内镜清除肝移植术后肝胆管内坏死物的临床研究

目的探讨内镜清除肝移植术后肝胆管内坏死物的技术方法及临床意义。方法回顾性分析36例肝移植术后出现肝胆管内坏死物使用胆道镜或十二指肠镜治疗的患者资料,分析治疗前后肝功能等实验室指标的变化情况。结果36例患者肝胆管坏死物分布为胆总管6例,肝内胆管（包括肝门部胆管）24例,肝内外胆管6例;内镜治疗总有效率72．2％（26／36）,16例患者肝胆管内坏死物完全清除,15例得到部分清除,5例无法清除。治疗后患者胆红素、肝转氨酶明显下降,差异有统计学意义（P〈0．05）。治疗过程中未发生与内镜治疗相关的严重并发症及死亡病例。36例患者随访时间均在6个月以上,最长84个月。现存活患者17例,其中3例二次肝移植,术后恢复良好;1例因肝功能不稳定仍留置胆管外引流管,必要时给予间断开放引流;余均已无带管,肝功能良好,生活质量良好。19例患者在随访过程中死于胆管相关并发症或其他疾病,其中11例生存4年以上。结论内镜清除肝移植术后肝胆管内坏死物是安全、有效的治疗方法,其微创,可重复,具有良好的临床应用价值。     

术中胆道镜联合液电碎石治疗难治性肝内胆管结石的评价

目的探讨术中胆道镜联合液电碎石治疗难治性肝内胆管结石的治疗策略和临床价值。方法11例难治性肝内胆管结石患者,术中经直视及胆道镜下对患者肝实质、肝内胆管及结石状况进行探查、评估。对拟保留肝叶内的胆管结石采用胆道镜下液电碎石、取石,一次无法取净的患者,二期经窦道胆道镜下液电碎石、取石。结果所有11例患者经术中或二期碎石,均取净结石,治疗成功率100％。手术顺利,术后无手术并发症。本组随访10例,失访1例,随访时间1～3年。3例停用熊去氧胆酸片1～2年后复发肝内胆管小结石,其余7例患者随访期间未见复发。结论术中胆道镜联合液电碎石在有效保证难治性肝内胆管结石治疗成功的同时,最大程度的保护了肝组织,降低了治疗难度及手术风险,减少了术后并发症的发生,提高了患者的生存质量。     

PTCS术在复杂肝内外胆管结石中的应用

目的探讨经皮肝胆道镜(percutaneous transhepatic cholangioscopy,PTCS)手术对复杂肝内外胆管结石的临床治疗效果。方法纳入梅州市人民医院2012年1月-2015年6月确诊为复杂肝内外胆管结石的患者76例,其中采用二步造瘘PTCS治疗组38例,行一步造瘘PTCS组38例,收集并比较2组患者术前、术中及术后资料,并对纳入研究病例进行2年随访。结果二步造瘘PTCS治疗组的结石复发率、胆管炎复发率均低于一步造瘘PTCS组,差异具有统计学意义(P0.05);且二步造瘘PTCS治疗组肝内胆结石取净率高于一步造瘘PTCS组(P0.05)。结论二步造瘘PTCS方法可以降低结石残存率和结石复发率,是治疗复杂肝内外胆管结石的有效治疗方法。     

经皮肾镜治疗复杂性胆管结石的应用体会

目的:探讨经皮肾镜在复杂性胆管结石中的临床应用疗效.方法:回顾性分析2013-01/2015-03在宜春市人民医院运用经皮肾镜治疗的73例复杂性胆管结石患者临床资料.所有病例术前都行B超、计算机断层扫描或者核磁共振成像确诊,排除凝血功能异常、顽固性高血压和严重脏器功能障碍的病例后,开始实施经皮肾镜取石手术.术后通过采用门诊、电话、手机短信或微信等方式进行随访,随访时间截至2015-08.结果:2013-01/2015-03在宜春市人民医院经皮肾镜联合气压弹道碎石共治疗肝内外胆管结石73例,碎石成功率达到100%.其中1次性取净结石48例(65.8%),2-3次取净结石22例(30.1%),3-4次取净结石3例(4.1%).术后l例肝内弥漫性结石女性患者经过4次经皮肾镜联合气压弹道碎石治疗.73例患者中,联合行左肝外叶切除术7例,胆肠吻合术2例.术后3例留置T管的患者术后瘘管处出血,术后腹胀呕吐2例,无其他严重并发症发生.73例患者拔除T管后随访3-12 mo,平均随访10 mo,肝内胆管结石复发率为3/73.结论:经皮肾镜治疗复杂性胆管结石具有术中术野清晰,清除结石效率高,患者手术时间短,术后恢复快,住院时间短,住院费用少等优点,是一种安全、经济、高效的手术方法.     

