经内镜胆道引流治疗胆道梗阻

目的：进一步提高经内镜胆道引流术的成功率。方法：总结1998年1月至2001年9月对320例胆道梗阻患者行十二指肠镜下各种胆道引流术的经验，其中鼻胆管引流术（ENBD）242例，胆道内置管引流术（ERBD）43例，胆道金属支架术（EMBE）35例。结果：305例得到成功引流，胆道梗阻症状缓解；失败15例。其中ENBD失败10例，经调整鼻胆管位置或重新置管获得成功；ERBD失败3例，2例选用合适长度的支架后引流成功，1例经努力仍未成功改用经皮肝穿刺胆道引流；EM-BE失败2例，其中1例金属支架未超出肿瘤狭窄段，经原金属支架再套入另一金属支架而成功，另1例支架放置1月又出现胆道阻塞，经原金属支架通道再放入塑料支架而恢复通畅引流。结论：经内镜引流治疗胆道梗阻疗效确切，及早分析内镜引流失败原因并采取相应的对策，绝大多数引流失败是可以避免或补救的。     

Drug-eluting stent in malignant biliary obstruction

Introduction

In unresectable malignant bile duct obstruction, endoscopic stent insertion is the treatment of choice. However, the current stent allows only mechanical palliation of the obstruction, and has no anti-tumor effect. Currently, in the vascular field, the drug-eluting stent (DES) is very highly favored.

Material and methods

The requirements for a DES in a non-vascular tract, such as the bile duct, are far different from those of a DES to be used in the vascular tract. The non-vascular DES must suppress tumor proliferation as well as mucosal hyperplasia. For example, the non-vascular stent might be covered with a membrane that gradually releases a chemo-agent. We do not have much experience with DES in the bile duct. Nonetheless, we are continuously testing many anti-tumor agents in animal and human studies.

Conclusion

We expect and hope DES will work effectively for tumor cells in diverse ways and, more importantly, will prolong stent patency and the patients’ survival periods. But considerable investigation and a clinical study of DES will be required to achieve these goals.     

Mitochondrial antibodies in extrahepatic biliary obstruction

Sera from 732 patients were screened for mitochondrial antibodies by immunofluorescence. Such antibodies were not found in any of the 36 patients of this series with extrahepatic biliary obstruction, 14 of whom had obstruction lasting more than 3 months. Mitochondrial antibodies were found in all 5 patients with primary biliary cirrhosis, in 3 patients with chronic hepatitis, and in 1 patient with alcoholic cirrhosis. It is concluded that the presence of mitochondrial antibodies remains a useful diagnostic tool in the differential diagnosis between primary biliary cirrhosis and extrahepatic biliary obstruction.     

高位胆道梗阻内镜下选择性胆管插管导丝引导方法探讨

目的探讨导丝引导技术在高位胆道梗阻内镜下选择性胆管插管中的应用价值。方法对344例经ERCP诊治的高位胆道梗阻患者,乳头部胆管插管成功后应用导丝直通法、导管导丝法、乳头切开刀法、导管导丝＋导丝弯曲法、导丝α及反α结袢法、导丝旋转法、导丝直通联合取石球囊法及多孔导向导管法等多种导丝引导方法进行选择性胆管深插管,使其通过胆管狭窄段,进入目标胆管。观察插管效果。结果336例高位胆道梗阻患者顺利完成超选择性目标胆管插管,随后完成相应内镜下治疗,总成功率为97．67％。所有患者在插管过程中无合并胆道出血及穿孔等病例。结论高位胆道梗阻内镜下选择性胆管插管中不同导丝引导方法可以提高微创诊疗成功率、缩短操作时间,减少患者痛苦、降低并发症的发生率。     

Percutaneously placed biliary stents in the management of malignant biliary obstruction

The malagement of malignant obstruction of the biliary tree is difficult and often unsuccessful. Advances in the technique of percutaneous transhepatic catheterization have made possible the nonoperativeiinternal drainage of obstructed lesions. We report successful decompression of ten patients with unresectable biliary neoplasms using percutaneously placed internal biliary stents.     

三种非手术胆管引流方法治疗肝门部恶性胆道梗阻的疗效评估

目的探讨不同非手术胆管引流方法治疗肝门部恶性胆道梗阻（MHBO）的疗效和并发症发生率。方法245例MHBO患者分为3组,其中内镜治疗组86例、经皮治疗组104例、内镜与经皮联合组（联合治疗组）55例。245例患者中,BismuthⅠ型31例、Ⅱ型24例、Ⅲ型108例、Ⅳ型74例。对各组患者的临床资料进行回顾性分析,并对其中具有可比性的数据进行统计学处理。结果内镜治疗组、经皮治疗组和联合治疗组减黄有效率分别为82．4％（56／68,除外18例近期并发胆管炎行PTBD者）、72．1％（75／104）和89．1％（49／55）,其中Bismuth Ⅲ型患者减黄有效率分别为78．6％（22／28,除外7例近期并发胆管炎行PTBD者）、69．8％（30／43）和90．0％（27／30）,且Ⅲ型患者中双侧引流减黄有效率89．5％（34／38）明显优于单侧引流73．0％（46／63）。内镜治疗组近期并发胆管炎19例,发生率为22．1％（19／86）,明显高于经皮治疗组的5．8％（6／104）和联合治疗组的5．5％（3／55）（P均〈0．05）。Bismuth Ⅲ型及以上患者中,内镜、经皮及联合治疗组近期胆管炎发生率分别为33．3％（18／54）、6．6％（5／76）和5．8％（3／52）,内镜治疗组明显高于其他两组（P〈0．05）。结论对于不能手术的MHBO,内镜和（或）经皮方法减黄治疗有效,但内镜治疗胆管炎发生率高;Bismuth Ⅲ型及以上患者内镜与经皮联合治疗胆管炎并发症发生率低,减黄效果好。     

