胆道梗阻后炎症反应发生的过程及机制

胆道梗阻(biliary obstruction)的病因非常复杂,但胆道梗阻后产生的一系列病理生理变化却大致相同,炎症反应作为其中的主要变化在胆道梗阻后造成的肝脏及机体损伤中起着十分重要的作用。了解并理清炎症反应在胆道梗阻后的病理生理变化中的作用及影响对认识这个疾病有着特别的意义。笔者就胆道梗阻后炎症反应产生的过程及机制予以综述。     

梗阻性黄疸肝内增生胆管上皮细胞凋亡的实验研究

目的：研究梗阻性黄疸肝内胆管上皮细胞凋亡对增生胆管的影响。方法：应用末端脱氧苷酸转移酶介导的脱氧三磷酸尿苷（dUTP）缺口末端标记技术（TUNEL）观察大鼠胆道梗阻及胆肠内引流术后肝内胆管上皮细胞凋亡与胆管增生的关系。结果：胆道梗阻后，肝内胆管明显增生，胆管上皮细胞凋亡明显增加；早期胆肠内引流术后，增生的胆管及胆管上皮细胞凋亡明显减少。结论：胆道梗阻胆管上皮细胞凋亡增加可能与清除过度增生的胆管有关，是机体维持自身组织稳定的一种重要机制；早期胆肠内引流术后，随着增生的胆管减少，胆管上皮细胞凋亡明显减少。     

经皮肝穿胆道置管引流治疗恶性梗阻性黄疸

目的 了解介入治疗恶性梗阻性黄疸的疗效。方法 采用经皮肤穿刺放置内支架或外引流对32例恶性梗阻性黄疸患者进行治疗。结果 中下段胆管梗阻疗效好，治疗一周后多数患者血清胆红素下降超过50％，15天后有16例患者血清胆红素降至正常。结论 胆道介入治疗确实有良好的缓解或消除黄疸的效果，特别是中下段胆道梗阻，黄疸可完全消退，但对上段胆道梗阻的患者，仅能部分缓解黄疸，疗效不如中下段胆道梗阻患者。     

Surgical and endoscopic palliation for pancreatic cancer

Patients with pancreatic cancer often present with locally advanced or metastatic disease and are deemed not to be candidates for a curative resection. Palliation in these patients focuses on relief of biliary obstruction, gastroduodenal obstruction and pain. Palliative treatment modalities include both surgical and nonsurgical approaches. Biliary obstruction is often initially treated with endoscopic biliary stenting. Two major types of biliary stents are used, plastic and metallic stents. Both of these provide similar initial relief of biliary obstruction, however, plastic stents have a greater propensity for occlusion and should primarily be used in patients with anticipated short survival duration. Metallic stents have a greater initial cost, but provide an overall cost-saving in patients with expected survival duration of over 6 months. Surgical palliation for biliary obstruction should be primarily considered in patients who fail endoscopic biliary decompression or who develop clinical evidence of gastroduodenal obstruction. In these patients, surgical palliation should consist of biliary decompression with a choledochojejunostomy when ever feasible, a gastroduodenal bypass and a chemical splanchnicectomy for pain relief. An initial prophylactic gastroenterostomy at the time of endoscopic biliary decompression is rarely indicated. The role of palliative pancreaticoduodenectomy remains controversial and to date there are no prospective randomized data to support its role in palliation of locally advanced pancreatic cancer. This review examines the available data from prospective trials for surgical and nonsurgical palliation of locally advanced and metastatic pancreatic cancer.     

Bile obstruction in hepatocellular carcinoma--visualization by endoscopic retrograde cholangiography. A case report

Extrahepatic biliary obstruction is a rare presentation in hepatocellular carcinoma (HCC), only 31 cases having been reported in the literature. We describe a patient with extrahepatic biliary obstruction in whom endoscopic retrograde cholangiography was suggestive of cholangiocarcinoma. Laparotomy and subsequent investigation, however, confirmed HCC metastasizing to the common hepatic duct. The cholangiographic appearance of HCC involving extrahepatic bile ducts is emphasized and features differentiating it from cholangiocarcinoma are highlighted. Even though extrahepatic biliary obstruction in HCC is rare, this disorder should be considered in the differential diagnosis of obstructive biliary tract disease.     

