恶性梗阻性黄疸的介入治疗

目的探讨恶性梗阻性黄疸的介入治疗方法及其疗效。方法对256例恶性梗阻性黄疸患者,施用经皮经肝穿刺胆道引流术(PTCD)加金属内支架置入术或结合局部动脉化疗术,共使用256条外引流管和256枚金属内支架。结果 256例患者采用经皮经肝穿刺置入外引流管及支架置入术,均一次置入成功。术后总胆红素、直接胆红素、碱性磷酸酶均明显下降。术后256例患者黄疸消退满意;112例黄疸消退,并于术后4周行局部灌注化疗术。结论经皮经肝穿刺胆道外引流加内支架置入术是姑息性治疗恶性梗阻性黄疸的安全、有效方法,结合局部动脉灌注化疗,能提高患者的生命质量及延长生存期。     

金属胆道支架在恶性胆道梗阻治疗中的临床应用

目的：探讨金属胆道支架置人结合肿瘤区域化疗在恶性胆道梗阻治疗中的应用价值。方法：46例不能根治切除的恶性胆管梗阻患者中，42例行经皮肝穿刺胆道引流（PTCD）后支架置放术，另4例行经腹胆道支架置放术。支架置放术后，36例采用皮下埋置化疗泵化疗药物注射，8例采用分次动脉插管化疗药物灌注。结果：经PTCD成功后支架置人成功率95．2％，经腹支架置人成功率100％。结论：金属胆道支架置人成功率高，手术损伤，支架通畅率高，结合肿瘤区域化疗，可进一步提高疗效。     

经皮肝穿胆道内外引流治疗上段胆管癌所致黄疸31例

目的探讨经皮肝穿胆道内外引流治疗上段胆管癌所致黄疸的疗效。方法对诊断为上段胆管癌致恶性梗阻性黄疸的患者，在X线监视下实行、经皮肝穿胆道内外引流术，并观察其疗效。结果本组患者均一次胆道引流成功，所有患者术后病情明显好转，随访1个月引流效果均较满意。结论经皮肝穿胆道内皮引流是一种姑息性方法，如能在此基础上进行根治性手术治疗或结合对肿瘤的化疗、放疗治疗，可进一步延长生命。     

经皮经肝穿刺胆管引流术联合经肝动脉内灌注化疗栓塞治疗原发性肝癌合并梗阻性黄疸的初步观察

目的探讨经皮经肝穿刺胆管引流术(PTCD)联合经肝动脉内灌注化疗栓塞(TAE)治疗原发性巨块型肝癌合并梗阻性黄疸的方法和临床应用初步效果。方法原发性巨块型肝癌患者25例,其中男性15例,女性10例;年龄35～65岁,平均年龄48岁。因肿瘤压迫或侵蚀胆总管/肝总管合并梗阻性黄疸。在影像诊断明确病变部位和梗阻程度后,先行经皮经肝穿刺胆管(PTC),明确肝胆管侵犯和梗阻细节,酌情置入引流导管行外引流或胆管支架行内引流;术后1周患者黄疸减轻后常规进行肝动脉内介入灌注化疗与栓塞。结果 10例置入外引流管,10例置入胆道支架,5例同时置入外引流管和胆道内支架。引流术后全部外引流病例引流通畅,内引流患者大便色泽改变;血清胆红素、总胆红素下降明显,患者全身状况明显改善。5例出现右侧少量胸腔积液,其他未出现明显并发症。TAE术后肝脏肿块均不同程度缩小(t=10.00,P<0.01)。随访患者最长生存期为3年。结论 PTCD联合TAE治疗原发性肝癌引起的梗阻性黄疸疗效可靠,应根据胆管梗阻部位及程度确定治疗方案,及时施行手术可进一步提高患者生存期。     

Ⅲ段胆肠吻合术在6例肝门部恶性梗阻治疗中的应用体会

目的 回顾性分析Ⅲ段胆肠吻合术在6例肝门部恶性梗阻治疗中的应用结果. 方法 6例肝门部胆管恶性梗阻患者:其中男性4例,女性2例,平均年龄58.6岁,术中肿瘤均无法切除,肝门部无法解剖,采用Ⅲ段胆肠吻合术.结果 术后患者均无手术严重并发症,血胆红素水平逐渐恢复至正常水平,均痊愈出院. 结论Ⅲ段胆肠吻合作为一种内引流方式可达到有效解除黄疸,延长生存、提高生活质量的姑息目的.     

