内镜胆道内支架引流治疗伴肝脏转移的胰头癌16例

目的:评价伴肝脏转移的胰头癌患者内镜胆道内支架引流治疗的临床意义.方法:门诊就诊和转院的胰头癌伴有肝脏转移患者,如具有严重的梗阻性黄疸则符合内镜逆行胆胰管造影救治指征,然后按照知情同意的原则进入治疗研究计划.均应用内镜胆道内支架引流技术,包括金属内支架和塑料支架.治疗出院后随访观察至患者死亡.结果:16例患者进入治疗研究,其中伴有腹膜后淋巴结转移5例.均采用内镜胆道支架引流术,其中应用胆道金属支架12例,胆道塑料支架4例,胰管内支架6例.治疗后1 wk时梗阻性黄疸缓解率100%,精神状况明显好转75.0%(12/16),食欲改善25.0%(4/16),睡眠改善37.5%(6/16).治疗后的患者最短生存期为9d,最长生存期为134 d,平均81.4 d±50.2 d.随访数据表明治疗有意义的97%,治疗效果满意的11例.结论:对于伴有肝脏转移的胰头癌患者,内镜胆道内支架引流技术不仅能解除梗阻性黄疸,而且可以一定程度的改善生存质量,具有一定的临床应用价值.     

胰头癌的内镜支架引流治疗

目的探讨经内镜支架引流姑息性治疗胰头癌的临床意义。方法2003年8月至2007年8月对197例胰头癌患者进行内镜支架引流姑息性治疗,并观察其疗效。结果197例均伴有胆道梗阻,伴有远端胰管扩张126例,伴有胰体尾萎缩91例。放置胰管支架108例,成功率96．4％;放置胆管支架197例,成功率为99．0％。内镜治疗成功的195例术后黄疸均消失,101例疼痛患者完全缓解98例,部分缓解3例。术后24例出现血清淀粉酶升高,对症处理后恢复正常。随访率93．8％,平均生存期（373．57±157．35）d,最长生存期842d。结论经内镜支架引流姑息性治疗胰头癌是一种确实有效的方法,可以提高患者生存质量,延长生存期。     

内镜下胆道支架治疗恶性胆道梗阻85例

目的探讨内镜下胆道支架对恶性梗阻性黄疸的治疗效果和临床应用价值。方法选择85例无法手术根治性切除的恶性胆道梗阻患者,内镜下放置胆道支架。结果85例胆管恶性梗阻患者中,行经内镜逆行胰胆管造影（ERCP）操作115例次,胆道支架放置成功109例次,操作成功率为94．78％,消除黄疸总有效率为95．41％,并发症发生率为8．26％,平均存活期约为7．4个月。结论胆道支架置入术治疗恶性梗阻性黄疸疗效确切,具有创伤小、并发症少、符合生理等特点,对无法手术根治性切除的恶性胆道梗阻患者,镜下放置胆道支架是最佳的首选治疗方法。     

内镜超声引导下胆管引流在胆管造影失败的梗阻性黄疸患者中的治疗价值（含视频）

目的 探讨内镜超声引导下胆管引流术（EUS-BD）在经内镜逆行胆管造影术（ERC）失败的梗阻性黄疸患者中的有效性及安全性。 方法 回顾性分析2015年10月至2017年7月在南京鼓楼医院行EUS-BD的17例梗阻性黄疸患者资料，分析术式、技术成功率、临床有效性及术后并发症、随访情况。 结果 17例患者中16例手术成功，技术成功率94.1％（16／17）。采取的手术方式包括：内镜超声引导下肝胃吻合术12例；内镜超声引导下顺行金属支架置入术2例；内镜超声引导下会师术1例；内镜超声引导下胆总管十二指肠吻合术1例。手术成功的16例患者术后胆红素均有不同程度下降，临床有效率94.1％（16／17）。术后并发症包括胆道感染5例，胆漏2例，气腹、十二指肠穿孔1例。16例患者术后随访14～390 d，有2例患者术后1个月因原发病加重死亡，另有2例患者术后再发黄疸加重，循原途径更换支架后，胆红素再次下降。 结论 EUS-BD手术成功率及临床有效率均较高，可作为ERC失败的梗阻性黄疸患者的备选治疗方案，手术方式需根据患者的具体情况选择。     