IODIDA scanning for functional and morphologic assessment of the liver and bile ducts before and following surgical interventions in bile duct obstruction

PROBLEM: Full pre- and postoperative assessment is mandatory in the management of complex cases of incomplete biliary obstruction. Investigations should not only define the level of extrahepatic bile duct obstruction but also detect intrahepatic obstruction, give some index of liver function and of the dynamics of biliary flow. Computed tomography, ultrasonography and direct cholangiography are very valuable. IODIDA-scanning provides a non-invasive method which not only complements other studies but also gives information otherwise unobtainable. CLINICAL MATERIAL: In an initial retrospective study 36 patients, 12 of whom had previously undergone operation for biliary obstruction, were fully investigated with particular reference to the use of IODIDA-scanning. PROCEDURE: 2-5 mCi of 99mTc labelled IODIDA were injected intravenously and the liver and upper abdomen scanned at 1 minute intervals and displayed at 5 minute intervals during the first hour. RESULTS: All patients were studied on admission and then postoperatively at intervals. In 31 of 36 patients IODIDA-scanning gave reliable evidence of the level of obstruction of biliary flow and of the patency of biliodigestive anastomosis. Assessment of liver function before and after biliary reconstruction was also possible. CONCLUSION: IODIDA-scanning has proved a valuable non-invasive method for the assessment of liver parenchymal function, intrahepatic abnormalities and of bile flow in cases of complex biliary obstruction. This is particularly valuable with the Roux-Y biliary reconstruction since ERCP is impossible and PTC an invasive method which, although supplying an accurate picture of major biliary obstruction, fails to characterize hepatic function and bile flow.     

联合应用胆道支架与十二指肠支架植入术治疗恶性胆管梗阻合并十二指肠梗阻

目的评价联合应用胆道支架与十二指肠支架植入术治疗恶性梗阻性黄疸合并十二指肠梗阻的疗效。方法 18例恶性梗阻性黄疸合并十二指肠梗阻患者接受双管腔内支架植入术,其中胰腺癌12例,胆管癌3例,十二指肠癌2例,腹腔淋巴结转移1例。14例患者首先出现胆管梗阻症状,然后出现十二指肠梗阻症状;4例患者同时表现为胆管及十二指肠梗阻症状。对所有患者均先行经皮肝穿刺植入胆管支架解决胆管梗阻,再经口植入十二指肠支架治疗十二指肠梗阻。结果 18例患者均成功植入胆道及肠道支架。所有患者血清总胆红素均明显下降,1例十二指肠支架植入后5天死于吸入性肺炎,未出现其他严重并发症。17例患者消化道梗阻症状缓解,生存期为3~17个月,中位生存期8.6个月。结论管腔内双支架植入术是治疗恶性梗阻性黄疸合并十二指肠梗阻的有效治疗方法。     

Experimental and clinical studies on the effect of biliary drainage in obstructive jaundice

Mitochondrial respiratory function, ketogenesis and collagen metabolism of the liver in biliary obstruction and after its relief were investigated in dogs and patients with obstructive jaundice. In dogs, it was found that hepatic mitochondrial respiratory function decreased significantly with prolongation of biliary obstruction, but recovered to varying degrees depending on both the duration of obstruction and of the period after the relief of obstruction. Ketogenesis was also impaired by biliary obstruction and its recovery was found in a slight degree only in cases with short-term obstruction. Hepatic collagen content and the synthetic ability significantly increased in biliary obstruction, and returned to normal levels with a relatively short period after the relief. Analogous results were obtained in clinical cases, but the decrease in serum bilirubin was somewhat delayed and increased hepatic collagen content continued after relief of the obstruction. When major surgery is required in patients with obstructive jaundice, biliary drainage should be carried out first 4 to 6 weeks before the performance of major operations. In cases with biliary obstruction for 12 weeks or more, it is desirable to wait for more than 6 weeks after biliary drainage since recovery of hepatic function, especially mitochondrial function, will be extremely slow.     