梗阻性黄疸患者胆道内、外引流手术前后血清白细胞介素的表达及临床意义

了解梗阻性黄疸胆道内、外引流术式对血清白细胞介素-6(IL-6)和白细胞介素-12(IL-12)含量的影响。方法：43例由恶性肿瘤引起的梗阻性黄疸中，胆道内引流32例，胆道外引流术11例，43例患者术前、术后均测得血清IL-6和IL-12含量。结果显示，梗阻性黄疸内、外引流术前血清IL-6和IL-12低于正常组，行胆道内引流术后血清IL-6、IL-12的值与正常组比较无显著性差异，表明其免疫功能有所恢复，而胆道外引流术后血清IL-6、IL-12的值低于正常组，表明免疫功能仍受损。该结论提示在临床上对于一般情况差，不能行根治手术的梗阻性黄疸病人，应尽可能行胆道内引流术。     

胆道支架联合高强度超声聚焦刀治疗胰腺癌合并梗阻性黄疸的临床观察

目的探讨胆道支架联合高强度超声聚焦刀(HIFU)治疗胰腺癌导致的梗阻性黄疸的疗效与安全性。方法选择2013年1月至2017年2月80例胰腺癌合并梗阻性黄疸经胆道支架置入治疗的患者,根据支架置入术后是否进行HIFU治疗将患者分为联合治疗组(38例)与单纯支架组(42例),对比2组患者支架通畅时间及生存期。结果 2组患者黄疸均在胆道支架置入后缓解。7例患者在胆道支架置入术后并发胆管炎。80例患者随访(5.13±2.94)个月。15例患者发生支架再狭窄。联合治疗组患者中位支架通畅时间为179 d,中位生存期为209 d;单纯支架组患者中位支架通畅时间为119 d,中位生存期为145 d;2组患者比较差异有统计学意义(P0.05)。根据单因素与多因素Cox回归分析结果,胆道支架术后进行HIFU治疗及肿瘤分期较早是延长患者生存期的因素(P0.05)。结论胆道支架联合HIFU治疗胰腺癌导致的梗阻性黄疸安全有效;HIFU能够显著延长胆道支架通畅的时间以及生存期。     

自膨式金属支架及手术解除晚期结直肠癌肠梗阻的疗效比较

背景：对于发生梗阻的晚期结直肠癌患者,置入金属支架的治疗效果尤其是远期疗效知之甚少。 目的：比较自膨式金属支架和姑息性手术解除晚期结直肠癌患者肠梗阻的疗效。 方法：纳入采用自膨式金属支架和姑息性手术两种治疗方式的186例患者,回顾性分析两组患者性别、年龄、梗阻部位、转移部位、支架类型、支架直径、术后并发症、住院时间、化疗、手术至初次化疗时间和晚期梗阻等资料。 结果与结论：支架组的技术成功率低于手术组(P=0.030),临床成功率无差异。与手术组比较,支架组并发症发生率较低,但是主要并发症发生率比较,差异无显著性意义(P=0.839)。支架组住院时间、手术到化疗时间均比较短,但其晚期梗阻的发生率明显高于手术组(P=0.028)。Logistic多元回归分析发现,支架直径和化疗是影响晚期梗阻的独立危险因素。说明对于无法切除并发梗阻的结直肠癌患者支架置入治疗具有更好的早期疗效,但是长期疗效较差,尤其是放置支架直径较小的化疗患者,可能需要再次放置支架或手术以解除晚期梗阻。     