放置金属支架姑息性解除恶性胆道梗阻57例

目的内镜法放置胆道支架,姑息性治疗胆管恶性梗阻的最大缺陷是支架的阻塞,造成阻塞的重要原因之一是通常的塑料支架口径较小,而放置可膨式金属支架使得内引流中口径达到1cm.方法我们从1994年4月-1996年5月放置膨胀式金属道支架治疗57例无法根治的恶性梗阻性黄疸患者,其中采用内镜法置管54例,经皮肝穿刺法3例.结果导丝定位后支架放置的成功率为95%,2例发生胆管炎,经保守治疗得以控制.术后两周内黄疸完全消退21例,明显减退23例,然而9例患者在平均147d 后由于引流失效出现晚期胆管炎.全组有23例术前采用鼻胆管和3例采用内置管临时性引流,临时性引流具有可预先了解引流效果和控制炎症的优点.结论对于无法切除的恶性胆道梗阻患者,放置金属胆道支架可有效解除黄疸,改善生活质量,但欲获得最佳疗效,需严格掌握置管指证.为获得持久的引流效果.肿瘤两端支架的长度不宜短于2cm;对肝门部胆管癌,Bismuth 分型对挑选合适的引流部位有较大的参考价值.     

恶性胆道梗阻内镜支架治疗的荟萃分析

恶性胆道梗阻是指由胰头癌、壶腹癌、胆管癌或其他肿瘤侵犯胆道、转移的淋巴结压迫远端胆道等引起的梗阻性黄疸。由于患者就诊时往往已是肿瘤晚期，黄疸较深，结合肝胆胰区的解剖特点，这类患者不适合进行手术根治性治疗，通过内镜放置支架解除胆道梗阻症状成为该类患者的首选姑息性治疗手段。但到目前为止，对于具体的恶性胆道梗阻（远端胆道梗阻，非肝门部）患者选择哪一种支架没有一个明确的结论。     

经皮穿刺内支架置入联合区域性动脉化疗栓塞治疗恶性梗阻性黄疸

目的 观察经皮肝穿刺胆管内支架置入联合区域性动脉化疗的方法进行栓塞治疗恶性梗阻性黄疸的疗效.方法 梗阻性黄疸患者68例,采用经皮肝穿刺支架置入术(PTCD)联合肝动脉灌注化疗栓塞(TACE)观察治疗成功率、并发症及临床效果.结果 PTCD成功率100%,Ⅰ期支架置入成功率78.6%(44/56),Ⅱ期支架置入成功率100%(12/12).术后并发PTCD引流管脱落2例,腹腔出血2例.随访62例(6个月～3 a),平均生存时间为18.2个月.结论 采用PTCD联合TACE治疗恶性梗阻性黄疸,成功率高,并发症少,可延长患者生存期.     

可膨式金属胆道支架解除恶性胆管梗阻的中长期疗效

为总结经内镜放置可膨式金属胆道支架（ＥＭＢＥ）的中远期疗效，回顾了７６例恶性胆管梗阻接受ＥＭＢＥ治疗患者的资料，并与同期５３例次放置普通塑料支架的疗效进行对比。结果前者操作成功率９３．８％，与操作有关的并发症发生率６．６％，黄疸消除率为８７．０％，金属支架的平均通畅期为３１０天，明显高于塑料支架的８５天（Ｐ＜０．０１），患者平均存活期为２１０天。随访患者中有１６例（３４．８％）发生支架阻塞，平均发生时间１８５．５天。结果表明可膨式金属胆道支架的平均通畅性能显著优于普通塑料支架，可持久有效解除恶性肿瘤所致的肝外胆管梗阻，为提高ＥＭＢＥ的疗效必须严格掌握适应证     

