Mirizzi综合征的诊断与腹腔镜胆囊切除术治疗的体会

目的 探讨Ｍｉｒｉｚｚｉ综合征的诊断和应用腹腔镜胆囊切除术（ＬＣ）治疗１型Ｍｉｒｉｚｚｉ综合征。方法 对３５例１型Ｍｉｒｉｚｚｉ综合征病例,在诊断和ＬＣ的方法进行回顾性分析。结果 该综合征１型在术前确诊２６例（７４．２９％）,其中临床症状结合Ｂ诊断１１例（２５．７１％）,３５例ＬＣ中转开腹胆囊切主４例,延期剖腹及ＥＲＣＰ诊断１５例（５７．６９％）,术中确诊９例（２５．７１％）。３５例ＬＣ中 工腹胆     

磁共振胰胆管造影术与内镜逆行胰胆管造影术的对照研究

目的 通过磁共振胰胆管造影术（ＭＲＣＰ）与内镜逆行胰胆管造影术（ＥＲＣＰ）的对照研究，评价ＭＲＣＰ对胰胆系疾病的诊断价值。方法 ４０例疑有胰胆系疾病的患者进行了ＭＲＣＰ及ＥＲＣＰ检查，两者结果作对照研究。结果 本组资料中ＭＲＣＰ对胰胆系疾病总的诊断价值为敏感度８９．１％、特异度１００％、准确度９０％，ＥＲＣＰ总的诊断价值为敏感度８４．２％、特异度１００％、准确度８５％，两者统计学上无显著性差异。结     

核磁共振胰胆管造影与内镜下逆行胰胆管造影在胰胆疾病诊断方面的对比研究

目的：探索核磁共振胰胆管造影（ＭＲＣＰ）检查在临床应用中的价值。方法：对１１０例胰胆管疾病患者选择性地行ＭＲＣＰ检查,并与内镜下逆行胰胆管造影（ＥＲＣＰ）检查作比较,结合内镜下治疗以及外科手术,以明确两者之间的相关性。ＥＲＣＰ和手术结果作为金标准。结果：１１０例患者ＭＲＣＰ图像质量均较高,对胆管扩张诊断的敏感性为８５．０６％（７８／８７）,对胆管下段狭窄伴扩张诊断的敏感性为９０％（１８／２０）。Ｍ     

ERCP对胆囊切除术后综合征的病因诊断价值

为探讨ＥＲＣＰ对胆囊切除术后综合征的病因诊断价值，对１０８例胆囊切除术后综合征进行ＥＲＣＰ检查，插管成功率９６．３％，有效诊断率８７．０％，结果表明胆总管和（或）肝内、外胆管残余结石占３６．１％，胆总管炎性扩张或狭窄占１７．６％，胆囊管残留过长占６．５％，胆管损伤占１．８％。认为ＥＲＣＰ检查对胆囊切除术后综合征不仅能明确其病因，而且对选择治疗方法也有重要意义。     

肾综合征出血热病毒结构蛋白致病作用的研究

为阐明肾综合征出血热（ＨＦＲＳ）发病机制，用免疫组化法检查了３０例患者ＨＦＲＳ病毒的膜蛋白（ＭＰ）、核蛋白（ＮＰ）在外周血单个核细胞（ＰＢＭＣ）中的表达情况，同时用放免等技术检测了血浆内皮素（ＥＴ）、Ｐ物质（ＳＰ）和肾功能相关指标。发现ＨＦＲＳ患者从４～５病日起至１３病日，ＰＢＭＣ中均有ＭＰ和ＮＰ表达，但随着病情的好转，其表达强度逐渐减弱。经染色鉴定ＭＰ与ＮＰ阳性细胞主要是单核细胞。入院时ＰＢＭＣ中ＭＰ和ＮＰ表达强度并不相同，ＭＰ的表达强度与血浆ＥＴ／ＳＰ比值、病情及肾脏损伤轻重呈平行关系。提示ＨＦＲＳ病毒能侵犯ＰＢＭＣ并在其中复制，表达病毒结构蛋白，而ＭＰ与ＨＦＲＳ病毒的致病作用相关；病程中血浆ＥＴ／ＳＰ比值升高是使肾损加重的重要因素。     

