肝外胆管癌的诊断体会

回顾性分析了１９７１￣１９９４年４８例肝外胆管癌资料，着重讨论了肝外胆管癌的影像学检查，认为Ｂ超检查作为肝外胆管癌的初筛诊断，经济可靠；ＣＴ及ＭＲＩ作为肝外胆管癌的定位诊断，检查无痛苦，诊断准确率高，但存在费用昂贵问题；ＰＴＣ及ＥＲＣＰ为介入性影像学检查，不仅对肝外胆管癌的定位诊断准确可靠，对手术方案的设计也有很大的参考意义。     

人肝细胞癌和癌旁组织中性激素受体的改变

目的探讨肝细胞癌（ＨＣＣ）患者癌组织与癌旁组织中雄、雌激素受体的变化．方法用葡聚糖包裹活性炭吸附法检测２１例ＨＣＣ患者的癌组织和癌旁组织中雄激素受体（ＡＲ）和雌激素受体（ＥＲ），同时测量７例男性肝硬变患者肝组织中的ＡＲ和ＥＲ．结果癌组织中ＡＲ阳性率（７１４％）显著高于癌旁组织（３１３％）（Ｐ＜００１）及硬变肝组织（Ｐ＜００５）中的ＡＲ阳性率（２８６％），而ＥＲ含量均无显著差异（Ｐ＞００５）．结论ＡＲ表达的增加与肝细胞的癌变有关，部分ＨＣＣ具有雄激素依赖性，为ＨＣＣ可能的内分泌治疗提供分子生物学方面的理论依据．     

乙型肝炎及原发性肝癌患者sIL-2R的变化

目的探讨ｓＩＬ２Ｒ水平与乙型肝炎病情的关系及其在原发性肝癌早期诊断中的价值．方法以ＥＬＩＳＡ法动态检测１１３例乙型肝炎及６例原发性肝癌患者ｓＩＬ２Ｒ水平，另选３１例健康体检者作对照组．结果以ｑ检验、ｔ检验进行统计学处理（微机处理，ＰＯＭＳ２００版）．结果各型乙型肝炎ｓＩＬ２Ｒ水平均显著高于正常对照（ＮＣ）组（Ｐ＜００１），其顺序依次为：ＨＣＣ＞ＣＳＨ＞ＣＨ（ＩＩ）＞ＬＣ＞ＣＨ（ＩＩ）＞ＡＨ＞ＣＨ（Ｉ）＞ＮＣ．ＨＣＣ组ｓＩＬ２Ｒ均值达正常值的２倍以上，且与ＣＨ（Ｉ），ＣＨ（Ｉ），ＡＨ间存在显著性差异（Ｐ＜００１，＜００５及＜００５）；ＣＨ（ＩＩ）组显著高于ＣＨ（Ｉ）组（Ｐ＜００１）．ＨＢｅＡｇ阳性组及ＨＢＶＤＮＡ阳性组ｓＩＬ２Ｒ水平显著高于阴性组．结论ｓＩＬ２Ｒ是监测乙型肝炎病情、ＨＢＶ复制及诊断早期原发性肝癌的一项敏感标志．     

125例梗阻性黄疸的ERCP诊断分析

１对象和方法１．１对象１９８１０１／１９９８０３我院共进行ＥＲＣＰ８２１例，经Ｂ超、ＣＴ及ＥＲＣＰ检查并手术证实的梗阻性黄疸患者１２５例，其中男６２例，女６３例，年龄２１岁～７７岁，平均年龄５２岁；汉族８７例，维吾尔族３８例．总胆红素定量６２μｍ...     

