术中胆道支架置入联合碘125粒子腔内照射治疗恶性胆道梗阻（附13例报告）

恶性胆道梗阻病死率高,外科根治性切除是恶性胆道梗阻首选的治疗方式,但外科手术切除率较低。对不能手术切除的患者,非手术治疗或姑息性治疗成为主要的治疗方法。我院采用开腹胆道支架置入后加瘤体碘125粒子放射治疗13例恶性梗阻性黄疸患者,取得了一定疗效,现报道如下。1资料与方法     

经皮肝穿胆道内支架置入术在复发性胆道恶性梗阻中的应用

经皮肝穿胆道内支架置入术是复发性胆道恶性梗阻的一种有效的姑息性治疗手段。1999年4月至2003年3月间，我科对15例胆道恶性梗阻手术后复发再出现梗阻性黄疸病人，进行了PTCD术，对其中12例病人成功地放置了金属胆道内支架。为病人解除了胆道梗阻，取得了良好的效果。现报告如下。     

腔内支架成形术治疗颈动脉狭窄(附64例报告)

目的：介绍颈动脉腔内支架成形术的基本方法，总结64例经验体会，探讨该术式治疗颈动脉狭窄的操作和并发症的预防。方法：64例颈动脉狭窄病人行腔内支架成形术，共放支架66个，其中Wallstent支架41个，Smart支架22个．OptiMed支架3个。应用脑保护装置26例。结果：术中出现较重卒中2例：1例术出现左眼视野缺损．3个月后仍有残余症状：1例术中出现意识丧失、右侧肢体偏瘫，经救治神志恢复。出现轻度卒中3例。10例出现一过性血压降低、心动过缓，其后逐渐恢复。1例术后出现原有神经系统症状加重。神经系统并发症发生率为7．88％，严重卒中是3.13％。循环系统并发症是15．63％。应用脑保护装置的病人仅有1例发生一过性神经系统并发症。结论：颈动脉腔内支架成形术是治疗颈动脉狭窄的有效手段，在有经验的医师操作下，治疗是安全的。使用脑保护装置可明显减少神经系统并发症。     

高位恶性梗阻性黄疸胆道内支架置入治疗的临床应用

目的评价高位恶性梗阻性黄疸胆道内支架置入治疗的疗效及临床价值。方法42例高位恶性梗阻性黄疸病人分别行单侧／双侧穿刺入路，充分胆道内外引流后，置入支架。其中肝总管内置入单枚支架19例；双侧肝管穿刺，行左肝和右肝胆管同时置入支架11例；采用单侧肝管穿刺入路，于左-右肝管间和肝管-胆总管间均置入支架12例。共置入支架65枚，其中3枚为覆膜支架，其余均为自膨式裸支架。结果42例病人中，手术成功率达100％，其中2例病人分别于术后4个月和9个月发生支架内梗阻，行二次介入治疗；1例病人于胆道支架置入术后17个月发生十二指肠梗阻，再行十二指肠支架置入术；1例病人于围手术期因严重胆系感染而死亡．全部病人随访3～112周（平均49周），均获得满意的减黄效果。结论根据不同梗阻部位，采用多种胆道支架置入技术治疗高位恶性梗阻性黄疸是一种安全可靠、疗效确切的姑息性疗法。     

330例内镜下胆道内支架的置入应用体会

目的探讨内镜下胆道内支架的置入及应用体会。方法回顾性分析我院2001年1月～2009年4月330例成功置入胆道内支架的临床资料。结果胆管塑料支架引流274例（胆胰管双支架5例、胰管支架4例）,胆管金属支架引流56例,其中肝门胆管癌85例,壶腹周围癌81例,结石并良恶性狭窄59例,胆管肿瘤及其它器官恶性肿瘤术后的梗阻性黄疸98例,其余胆漏1例,胆道损伤4例,硬化性胆管炎2例。无胆道损伤、穿孔等严重并发症。结论内镜下胆道内支架置入对胆道良恶疾病的治疗是安全可行的,术中助手应该加强于操作者的配合可大大减少操作中的并发症,且安全可行,值得应用和推广。     