磁共振胰胆管造影术与经内镜逆行胰胆管造影术诊断阻塞性黄疸的价？…

目的：比较磁共振胰胆管造影术（ＭＲＣＰ）与经内镜逆行胰胆管造影术（ＥＲＣＰ）对阻塞性黄疸的诊断价值。方法：５５列阻塞性黄疸患者分别行ＭＲＣＰ和ＥＲＣＰ,其中１例行ＥＲＣＰ失败改行经皮肝胆管造影术（ＰＴＣ）。ＭＲＣＰ采用重Ｔ２加权及超快速自旋回波水成像技术进行,ＥＲＣＰ和ＰＴＣ按常规方法进行。结果：ＭＲＣＰ与ＥＲＣＰ（或ＰＴＣ）总的诊断准确率分别为９０．９％（５０／５５）和９８．２％（５４／５５）,     

ERCP对原发性肝外胆管癌的诊断价值

ＥＲＣＰ检查梗阻性黄疸２８７例中原发性肝外胆管癌４８例，其中胆囊癌４例（８％），肝总管癌１１例（２３％），胆总管癌１２例（２５％），壶腹癌１７例（３６％），胆管多部位癌４例（８％）。另外胰头癌浸润胆总管５例。本文探讨了原发性肝外胆管癌的Ｘ线特征、鉴别诊断；对比分析了ＥＲＣＰ与Ｂ超的诊断价值。     

胰腺癌的内镜诊治

近年来，内镜在胰腺癌的诊治中起着越来越重要的作用，内镜结合其他检查手段及治疗方法，可大大提高胰腺癌的早期诊断及治疗率。１　内镜下逆行胰胆管造影检查 内镜下逆行胰胆管造影（ＥＲＣＰ）是将纤维十二指肠镜插至十二指肠降部，经内镜活检钳通道插入造影导管至胰管或胆管内，注入造影剂的逆行胰、胆管造影。目前已成为胰、胆疾病的重要检查手段。ＥＲＣＰ影像可归纳为梗阻型、狭窄型、混合型及胰管分支缺损型四型，其中以狭窄型和梗阻型多见。胰头癌的ＥＲＣＰ表现为主胰管截断，胆管及远侧胰管扩张，胰体尾癌常表现为胰管局限性狭窄…     

肝外胆管癌的诊断体会

回顾性分析了１９７１￣１９９４年４８例肝外胆管癌资料，着重讨论了肝外胆管癌的影像学检查，认为Ｂ超检查作为肝外胆管癌的初筛诊断，经济可靠；ＣＴ及ＭＲＩ作为肝外胆管癌的定位诊断，检查无痛苦，诊断准确率高，但存在费用昂贵问题；ＰＴＣ及ＥＲＣＰ为介入性影像学检查，不仅对肝外胆管癌的定位诊断准确可靠，对手术方案的设计也有很大的参考意义。     