Clinical outcome of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction

Background: Previous studies have shown that self-expanding metal stents are an effective method for palliation of malignant biliary or duodenal obstruction. We present our experience with the use of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction. Methods: We performed a retrospective review of all patients undergoing simultaneous biliary and duodenal self-expandable metal stent placement between November 98 and May 2001. All the patients had documented evidence of biliary obstruction and symptomatic duodenal obstruction. The patients received endoscopic biliary stenting with biliary Ultraflex or Wallstents, and endoscopic duodenal stenting using enteral Wallstents. They were followed until their death. Results: We identified 18 patients (11 men and 7 women) whose mean age was 65 years, (range, 46–85 years). Malignancies included pancreatic 14 (78%), biliary 2 (11%), lymphoma 1 (5%), and metastatic 1 (5%) disorders. Ten patients previously had plastic biliary stents placed for past malignant biliary obstruction (4 patients had recurrent biliary obstruction). All the patients had evidence of duodenal obstruction. Combined metal stenting was successful in 17 patients. One procedure failed due to a tortuous duodenal stricture. All the patients had effective palliation of biliary obstruction, as evidenced by a decrease in the level of total bilirubin and alkaline phosphatase. Of the 17 patients with successful duodenal stenting, 16 had a good clinical outcome, with relief of obstructive symptoms. No immediate stent-related complications were noted. During the follow-up period, 12 patients died of progression of the underlying malignancy. None of the deaths were stent related. Median survival time was 78 days. Two patients had recurrent biliary obstruction from tumor ingrowth at 45 and 68 days, respectively. Both underwent restenting: one by endoscopic retrograde cholangiopancreatography (ERCP) and the other by percutaneous transhepatic cholangiography (PTC). Two other patients had recurrent duodenal obstruction, respectively, 36 and 45 days after the initial stenting. One obstruction was secondary to tumor ingrowth, and the other was caused by distal stent migration. Both patients had successful duodenal restenting. Conclusion: Combined self-expandable metal stenting for simultaneous palliation of malignant biliary and duodenal obstruction may provide a safe and less invasive alternative to surgical palliation with an acceptable clinical outcome. Simultaneous self-expandable metal stents should be considered as a treatment option for patients who are poor candidates for surgery.     

肝外胆管梗阻性疾病的MRCP诊断价值

目的探讨磁共振胆胰管成像技术对肝外胆管梗阻性疾病的诊断价值。方法对52例经病理或随访证实的肝外胆管梗阻性疾病患者的MRCP资料进行回顾性分析,总结良恶性肝外胆管梗阻的不同MRCP表现。结果52例中,MRCP均能够准确测定胆管扩张程度和梗阻的水平,其中良性梗阻27例,MRCP主要表现为胆管均匀扩张及逐渐狭窄,肝外胆管较肝内胆管扩张明显,肝内胆管呈“枯树枝状”;恶性梗阻25例,MRCP主要表现为胆管截断,胆胰管扩张,出现“双管征”,肝内外胆管扩张一致。恶性梗阻患者的肝内外胆管扩张程度明显大于良性梗阻者。结论MRCP作为一种无创的影像检查方法,对肝外胆管梗阻性疾病的诊断具有较高准确性,     

Percutaneous transhepatic biliary decompression. Results and complications in 30 patients

The palliative management of malignant obstruction of the biliary tree continues to challenge clinicians. The technique of PTBD has become increasingly popular to decompress the obstructed biliary system. Our initial experience with 30 consecutive patients treated with PTBD has been retrospectively reviewed. Internal drainage and effective biliary decompression was achieved in 90 and 86 percent of patients, respectively. Complications developed in 7 of 11 patients with long-term PTBD. Two patients died from septic complications. Three of 10 patients had major complications associated with preoperative PTBD. The remaining seven patients had permanent PTBD but did not derive any clinical improvement. Postoperative mortality after palliative procedures for malignant biliary obstruction is most often associated with carcinomatosis and advanced disease. Palliative biliary bypass provides effective palliation until the patient's death. There are groups of patients with an expected survival of more than 3 months and technically bypassable biliary obstruction who are best palliated by biliary enteric anastomosis. Patients with advanced disease are not candidates for either form of treatment. In patients with lesions not suitable for surgical bypass, PTBD remains a useful alternative.     