术前胆道引流对肝胆管结石合并胆汁性肝硬化的作用

目的探讨肝胆管结石合并继发性胆汁性肝硬化病人，在进行肝叶切除手术前行胆道引流（PBD）的作用。方法回顾性分析67例行肝叶切除治疗合并继发性胆汁性肝硬化的肝胆管结石病例，其中PBD组35例均行术前胆道引流，非PBD组32例未行术前胆道引流，将两组的肝功能变化、结石清除率、并发症发生情况等进行比较分析。结果PBD组的术前肝功能较入院前有所改善，术中结石清除率高于非PBD组，两组的手术并发症发生情况无显著差异。结论术前胆道引流虽然没有减少手术并发症，但可以改善术前肝功能，增加结石清除率。     

68例恶性梗阻性黄疸患者ERCP诊治的分析

目的 探讨经内镜逆行胰胆管造影(ERCP)及其相关技术在恶性梗阻性黄疸患者诊断和治疗中的作用.方法 回顾性分析68例恶性梗阻性黄疸患者的ERCP诊断情况,以及ERCP相关性治疗,包括内镜下鼻胆管引流(ENBD)、内镜下胆管金属支架引流术(EMBD)、塑料支架引流术(ERBD)、超声引导下经皮肝穿刺胆道引流术(PTCD)联合ERCP支架植入术的应用情况,并对患者的预后及并发症进行总结分析.结果 68例患者均经ERCP检查,共成功发现病变显影54例(79.4％),其中壶腹癌(16/18)、乳头癌(10/12)、胆管下段癌(8/l0)、胆囊癌(5/5)、肝癌侵犯胆管(2/2)肝门部胆管癌(6/11)、胰腺癌(6/8).术后7d胆红素及ALP水平较术前均明显下降,大部分患者症状明显缓解.术后并发急性胰腺炎8例(14.8％),电解质紊乱9例(16.7％),并发消化道出血3例.49例接受为期6个月的随访,其中死亡12例(24.5％).结论 ERCP及其相关治疗手段能够减轻黄疸,缓解症状,提高生活质量,延长生存期,是姑息性治疗恶性梗阻性黄疸的重要方法.     

Intrahepatic biliary cysts in congenital biliary atresia

A case of pronounced cystic dilatation of the intrahepatic bile ducts with biliary atresia is presented. Intrahepatic biliary cysts have been described in biliary atresia, although, as far as we are aware, none as extensive as in this case. The cysts represent end-stage obstruction with irreversible liver injury; thus, drainage of these cysts does not alleviate the condition. The differential diagnosis includes Caroli's disease, congenital hepatic fibrosis, and polycystic liver disease.     

Extrahepatic biliary atresia. Morphological study of 98 biliary remnants

Histologic examination was performed on 98 biliary remnants. Classification into three types was made according to the presence of epithelial structure; biliary and glandular formations had to be separated. Atretic lesions were predominantly observed at the pars inferior of the remnants. These histological findings agree with the theory of a dynamic ascending process that leads to progressive, complete destruction of the biliary and glandular structure, although main ducts may remain preserved by the vicinity of the porta hepatis. Classic clinical data suggest that the damage is initiated in utero. The lesions certainly progress after birth; in some cases the fibrotic process of the remnant may have already reached completion at birth, whereas in some others it may become clinically evident after birth.     

Expression of cell cycle-related molecules in biliary premalignant lesions: biliary intraepithelial neoplasia and biliary intraductal papillary neoplasm