肝纤维化的基因治疗

肝纤维化是多种慢性肝病的共同病理基础与特征 ,表现为以胶原为主的肝脏细胞外基质 (ＥＣＭ )各成分合成增多 ,降解相对不足 ,过多沉积在肝内。若进一步发展引起肝小叶改建、假小叶与结节形成 ,则进入肝硬化。目前认为肝纤维化是可逆性病变 ,而肝硬化则不可逆转。但在实际工作中 ,对肝纤维化治疗仍缺乏有效办法 ,因此如何从抑制ＥＣＭ过度合成 ,或从促进ＥＣＭ降解的角度 ,积极寻找肝纤维化治疗的新方法 ,具有重要的现实意义与社会意义。基质金属蛋白酶 (ｍａｔｒｉｘｍｅｔａｌｌｏｐｒｏｔｉｎａｓｅｓ,简称ＭＭＰｓ)是一组重要的锌离子依赖的蛋白水解酶 ,参与多种组织的病理和生理性基质溶解和重建过程。目前认为 ,ＭＭＰｓ在肝内ＥＣＭ降解过程中发挥重要作用。肝内ＭＭＰｓ来源主要为肝星状细胞 (ＨＳＣ) ,其在早期肝损伤等条件下被激活 ,由静态转为肌纤维样细胞 ,合成ＭＭＰ 1、ＭＭＰ 2、ＭＭＰ 3等参与肝内ＥＣＭ降解。其中肝内间质胶原酶 (大鼠为ＭＭＰ 13,人为ＭＭＰ 1)主要分解Ⅰ、Ⅲ型胶原 ,在阻止肝脏ＥＣＭ过度沉积中起着重要作用。从已进行的研究表明 ,ＭＭＰ 1在肝纤维化过程中表达数量上并无显著改变 ,但其降解胶原的...     

Mirizzi综合征的内镜诊断与治疗

目的探讨微创治疗在Mirizzi综合征诊治中的临床价值。方法回顾性分析2001年6月至2006年5月，采用微创方法（十二指肠镜、胆道镜和腹腔镜联合）治疗Mirizzi综合征患者38例的情况。结果Mirizzi综合征患者均经B超、ERCP等影像学检查，其ERCP典型表现为肝总管可见边缘完整的充盈缺损，充盈缺损以上的肝总管及肝内胆管轻至重度扩张，合并胆囊萎缩及胆囊结石。术前放置ENBD导管，38例中35例通过三镜联合（腹腔镜、胆道镜和十二指肠镜）手术获得成功，无胆漏、胆道出血、胆管狭窄等严重并发症的发生。结论ERCP检查是一种可靠、直接的检查手段可以显著提高Mirizzi综合征患者的术前诊断率，微创手术治疗是安全可行的。     

Mirizzi syndrome

Opinion statement Mirizzi syndrome is an important complication of gallstone disease. If not recognized preoperatively, it can result in significant morbidity and mortality. Preoperative diagnosis may be difficult despite the availability of multiple imaging modalities. Ul-trasonography (US), CT, and magnetic resonance cholangiopancreatography (MRCP) are common initial tests for suspected Mirizzi syndrome. Typical findings on US suggestive of Mirizzi syndrome are a shrunken gallbladder, impacted stone(s) in the cystic duct, a dilated intrahepatic tree, and common hepatic duct with a normal-sized common bile duct. The main role of CT is to differentiate Mirizzi syndrome from a malignancy in the area of porta hepatis or in the liver. MRI and MRCP are increasingly playing an important role and have the additional advantage of showing the extent of inflammation around the gallbladder that can help in the differentiation of Mirizzi syndrome from other gallbladder pathologies such as gallbladder malignancy. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the diagnosis of Mirizzi syndrome. It delineates the cause, level, and extent of biliary obstruction, as well as ductal abnormalities, including fistula. ERCP also offers a variety of therapeutic options, such as stone extraction and biliary stent placement. Percutaneous cholangiogram can provide information similar to ERCP; however, ERCP has an additional advantage of identifying a low-lying cystic duct that may be missed on percutaneous cholangiogram. Wire-guided intraductal US can provide high-resolution images of the biliary tract and adjacent structures. Treatment is primarily surgical. Open surgery is the current standard for managing patients with Mirizzi syndrome. Good short-and long-term results with low mortality and morbidity have been reported with open surgical management. Laparoscopic management is contraindicated in many patients because of the increased risk of morbidity and mortality associated with this approach. Endoscopic treatment may serve as an alternative in patients who are poor surgical candidates, such as elderly patients or those with multiple comorbidities. Endoscopic treatment also can serve as a temporizing measure to provide biliary drainage in preparation for an elective surgery.     

Mirizzi's syndrome must be ruled out in the differential diagnosis of any patients with obstructive jaundice.