原发性肝癌雌激素受体表达及内分泌治疗

目的研究原发性肝癌雌激素受体（ＥＲ）的表达及内分泌治疗的临床价值．方法应用Ｌｅｅ氏荧光配体细胞化学法检测４１例手术病理确诊的原发性肝癌ＥＲ的表达．本组男３８例，女３例，年龄２５岁～７２岁．同时检测肝癌的组织类型、分化程度、肿瘤大小、血清ＡＦＰ及ＣＥＡ．６例ＥＲ阳性者采用他莫昔芬治疗（每次２０ｍｇ，２次／ｄ，长期服用）并观察疗效．结果肝癌组织ＥＲ阳性２０／４１例，阳性率４８８％．ＥＲ阳性率与患者年龄、性别、ＡＦＰ、ＣＥＡ含量及组织类型（梁状型ＥＲ阳性４５０％，腺样型３３３％，实体型７１４％，硬化型６６７％，透明细胞型２５０％；Ｐ＞００５）无明显关系，与肿瘤体积（≥１０ｃｍ，ＥＲ阳性率７５０％；＜１０ｃｍ，ＥＲ阳性２３８％；Ｐ＜００１）和分化程度（分化好２６例，ＥＲ阳性３４６％；分化差１５例，ＥＲ阳性７３３％；Ｐ＜００５）有显著关系．本组ＥＲ阳性病例中６例经他莫昔芬内分泌治疗有效５／６（８３３％），其中４例ＡＦＰ下降．结论ＥＲ阳性肝细胞癌患者进行内分泌治疗有一定疗效     

原发性肝癌血清性激素及组织性激素受体的研究

目的研究人体性激素水平变化与原发性肝细胞癌的关系．方法应用放免法测定肝癌组（２０例），肝硬变组（１６例）及正常对照组（２０例）血清雌二醇（Ｅ２）及睾酮（ＴＴＴ）含量，并用放免组化法（ＰＡＰ法）检测肝癌组织及肝硬变组织的雌二醇受体（ＥＲ）及睾酮受体（ＡＲ）含量．结果肝癌组血清Ｅ２含量（４４５５±９３１ｎｇ／Ｌ）明显高于正常对照组（７６６ｎｇ／Ｌ±１７０ｎｇ／Ｌ）而低于肝硬变组（６４９６ｎｇ／Ｌ±１７６ｎｇ／Ｌ）（Ｐ＜００１）；前者ＴＴＴ含量（２５３３００ｎｇ／Ｌ±５６５６０ｎｇ／Ｌ）明显低于后二者（４５８５８０ｎｇ／Ｌ±３４９６０ｎｇ／Ｌ）（Ｐ＜００１）．肝癌组织ＥＲ（８０％）较肝硬变时（４４％）明显增加（Ｐ＜００２５），且与血清Ｅ２含量有明显负相关关系（ｒ＝－０８４７３，Ｐ＜０００１）．ＡＲ阳性百分率在两者无明显差别（ｒ＝－０３１３５，Ｐ＞００５）．结论血清ＴＴＴ含量改变及肝组织ＡＲ浓度改变与肝癌无明显关系，而血清Ｅ２含量改变及肝组织ＥＲ浓度改变与肝癌的发生、发展有密切关系．提示原发性肝细胞癌是一雌激素依赖性肿瘤．     

原发性肝癌组织P16蛋白的缺失与HBV感染

目的研究Ｐ１６蛋白缺失与原发性肝癌发生发展的关系以及ＨＢＶ感染与Ｐ１６蛋白缺失的相关性．方法用免疫组化技术（ＬＳＡＢ法）检测７０例原发性肝癌组织标本中的Ｐ１６蛋白和ＨＢｓＡｇ．结果有６０６％（４０／６６）的肝细胞癌（ＨＣＣ）和７５０％（１／４）的胆管细胞癌（ＣＣＣ）Ｐ１６蛋白缺失；Ⅰ，Ⅱ，Ⅲ和Ⅳ级（按Ｅｄｍｏｎｄｓｏｎ标准）ＨＣＣＰ１６蛋白缺失率分别为００％（０／１），４４１％（１５／３４），８２１％（２３／２８）和６６７％（３／４），组间差异显著（Ｐ＜００５）．在有癌旁肝组织的４８例标本中，癌组织Ｐ１６蛋白阴性率（７２６％）明显高于癌旁肝组织（４１２％，Ｐ＜００５）．有６２５％（３０／４８）的ＨＣＣ癌旁肝组织ＨＢｓＡｇ阳性．ＨＢｓＡｇ阳性病例与阴性病例的Ｐ１６阴性率分别为７３３％（２２／３０）和６６７％（１２／１８），差异无显著性（Ｐ＞００５）．结论Ｐ１６蛋白缺失与原发性肝癌相关，与肝癌的恶性发展关系密切，可能对预后有重要影响．ＨＢＶ感染与Ｐ１６蛋白缺失无明显相关性．     