Cholangiocarcinoma of intrahepatic and extrahepatic bile ducts has a multistep carcinogenesis. Two premalignant lesions have been suggested for invasive cholangiocarcinoma: biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct. How the carcinogenetic process differs between biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct is not clear. In this study, we performed a pathological study to reveal the expression of key molecules related to the cell cycle during 2 carcinogenetic lineages. We immunohistochemically examined the expression of p21, p53, cyclin D1, and Dpc4 in a total of 89 cases: nonneoplastic biliary epithelium, biliary intraepithelial neoplasia, intraductal papillary neoplasm of the bile duct, and invasive cholangiocarcinoma. The expression of p21, p53, and cyclin D1 was up-regulated with histological progression in both biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct, whereas Dpc4 expression was down-regulated in these 2 lineages. In biliary intraepithelial neoplasia, p21 expression was significantly up-regulated early on. In contrast, levels of all molecules changed gradually in intraductal papillary neoplasm of the bile duct. Changes in p53 expression during histological progression differed significantly between biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct. p53 expression was dramatically up-regulated at the invasive stage of biliary intraepithelial neoplasia, whereas it was quite low in noninvasive biliary intraepithelial neoplasia. In contrast, p53 expression was already up-regulated in low-grade intraductal papillary neoplasm and reached a plateau in high-grade intraductal papillary neoplasm and invasive cholangiocarcinoma. This study suggested p21, p53, cyclin D1, and Dpc4 to be involved in the carcinogenesis of both biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct. p53 expression was regulated differently in biliary intraepithelial neoplasia compared with intraductal papillary neoplasm of the bile duct.     

A case of unclassified multicystic biliary tumor with biliary adenofibroma features

A 40-year-old Japanese man was admitted to our hospital for evaluation of upper abdominal pain. Abdominal computed tomography (CT) revealed a well-circumscribed multicystic mass measuring approximately 7 × 6 cm. The mass contained a solid lesion measuring 3 × 2 cm. Biopsy of a swollen cervical lymph node led to a diagnosis of diffuse large B-cell lymphoma. After initial chemotherapy for lymphoma, the multicystic mass was surgically resected. The tumor was composed of a multicystic lesion and a solid lesion. Histopathologic examination of the multicystic lesion revealed that the locules were lined by biliary epithelium, demonstrating various degrees of cytological atypia. The stroma was fibrous, and the tumor showed marked apocrine snouts. Part of the tumor showed papillary growth with strong cytological atypia. The solid lesion showed tubulocystic proliferation of tumor cells, with prominent apocrine snouts, embedded in dense and partially hyalinized fibrous stroma. The morphology of the solid part was quite similar to that of reported biliary adenofibroma. Despite lengthy discussion, an appropriate pathological diagnosis could not be found among the current classifications of biliary tumor. The tumor was finally diagnosed as unclassified multicystic biliary tumor with adenofibroma features.     

胆道闭锁肝内外胆系组织病理形态学分析

目的 通过胆道闭锁（BA）肝门纤维块、肝脏组织的病理及其超微结构观察，对肝门成纤维细胞分化程度进行评分，并与肝纤维化分级进行相关分析。方法 选取BA患儿作为研究对象，术中取肝门纤维块及肝脏组织标本；研究同期选取疑似BA经术中胆道造影除外BA，诊断为胆汁淤积综合征和先天性胆管扩张症患儿作为对照组，留取肝脏组织标本。在光镜和电镜下观察标本的病理改变，以及肝细胞、毛细胆管和肝门成纤维细胞的超微结构。采用SPSS14．0软件，半定量比较BA与对照组肝脏纤维化的差异，检验肝门纤维块成纤维细胞活跃程度与肝纤维化分级的相关性。结果 2005年7月至2006年5月复旦大学附属儿科医院收治的21例BAKasai根治术病例，手术平均年龄（66±20）d；对照组为5例胆汁淤积综合征和10例先天性胆管扩张症患儿。BA组肝组织病理改变主要是肝内门脉区胆管炎症及纤维化形成，肝纤维化程度明显高于同年龄胆汁淤积综合征和先天性胆管扩张症患儿；肝门纤维块毛细胆管增生，部分管腔闭锁、狭窄，腔内炎细胞浸润及部分淤胆，大量间质成分增生；电镜下肝门成纤维细胞活跃、肝脏毛细胆管上皮微绒毛缺失、肝细胞及肝血窦内电子致密物质增多及部分毛细胆管扩张；肝门成纤维细胞分化程度与肝组织纤维化程度相关（P=0．04）。结论 BA肝组织病理改变主要是肝内门脉区胆管炎症及严重纤维化形成；超微结构改变提示肝门部成纤维细胞活跃，其分化程度与肝纤维化程度相关。