BACKGROUND/AIMS: Mirizzi syndrome is a rare benign complication of long-standing cholelithiasis and neither diagnostic modality nor clinical feature has a 100% sensitivity and specificity. The objective of our study was to call attention to the importance of this rare syndrome with its miscellaneous treatments. METHODOLOGY: Between January 1992 and June 1997, a total of 8 (4 females and 4 males) patients, who were operated and diagnosed as Mirizzi syndrome, were retrospectively evaluated. RESULTS: The mean age was 53.75 years. During the same time period 0.98% of the total 812 cholelithiasis patients were Mirizzi syndrome. The ultrasound was used in 7, computed tomography (CT) in 4 and endoscopic retrograde cholangiopancreatography (ERCP) in 2 cases. Ultrasound allowed the detection of cholelithiasis in all, but proximal bile duct dilatation in only 71% of cases. CT detected the non-specific findings of syndrome in 75% of cases. In 2 patients, because of the difficulties due to the patients themselves and the technical management problems. ERCP could not detect the pathology properly. In 2 of 5 type I patients, we performed only cholecystectomy and in another 2 cholecystectomy plus T-tube drainage. In 1 case, due to major hepatic duct injury during surgery, cholecystectomy plus hepaticojejunostomy over the Y-stent was performed. Biliary fistula developed in 1 patient with T-tube drainage and was successfully managed with conservative treatment. In all type II patients we preferred cholecystectomy plus choledochoduodenostomy and all of them were free of complications. CONCLUSIONS: If there is no question about the security of the common bile duct at surgery in type I patients, we recommended cholecystectomy, otherwise cholecystectomy plus exploration of common bile duct and/or drainage should be the procedure of choice. However, in type II patients cholecystectomy plus choledochoduodenostomy is a safe and effective procedure to perform.     

Values and limitations of 18F-fluorodeoxyglucose-positron-emission tomography with preoperative evaluation of patients with pancreatic masses

The aim of this study was to determine the value and limitations of 18F-fluorodeoxyglucose (FDG)-position-emission tomography (PET) for differentiating benign and malignant pancreatic disease and for staging malignant disease. One hundred fifty-nine patients with 89 malignant and 70 benign pancreatic lesions all received PET, computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) before pancreatic surgery. The original reports were compared for all patients (group I; N = 159), for a subgroup that neither had fasting plasma glucose levels > or =130 mg/dL or known elevated levels of C-reactive protein ([CRP], group II; n = 123), and for the remaining patients (group III; n = 36). For group I, accuracy values (areas under receiver operating characteristic [ROC] curves) for differentiation of benign/malignant masses were 0.86 (PET), 0.93 (ERCP), 0.82 (CT), and 0.95 for ERCP + PET (N = 159). For group II, ROC areas increased to 0.92 (PET), 0.94 (p < 0.05; n = 123) (ERCP), 0.82 (CT), 0.97 (p < 0.05; n = 123) (ERCP + PET). The results for group III were 0.71 (PET), 0.81 (CT), and 0.93 (ERCP); (n = 36). With 54 patients of group II that either had contradictory or indeterminate/technically unsuccessful CT/ERCP, PET was correct in 43 patients (84%). Sensitivity/specificity for lymph node staging was 49%/63%, respectively. For patients with hepatic metastasis, PET was 70% sensitive and 95% specific, missing some metastasis that were <1 cm. PET detected peritoneal metastasis in 25% of patients, missing poorly localized microscopic spread. For selected patients who have indeterminate pancreatic masses but no hyperglycemia or serologic evidence of active inflammation, FDG-PET is an independent functional assay that significantly adds to the diagnostic accuracy of ERCP and CT in the differentiation of benign and malignant pancreatic disease. PET can reliably detect hepatic, peritoneal, and other distant metastases that are > or =1 cm.     