经皮肝穿刺胆道腔内射频消融联合胆道支架治疗恶性胆道梗阻的临床观察

目的：探讨经皮肝穿刺胆道腔内射频消融技术姑息性治疗恶性梗阻性黄疸的安全性及可行性。方法选取2013年1月－2014年3月接受治疗的20例无法切除的恶性梗阻性黄疸患者作为实验组,其中9例不能外科手术切除患者透视下行经皮肝穿刺胆道腔内射频消融术,并留置金属胆道支架;同期随机纳入11例相似病情患者作为对照组,经皮肝穿刺胆道造影（PTC）成功后仅行胆道支架置入。观察两组手术并发症及黄疸缓解情况,密切随访并比较术后3和6个月支架的通畅性。结果所有患者术后通过门诊或电话均获得完整随访。实验组及对照组术后3个月支架通畅率分别为100％,72．7％（χ2＝2．888,P ＝0．218）,术后6个月支架通畅率分别为：87．5％、27．3％（χ2＝6．739,P ＝0．02）。随访期内射频组1例患者于术后113 d 死于消化道出血,对照组1例患者于57 d 死于肝功能衰竭,1例患者于术后142 d 死于弥散性血管内凝血。结论经皮肝穿刺胆道腔内射频消融对恶性胆道梗阻的治疗是安全和可行的,在延长自膨式金属支架通畅性方面初步疗效令人满意,但尚需大量样本随机对照研究进一步验证。     

内镜下同期放置双侧金属胆道支架的方法探讨

目的 探讨经内镜同期置入双侧可膨式金属胆道支架的方法。方法9例Ⅱ～Ⅳ型肝门部胆管恶性梗阻患者,平均血胆红素（162．8±193．8）μmol／L,内镜下插入双导丝分别留置在左、右侧胆管内,在充分扩张狭窄段后,逐一插入金属支架至双侧肝管予以释放。观察操作的便利性、成功率、控制黄疸有效性、早期并发症和近期的临床疗效。结果全组均一次成功置入双侧支架,分别采用“Y”型支架置入法2例、塑料支架过渡法1例和并行支架法6例,平均耗时（38．1±14．8）min,以并行法置入且留置支架末端在乳头外的方法最为便捷。9例患者术后除1例外其他黄疸均迅速消退,3周内均退至正常,无明显并发症发生。结论同期置人双侧金属支架是安全可行的,可迅速有效地控制肝门部肿瘤所致的黄疸和胆道感染;采用特殊设计的金属支架并行置入,并将支架末端留置在乳头外,是较为简便效佳的方法。     

Palliation for Extrahepatic Biliary Obstruction by Metastatic Colorectal Carcinoma

Objectives: Extrahepatic biliary obstruction due to metastatic colorectal carcinoma, though rare, can account for the occurrence of obstructive jaundice even in the presence of hepatic metastases. The present report aims at reviewing our experience with the palliative treatment of these patients. Methods: During a 5-yr period, 11 patients with obstructive jaundice had documented extrahepatic biliary obstruction secondary to metastatic colorectal carcinoma. Their clinical records were retrospectively analyzed. Results: Nonoperative drainage was performed in eight patients by either the endoscopic (n = 5) or percutaneous (n = 3) route. Palliation was achieved in six patients with a mean hospital stay of 24.5 days (14 % of survival). Three patients died of hepatorenai failure before a drainage procedure could be performed. Blocked stent and cholangitis were noted in two patients. The mean survival was 5 months in the drainage group. Conctusions: The occurrence of obstructive jaundice in patients with metastatic colorectal carcinoma deserves routine investigation to exclude extrahepatic biliary obstruction. Endoprosthesis insertion by nonoperative means should be considered for palliation.     

Treatment of benign biliary strictures in chronic pancreatitis by self-expandable metal stents

AIM: To determine the efficacy the value of self-expandable metal stents in patients with benign biliary strictures caused by chronic pancreatitis. METHOD: 61 patients with symptomatic common bile duct strictures caused by alcoholic chronic pancreatitis were treated by interventional endoscopy. RESULTS: Initial endoscopic drainage was successful in all cases, with complete resolution of obstructive jaundice. Of 45 patients who needed definitive therapy after a 12-months interval of interventional endoscopy, 12 patients were treated with repeated plastic stent insertion (19.7%) or by surgery (n = 30; 49.2%). In 3 patients a self-expandable metal stent was inserted into the common bile duct (4.9%). In patients treated with metal stents, no symptoms of biliary obstruction occurred during a mean follow-up period of 37 (range 18-53) months. The long-term success rate of treatment with metal stents was 100%. CONCLUSIONS: Endoscopic drainage of biliary obstruction by self-expandable metal stents provides excellent long-term results. To identify patients who benefit most from self-expandable metal stent insertion, further, prospective randomized studies are necessary.     