诊断为肝炎的梗阻性黄疸95例原因分析

目的分析引起梗阻性黄疸的常见原因．方法根据临床特征、相关实验室报告、Ｂ超和ＣＴ之影像学检查对我科于１９８７－１９９５年的８年间确诊的９５例梗阻性黄疸进行了病因分析．结果梗阻性黄疸９５例中，５３例为良性梗阻（５５８％），４２例为恶性梗阻（４４２％）．良性梗阻中以胆结石、胆虫症和胆道感染居多（７７３％），恶性梗阻中以胰腺癌、肝外胆管癌和胆囊癌居多（６４２％）．恶性梗阻的平均发病年龄（４７６岁）比良性梗阻（３４３岁）大．Ｂ超对良性梗阻的阳性率为９０５％（４８／５３），恶性梗阻为９５２％（４０／４２）．ＣＴ对良性和恶性梗阻分别为８２９％（３４／４１）和９３３％（２８／３０）．结论临床特征、相关实验室检查、Ｂ超和ＣＴ检查能满足梗阻性黄疸诊断的需要．     

逆行胰胆管造影对梗阻性黄疸的诊断价值

ＥＲＣＰ对梗阻性黄疸的诊断价值。３２例梗阻性黄疸做逆行胰胆管造影（ＥＲＣＰ），与Ｂ超和ＣＴ进行对比，探讨对其定位与病因的诊断价值。结果：恶性胆道梗阻１８例（５６．３％），良性梗阻１４例（４３．７％）。ＥＲＣＰ、Ｂ超及ＣＴ定位诊断率分别为９３．７％、８７．５％与８１．３％，三者比较差异无显著性（Ｐ＞０．０５）；病因诊断率分别为９０．６％、６２．５％与５６．３％，ＥＲＣＰ与Ｂ超和ＣＴ比较差异显著（Ｐ＜０．０５）；误诊率分别为９．４％、９．４％与３．１％，三者比较无显著性差异（Ｐ＞０．０５）。ＥＲＣＰ对梗阻性黄疸的病因诊断率明显优于Ｂ超和ＣＴ，对梗阻性黄疸是一种安全且不可缺少的诊断方法。     

ERCP对肝外胆管癌的诊断价值

肝外胆管癌临床表现多不典型 ,易误诊漏诊 ,术前诊断主要靠逆行胰胆管造影 (ＥＲＣＰ)、经皮肝穿胆道造影 (ＰＴＣ)、Ｂ超和ＣＴ检查[1] 。本文对经手术病理证实的 33例肝外胆管癌的ＥＲＣＰ资料进行回顾性的分析 ,以探讨ＥＲＣＰ对肝外胆管癌的诊断价值。1　资料和方法1.1　一般资料　本组 33例肝外胆管癌中男 2 7例 ,女6例 ,年龄 4 6～ 6 8岁 ,平均 5 6 72岁。临床表现黄疸2 9例 ,腹痛腹胀 2 5例 ,皮肤瘙痒 2 5例 ,乏力 2 1例 ,食欲不振 2 5例 ,发热寒战 4例。病理分型腺癌 32例 ,鳞癌 1例。1.2　方法　 33例肝外胆管癌术前均行ＥＲＣＰ …     