Adjuvant therapies using biliary stenting for malignant biliary obstruction

The aim of this study was to analyze the patency of expandable metallic stents in malignant biliary obstruction and to evaluate the efficacy of adjuvant therapy accompanied by biliary stenting. We analyzed 29 patients in whom bile duct stenting was performed for malignant biliary obstruction. Their types of disease were: hilar ductal carcinoma (n = 8), gallbladder carcinoma (n = 11), and pancreatic carcinoma (n = 10). Initially, 46 expandable metallic stents were placed in 29 patients. In 23 of the 29 patients, adjuvant therapy was administered. Seventeen patients underwent radiotherapy, and 16 patients received various systemic chemotherapies. In principle, hyperthermia was performed twice a week, simultaneously with radiotherapy. Patient survival and the probability of stent patency were calculated using actuarial life table analysis. There was no significant difference in stent patency among the patients according to type of disease. Hyperthermia did not influence the stent patency rate. The median stent patency time was significantly greater in the chemo-radiation group than in the no-adjuvant therapy group: 182 days versus 68 days, respectively (P = 0.017). Moreover, a significant increase was seen in the median survival time in the chemo-radiation group: 261 days versus 109 days (P = 0.0337). Complications occurred in 9 patients (31.0%). Stent occlusion occurred in 6 patients (20.7%), with all of these patients managed successfully using a transhepatically placed new expandable metallic stent, employing the stent-in-stent method. Stent migration occurred in 2 patients after radiotherapy. Adjuvant therapies such as radiotherapy and systemic chemotherapy, in combination with stent insertion, resulted in an increase in the patency period of expandable metallic stents and in increased patient survival time.     

ERCP放置胆管内支架姑息治疗难以切除的恶性胆管梗阻

目的探讨ERCP放置胆管内支架对难以切除的恶性胆管梗阻的临床治疗效果。方法对54例恶性肿瘤引起的梗阻性黄疸患者,经ERCP将导丝插入胆管并超过梗阻部位,扩张狭窄处,用推送导管将已经选择合适的引流支架置于胆管适当部位,其两端均超过梗阻段2cm以上。结果54例患者中51例插管成功,3例插管不成功的患者中1例乳头开口于憩室内,另2例肿瘤完全阻塞导丝无法通过。成功率为94.44%(51/54)。34例胆管内放置8FZ型自膨胀式金属支架,其余20例行8～10F塑料内支架引流。术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻。其中39例2周内血清总胆红素下降50%以上,血清总胆红素退至34μmol/L以下。放置胆管内支架1周后,患者血清总胆红素由术前235.45±56.67μmol/L降至78.36±37.58μmol/L,肝功能较术前显著改善(P<0.05,P<0.01)。31例胆总管下段梗阻患者与12例肝门部胆管梗阻患者相比,放置胆管内支架引流治疗1周、2周后,其胆红素下降明显优于肝门部胆管梗阻患者(P<0.01)。34例放置胆管金属支架患者中,有12例于术后2个月发生支架阻塞,再次放置塑料内支架后引流通畅,1例放置金属支架术后患者第10个月出现支架阻塞予以再次植入金属支架。另外20例放置塑料内支架者,有3例于术后1～4周出现血清总胆红素再次上升,经ERCP检查发现支架移位和阻塞,予以更换内支架,其中1例植入塑料双支架。结论经ERCP内镜下胆管放置内支架,对解除恶性胆管梗阻性黄疸、缓解症状、提高患者生存质量具有满意疗效,对胆总管下段梗阻性黄疸的疗效优于肝门部胆管梗阻。     

Endoscopic palliation of malignant biliary obstruction

Malignant biliary obstruction often presents with challenges requiring the endoscopist to assess the location of the lesion, the staging of the disease, the eventual resectability and patient preferences in term of biliary decompression. This review will focus on the different modalities available in order to offer the most appropriate palliation, such as conventional endoscopic retrograde cholangiopancreatography, endoscopic ultrasound guided biliary drainage as well as ablative therapies including photodynamic therapy or radiofrequency ablation.     

经皮肝穿刺胆道内支架植入治疗恶性胆道梗阻64例

目的：总结经皮肝穿刺胆道内支架植入治疗恶性梗阻性黄疸的经验，探讨其临床疗效及价值。方法：64例患者均采用X线透视下经皮肝穿刺胆道内支架植入术治疗恶性梗阻性黄疽。根据梗阻部位的不同解剖决定放置支架的方式。结果：64例患者中，50例植入单支支架于肝总管或(和)胆总管，14例植入2支以上支架于总管和分支胆管，其中2例肝内胆管支架的桥接通过肝实质。58例患者2周内血清胆红素降低75％以上。结论：经皮肝穿刺刺内支架植入是治疗恶性胆道梗阻性的有效方法。