Treatment of unresectable hepatic hilar malignancies with self-expanding metallic stents

BACKGROUND/AIMS: This study assesses the treatment of biliary obstruction in patients with hilar malignancies by metallic stents. METHODOLOGY: Twenty-one consecutive patients with unresectable malignant biliary obstruction at the hepatic hilum (Bismuth type II, III and IV) were treated with percutaneous transhepatic placement of self-expandable metallic endoprostheses. The endoprostheses were successfully inserted in all patients. In 12 patients all segments of the liver were drained and in 9 patients partial segments of the liver were drained. RESULTS: Seventeen patients (81%) showed relief from jaundice and could be freed of external drainage tubes. Ten patients (48%) showed no recurrent symptoms due to stent obstruction until death. Overall survival was 4.86+/-4.15 (mean+/-SD) months, stent patency was 3.76+/-3.64 months and comfort index representing a ratio of well-being was 70.5+/-38.3%. There was no significant difference in survival rate, stent patency or comfort index between the groups with complete and those with partial drainage. CONCLUSIONS: Even in patients with complicated hepatic hilar biliary occlusions, internal drainage using metallic stents can relieve jaundice and leave patients free of external tubes with a comfortable quality of life.     

胆胰管良恶性梗阻的双支架联合引流

目的 探讨胆、胰管良恶性狭窄或梗阻时内镜双支架联合引流的操作技术及其临床疗效。方法 所有患者先行经内镜逆行胰胆管造影，了解胆、胰管狭窄或梗阻的部位、程度，并确定置入支架的外径及长度；然后胆、胰管分别置入导丝，并在导丝引导下按常规分别置入胆管和胰管引流支架。术后观察血清淀粉酶变化及黄疸、腹痛、腹泻等临床症状的改善情况。结果 14例胆、胰管并存狭窄或梗阻患者（壶腹癌5例、胰头癌4例、乳头部癌3例及胰头部慢性炎症2例）均一次操作成功，置入胆管塑料支架14根（12例1根，1例2根），置入金属支架1根；同时还置入胰管支架14根。术后2周、1个月及3个月黄疸消失率分别为50．0％、71．0％和93．0％，术后2周上腹痛缓解率为75．0％；7例腹泻患者，术后1个月5例症状消失，2例明显减轻。未发生与操作相关的早期并发症，术后3个月未发现支架移位及阻塞情况。结论 胆、胰管良恶性狭窄患者经内镜双支架联合引流是一种简便、安全、有效的治疗方法，既能解除黄疸，又能减压止痛，改善胰腺外分泌功能。     

Successful endoscopic ultrasound-guided overstenting biliary drainage through a pre-existing proximal migrated metal biliary stent

Biliary endoscopic drainage using metallic self-expanded stents has become a well-established method for palliative treatment of malignant biliary obstruction. However, its occlusion, mainly by tumor overgrowth, is still the main complication without a standard treatment. We here describe a new method of treatment for biliary metallic stent occlusion, through the echo guided biliary drainage. We present a 68-year-old patient with metastatic pancreatic cancer previously treated for jaundice with ERCP and self-expandable metallic stent insertion. Four weeks later, the patient developed jaundice and symptoms of gastric outlet obstruction. A new ERCP confirmed obstruction of the second portion of the duodenum, due to diffuse tumor growth. EUS was performed, and the previous metal biliary stent was seen occluded at the distal portion in the common bile duct. A EUS-guided choledocododenostomy was performed and then, an overlapping self-expanding metal enteral stent was placed through the malignant obstruction. There were no early complications and the procedure was also clinically effective in relieving jaundice and gastric outlet obstruction symptoms. If ERCP fails in the management of occluded biliary metallic stents, EUS biliary drain can provide effective biliary decompression and should be considered an alternative to other endoscopic techniques.     