A rare surgical case of metachronous double carcinoma of the biliary tract

We report on a rare case of metachronous double carcinoma of the biliary tract, occurring in a 65-year-old male. The patient was admitted to the hospital with jaundice in March 2004. Ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) scans of the abdomen showed a minimally dilated intrahepatic biliary tree with normal-appearing choledocus. Obstruction of the common hepatic duct was revealed by endoscopic retrograde cholangiopancreatography (ERCP). The patient underwent a resection of the middle third of the extrahepatic duct and cholecystectomy (cholangiocarcinoma, pT1N0M0), with the surgical margins of resection showing as negative. After 2 years, during follow-up, the findings of a positron emission tomography (PET)-CT scan suggested a possible cholangiocarcinoma of the distal part of the biliary tract; CT and MRI scanning of the abdomen showed mild dilatation of the distal common hepatic duct; an ERCP showed mild dilatation of the retropancreatic remnant of the biliary tree with endoluminal defects. Eventually the patient underwent pancreaticoduodenectomy. The histopathological diagnosis of the resected specimen confirmed a cholangiocarcinoma; 10 lymph nodes were negative (pT1N0M0). At 6 months post-op after the second operation the patient is progressing well with no signs of recurrence. Patients with cholangiocarcinoma – in whom survival is prolonged with surgical resection – should undergo careful follow-up for both recurrence and second primary cancer. PET scanning seems to play the most important diagnostic role.     

多轴全方位机器人造影系统在内镜治疗胆道结石中的应用价值初探

目的探讨在行内镜逆行胰胆管造影（ERCP）时使用Artiszeego机器人对胆道进行3D旋转采集和三维重建的应用价值。方法对12例B超提示胆道扩张的病例,在行ERCP同时使用Artis zeego机器人进行3D旋转采集,并经工作站处理进行三维胆道重建,以内镜和手术取石结果为最终诊断,观察其对肝内外胆管结石诊断的符合率。结果12例患者均完成3D旋转采集和三维重建检查,其诊断结果与ERCP取石和手术取石结果均相符,诊断符合率100％,其中,ERCP诊断中2例肝外胆管结石数量不明,1例可疑结石及2例疑似肝内胆管结石病例均得到明确诊断。结论使用Artis zeego机器人对胆道进行3D旋转采集和三维重建有助于ERCP诊疗中对胆道病变做出精准判断。     

10955例经内镜逆行胰胆管造影术患者临床总结分析

目的探讨经内镜逆行胰胆管造影术（ERCP）对胆胰疾病的诊疗价值。方法回顾性分析1995年1月至2013年7月间完成ERCP诊治的患者10955例,其中男6186例,女4769例,平均年龄（65．57±14．44）岁。总结并分析ERCP诊治病种、发病年龄、年度数量、麻醉方式及插管成功率等指标。结果10955例患者中,诊断性ERCP167例,治疗性ERCP10788例。2002年至2012年ERCP手术例数年平均增长率是19．58％。首次ERCP胆管插管成功率是97．23％,总ERCP胆管插管成功率是99．59％。常见的ERCP诊治疾病包括肝外胆管结石（40．85％）、肝门部胆管癌（10．53％）、化脓性胆管炎（10．44％）、胰头癌（10．04％）、慢性胰腺炎（8．24％）、肝外胆管癌（7．68％）、壶腹周围癌（6．96％）、胆源性胰腺炎（3．94％）、良性乳头狭窄（3．88％）、乳头癌（3．50％）。肝外胆管结石、化脓性胆管炎、良性乳头狭窄高发年龄是40～50岁,慢性胰腺炎高发年龄是50—60岁,胆源性胰腺炎、肝门部胆管癌、肝外胆管癌、胰头癌、壶腹周围癌、乳头癌的高发年龄是70—80岁。2011年至2013年中,98．74％患者行全凭静脉麻醉ERCP。结论ERCP已经成为胆胰疾病诊治的重要手段,适合于肝外胆管结石、化脓性胆管炎、恶性胆管梗阻等疾病,尤其是高龄患者的诊治。全凭静脉麻醉ERCP是安全、有效的。     

