ERCP放置胆管内支架姑息治疗难以切除的恶性胆管梗阻

目的探讨ERCP放置胆管内支架对难以切除的恶性胆管梗阻的临床治疗效果。方法对54例恶性肿瘤引起的梗阻性黄疸患者,经ERCP将导丝插入胆管并超过梗阻部位,扩张狭窄处,用推送导管将已经选择合适的引流支架置于胆管适当部位,其两端均超过梗阻段2cm以上。结果54例患者中51例插管成功,3例插管不成功的患者中1例乳头开口于憩室内,另2例肿瘤完全阻塞导丝无法通过。成功率为94.44%(51/54)。34例胆管内放置8FZ型自膨胀式金属支架,其余20例行8～10F塑料内支架引流。术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻。其中39例2周内血清总胆红素下降50%以上,血清总胆红素退至34μmol/L以下。放置胆管内支架1周后,患者血清总胆红素由术前235.45±56.67μmol/L降至78.36±37.58μmol/L,肝功能较术前显著改善(P<0.05,P<0.01)。31例胆总管下段梗阻患者与12例肝门部胆管梗阻患者相比,放置胆管内支架引流治疗1周、2周后,其胆红素下降明显优于肝门部胆管梗阻患者(P<0.01)。34例放置胆管金属支架患者中,有12例于术后2个月发生支架阻塞,再次放置塑料内支架后引流通畅,1例放置金属支架术后患者第10个月出现支架阻塞予以再次植入金属支架。另外20例放置塑料内支架者,有3例于术后1～4周出现血清总胆红素再次上升,经ERCP检查发现支架移位和阻塞,予以更换内支架,其中1例植入塑料双支架。结论经ERCP内镜下胆管放置内支架,对解除恶性胆管梗阻性黄疸、缓解症状、提高患者生存质量具有满意疗效,对胆总管下段梗阻性黄疸的疗效优于肝门部胆管梗阻。     

影像学评价对选择Budd-Chiari综合征介入治疗途径的价值

目的 探讨BCS介入术前彩色多普勒超声、CT、磁共振、血管造影等影像学检查对设计介入治疗途径的价值。方法 根据彩色多普勒超声、CT、磁共振、血管造影等影像学检查结果，依据下腔静脉与肝静脉、副肝静脉的关系．采用不同的介入手术方法及入路，经股静脉、经颈静脉、经皮经肝穿刺或经副肝静脉开通下腔静脉、肝静脉、副肝静脉或同时开通。结果 根据术前影像学检查，决定手术方案、选择合理的术式和入路。50例手术均获得成功，疗效确切。其中下腔静脉狭窄34例（膜性20例，节段性14例），肝静脉狭窄、闭塞10例，下腔静脉狭窄伴肝静脉阻塞3例，肝静脉闭塞伴副肝静脉狭窄、闭塞2例。49例下腔或，和肝静脉开通后球囊扩张，共置入金属支架29例。肝小静脉闭塞1例，行TIPS术。术后随访1～36月，其中2例下腔静脉膜性狭窄球囊扩张术后分别于6和8个月出现再狭窄，后行金属支架置入．症状消失。1例因肾功能衰竭死亡。结论 通过术前检查．正确选择手术方式，可避免手术盲目性，避免再次手术，减少手术并发症，节约手术费用，获得良好的手术效果。     

介入治疗下腔静脉节段闭塞型Budd—Chiari综合征的方法学研究

目的探讨介入治疗下腔静脉节段闭塞型Budd-Chiari综合征（BCS）的有效方法。方法对经造影确诊的26例下腔静脉肝后段节段型完全闭塞型BCS患者,采用聚乙烯球囊导管或国产Inoue球囊导管行经皮腔内血管成形术（PTA）及支架置入,其中闭塞段穿刺过程中综合运用直接穿刺技术、导管挤钻技术、逆向穿刺技术、双向穿刺技术、导丝轨道技术。PTA前后行下腔静脉造影及血液动力学检查;观察患者临床表现变化及并发症发生情况。结果23例成功穿通闭塞段并行PTA治疗,均无严重并发症,技术成功率为88．5％;15例置入下腔静脉支架。术后闭塞段下腔静脉内径为（19．20±6．21）cm,下腔静脉压、下腔静脉至右房压力阶差显著降低,右心房压显著升高;随访1～5a复发3例。结论介入治疗下腔静脉节段闭塞型BCS安全、有效,综合应用各种穿刺技术及合理选择球囊导管类型、直径可提高成功率、减少并发症。     