经皮肝Ⅰ期胆道造瘘联合胆道镜治疗胰十二指肠切除术后继发胆管结石

目的探讨经皮肝I期胆道造瘘(PTOBF)联合胆道镜治疗胰十二指肠切除术后继发胆管结石的安全性和有效性,探讨胰十二指肠切除术后胆肠吻合口狭窄的原因及处理对策。方法回顾性分析2017年10月至2021年5月于山东省第二人民医院接受PTOBF联合术中硬质胆道镜、术后电子胆道镜治疗的12例胰十二指肠切除术后继发胆管结石患者的临床资料。结果所有患者均成功行PTOBF,经胆道镜取净肝胆管结石,术中发现胆肠吻合口狭窄8例(线结性狭窄3例),经胆道气囊扩张及胆肠吻合口线结拆除,7例近期缓解(87.5%),1例再次胆肠吻合手术。结论PTOBF联合胆道镜治疗胰十二指肠切除术后继发胆管结石安全有效,取净率高,可缓解胆肠吻合口狭窄。     

经皮肝Ⅰ期胆道造瘘联合胆道镜治疗胰十二指肠切除术后继发胆管结石

目的探讨经皮肝I期胆道造瘘(PTOBF)联合胆道镜治疗胰十二指肠切除术后继发胆管结石的安全性和有效性,探讨胰十二指肠切除术后胆肠吻合口狭窄的原因及处理对策。方法回顾性分析2017年10月至2021年5月于山东省第二人民医院接受PTOBF联合术中硬质胆道镜、术后电子胆道镜治疗的12例胰十二指肠切除术后继发胆管结石患者的临床资料。结果所有患者均成功行PTOBF,经胆道镜取净肝胆管结石,术中发现胆肠吻合口狭窄8例(线结性狭窄3例),经胆道气囊扩张及胆肠吻合口线结拆除,7例近期缓解(87.5%),1例再次胆肠吻合手术。结论PTOBF联合胆道镜治疗胰十二指肠切除术后继发胆管结石安全有效,取净率高,可缓解胆肠吻合口狭窄。     

经皮胆管镜治疗肝内外胆管结石的探讨

目的 探讨经皮胆管镜治疗肝内外胆管结石的疗效和结石复发的防治。方法 43例经皮经肝胆管引流和窦道扩张后,经皮经肝胆管镜(PTCS)治疗肝内外胆管结石;22例术后T管留置>3周者,行术后胆管镜(POCS)治疗。该65例中肝内胆管结石(IHS)40例(I型12例,IE型28例),胆总管结石(CBI)结石)25例。结果 43例PTCS扩张窦道直径平均19.1 F,建立窦道时间平均17.1d。65例中11例直接取石,54例行液电碎石(EHL)后取石,其中25例配合乳头括约肌切开。40例IHS至结石清除每例治疗次数平均5.2次,25例CBD结石平均1.9次。37例(56.9％)有胆管或胆肠吻合口狭窄,用探条或气囊扩张,3例留置金属支架,结石清除率98.5％(64/65)。11例合并胆道感染,1例IHS伴胆汁性肝硬化合并肾功能不全死亡。 平均随访30.8个月,结石复发率7.1％。结论 经皮胆管镜和EHL是治疗胆系结石安全、有效的办法;胆管或胆肠吻合口狭窄长度<0.5 cm者,器械扩张效果良好;治疗狭窄可提高结石清除率,降低结石复发率。     

肝移植术后胆管并发症的内镜治疗价值

目的评估肝移植术后胆管并发症内镜治疗的临床价值。方法我院从2001年3月至2006年10月进行的45例肝移植中,术后出现胆管并发症16例,其中胆漏1例,胆管狭窄8例,胆管狭窄并胆管结石2例。11例接受了内镜介入治疗计14次,包括内镜下放置鼻胆管外引流4例,放置支架内引流10例,气囊扩张10例,乳头括约肌小切开7例,乳头括约肌切开加取石2例。结果1例因内镜治疗时导丝无法通过狭窄段,改行PTC放置胆管支架,其余胆管并发症经内镜介入治疗有效。结论ERCP有助于肝移植术后胆管并发症诊断,治疗有效、安全,是肝移植术后胆管并发症首选治疗方法。     