Diagnosis and treatment of congenital choledochal cyst: 20 years' experience in China

AIM To summarize the experience of diagnosis andtreatment of congenital choledochal cyst in the past 20years(1980-2000).METHODS The clinical data of 108 patients admitted from1980 to 2000 were analyzed retrospectively.RESULTS Abdominal pain,jaundice and abdominal masswere presented in most child cases.Clinical symptoms inadult cases were non-specific,resulting in delayeddiagnosis frequently.Fifty-seven patients(52.7%)hadcoexistent pancreatiobiliary disease.Carcinoma of thebillary duct occurred in 18 patients(16.6%).Ultrasonicexamination was undertaken in 94 cases,ERCP performedin 46 cases and CT in 71 cases.All of the cases werecorrectly diagnosed before operation.Abnormalpancreatobiliary duct junction was found in 39 patients.Before 1985 the diagnosis and classification of congenitalcholedochal cyst were established by ultrasonographypreoperatively and confirmed during operation,the mainprocedures were internal drainage by cyst enterostomy.After 1985,the diagnosis was established by ERCP andCT,and cystectomy with Roux-en-Y hepaticojejunostomywas the conventional procedures.In 1994,we reported anew and simplified operative procedure in order to reducethe risk of choledochal cyst malignancy.Postoperativecomplication was mainly retrograde infection of biliarytract,which could be controlled by the administration ofantibiotics,there was no perioperative mortality.CONCLUSION The concept in diagnosis and treatment ofcongenital choledochal cyst has obviously been changedgreatly.CT and ERCP were of great help in theclassification of the disease.Currently,cystectomy withRoux-en-Y hepaticojejunostomy is strongly recommendedas the choice for patients with type Ⅰ and type Ⅳ cysts.Piggyback orthotopic liver transplantation is indicated intype Ⅴ cysts(Caroli's disease)with frequently recurrentcholangitis.     

A rare surgical case of metachronous double carcinoma of the biliary tract

We report on a rare case of metachronous double carcinoma of the biliary tract, occurring in a 65-year-old male. The patient was admitted to the hospital with jaundice in March 2004. Ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) scans of the abdomen showed a minimally dilated intrahepatic biliary tree with normal-appearing choledocus. Obstruction of the common hepatic duct was revealed by endoscopic retrograde cholangiopancreatography (ERCP). The patient underwent a resection of the middle third of the extrahepatic duct and cholecystectomy (cholangiocarcinoma, pT1N0M0), with the surgical margins of resection showing as negative. After 2 years, during follow-up, the findings of a positron emission tomography (PET)-CT scan suggested a possible cholangiocarcinoma of the distal part of the biliary tract; CT and MRI scanning of the abdomen showed mild dilatation of the distal common hepatic duct; an ERCP showed mild dilatation of the retropancreatic remnant of the biliary tree with endoluminal defects. Eventually the patient underwent pancreaticoduodenectomy. The histopathological diagnosis of the resected specimen confirmed a cholangiocarcinoma; 10 lymph nodes were negative (pT1N0M0). At 6 months post-op after the second operation the patient is progressing well with no signs of recurrence. Patients with cholangiocarcinoma - in whom survival is prolonged with surgical resection - should undergo careful follow-up for both recurrence and second primary cancer. PET scanning seems to play the most important diagnostic role.     