术中植入金属支架解除不宜切除肿瘤所致消化道便阻

目的探索术中姑息性解除无法切除肿瘤患者的消化道梗阻,改革传统改道吻合引流的手术方法,提高术后引流通畅率并减少并发症.方法外科剖腹术中探查明确不宜作肿瘤切除且已有消化道梗阻或有消化道梗阻倾向者,在将肿瘤病灶匡置的同时于狭窄、梗阻的消化道管腔近端2cm处剖-1.5cm～2.5cm小口并吸尽腔内胆汁、胃液或肠内容物;用探条尖端顶住梗阻部位潜在腔隙,将超滑导丝经其孔径插入直至挤过狭窄段进入远端肠腔并经手捏肠管证实导丝在远端肠腔无误;经导丝引入扩张探条行预扩张后退出探条将塑料软管套配其上再次经导丝引导塞入狭窄段;保留塑料软管及导丝,退出扩张探条;选择合适支架将一端聚拢塞入塑料软管并用推送管将支架近端推送至距狭窄段2cm左右;固定推送管后撤塑料管直至塑料管退出、支架完全释放;缝合胃、肠管(或胆管)切口,清洗腹腔后逐层缝合腹壁及皮肤.结果11例患者共术中植入金属支架9枚,其中胆道支架4枚,胃幽门部及十二指肠支架5枚,结肠支架2枚.术后所有患者梗阻症状均获解除,经随访1mo～5mo均未再出现原狭窄部位梗阻表现,也未出现与支架植入相关的并发症.结论术中植入金属支架对姑息性解除无法切除肿瘤患者的消化道梗阻,改革传统手术方法减轻手术创伤、提高术后引流通畅率并减少并发症具有积极意义.     

自膨式金属支架置入术治疗胃十二指肠狭窄临床病例研究

目的 评价自膨式金属支架置入术对治疗胃十二指肠狭窄或者梗阻的效果.方法 对2005年至2011年间行胃十二指肠自膨式金属支架置入术的24例病例资料进行回顾分析.对患者术前及术后进食情况用胃出口梗阻记分系统(GOOSS)进行评估,经配对样本秩和检验比较两组差异.结果 支架置入的成功率100％(24/24),整个操作用时平均(25.9±11.0)min.20例(83.3％)患者在术后可进流质软食,患者术前GOOSS评分为0.14分(P50=0),术后第7天GOOSS评分为1.42分(P50=2),比较差异具有统计学意义,P＜0.01.3例患者出现消化道少量出血,无穿孔、误吸等严重并发症发生.结论 内镜下自膨式金属支架置入术是治疗胃十二指肠梗阻或狭窄的一种有效方法.     

胃十二指肠恶性梗阻支架置入后失效原因及处理

经内镜放置膨胀式金属支架，为胃、十二指肠和近端小肠恶性梗阻患者的重要姑息性治疗措施，能有效缓解患者的梗阻症状，增加进食，避免外科手术创伤，提高生存质量。但支架置入后常会出现支架失效，引起再梗阻，必须对此进行处理，维持支架通畅。现总结我院2003年10月-2008年10月胃、十二指肠恶性梗阻支架置入后再梗阻患者内镜处理情况。     

经内镜置入金属支架治疗胃十二指肠恶性梗阻的临床应用

目的经内镜置入金属内支架缓解不能手术的胃十二指肠恶性梗阻患者的症状。方法 31例胃十二指肠恶性梗阻患者均有反复恶心呕吐症状,且不能手术治疗。在透视监视下,使用介入放射学方法置入33个自膨胀式金属内支架。结果 31例患者支架置入均成功,随访期间患者均能进食,呕吐减轻,生活质量提高。无严重并发症发生。结论金属内支架置入是对胃十二指肠恶性梗阻一种简单、有效的治疗方法,对不能手术的胃出口部狭窄和术后吻合口狭窄有很好的缓解作用。     