不同途径胆道内支架置入治疗恶性阻塞性黄疸

目的：探讨不同方式胆道内支架置入术治疗恶性阻塞性黄疸的临床应用价值、优缺点及选择。 方法：回顾分析40 例恶性阻塞性黄疸患者的临床资料,其中记忆合金胆道内支架18 例经开腹手 术置入,经PTCD 置入5 例,经ERCP 置入17 例。 结果：患者均完成胆道内支架置入达到内引流。支架植入术后胆红素均在第3 天下降约80 μmol/L; 谷 草转氨酶、谷丙转氨酶、碱性磷酸酶及谷氨酰转肽酶也在术后第3 天开始较术前明显下降(P<0.05)。 主要并发症有胆道出血3 例, 胆管炎8 例, 多器官衰竭1 例;并发症发生率为30.0%,经非手术治 疗后大多数恢复。全组中位生存时间为28 周, 平均生存(33.79±36.83) 周。全组围手术期死亡1 例, 病死率为2.5%。 结论：胆道内支架经开腹手术置入、经ERCP 置入及经PTCD 置入均可有效解除恶性阻塞性黄疸 的胆管梗阻, 改善肝功能但总并发症发生率较高。     

胆总管探查术后胆道内支架引流14例

为探讨胆总管探查术后一期缝合胆总管,同时解除因术后Oddi括约肌痉挛、水肿而致胆道高压的有效引流方法,我院于2005年7月至2007年7月对14例胆总管探查术后的患者成功采用胆道内支架引流术,临床效果满意,现报道如下。     

单纯胆道支架与125I粒子支架腔内照射治疗恶性梗阻性黄疸

目的 探讨单纯胆道支架与支架联合125I粒子条植入腔内照射治疗恶性梗阻性黄疸的临床价值.方法 对62例恶性阻塞性黄疸患者行经皮经肝胆管引流(PTCD)后随机分组:A组31例行胆道支架联合125I粒子条植入(实验组),B组31例行单纯胆道支架植入(对照组).比较两组患者术前、术后黄疸消退、复发情况、T淋巴细胞亚群变化以及生存时间.结果 A、B两组患者PTCD术前及支架植入术后1周血清总胆红素测定差异无统计学意义(P＞0.05).术后1个月、3个月血清总胆红素测定,A组优于B组(P＜0.05).随访期内,A组再次发生胆道梗阻1例,B组12例(P＜0.05).对比PTCD术前,A组术后1～2周CD4及CD4/CD8比值明显升高(P＜0.05),CD3变化无差异(P＞0.05).B组术后1～2周CD3、CD4及CD4/CD8比值变化无明显差异(P＞0.05).A组患者中位生存时间10.9个月,B组患者中位生存时间7.1个月,两组差异有统计学意义(P＜0.05).结论 125I粒子条联合胆道支架植入腔内照射治疗恶性梗阻性黄疸在黄疸消退、改善机体免疫机能及延长患者生存时间等方面均优于单纯胆道支架植入治疗.     

胆道支架治疗恶性梗阻性黄疸早期疗效及其影响因素

目的探讨胆道支架用于治疗恶性梗阻性黄疸(MOJ)的早期疗效及其影响因素。方法回顾性分析接受经皮肝穿胆管引流(PTCD)+胆道支架植入治疗的232例MOJ患者的临床资料,判断术后早期疗效,并采用单因素分析和Logistic回归分析其影响因素。结果 232例均成功实施PTCD+胆道支架植入术,并置管引流,术后早期疗效显著149例、有效36例、无效47例,总有效率79.74%(185/232)。肿瘤类型、梗阻水平、梗阻长度、肝功能Child-Pugh分级、腹腔积液、肝内病变、远处转移、肿瘤最大径、术前血小板计数(PLT)、CA125水平和术后胆道感染是影响早期疗效的重要因素(P均0.05);肝功能Child-Pugh分级、术前PLT、CA125水平和术后胆道感染是影响早期疗效的独立危险因素(P均0.05)。结论胆道支架植入术在改善MOJ患者肝功能、减黄方面具有一定价值;肝功能Child-Pugh分级、术前PLT、CA125水平和术后胆道感染是影响术后早期疗效的独立危险因素。     