经内镜乳头胆囊引流术治疗Mirizzi综合征并发梗阻性化脓性胆囊炎

目的探讨经内镜乳头胆囊引流术治疗Mirizzi综合征患者并发梗阻性化脓性胆囊炎的临床意义。方法回顾性总结8例患者的临床资料。8例患者均有急性右上腹痛,Murphy征阳性,经影像学和ERCP诊断为Mirizzi综合征Csendes分型Ⅰ型,胆道结石合并梗阻性化脓性胆囊炎。治疗方法为经内镜ERCP取石及相应治疗,继之行经乳头鼻胆囊引流术。结果8例均经内镜成功完成取石及鼻胆囊引流术,未发生并发症及死亡。术后患者胆囊区疼痛均明显缓解,体温、白细胞逐步恢复正常;1周后影像学检查显示胆囊及周围炎症明显好转或消失。6个月时随访,2例患者偶有胆囊区不适感。结论Mirizzi综合征的内镜取石治疗疗效确切,经内镜乳头胆囊引流术治疗其伴发的梗阻性急性化脓性胆囊炎在迅速缓解感染、减轻临床体征方面具有重要的作用。     

Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management

BACKGROUND: Mirizzi syndrome is a rare complication of prolonged cholelithiasis, characterized by narrowing of the common hepatic duct due to mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct. OBJECTIVES: To describe a series of eight consecutive patients with Mirizzi syndrome, at a single institution, submitted to surgical treatment and to comment on their aspects with emphasis on the diagnosis and treatment. METHODS: Four women and four men, with a mean age of 61.6 years (42 to 82 years), presenting Mirizzi syndrome were operated between 1997 and 2003. The following items were evaluated: clinical presentation, laboratory results, preoperative evaluation, operative findings, presence of choledocholithiasis, type of Mirizzi syndrome according to the classification by Csendes, choice of operative procedures, and complications. RESULTS: The most frequent symptoms were abdominal pain (87.5%) and jaundice (87.5%). All the patients presented altered hepatic function tests. The diagnosis of Mirizzi syndrome was intra-operative in seven (87.5%) patients, and preoperative in one (12.5%). Cholecystocholedochal fistula associated with choledocholithiasis was observed in three (37.5%) cases. Mirizzi syndrome was classified as Csendes type I in five (62.5%) patients, type II in one (12.5%), type III in one (12,5%) and type IV in another (12.5%). Cholecystectomy, as an isolated surgical procedure, was performed in four (50.0%) patients. One (12.5%) patient was submitted to partial cholecystectomy and closure of the fistulous orifice with the central part of the infundibula. Two (25.0%) patients were submitted to cholecystectomy and side-to-side choledochoduodenostomy and another (12.5%) to side-to-side choledochoduodenostomy remaining the gallbladder in situ. Seven (87.5%) patients had an uneventful recovery and were discharged in good conditions. One (12.5%) patient presented a postoperative sepsis due to a sub-hepatic abscess, and was reoperated. There was no operative mortality. CONCLUSION: The preoperative diagnosis of Mirizzi syndrome is difficult and an awarded suspicion is necessary to avoid lesions of the biliary tree. The problem may only become evident during the operation due to firm adherences around Calot's triangle. The success of the treatment is related to a precocious recognition of the condition, even at the time of surgery, and adapting the management considering to the individual characteristics of each case.     

Endoscopic ultrasound in pancreatic tumor diagnosis

In a prospective study from 1988 to 1990, 132 patients with suspected pancreatic tumor were examined with endoscopic ultrasound (EUS), transabdominal ultrasound (US), computed tomography (CT), and ERCP. The final diagnosis of 102 pancreatic tumors of different origin (76 malignant and 26 inflammatory tumors) and the exclusion of a pancreatic tumor in 30 patients was made by operation (N = 47), puncture (N = 36), autopsy (N = 3), or follow-up of a mean of 51 weeks (N = 46). Sensitivity and specificity in pancreatic tumor diagnosis were significantly higher for EUS (99% and 100%) than for US (67%/40%) and CT (77%/53%) and equal to ERCP (sensitivity 90%). This was even more obvious in small pancreatic tumors of 3 cm and less. However, as with the other imaging procedures, EUS was not able to differentiate reliably malignant from inflammatory pancreatic masses (accuracy 76% for malignancy and 46% for focal inflammation). From analysis of the endosonographic pattern of pancreatic tumors, no consistent morphologic features were identified which could have been specifically attributed to malignant or inflammatory masses. Our results show that EUS is superior to US and CT and equal to ERCP in pancreatic tumor diagnosis. In contrast to the indirect evidence obtained by ERCP, EUS provides direct visualization of tumor size and shape in almost all patients examined. Thus, EUS should be considered early in the evaluation of patients with suspected pancreatic tumors.     