胆管胸膜瘘三例

胆管胸膜瘘是胆道系统与胸膜腔之间的病理性交通,是肝胆疾病的严重并发症之一。该病较为典型的临床表现是胆汁性胸水、胸闷、呼吸困难,CT、MRI检查、经内镜逆行胰胆管造影或经皮肝穿刺胆管造影可明确诊断,治疗方法主要有经皮肝穿刺胆管造影术、经内镜逆行胰胆管造影术、胆总管切开T管引流、胆管胸膜瘘修补术等。由于胆管胸膜瘘症状隐匿且临床较少见,常被误诊、漏诊,现报告河南科技大学第一附属医院消化内科收治的3例胆管胸膜瘘患者。     

经皮经肝胆道镜技术的发展及其治疗胆石症的特点比较

肝内胆管结石是胆道系统疾病的一种类型,其病情复杂、易复发,传统手术治疗并发症多且对手术标准要求较高。经皮经肝胆道镜技术（PTCS）取石高效且应用广泛,但同时也存在其他治疗胆石症的医疗技术。本文主要探讨经皮经肝胆道镜技术自身发展的不断改变以及PTCS与其他胆石症治疗技术的效果比较。     

Ethanol injection therapy of an isolated bile duct associated with a biliary-cutaneous fistula

Bile leakage after hepatic resection often results in the formation of a biliary-cutaneous fistula. Such a fistula, when caused by an isolated bile duct in the remnant liver, can be intractable. We report a successful case of ethanol injection therapy of an isolated bile duct. A 73-year-old man underwent right hepatic resection for hepatocellular carcinoma. Bile leakage occurred after surgery, and the patient developed a biliary-cutaneous fistula. Fistulography revealed an isolated bile duct in the remnant portion of the caudate lobe without communication to the main biliary system. As conservative management with simple drainage was ineffective, injection therapy with ethanol was performed with a balloon occlusion catheter. After 11 therapy sessions, the bile duct was eradicated, and the biliary- cutaneous fistula was completely healed. The post-treatment course was uneventful. Ethanol injection therapy can be a choice for management of patients with a biliary fistula caused by an isolated bile duct.     

Successful treatment of complex cholangiolithiasis following orthotopic liver transplantation with interventional radiology

Bile duct stones are a serious and the third most common complication of the biliary system that can occur following liver transplantation.The incidence rate of bile duct stones after liver transplantation is1.8%-18%.The management of biliary stones is usually performed with endoscopic techniques;however,the technique may prove to be challenging in the treatment of the intrahepatic bile duct stones.We herein reporta case of a 40-year-old man with rare,complex bile duct stones that were successfully eliminated with percutaneous interventional techniques.The complex bile duct stones were defined as a large number of bile stones filling the intra-and extrahepatic bile tracts,resulting in a cast formation within the biliary tree.Common complications such as hemobilia and acute pancreatitis were not present during the perioperative period.The follow-up period was 20 mo long.During the postoperative period,the patient maintained normal temperature,and normal total bilirubin and direct bilirubin levels.The patient is now living a high quality life.This case report highlights the safety and efficacy of the percutaneous interventional approach in the removal of complex bile duct stones following liver transplantation.     

肝移植术后胆栓形成过程中内镜的诊治价值

目的 探讨内镜逆行胰胆管造影（ERCP）在肝移植术后胆栓形成过程中的诊断治疗价值.方法 71例肝移植术后出现肝功能异常、磁共振检查提示胆道内异物的患者,采用ERCP明确诊断并给予相应的治疗,对其临床资料进行回顾性分析.结果 71例患者共接受188次ERCP诊疗,多数患者伴有不同程度的吻合口和（或）胆管狭窄.术后＜3个月者均取出胆泥,3～6个月者取少量色素样结石,＞6个月者取出铸型胆栓,平均每位患者行2.6次内镜治疗,肝移植术后平均（22.7±15.6）个月形成铸型胆栓.术后发生胰腺炎2例,胆管炎3例,发生率2.6%（5/188）,均经保守治疗控制.随访56例,经内镜处理后患者肝功能均有明显改善,42例达到内镜治愈标准,10例因胆管广泛硬化性改变而行二次肝移植,4例死于移植术以外原因.结论 ERCP处理肝移植术后胆栓形成过程中的胆泥、小结石和胆栓安全可行,近期疗效较好,并可反复进行.     