开窗型支架治疗胸腹主动脉瘤(附1例报告)

胸腹主动脉瘤是指同时累及胸主动脉和腹主动脉的动脉瘤以及累及肾动脉领域及以上的腹主动脉瘤,其常规手术复杂,创伤巨大。腔内修复治疗胸腹主动脉瘤尚处于起步阶段,国内近期仅完成3例。近期,中国医科大学附属第一医院成功应用腔内修复技术救治Ⅳ型胸腹主动脉瘤1例。报告如下。     

肝外胆道肿瘤外科治疗远期疗效的评析(附139例随访资料)

目的 探讨胆道肿瘤的临床特征、治疗方法对远期生存率的影响，总结胆道肿瘤的诊治经验。方法 对1992年1月至2000年7月收治的139例胆道肿瘤（胆囊癌88例，胆管癌51例）的临床及随访资料进行回顾分析。应用SPSS10．0统计软件包进行统计学处理。结果 88例胆囊癌的总体5年生存率为5．22％，51例胆管癌的总体5年生存率为21．64％。根治切除组的1、3、5年生存率与姑息切除组、剖腹探查组、非手术组相比均有显著性差异（P＜0．01），而姑息切除组、剖腹探查组、非手术组间的生存率无显著性差异（P＞0．05）。多因素分析显示组织学分级、TNM分期及治疗方法与预后显著相关。结论 胆道肿瘤的远期疗效仍无显著改善；扩大根治术可望改善其预后，但需慎重选择病人；提高远期疗效的重点仍应放在肿瘤的早期诊治上。     

Biliary stent causing colovaginal fistula: case report.

OBJECTIVES: Perforation of the bowel during placement of a biliary stent is a known complication of this procedure. We report the endoluminal loss of a biliary stent during routine stent extraction that ultimately led to a chronic colovaginal fistula. This case emphasizes the need for evaluation of fecal passage of stents in patients with a known dislodged prosthesis. CASE REPORT: A 65-year-old white female underwent biliary stent placement for an episode of choledocholithiasis. The stent was lost in the duodenum during routine extraction. The patient was managed expectantly. She denied ever passing this stent via the rectum and began to develop symptoms of colovaginal fistula. Evaluation found a retained biliary stent in the sigmoid colon and a fistula into the vagina. The patient underwent elective low anterior resection and colovaginal fistula repair. DISCUSSION: Reports exist of migration of stents that lead to acute colonic perforation and the need for emergent surgery. For this reason, it has been suggested that dropped or migrated stents be purposefully retrieved. However, if the option of expectant observation is used, it is important to clearly document the fecal passage of these stents and be prepared to retrieve these objects if they have a prolonged bowel transit time.     

胆管支气管瘘29例临床分析

目的 总结胆管支气管瘘(bronchobiliary fistula,BBF)的病因、病理及诊治经验.方法 回顾性分析1976-2009年收治的29例BBF患者的临床资料.结果 29例患者均有腹痛、寒战发热、黄疸、肝肿大;胸闷、咳嗽并咯血及咯胆汁痰,量为100～200 ml/d;右下肺闻及湿性啰音或呼吸音减弱或消失.29例患者先后选择胸部X线片或腹部X线片、A型超声、BUS、CT或PTC、MRCP、ERCP等诊断措施.29例患者均采用手术治疗,术式分别为胆总管切开取石、T型管引流术及膈下或肝脓肿引流、瘘管切除或膈肌瘘口修补术19例(其中2例同时行肝右后叶不规则切除术);胆囊切除、胆总管切开取蛔虫及取结石、T型管引流、膈下脓肿引流及膈肌瘘口修补术3例;胆囊切除、胆总管切开取蛔虫及取结石,胆管空肠Roux-en-Y型吻合术1例;肝外伤性膈下脓肿引流术,胆总管切开、T型管引流术3例;单纯行膈下脓肿引流及胆总管切开及T型管引流术2例;Oddi括约肌狭窄行肝脓肿切开引流及膈肌瘘口修补术并行胆管空肠Roux-en-Y型吻合术1例.手术治愈26例;死亡3例.结论BBF来自肝胆管梗阻和感染导致胆源性肝脓肿及肺脓肿,手术解除梗阻、去除病灶、通畅引流是治愈BBF的关键措施.     