Endoscopic ultrasonography compared with computed tomography with ERCP in patients with obstructive jaundice or small peri-pancreatic mass.

Pre-operative assessment of a potentially resectable peri-pancreatic mass by computed tomography (CT) is widely used, but often of limited value for lesions less than 5 cm. ERCP is frequently used to evaluate those patients with associated obstructive jaundice. To determine the clinical effectiveness of endoscopic ultrasonography (EUS), patients with pancreatobiliary lesions of less than 5 cm with or without obstructive jaundice were evaluated. CT scan, ERCP, and EUS were performed on 60 patients with a peri-pancreatic mass and/or obstructive jaundice. The results of the examinations were compared with respect to detection of an abnormality, diagnosis, and prediction of resectability. ERCP and EUS were the most sensitive and specific in detecting an abnormality of the pancreatobiliary system. The accuracy of EUS compared with the accuracy of the combination of CT scan with ERCP was significantly higher for the evaluation of the specific type and extent of pancreatobiliary disease (73% vs. 30%, p less than 0.001) and prediction of resectability (75% vs. 38%, p less than 0.05). EUS aided patient management in 75% by providing more details about the disease, and changed management in 32% by making a diagnosis or changing an incorrect diagnosis. EUS represents a significant advance in the evaluation and clinical management of pancreatobiliary disease.     

Factors predicting adverse short-term outcomes in patients with acute cholangitis undergoing ERCP: A single center experience

AIM: To identify potential factors that can predict adverse short-term outcomes in patients with acute cholangitis undergoing endoscopic retrograde cholangiopancreatography(ERCP). METHODS: Retrospective analysis of consecutive patients admitted to our center for acute cholangitis and underwent ERCP from 2001 to 2012. Involvement of two or more organ systems was termed as organ failure(OF). Cardiovascular failure was defined based on a systolic blood pressure of 90 mmHg despite fluid replacement and/or requiring vasopressor treatment; respiratory failure if the Pa02 /Fi02 ratio was 300 mmHg and/or required mechanical ventilation; coagulopathy if the platelet count was 80; and renal insufficiency if serum creatinine was 1.9 mg/dL. Variables associated with short term adverse clinical outcomes defined as persistent OF and/or 30-d mortality was determined. RESULTS: A total of 172 patients(median age 62 years, 56.4% female) were included. The median door to ERCP time was 17 h. Bile duct stones were the most common etiology(n = 67, 39.2%). In multivariate analysis, factors that were independently associated with persistent OF and/or 30-d mortality included American Society of Anesthesiology(ASA) physical classification score 3(OR = 7.70; 95%CI: 2.73-24.40), presence of systemic inflammatory response syndrome(OR = 3.67; 95%CI: 1.34-10.3) and door to ERCP time greater than 72 h(OR = 3.36; 95%CI: 1.12-10.20). Door to ERCP time greater than 72 h was also associated with 70% increase in the mean length of stay(P 0.001). Every one point increase in the ASA physical classification and every 1 mg/dL increase in the preERCP bilirubin level was associated with a 34% and 2% increase in the mean length of hospital stay, respectively. Transfer status did not impact clinical outcomes. CONCLUSION: Higher ASA physical classification and delays in ERCP are associated with adverse clinical outcomes and prolonged length of hospital stay in patients with acute cholangitis undergoing ERCP.