引流术治疗的临床分析

目的 探究高危急性胆囊炎采用经皮经肝胆囊穿刺引流术治疗的临床效果.方法 选取收治的64例高危急性胆囊炎患者,随机分为两组,对照组(32例)患者采用开腹胆囊摘除术治疗,实验组(32例)患者采用经皮经肝胆囊穿刺引流术治疗,对两组患者治疗效果对比分析.结果 实验组患者手术时间与术中出血量均明显优于对照组,差异显著(P＜0.05),具有统计学意义.实验组患者术后并发症发生率为15.6％(5/32),对照组患者术后并发症发生率为28.1％(9/32),对比差异显著,P＜0.05,具有统计学意义.结论 在高危急性胆囊炎患者中,采用经皮经肝胆囊穿刺引流术治疗,其具有创伤小、康复快、并发症少、手术时间短等优势,能够显著改善患者的症状.     

腹腔镜胆囊切除术治疗急性胆囊炎临床分析

目的探讨腹腔镜胆囊切除术(LC)治疗急性胆囊炎的手术时机及效果。方法对实施腹腔镜胆囊切除术466例分急诊手术、限期手术组与择期手术组,对比分析三组手术时间、术后住院时间、中转开腹率及并发症发生率。结果急诊手术组80例,中转开腹5例(6.25%);限期手术组111例,中转开腹13例(11.7%);择期手术组275例,中转开腹8例(2.9%)。术后平均住院时间分别为7.1天、9.1天、6.5天。平均手术时间分别为55分钟、95分钟、50分钟。并发症率分别为1.25%、0.90%、0.36%。三组患者均痊愈出院。结论急性胆囊炎在发病早期是行LC的最好时期,择期手术仍切实可行;正确处理胆囊管及胆囊动脉是LC手术的关键;正确对待中转开腹是手术安全的保障。     

MRCP对胆囊管低位汇入及其相关并发症的诊断价值

目的：探讨MRCP对胆囊管低位汇入诊断及相关并发症分析,以提高对该病的认识。方法：回顾性分析107例经MRCP诊断为胆囊管低位汇入患者的MRI图像。结果：107例中,平行汇入组27例（25.2%）,螺旋汇入组80例（74.8%）,2组胆囊结石及胆囊炎发病率差异均有统计学意义（均P<0.05）,胆总管结石、胰腺炎发病率差异均无统计学意义（均P>0.05）。结论：MRCP在胆囊管低位汇入中有非常高的诊断价值,明确汇入分型可避免术中胆道损伤,指导相关并发症的预防。     

胆囊管打结法腹腔镜胆囊切除的临床研究

 目的探讨腹腔镜腔内打结技术在处理胆囊管胆囊切除术中的效果.方法 600例急慢性结石性胆囊炎和胆囊息肉样病变患者随机分成2组:A组,行打结法处理胆囊管腹腔镜胆囊切除术;B组,行钛夹法处理胆囊管腹腔镜胆囊切除术.比较两组处理胆囊管手术时间、术后平均住院时间、术中出血量、术后并发症及右上腹异物感发生率.结果 A组处理胆囊管手术时间明显延长,与B组比较差异有统计学意义(P＜0.01);但术后平均住院时间、术中出血量、术后并发症发生率差异无统计学意义(P＞0.05);B组右上腹异物感发生例数高于A组.结论无钛夹腔内打结法腹腔镜胆囊切除术具有异物感少,无钛夹留置体内等优点.     

Acute cholecystitis caused by malignant cystic duct obstruction: treatment with metallic stent placement

We report the successful management of acute cholecystitis using cystic duct stent placement in 3 patients with inoperable malignant cystic duct obstruction (2 cholangiocarcinoma and 1 pancreatic carcinoma). All patients underwent stent placement in the bile duct, using an uncovered stent in 2 and a covered stent in 1, to relieve jaundice occurring 8-184 days (mean 120 days) before the development of acute cholecystitis. The occluded cystic duct was traversed by a microcatheter and a stent was implanted 4-17 days (mean 12 days) after cholecystostomy. Acute cholecystitis was improved after the procedure in all patients. Two patients died 3 and 10 months later, while 1 has survived without cholecystitis for 22 months after the procedure to date.     

Diagnosis of acute cholecystitis: value of contrast agent in the gallbladder and cystic duct on Gd-EOB-DTPA enhanced MR cholangiography

To evaluate value of %volume of contrast agent in gallbladder and contrast in cystic duct in diagnosis of acute cholecysititis with Gd-EOB-DTPA MRC obtained 60 min after contrast injection (T1-MRC60min). We included 16 acute cholecystitis (AC), 23 chronic cholecystitis (CC), and 40 healthy volunteers. Receiver operating characteristic analysis showed cutoff value of 30.5% as predictor of AC comparing with healthy volunteers (sensitivity 93.8%, specificity 100%, AUC 0.958) and cutoff of 0% as predictor of AC comparing CC (sensitivity 81.2%, specificity 82.6%, AUC 0.823). In AC absent or obliterated cystic duct on T1-MRC60min showed 81.3%, 100%, sensitivity and specificity, respectively. These can be helpful for diagnosis of AC.     