胆管支气管瘘29例临床分析

目的 总结胆管支气管瘘(bronchobiliary fistula,BBF)的病因、病理及诊治经验.方法 回顾性分析1976-2009年收治的29例BBF患者的临床资料.结果 29例患者均有腹痛、寒战发热、黄疸、肝肿大;胸闷、咳嗽并咯血及咯胆汁痰,量为100～200 ml/d;右下肺闻及湿性啰音或呼吸音减弱或消失.29例患者先后选择胸部X线片或腹部X线片、A型超声、BUS、CT或PTC、MRCP、ERCP等诊断措施.29例患者均采用手术治疗,术式分别为胆总管切开取石、T型管引流术及膈下或肝脓肿引流、瘘管切除或膈肌瘘口修补术19例(其中2例同时行肝右后叶不规则切除术);胆囊切除、胆总管切开取蛔虫及取结石、T型管引流、膈下脓肿引流及膈肌瘘口修补术3例;胆囊切除、胆总管切开取蛔虫及取结石,胆管空肠Roux-en-Y型吻合术1例;肝外伤性膈下脓肿引流术,胆总管切开、T型管引流术3例;单纯行膈下脓肿引流及胆总管切开及T型管引流术2例;Oddi括约肌狭窄行肝脓肿切开引流及膈肌瘘口修补术并行胆管空肠Roux-en-Y型吻合术1例.手术治愈26例;死亡3例.结论BBF来自肝胆管梗阻和感染导致胆源性肝脓肿及肺脓肿,手术解除梗阻、去除病灶、通畅引流是治愈BBF的关键措施.     

近25年我国胆管支气管瘘文献分析：附213例报告

目的：探讨我国胆管支气管瘘（BBF）患者的临床特点。 方法：检索1989—2013年发表有关BBF的中文文献,提取患者的临床资料并进行汇总分析。 结果：最终纳入51篇文献,共213例BBF患者。BBF患者男女比例为1.22:1,平均年龄为（50.4±11.1）岁,70.1%有既往手术史。BBF患者常见的临床表现有咳胆色素痰（96.5%）、咳嗽（94.5%）、发热（83.8%）、腹痛（79.3%）、胸闷/胸痛（76.2%）、黄疸（59.2%）、呼吸困难（13.5%）;原发病因中包括胆管结石（41.8%）、肝包虫（31.0%）、胆道蛔虫（5.6%）、原发性或转移性肝脏肿瘤（5.2%）、外伤（4.7%）、肝脓肿（4.2%）、先天性病因（2.3%）、多种因素（1.9%）、其他单因素（1.9%）及胆囊结石伴胆囊穿孔（1.4%）。90.6%患者接受了外科手术治疗,总体治愈率为89.5%,好转率为3.3%,病死率为6.2%。 结论：BBF较为罕见,原发病因较复杂;痰液胆色素检验及ERCP等可快速明确诊断;患者及时接受外科手术等治疗可取得良好的治愈效果。     

胆管支气管瘘29例临床分析

目的 总结胆管支气管瘘(bronchobiliary fistula,BBF)的病因、病理及诊治经验.方法 回顾性分析1976-2009年收治的29例BBF患者的临床资料.结果 29例患者均有腹痛、寒战发热、黄疸、肝肿大;胸闷、咳嗽并咯血及咯胆汁痰,量为100～200 ml/d;右下肺闻及湿性啰音或呼吸音减弱或消失.29例患者先后选择胸部X线片或腹部X线片、A型超声、BUS、CT或PTC、MRCP、ERCP等诊断措施.29例患者均采用手术治疗,术式分别为胆总管切开取石、T型管引流术及膈下或肝脓肿引流、瘘管切除或膈肌瘘口修补术19例(其中2例同时行肝右后叶不规则切除术);胆囊切除、胆总管切开取蛔虫及取结石、T型管引流、膈下脓肿引流及膈肌瘘口修补术3例;胆囊切除、胆总管切开取蛔虫及取结石,胆管空肠Roux-en-Y型吻合术1例;肝外伤性膈下脓肿引流术,胆总管切开、T型管引流术3例;单纯行膈下脓肿引流及胆总管切开及T型管引流术2例;Oddi括约肌狭窄行肝脓肿切开引流及膈肌瘘口修补术并行胆管空肠Roux-en-Y型吻合术1例.手术治愈26例;死亡3例.结论BBF来自肝胆管梗阻和感染导致胆源性肝脓肿及肺脓肿,手术解除梗阻、去除病灶、通畅引流是治愈BBF的关键措施.