可回收支架用于良性气管狭窄患者24例效果观察

目的探讨可回收全覆膜金属支架用于良性气管狭窄的临床效果。方法对24例良性气管狭窄患者于透视引导下置入可回收全覆膜金属支架,支架完全覆盖狭窄段,两端分别超出狭窄段10～15mm。术后根据CT、气管镜检查和临床症状的缓解情况于4—8个月取出支架,观察支架置入前和取出后气管直径、气促评分、第一秒用力呼气量（FEV1）,统计并发症（分泌物滞留、肉芽组织增生、支架移位及咳出）发生情况。结果24例患者共置入31个气管支架,置入后支架膨胀完全,患者呼吸道梗阻症状立即缓解。支架取出后气管直径及FEV1明显高于、气促评分明显低于置人前（P均〈0．05）,临床症状均明显缓解。3例复发性多软骨炎患者支架未取出,出现分泌物滞留24例,肉芽组织增生21例,支架移位及咳出3例。结论可回收全覆膜金属支架用于良性气管狭窄效果确切,且较为安全。     

Budd-Chiari综合征30例临床分析

1　材料与方法　　本文总结自 1995～ 2 0 0 2我院收治的 3 0例Budd Chiari综合征 (BCS)患者。本组 3 0例经血管造影证实的BCS患者 ,男 18例 ,女 12例 ,年龄 2 4～ 63岁 ,平均 3 7 4岁 ,自症状出现到确诊的时间为 1～ 2 7a ,平均 6 8a。术前常规行CT、B超、胃镜检查 ,实验室检测血清白蛋白、总胆红素、血小板。单纯膜性下腔静脉闭塞的患者 ,采用经股静脉下腔静脉开通术和球囊成形术 ,必要时植入下腔静脉支架。对下腔静脉节段性闭塞的患者 ,在开通、扩张闭塞静脉后 ,植入下腔静脉支架。压迫性下腔静脉狭窄的患者均采取球囊扩张术和内支…     

内镜下金属支架引流术治疗肝门部胆管癌和肝外恶性胆道梗阻临床观察

临床上恶性胆道梗阻性疾病预后较差。对于不能手术切除者,通常选择内镜下置人胆道支架以解除梗阻,然而该技术对进展期肝门部肿瘤的疗效报道不一。目的：探讨内镜下金属支架引流术对肝门部胆管癌和肝外恶性胆道梗阻的疗效和并发症发生情况。方法：纳入上海交通大学附属第一人民医院2006年6月～2009年6月收治的82例接受ERCP下置入自膨式金属胆道支架引流治疗的恶性胆道狭窄患者,根据病变部位分为肝门部胆管癌组和肝外恶性胆道梗阻组,对其ERCP参数和术后6个月随访记录进行回顾性分析,并分析随访期间急性胆管炎发生的危险因素。结果：两组支架置入成功率均为100％。与肝外恶性胆道梗阻组相比,肝门部胆管癌组术后1周总胆红素降低显效率较低,术后6个月内急性胆管炎发生率增高,初次发生时间提前,支架再狭窄率增高（P=0．000）。ERCP术中括约肌切开为随访期间发生急性胆管炎的危险因素（P=0．004,OR：8．196）。结论：内镜下金属支架引流术对肝门部胆管癌的疗效不及肝外恶性胆道梗阻,且更易早期发生急性胆管炎和支架再狭窄,术中括约肌切开可增加术后急性胆管炎的发生风险。     

Reconstruction of stenotic or occluded iliofemoral veins and inferior vena cava using intravascular stents: re-establishing access for future cardiac catheterization and cardiac surgery