ERCP在不明原因肝外阻塞性黄疸的临床应用

目的探讨内镜逆行胰胆管造影（ERCP）在经常规检查不明原因肝外阻塞性黄疸的临床应用价值。方法收集经B超、cT和,或MRCP检查诊断不明原因胆胰疾病或肝外胆管梗阻病人45例,男28例,女17例,年龄21—80岁,均行ERCP术。结果45例病人行ERCP术,其中42例诊断为胆道微结石（Biliary microlithiasis,BML）,42例均行乳头扩张术／EST4-胆道取石术;3例为胆总管下端炎性狭窄而行胆道内支架植入术;1例ERCP取石术后并发轻症胰腺炎,经内科保守治疗后痊愈,l例因腹痛再发行胆囊切除术,其余患者经ERCP治疗后腹痛、黄疸均缓解。结论BML是不明原因肝外阻塞性黄疸的主要原因,ERCP是不明原因肝外阻塞性黄疸安全、有效的诊断及治疗手段。     

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。     

经内镜诊治肝移植术后胆道远期并发症

目的：探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植患者胆道远期并发症中的应用。方法：肝移植术后出现胆道远期并发症患者6例，共行ERCP 12次，根据患者的情况进行扩张、内镜下乳头切开取石、内支架置入等治疗。结果：1例胆总管结石行乳头切开后取石成功，1例胆道狭窄在胆道扩张后胆道梗阻症状解除，4例胆道狭窄合并胆总管结石的狭窄近端结石经乳头切开取出，狭窄远端结石行胆道扩张、内支架置入等治疗后取出。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度的下降，无严重并发症发生。结论：ERCP是诊断和治疗肝移植患者胆道远期并发症安全、有效的手段。     

经内镜射频消融和置入内支架联合治疗不能切除的胆胰肿瘤

目的探讨经内镜射频消融和置入内支架的联合治疗在延长不能切除的胆胰肿瘤患者胆道通畅期中的作用。方法共58例患者采用联合治疗：6例十二指肠乳头癌先作内镜下乳头局部切除，而后对残留病灶作射频消融；52例经ERCP测出肿瘤狭窄段的范围，对狭窄段作射频消融，然后置入相匹配的金属内支架。收集同期52例单放金属内支架者作为对照组。结果在联合治疗组中，3例治疗后2个月内因胆道严重感染、全身衰竭死亡，余55例胆道平均通畅期为9．2个月，平均存活期为16个月。其中48例再次梗阻后再次内镜下治疗，28例单作射频消融和20例射频消融加再置入内支架，通畅期又平均延长5．1个月。而单放内支架组胆道通畅期为6．1个月，平均存活期为13个月。结论射频消融能阻止肿瘤的局部增长，从而延长内支架的通畅期和患者的存活期。     

ERCP in orthotopic liver transplanted patients

BACKGROUND/AIMS: Biliary complications after orthotopic liver transplantation (OLT) are still common. The aim of the study was to assess the effectiveness of ERCP as a diagnostic and treatment tool in the management of biliary tract OLT complications. METHODOLOGY: The diagnostic and treatment effectiveness of ERCP in the management of biliary tract OLT complication from 1/1995 to 12/2001 was reviewed. RESULTS: 24/251 (9.6%) OLT patients presented biliary complications. These patients underwent a total of 31 ERCP (seven patients received two ERCP). The ERCP indication was cholestasis in 25 (80.6%). The success rate of these 31 ERCPs was 87%. In the 25 ERCPs indicated in patients with cholestasis, the procedure revealed strictures of the biliary anastomosis in 3, hepatic hilum strictures in 5, SOD in 4, lithiasis in 7 and sclerosing cholangitis in one. The final diagnosis of three patients with normal biliary tract was intrahepatic cholestasis. In three of the four patients with biliary leaks the ERCP's confirmed the diagnosis. The final treatment efficacy was 100% (7/7 patients), 50% (2/4 p.), 0% (0/3 p.), 75% (3/4 p.) and 100% (4/4 p.) for patients with biliary stones, strictures of the hilum, anastomotic strictures, biliary leaks and SOD, respectively. In the acute pancreatitis and in the PSC endoscopic treatment was not indicated. There were two mild cases of pancreatitis. CONCLUSIONS: Because of its availability, diagnostic accuracy, treatment efficacy and safety, ERCP should be used as the first-line procedure for treatment of biliary tract complications after OLT.