Pathophysiology of obstructive jaundice and its surgical problems

Mitochondrial respiratory function, ketogenesis, collagen metabolism of the liver in rats, dogs and patients with obstructive jaundice were investigated. In animal experiments, it was revealed that mitochondrial respiratory function and ketogenesis decreased significantly with prolongation of biliary obstruction. Hepatic collagen content and its synthesis significantly increased in biliary obstruction. After relief of biliary obstruction in these dogs and patients, these functions and contents improved or returned to near normal levels according to the duration of biliary obstruction and period after relief. By steroid hormone and CoQ administration to jaundiced rats, improvement of mitochondrial function was obtained to some extent. Cross circulation between the jaundiced rat and normal one was performed and it was found that mitochondrial function in normal rat was decreased and that of jaundiced rat improved, especially in renal mitochondria. When major surgery is required in patients of biliary obstruction with severe jaundice, biliary drainage should be carried out first 4 to 6 weeks before major operation. Steroid or CoQ therapy and plasma exchange are also useful for these patients.     

Self-expandable metallic stents for malignant biliary obstruction with an anomalous pancreaticobiliary junction

Background Anomalous pancreaticobiliary junction (APBJ) is associated with pancreaticobiliary cancer. Limited data are available on endoscopic biliary drainage for unresectable malignant biliary obstruction with APBJ. This study evaluated the efficacy and safety of self-expandable metallic stents (EMSs) for the management of malignant biliary obstruction with APBJ. Methods Between 1993 and 2005, 324 patients with unresectable malignant biliary obstruction underwent insertion of an EMS. Six of these patients with concomitant APBJ constituted the subjects of this study. Early (≤30 days after EMS insertion) and late (>30 days after EMS insertion) stent-related complications and stent patency were evaluated in these six patients. Results The cause of biliary obstruction was gallbladder cancer in four patients and pancreatic cancer in two patients. Uncovered EMSs were inserted across the common channel without performance of a biliary sphincterotomy. The diameter of the uncovered EMS used was based on the diameter of the common channel. For all six patients, endoscopic biliary drainage was successful, and their jaundice subsided steadily. None of the six patients experienced early complications, including acute pancreatitis. The mean stent-related complication-free period was 163 days. Stent occlusion caused by tumor ingrowth occurred in two patients. Acute cholangitis and cholecystitis were observed in one patient each. Conclusions Uncovered EMSs are effective for palliation of unresectable malignant biliary obstruction in patients who have APBJ without increasing the risk of stent-related early complications.     

胆道蛔虫病ERCP术后并发绞窄性肠梗阻1例

胆道蛔虫症、肠梗阻均为常见急腹症。胆道蛔虫症和肠梗阻同时存在较少见,两者临床症状相似,漏诊后果严重,应引起重视。     

Reticulo-endothelial function in rats with obstructive jaundice

Reticulo-endothelial function was evaluated by measuring the biokinetics of a standardized 99mTc-sulphur colloid using scintillation camera technique in rats with biliary obstruction. There was no difference in the uptake of the colloid in the liver (K1) between sham operation and biliary obstruction at 1 week and 3 weeks. However, when corrected for changes in liver volume, the corrected colloidal uptake rate (cK1) of the liver was significantly decreased in 1 week's biliary obstruction (P less than 0.005 compared with sham operation) and 3 weeks' biliary obstruction (P less than 0.025 compared with 1 week obstruction). Colloidal uptake rate of the extrahepatic reticulo-endothelial system (K2) was significantly increased (P less than 0.005) in rats with 3 weeks' biliary obstruction. Activity distribution of 99mTc-sulphur colloid in 3 weeks' biliary obstruction was significantly decreased in both total organ basis and per gram basis (P less than 0.005). The results demonstrated a depression of RE activity of the liver in biliary obstruction.     