Endoscopic diagnosis and treatment of biliary leak in patients following liver transplantation:a prospective clinical study

Introduction As a choice of therapy, orthotopic liver trans- plantation (LT) is widely applied to end- stage liver disease. However, 13%-35% of procedures are complicated by problems of the biliary tract, the most common being stricture and leakage.[1-5] In an analysis of 259 LT recipients, Hwang et al[6] found 12 episodes of anastomotic bile leak and 42 episodes of anastomotic stenosis in 50 recipients. For choledochocholedochostomy cases, the common types of biliary leak are T-tube and an…     

ERCP对肝移植术后胆漏诊治作用的前瞻性临床观察

目的观察经内镜逆行胰胆管造影术(ERCP)对肝移植术后胆漏的诊断和治疗作用,并随访胆漏愈合后胆管狭窄的发生情况。方法选择经ERCP证实为肝移植术后胆漏13例患者,其中T管漏6例、吻合口漏7例。行内置管引流术6例、鼻胆管引流术2例、鼻胆管联合内置管引流术3例、十二指肠乳头括约肌切开术2例。部份患者联合应用生长激素。结果10例完整随访者胆漏愈合时间10-35d,平均15.3d,随诊胆管造影证实出现吻合口狭窄4例、肝总管狭窄3例、肝内外胆管多发性狭窄1例。胆漏愈合后有80%患者会出现不同形式的胆管狭窄。结论经内镜鼻胆管引流或内置管引流是治疗肝移植术后胆漏的有效方法。鼻胆管引流联合内置管引流除具有疗效确切、便于观察等优点外,理论上有防治鼻胆管意外脱落引起严重后果和预防后续胆管狭窄形成的作用,但其上述作用有待进一步观察。     

Management of excluded segmental bile duct leakage following liver resection

Background:

Postoperative bile leak secondary to a fistula is a known complication of hepatic surgery. Four different biliary fistula sub-types have been described: type A refers to minor leakage from the bile duct stump; type B to major leakage caused by insufficient closure of the bile duct stump; type C to major leakage caused by injury to the bile duct, and type D (the rarest) to the division and exclusion of a bile duct. This complication results from functional liver parenchyma in which bile drainage is excluded from the main duct.

Methods:

A retrospective review of the database for 163 patients diagnosed with post-hepatic surgery bile leak from April 1992 to June 2007 was performed.

Results:

Three patients were found to have type D biliary fistula, with durations of 3–21 months. The bile leak developed after a right hepatectomy in two patients and a right hepatectomy extending to segment IV in one patient. All three patients were rescheduled for surgical exploration, following failure of medical treatment. The procedure consisted of repeat resection of the independent liver parenchyma containing the fistula. One patient developed a postoperative leak from a hepaticojejunal anastomosis (treated conservatively) and the other two patients had an uneventful recovery. No recurrence of bile leak was encountered during their follow-up.

Conclusions:

Our experience indicates that conservative treatment is deceptive and not efficacious. For this condition, surgical intervention is the treatment of choice because it is very effective and is associated with a low morbidity.     