MSCT对囊性肾瘤的诊断价值

目的：探讨囊性肾瘤(CN)的 MSCT表现及病理特点。方法回顾性分析7例经术后病理证实的肾脏 CN MSCT 表现及病理特点。结果7例均为单侧发病,男5例,女2例,MSCT表现均为囊性病变,边界清楚,囊壁及分隔厚度均匀无附壁结节,增强扫描囊壁及分隔均匀强化,而囊内密度不均,增强扫描无强化。结论肾脏CN的 MSCT表现具有特征性。     

Percutaneous cystic duct stent placement for the treatment of acute cholecystitis resulting from common bile duct stent placement for malignant obstruction

Common bile duct (CBD) stent placement to relieve malignant biliary obstruction can occasionally cause cystic duct obstruction and acute cholecystitis. Cholecystostomy tube placement is often performed in patients with limited life expectancy but can have a significant impact on quality of life. To allow cholecystostomy tube removal, percutaneous metallic stent placement was performed across the cystic duct via the tube tract in such a patient. The procedure included traversal across the previously placed CBD stent. At 5-month follow-up, the patient remained symptom-free. In select patients who develop acute cholecystitis after CBD stent placement for malignant obstruction, percutaneous stent placement across the cystic duct may be considered a treatment option.     

Percutaneous obliteration of the cystic duct with a holmium:yttrium-aluminum-garnet laser: results of in vitro and animal experiments.

OBJECTIVE. The purpose of this study was to investigate the feasibility of using a holmium:yttrium-aluminum-garnet laser to permanently occlude the cystic duct in order to isolate the gallbladder from the biliary-enteric circulation and prevent gallstone formation. MATERIALS AND METHODS. To determine the optimal laser parameters (power and pulsing rate) for cystic duct thermocoagulation, 20 freshly excised porcine gallbladders with intact cystic ducts underwent low-energy (0.075-0.085 J/pulse) or high-energy (0.20-0.25 J/pulse) thermocoagulation. Histopathologic examination was done to determine the extent of cystic duct injury. After in vitro experiments, percutaneous transcholecystic laser thermocoagulation of the cystic duct was performed on 23 anesthetized domestic pigs (four controls). Cholangiograms immediately after laser thermocoagulation were obtained to assess cystic duct occlusion. Animals were sacrificed for histopathologic correlation immediately after laser thermocoagulation (n = 4), 72 hr later (n = 4), and 6 weeks later (n = 15). RESULTS. In the in vitro studies, all 10 cystic ducts in the high-energy group were occluded, while only four in the low-energy group were occluded. At histology, all cases in both groups showed circumferential injury to the cystic duct wall without injury to the cystic artery or vein. In the in vitro experiments, the cystic duct was successfully cannulated in 21 (91%) of 23 animals. Cholangiography after thermocoagulation showed occlusion of the cystic duct in 16 (84%) of 19 cases. Immediately after laser thermocoagulation, the cystic duct mucosa was circumferentially destroyed, whereas after 72 hr necrosis of the cystic duct wall and periductal tissues had occurred. By 6 weeks, all pigs had complete cystic duct fibrosis without injury to the common bile duct. CONCLUSION. Holmium:yttrium-aluminum-garnet laser thermocoagulation of the cystic duct can be performed easily, results in immediate cystic duct occlusion, and leads to permanent fibrous ductal obliteration by 6 weeks.     

Unruptured pseudoaneurysm of the cystic artery with acute calculous cholecystitis incidentally detected by computed tomography

Pseudoaneurysm of the cystic artery is rare; to our knowledge, fewer than 30 cases have been reported worldwide. We report the first case of an unruptured pseudoaneurysm of the cystic artery with concurrent acute calculous cholecystitis. We incidentally detected the aneurysm by contrast-enhanced computed tomography (CT) in the edematous, thickened wall of the gallbladder neck in a 71-year-old man, whereas in most of the reported cases the disease presented as hemobilia. Because of the high risk of aneurysm rupture in this location, we avoided such interventions as percutaneous cholecystostomy and laparoscopic cholecystectomy. The aneurysm was localized pathologically in the undisrupted gallbladder wall, and elective open cholecystectomy with ligation of the cystic artery was performed successfully. Our case highlights the usefulness of CT for both diagnosis and patient management. Open cholecystectomy with ligation of the cystic artery is demonstrated as a reasonable first line of treatment for this unusual condition.     

Rapid and accurate diagnosis of acute cholecystitis with 99mTc-HIDA cholescintigraphy.

Technetium-99m dimethyl acetanilide iminodiacetic acid (HIDA) cholescintigraphy was performed on 90 patients with suspected acute cholecystitis. Visualization of the gallbladder established patency of the cystic duct and excluded the diagnosis of acute cholecystitis in 50 of 52 patients. Nonvisualization of the gallbladder with visualization of the common bile duct was diagnostic of acute cholecystitis in 38 patients, all subsequently proven at surgery. The observed accuracy of this procedure is 98% and specificity is 100%. The false negative rate is 5% and false positive rate is zero. Technetium-99m-HIDA has many advantages which make it the procedure of choice in evaluating a patient for suspected acute cholecystitis. It is a rapid, simple, safe examination which provides functional as well as anatomic information about the hepatobiliary system in individuals with a serum bilirubin level up to 8 mg/100 ml.     

A diagnostic dilemma of atypical gallbladder appearance on Tc-99m HIDA cholescintigraphy resolved with SPECT/CT

Tc-99m HIDA cholescintigraphy is the diagnostic procedure of choice for acute cholecystitis. Acute cholecystitis is associated in vast majority of the cases with cystic duct obstruction. The demonstration of presence (cystic duct patency) or absence (cystic duct obstruction) of visualization of the gallbladder on cholescintigraphy is critical to the diagnosis of acute cholecystitis. The visualization of the gallbladder rules out acute cholecystitis in most of the cases. Although, in most cases, determination of visualization or nonvisualization of gallbladder is straight forward, occasionally it can be challenging. We describe a patient with suspected acute cholecystitis, in whom an unusual appearance of the gallbladder on hepatobiliary scintigraphy was clarified with SPECT/CT, an approach that is rarely used in Tc-99m HIDA cholescintigraphy.