Abstract：

Objective To summarize the etiology,pathological mechanism, and the experience of diagnosis and treatment of bronchobiliary fistula (BBF). Methods Clinical data of 29 BBF patients admitted and operated on from 1976 to 2009 were analyzed retrospectively. Results Clinical menifestation included abdominal pain, chill and high fever,jaundice, hepatomegaly, chest distress, cough, hemoptysis,bilious cough, moist rale in the lower right lung or decreased or disapeared breath sound. Abdominal radiograph, chest X-ray, BUS, CT, PTC, MRCP and ERCP are helpful for localizing diagnosis. All the 29patients were surgically treated. 19 patients were treated by choledochotomy to extract common bile duct stones, T-tube drainage, liver abscess drainage, fistula excision and diaphragmatic repair. Three patients were treated by cholecystectomy, choledocholithotomy, and T-tube drainage. One patient underwent cholecystectomy, choledocholithotomy, and Roux-en-Y hepatojejunostomy. Three patients received liver abscess drainage, choledochotomy, T-tube drainage. 2 patients did subphrenic abscess drainage,choledochotomy, T-tube drainage. One patient complicating Oddi sphincter stenosis received liver abscess drainage, diaphragmatic repair, and Roux-en-Y hepatojejunostomy. 26 patients were cured. 3 patients died.Conclusions The etiology of BBF is obstruction related bilious tract infection leading to liver abcess and lung abscess. In the process of surgical treatment, relief of bilious tract obstruction, clearance of focal lesion and effective drainage of biliary tract are the mainstay of management.     

2280例肝门胆管癌的荟萃分析

目的 探讨我国肝门部胆管癌(hilar cholangiocarcinoma,HCC)的流行病学、临床特点、诊断方法、Bismuth-Corlette分型、病理类型、治疗方式、并发症及预后,以期指导临床.方法 以肝门胆管癌为检索词,在中国知网、重庆维普、中国学术期刊网全文数据库CNKI进行检索.将所得22篇文献,共2280例HCC的临床资料进行统计学分析.临床资料分析及数据提取分别由两人完成.结果 与姑息性切除组比较,根治性切除组术后1年生存率(84.0％与46.8％,OR=5.71,95％CI 3.99～8.17,P＜0.01)和术后3年生存率(31.5％与13.5％,OR=4.43,95％CI 2.07～9.47,P＜0.01)均较高.与姑息性切除组相比,内外引流组术后1年生存率(27.2％与38.7％,OR=0.47,95％CI0.31～0.72,P＜0.01)较高.经卡方检验,我们同时发现2002年后HCC手术切除率比2002年前有上升(X2 =35.9588,P＜0.01),但根治性切除率却没有明显变化(X2=2.1052,P=0.1468).结论 根治性切除组术后1、3年生存率高于姑息性切除组.内外引流组术后1年生存率高于姑息性切除组.根治性切除术仍是治疗HCC最理想的方法.如果无法达到根治性切除,姑息性引流术是较好的选择.姑息性切除术并不能提高生存率,因而不被提倡.     