OBJECTIVES: The study evaluated the safety and efficacy of stent reconstruction of stenotic/occluded iliofemoral veins (IFV) and inferior vena cava (IVC). BACKGROUND: Patients with congenital heart defects and stenotic or occluded IFV/IVC may encounter femoral venous access problems during future cardiac surgeries or catheterizations. METHODS: Twenty-four patients (median age 4.9 years) underwent implantation of 85 stents in 22 IFV and 6 IVC. Fifteen vessels were severely stenotic and 13 were completely occluded. Although guide wires were easily passed across the stenotic vessels, occluded vessels required puncture through the thrombosed sites using a stiff wire or transseptal needle. Once traversed, the occluded site was dilated serially prior to stent implantation. RESULTS: Following stent placement, the mean vessel diameter increased from 0.9 +/- 1.6 to 7.4 +/- 2.6 mm (p < 0.05). Twenty-one of 28 vessels had long segment stenosis/occlusion requiring two to seven overlapping stents. Repeat catheterizations were performed in seven patients (9 stented vessels) at mean follow-up of 1.6 years. Seven vessels remained patent with mean diameter of 6.4 +/- 2.0 mm. Two vessels were occluded, but they were easily recanalized and redilated. Echocardiographic follow-up in two patients with IVC stents demonstrated wide patency. In four additional patients, a stented vessel was utilized for vascular access during subsequent cardiac surgery (n = 3) and endomyocardial biopsy (n = 1). Therefore, 13 of 15 stented vessels (87%) remained patent at follow-up thus far. CONCLUSIONS: Stenotic/obstructed IFV and IVC may be reconstructed using stents to re-establish venous access to the heart for future cardiac catheterization and/or surgeries.     

Percutaneous T-tube placement for bilateral internal drainage in malignant hilar obstruction

BACKGROUND/AIMS: The aim of this retrospective study was to determine the efficacy and safety of percutaneous T-tube placement for malignant hilar obstruction. Results were compared with self-expanding metal stents. METHODOLOGY: Between June 1989 and April 1999, 24 consecutive patients with type II, III, IV hilar obstructions underwent T-tube (n = 12) and metal stent placement (n = 12). A 9-F T-tube was placed percutaneously into the right and left hepatic ducts. Metal stents (diameter: 6-10 mm) were placed in both ducts. RESULTS: Stent placement was successful in all patients. Early complications occurred in 2 patients in the metal stent group (arterio-biliary fistula and cholangitis). In the T-tube group, the 30-day mortality rate were 25%. These were not procedure related. The median patency period in the metal stent group (365.0 +/- 113.3 days) was longer than in the T-tube group (167.0 +/- 71.1 days). There were no significant differences in the median survival rates (224.0 +/- 39.0 days vs. 197.0 +/- 104.8 days). CONCLUSIONS: Internal T-tube placement for drainage of malignant hilar obstruction is safe and associated with few complications. The advantage of this procedure is removability of the T-tube stents.     

Covered metal stents for management of inoperable malignant colorectal strictures

BACKGROUND: Metal stents have been reported as an effective alternative to surgery for the palliation of patients with colorectal neoplastic obstruction. Because most of the published series describe the use of uncovered stents, the purpose of our study was to prospectively evaluate the effectiveness, feasibility, safety, and outcome of covered stents for the palliative treatment of malignant colorectal strictures. METHODS: Sixteen patients with advanced distal colorectal cancer underwent placement of 10 and 12 cm long, 23 mm diameter covered stents under fluoroscopic and endoscopic control. Clinical and endoscopic follow-up was scheduled at 3- to 6-week intervals. RESULTS: Stent insertion was successful in 15 of 16 patients (93%). Perforation occurred in one patient during stent placement requiring colostomy. Relief of bowel obstruction was documented in all successfully treated patients. The median follow-up was 21 weeks (range 1 to 46). No recurrence of obstruction was observed during the follow-up period. Stent migration occurred in 2 patients, 7 and 21 days after stent placement. CONCLUSIONS: Covered stents may provide safe and effective palliation of patients with malignant rectosigmoid strictures. Prolonged luminal patency and sealing of fistulous tracts are potential advantages of covered versus uncovered stents in the palliative treatment of colorectal malignancies. ?     