Diagnostic and therapeutic ERCP in hepatic hydatid disease

BACKGROUND: This retrospective study evaluated the use of diagnostic and therapeutic ERCP in pre- and postoperative patients with hepatic hydatid disease. METHODS: For 8 years, ERCP was performed in 39 patients with hepatic echinococcal disease. Indications in the preoperative group of patients (n = 19) included a cholestatic enzyme profile in all cases; jaundice or acute cholangitis also was present in, respectively, 14 and 7 cases. In the postoperative group (n = 20), indications for ERCP included persistent external biliary fistula after surgery in 10 patients, jaundice in 8, acute cholangitis in 7, and right upper quadrant pain in 2 patients. RESULTS: ERCP findings in the preoperative group included cystobiliary fistula (9 patients), external compression of the hepatic biliary system (5), hydatid vesicles and/or membranes within the biliary tract (3), intrahepatic duct stricture (1), and a normal cholangiogram (4). The most common ERCP finding in the postoperative group was external biliary fistula (10 patients); other findings consisted of hydatid cyst material within the bile duct (4), bile duct stenosis (2), cystobiliary fistula and hydatid cyst material in the bile duct (1), cystobiliary fistula (1), hydatid membranes in the gallbladder (1), extrinsic compression to bile ducts (1), and a normal cholangiogram (1). In the preoperative group, endoscopic sphincterotomy was performed in 11 patients, with balloon catheter extraction in 2; complete resolution of findings was achieved in 10 cases. In the postoperative group, sphincterotomy (with balloon or basket extraction as needed) was performed in 19 patients, stents were placed in 2 patients, 1 patient underwent balloon dilatation, and 1 had nasobiliary drainage; there was complete resolution of the findings in 14 of the 20 patients. CONCLUSIONS: ERCP and related therapeutic maneuvers are safe and valuable in the pre- and postoperative management of patients with hepatic hydatid disease.     

多次胆道术后再次胆道手术的临床分析

目的总结多次胆道手术后再次胆道手术的原因、临床特点及处理经验。方法回顾性分析2009年3月至2011年9月期间,解放军总医院第一附属医院肝胆外科收治的9例已于外院行3次以上胆道手术的再次胆道手术患者,对这些病例的临床资料进行分析。结果本组病例中再次手术的主要原因是胆道狭窄6例(66.7%),肝胆管结石复发合并胆管炎3例(33.3%)。本次手术方式分别为1例带血管蒂胃瓣修复,8例胆肠Roux-en-Y吻合,其中l例附加肝左外叶切除。术后随访3～18个月,胆道感染的症状消失,肝功能基本正常。结论多次胆道术后再次胆道手术的主要原因是胆道狭窄,对于多次胆道术后需再次手术的病例,术前利用影像学对病情准确评估,制定合理的治疗方案,提高手术技能以及做好围手术期的处理是保证手术成功的关键。     

胆道镜下激光碎石术治疗残留胆管结石的临床观察

目的探讨电子胆道镜下激光碎石治疗手术后难取性胆道残留结石的疗效和安全性。方法回顾2007年2月-2009年2月电子胆道镜下激光碎石治疗难取性肝内、外残留结石22例的临床资料,观察治疗情况和效果。结果取石成功率95．5％（21／22）,其中一次性取石成功率86．4％（19／22）,经二次成功取石2例,1例患者因肝内多部位胆管结石且部分结石位于Ⅱ级以上胆管、胆管成角大胆道镜未能进入而无法完成碎石、取石治疗。未发生胆道出血、窦道穿孔、感染等并发症。结论胆道镜下激光碎石治疗手术后难取性胆道残留结石疗效确切,并发症少,安全可行。     

A case of biliary cast syndrome after cadaveric liver transplantation]

We experienced one fatal case of biliary cast syndrome after cadaveric liver transplantation involving both intrahepatic ducts. A 58-year-old man underwent cadaveric liver transplantation because of hepatitis B virus related liver cirrhosis and concomitant hepatocellular carcinoma. Five weeks after the liver transplantation, postoperative course was complicated by development of acute cholangitis. Subsequent endoscopic retrograde cholangiography revealed diffuse intrahepatic bile duct strictures without filling defects. Percutaneous liver biopsy, which was done to exclude rejection, revealed biliary cast. Successful endoscopic removal was precluded due to its diffuse involvement. Because of the deterioration of patient's condition by refractory biliary obstruction and cholangitis, retransplantation from cadaveric donor was performed. Debridement of the biliary tree after graft removal yielded a near-complete cast of the intrahepatic ductal system. Biliary cast syndrome should be suspected when jaundice or cholangitis is associated with dilated ducts on abdominal imaging studies in cadaveric liver transplantation recipients. Initial therapeutic options include removal of biliary cast after endoscopic or percutaneous cholangiography. Although endoscopic retrieval of biliary cast by endoscopic retrograde cholangiopancreatography could be employed as a first-line management, other modalities such as endoscopic nasobiliary drainage, percutaneous transhepatic drainage, or retransplantation should be considered when complete removal is not feasible and the condition of the recipient deteriorates.