经皮肝穿胆道内外引流治疗恶性梗阻性黄疸

目的 评价经皮肝穿胆道内外引流术（PTBIED）治疗恶性梗阻性黄疸的临床价值。方法 对43例恶性梗阻性黄疸患者，进行了PTBIED治疗，其中肝门部转移癌14例，胆囊癌8例，胆管癌8例，胰头癌13例。结果 PTBIED成功率为90%，40例血清总胆红素降至正常，3例下降不满意，术后1个月内死亡4例，6个月内死亡20例，生存超过12个月13例。并发症为胆道活动性出血8例（18.6%)，败血症10例（23.3%)，胆道逆行感染6例（14.0%)。胆汁性腹膜炎1例（2.3%)。结论 PTBIED是姑息性治疗手术不能切除的恶性梗阻性黄疸有效的和安全的方法。     

Outcome of hepaticojejunostomy for biliary tract obstruction following liver transplantation

Abstract: Background: Strictures and concrements are the most common biliary complications following liver transplantation. Endoscopic treatment might not lead to a definitive cure in all patients, especially in strictures involving the biliary bifurcation. The aim of this study was to determine the efficacy and the long‐term outcome of hepaticojejunostomy (HJS) for post‐transplant biliary tract obstruction. Material and methods: Thirty‐seven patients were retrospectively studied for resolving of cholestasis and the incidence of recurring biliary obstruction. Results: Surgery was performed because of anastomotic strictures in 11, ischemic strictures at the donor common bile duct in seven, strictures involving the bile duct bifurcation in 10, hepatolithiasis without strictures in one and biliary cast formation diagnosed by endoscopic retrograde cholangiography or T‐tube cholangiography in eight patients. Cholestasis instantly improved in 82% of the patients. After a long‐term follow‐up of median 33 months (range 3–149), 28 of the patients (76%) required no further intervention for recurring biliary obstruction following HJS. Anastomotic strictures were observed in six (16%), recurring biliary concrements in two patients (5%). Conclusion: HJS did prevent recurrent biliary obstruction in the majority of the patients. We therefore recommend early HJS for complicated post‐transplant biliary tract obstruction not treatable by a limited number of endoscopic interventions.     

Radionuclide cholescintigraphy in patients with suspected biliary tract obstruction

Radionuclide cholescintigraphy is used to help establish the diagnosis of acute cholecystitis and is thought to provide additional information regarding the patency of the biliary duct system. Nonvisualization of the extrahepatic biliary duct system and lack of excretion into the duodenum despite uptake in the liver (a positive study) is considered indicative of common bile duct obstruction. The authors retrospectively reviewed 281 hepatobiliary cholescintigrams done at Stamford Hospital from July 1, 1987 to June 30, 1989. Previous authors have demonstrated a false-positive rate of eight to 15 per cent in those cases that have a documented normal extrahepatic biliary system at operation. Of those patients explored after a common bile duct obstruction pattern depicted by cholescintigram in the authors' series, 46 per cent of patients were found to have normal extrahepatic biliary systems. Factors possibly contributing to this high false-positive rate are discussed. The utility of radionuclide hepatobiliary scans may be limited for diagnosis of biliary duct obstruction.     

胆道镜治疗肝移植术后肝内胆管阻塞40例

目的探讨胆道镜在诊断及治疗肝移植术后肝内胆管阻塞的价值。方法回顾性分析40例肝移植术后肝内胆管阻塞患者的资料。所有病例均经T管造影证实为肝内胆管阻塞伴狭窄,经T管途径扩张窦道并行胆道镜,再于X线透视下放管支撑。结果29例疗效满意;8例得到控制;3例效果较差,接受了再次移植。结论胆道镜治疗是肝移植术后肝内胆管阻塞的有效治疗方法。     

The management of obstructive jaundice in pancreatic cancer

Patients with pancreatic cancer often present with advanced disease; so, curative surgical resection is possible in a small number of patients. Palliation in these patients focuses particularly on relief of biliary obstruction. Palliative treatment modalities include both surgical and nonsurgical approaches. Biliary obstruction is initially treated with endoscopic biliary stenting, plastic or metallic stents. Both of these provide similar initial relief of biliary obstruction; however, plastic stents have a greater risk of occlusion and should be used in patients with short survival duration. Metallic stents have a greater initial cost, but provide an overall cost-saving in patients with expected survival more than 6 months. There is no evidence of benefit from routine stenting of jaundiced patients before resection. Surgical palliation for biliary obstruction should be primarily considered in patients who fail endoscopic or percutaneous biliary decompression or who develop gastroduodenal obstruction, It is also indicated for patients with good performance status and expected survival of over 6 months. Surgical decompression of biliary tree should be made with a choledochojejunostomy whenever feasible, associated to a gastroduodenal bypass.