Multicenter randomized trial of the spiral Z-stent compared with the Wallstent for malignant biliary obstruction

BACKGROUND: The industry standard since 1990 for self-expanding biliary metallic stents has been the Wallstent. In 1998 the Spiral Z-stent was released. This randomized trial compared the Z-stent with the Wallstent in the treatment of malignant biliary obstruction. METHODS: Patients with unresectable malignant biliary obstruction distal to the bile duct bifurcation were randomized to receive a 10-mm diameter Wallstent or a 10-mm diameter Z-stent. RESULTS: A total of 145 patients were randomized; 13 were excluded. Sixty-four patients who received a Z-stent and 68 who had a Wallstent are included in the analysis. Tumors responsible for bile duct obstruction were pancreatic cancer (108), cholangiocarcinoma (15), metastatic cancer (6), and papillary cancer (3). Metallic stents were successfully placed in all patients. Seven technical problems were encountered during placement of the Z-stent and 5 with the Wallstent. There were 21 occlusions requiring reintervention (8 Z-stent, 13 Wallstent; p = 0.30). Median time to reintervention was the following: Z-stent, 162 days; Wallstent, 150 days (p = 0.22). A total of 104 patients died of progressive disease or other cause; 7 patients remain alive with patent stents. The overall calculated median patency rates were: Z-stent, 152 days; Wallstent, 154 days (p = 0.90). CONCLUSIONS: The Spiral Z-stent is comparable with the Wallstent in terms of placement, occlusion rates, and overall patency. Occasional early occlusion of both stents suggests tumor characteristics instead of the size of the mesh openings in the stents as important factors.     

Endoscopic bilateral metallic stenting for malignant hilar obstruction using newly designed stents

Background/Purpose

Whether unilateral or bilateral drainage should be performed for malignant hilar biliary obstruction is controversial. Moreover, endoscopic placement of bilateral metallic stents is difficult and complicated.

Methods

New metallic stents, such as the Niti-S Y-type stent (Y-stent), BONASTENT M-Hilar, and Niti-S large cell D-type stent (LCD), have recently been developed for bilateral stent-in-stent procedures to facilitate contralateral stent deployment through the interstices of the first metallic stent. We review the features and efficacy of these metallic stents designed for bilateral drainage in patients with hilar biliary obstruction.

Results

The newly designed stents examined exhibited high technical success rates, low stent-related complications, and good stent patency. Endoscopic reinterventions for occluded stents could be performed easily, particularly in patients with bilateral LCD placement.

Conclusion

Endoscopic bilateral stenting using newly designed metallic stents is feasible, safe, and effective in patients with unresectable malignant hilar biliary obstruction.     

Long-term effect of stent placement in 115 patients with Budd-Chiari syndrome

AIM: To report the long-term effect of stent placement in 115 patients with Budd-Chiari syndrome (BCS).METHODS: One hundred and fifteen patients with BCS were treated by percutaneous stent placement. One hundred and two patients had IVC stent placement, 30 patients had HV stent placement, 17 of them underwent both IVC stent and HV stent. All the procedures were performed with guidance of ultrasound.RESULTS: The successful rates in placing IVC stent and HV stent were 94 % (96/102) and 87 % (26/30), respectively.Ninety-seven patients with 112 stents (90 IVC stents, 22 HV stents) were followed up. 96.7 %(87/90) IVC stents and 90.9 %(20/22) HV stents remained patent during follow up periods (mean 49 months, 45 months, respectively). Five of 112 stents in the 97 patients developed occlusion. Absence of anticoagulants after the procedure and types of obstruction (segmental and occlusive) before the procedure were related to a higher incidence of stent occlusion.CONCLUSION: Patients with BCS caused by short length obstruction can be treated by IVC stent placement, HV stent placement or both IVC and HV stent placement depending on the sites of obstruction. The long-term effect is satisfactory.Anticoagulants are strongly recommended after the procedure especially for BCS patients caused by segmental occlusion.     

Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents

BACKGROUND: Endoscopic management of malignant hilar biliary obstruction is controversial with respect to optimal types of stents and extent of drainage. This study evaluated outcomes of selective MRCP and CT-targeted drainage with self-expanding metallic stents. METHODS: Consecutive patients undergoing attempted palliative ERCP for malignant hilar biliary obstruction were prospectively followed. Whenever possible, management strategy included evaluation and staging for potential resectability before ERCP, with primary placement of metallic stents at the first ERCP in nonsurgical candidates, and early conversion to a metallic stent when a tumor proved to be unresectable. MRCP and/or CT were used to plan selective guidewire access, opacification, and drainage only of the largest intercommunicating segmental ducts. Unilateral stent placement was intended in all cases except for selected patients with Bismuth II cholangiocarcinoma. RESULTS: Thirty-five patients were included. Bismuth classification was I, 10; II, 6; III, 8; and IV, 11. Tumor origin was bile duct (17), gallbladder (5), and metastatic (13). Metallic stents were placed in 27 patients as the initial stent, and in 8 after plastic stent placement. Initial stents were placed endoscopically in 33 patients and percutaneously in 2 patients in whom lumenal tumor precluded ERCP. Stent placement was unilateral in 31 patients and bilateral in 4 patients. There were no episodes of cholangitis or other complications within 30 days after any procedures. Initial metallic stents were clinically effective in 27 (77%) of the 35 patients. Additional percutaneous drainage in 3 patients who did not respond to initial stent placement did not resolve jaundice. Median patency of first metallic stents was 8.9 months for patients with primary bile duct tumors and 5.4 months for all patients, and was not related to Bismuth classification. No further intervention was needed in 25 (71%) patients. CONCLUSIONS: Unilateral metallic stent placement by using MRCP and/or CT to selectively target drainage provides safe and effective palliation in most patients with malignant hilar biliary obstruction.     

超声引导下下腔静脉内支架置入术治疗布—加氏综合征

目的 探讨布-加氏综合征全新的介入治疗方法。资料和方法 36例患者,其中IVC狭窄21例,闭塞15例,闭塞段最长7.2cm。在超声引导下经股静脉穿刺行IVC开通,球囊扩张及内支架置入术。结果 手术成功35例(97％)。术后IVC压力由3.3kpa降至1.3kpa(P<0.01),阻塞远端IVC血流峰值由0.19m/s增至0.57m/s(P<0.01),并出现正常心房波和呼吸波。IVC血流受阻症状、体征很快消失,平均随访9个月,病情稳定无复发。结论 超声引导下IVC支架成形术,操作难度不大、直观,适应范围广,副作用少,费用低,宜作为IVC阻塞的常规治疗方法。     

Treatment of unresectable hepatic hilar malignancies with self-expanding metallic stents

BACKGROUND/AIMS: This study assesses the treatment of biliary obstruction in patients with hilar malignancies by metallic stents. METHODOLOGY: Twenty-one consecutive patients with unresectable malignant biliary obstruction at the hepatic hilum (Bismuth type II, III and IV) were treated with percutaneous transhepatic placement of self-expandable metallic endoprostheses. The endoprostheses were successfully inserted in all patients. In 12 patients all segments of the liver were drained and in 9 patients partial segments of the liver were drained. RESULTS: Seventeen patients (81%) showed relief from jaundice and could be freed of external drainage tubes. Ten patients (48%) showed no recurrent symptoms due to stent obstruction until death. Overall survival was 4.86+/-4.15 (mean+/-SD) months, stent patency was 3.76+/-3.64 months and comfort index representing a ratio of well-being was 70.5+/-38.3%. There was no significant difference in survival rate, stent patency or comfort index between the groups with complete and those with partial drainage. CONCLUSIONS: Even in patients with complicated hepatic hilar biliary occlusions, internal drainage using metallic stents can relieve jaundice and leave patients free of external tubes with a comfortable quality of life.     

Treatment of malignant esophageal obstruction with silicone-coated metallic self-expanding stents.

Six patients with high-grade malignant esophageal obstruction were treated with silicone-coated metallic self-expanding esophageal stents (Z stents). Endoscopic placement of stents was well tolerated. All patients achieved excellent palliation, defined by a decrease of at least two dysphagia grades, which was sustained. Complications occurred during follow-up in four patients and included stent migration, silicone disruption with tumor ingrowth, food impaction, and perforation (discovered at autopsy) at the distal stent site. Three of the four complications were promptly treated by endoscopic or radiologic intervention. Recent modification in stent design and placement technique will hopefully reduce complications. The self-expanding stent has several theoretical advantages over the rigid plastic stent and Nd:YAG laser for palliation of obstructing esophageal malignancy.