Biliary drainage in inoperable malignant biliary distal obstruction: A systematic review and meta-analysis

BACKGROUNDEndoscopic drainage remains the treatment of choice for unresectable or inoperable malignant distal biliary obstruction (MDBO). AIMTo compare the safety and efficacy of plastic stent (PS) vs self-expanding metal stent (SEMS) placement for treatment of MDBO. METHODSThis meta-analysis was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A comprehensive search was performed in MEDLINE, Cochrane, Embase, Latin American and Caribbean Health Sciences Literature, and grey literature to identify randomized clinical trials (RCTs) comparing clinical success, adverse events, stent dysfunction rate, reintervention rate, duration of stent patency, and mean survival. Risk difference (RD) and mean difference (MD) were calculated and heterogeneity was assessed with I² statistic. Subgroup analyses were performed by SEMS type. RESULTSTwelve RCTs were included in this study, totaling 1005 patients. There was no difference in clinical success (RD = -0.03, 95% confidence interval [CI]: -0.01, 0.07; I² = 0%), rate of adverse events (RD = -0.03, 95%CI: -0.10, 0.03; I² = 57%), and mean patient survival (MD = -0.63, 95%CI: -18.07, 19.33; I² = 54%) between SEMS vs PS placement. However, SEMS placement was associated with a lower rate of reintervention (RD = -0.34, 95%CI: -0.46, -0.22; I² = 57%) and longer duration of stent patency (MD = 125.77 d, 95%CI: 77.5, 174.01). Subgroup analyses revealed both covered and uncovered SEMS improved stent patency compared to PS (RD = 152.25, 95%CI: 37.42, 267.07; I² = 98% and RD = 101.5, 95%CI: 38.91, 164.09; I² = 98%; respectively). Stent dysfunction was higher in the covered SEMS group (RD = -0.21, 95%CI: -0.32, -0.1; I² = 205%), with no difference in the uncovered SEMS group (RD = -0.08, 95%CI: -0.56, 0.39; I² = 87%).CONCLUSIONWhile both stent types possessed a similar clinical success rate, complication rate, and patient-associated mean survival for treatment of MDBO, SEMS were associated with a longer duration of stent patency compared to PS.     

Biliary reconstruction with or without an internal biliary stent in orthotopic liver transplantation: a prospective randomised trial

Abstract Choledochocholedochostomy (CCD) with a 7 fr/8 fr Cotton Leung internal biliary stent removed at endoscopic retrograde cholangiography (ERC) 3 months following orthotopic liver transplantation (OLT) was the technique used on our unit for biliary reconstruction. From June 1995 to July 1996, we randomised 37 OLT patients with CCDs to receive either an internal stent (group I, n d = 18) or no stent (group II, n = 19). Patients in group I had an ERC at 3 months for stent removal whereas patients in group II had an ERC if indicated. The mean follow up was 19 (13–26) months. Biliary complications occurred in 9 out of 18 patients in group I compared to 1 out of 19 patients in group II ( P = 0.007). In group I, ERC was required for complications in 8 patients and early surgery in 2, compared to 1 ERC for abnormal liver function tests in group II. Five of the early complications in group I were stent related. Late biliary stenosis occurred in 1 patient at 9 months. There was one stent-related death. The use of stents contributes to biliary complications and CCD without stenting is safe after OLT.     

Biliary papillomatosis: report of seven cases and review of English literature

Biliary papillomatosis is rare. Before 1993, there were only 21 cases reported in the English literature. This article reports our experience in managing this disease and reviews experiences from recent English literature. A retrospective review of patients with biliary papillomatosis was conducted in our institution. A search of the English literature between 1993 and 2002 was performed in the MEDLINE database using "biliary papillomatosis" as the keyword. Seven patients with biliary papillomatosis were treated in our hospital. Another 50 cases were reported in the recent literature. This amounted to a total of 78 cases so far reported. The male to female ratio was approximately 2 : 1. The mean age at presentation was 63 years. Most patients presented typically with cholangitis. Malignant change was present in 33 patients (42%). Concomitant intrahepatic and extrahepatic disease was noticed in 33 patients (42%). The overall resection rate was 55%. The mean survival was 28 months following resection, irrespective of histological type. Patients without tumor resection had a poorer survival of less than 11 months. Biliary papillomatosis presents typically with biliary obstruction and it occurs most often in elderly males. Resection is recommended because of the considerable malignancy rate, diffuse pattern of disease, and better survival following curative surgery. Malignant histology is not always associated with a poorer prognosis provided that radical resection can be achieved.