Endoscopic insertion of biliary stents in 18 patients with metallic duodenal stents who developed secondary malignant obstructive jaundice

AIM: The aim of this work was to evaluate the feasibility of endoscopic insertion of biliary stents in patients with duodenal stents who develop secondary malignant obstructive jaundice. PATIENTS AND METHODS: The study population included 133 patients with unresectable malignant duodenal obstruction. In 106 patients a biliary stent was inserted before or at the same time as the duodenal stent. Malignant biliary obstruction appeared secondarily in 18 patients; fifteen of these patients already had a biliary stent. We present our experience of biliary stent insertion in these 18 patients with metallic duodenal stents. RESULTS: Biliary obstruction was successfully alleviated in 17 out of 18 patients (94%) without complication. Insertion of a new biliary stent failed in one patient because the mesh of the duodenal stent passed over the metallic biliary stent already in place. Mean duration of endoscopic insertion was 95 minutes (range: 60 - 180). All patients remained free of biliary complications to death (57 days, range: 30 - 120). CONCLUSION: Our report shows that endoscopic insertion of a biliary stent is feasible in patients who have metallic duodenal stents. Technical difficulties exist especially if the mesh of the duodenal stent passes over the papilla.     

Polyurethane-covered metal stent for management of distal malignant biliary obstruction

BACKGROUND: The efficacy of polyurethane-covered metal expandable stents for treatment of neoplastic distal biliary obstruction was analyzed. METHODS: Twenty-one patients with unresectable malignant tumors involving the mid to distal bile duct who were seen with obstructive jaundice were consecutively enrolled. Eighteen patients underwent endoscopic implantation of a polyurethane-covered metal stent and 3 patients underwent transhepatic insertion because of duodenal obstruction. The stent patency, complications, and patient survival were analyzed. RESULTS: Effective biliary decompression was achieved in all patients. Adverse events were minor: mild pancreatitis (1) and cholecystitis (2) occurred within 7 days of stent insertion. Mean survival and stent patency were 233 days and 206 days, respectively. Stent occlusion occurred in 3 patients (14%) after a mean of 188 days. Tumor ingrowth through the stent mesh was not observed. However, 2 stents were occluded by tumor overgrowth and 1 by compacted alimentary debris. CONCLUSIONS: A polyurethane membrane may prevent tumor ingrowth and reduce the occlusion rate for expandable metal stents implanted in patients with malignant obstruction of the distal bile duct.     

Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents.

Twenty patients with chronic pancreatitis and signs of biliary obstruction were treated by endoscopic placement of self expandable metal mesh stents, and followed up prospectively. Eleven had been treated previously with plastic endoprostheses. All had persistent cholestasis, seven patients had jaundice, and three overt cholangitis. Endoscopic stent placement was successful in all cases. No early clinical complication was seen and cholestasis, jaundice or cholangitis rapidly resolved in all patients. Mean follow up was 33 months (range 24 to 42) and consisted of clinical evaluation, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 18 patients, successive ERCPs and cholangioscopies have shown that the metal mesh initially embeds in the bile duct wall and is rapidly covered by a continuous tissue by three months. The stent lumen remained patent and functional throughout the follow up period except in two patients who developed epithelial hyperplasia within the stent resulting in recurrent biliary obstruction, three and six months after placement. They were treated endoscopically with standard plastic stents with one of these patients ultimately requiring surgical drainage. No patient free of clinical or radiological signs of epithelial hyperplasia after six months developed obstruction later. This new treatment could become an effective alternative to surgical biliary diversion if further controlled follow up studies confirm the initial impression that self expandable metal mesh stents offer a low morbidity alternative for longterm biliary drainage in chronic pancreatitis without the inconvenience associated with plastic stents.     

Endoscopic biliary drainage in chronic pancreatitis

Between April 1982 and March 1988, 25 patients with chronic pancreatitis presented with biliary stenosis and significant cholestasis. They were treated by endoprosthesis placement. Nineteen patients had jaundice, and, initially, seven had cholangitis (including three with hepatic abscesses). ERCP was successful in all 25 patients. Cholangitis, cholestasis, and jaundice resolved in all cases after stent placement. Two patients died in the 2 months after treatment. Complete follow-up (mean duration, 14 months, range 7 to 42 months) was available for 19 of the 23 remaining patients. Migration of the stent occurred in 10 patients and stent blockage in 8 patients, with relapsing cholestasis (N = 12), cholangitis (N = 4), or without symptoms (N = 2). Only three of these patients are now asymptomatic without a stent in place after 12 to 72 months. In all of the other cases, stents have been replaced or patients have been treated by surgery. We conclude that endoscopic biliary drainage is an effective treatment for resolving cholangitis or jaundice in patients with chronic pancreatitis and biliary stenosis, but that the results of definitive endoscopic drainage for these patients are less satisfactory because resolution of the stricture after removal of the stent is rarely obtained.