经皮经肝穿刺胆管引流术联合经肝动脉内灌注化疗栓塞治疗原发性肝癌合并梗阻性黄疸的初步观察

目的探讨经皮经肝穿刺胆管引流术(PTCD)联合经肝动脉内灌注化疗栓塞(TAE)治疗原发性巨块型肝癌合并梗阻性黄疸的方法和临床应用初步效果。方法原发性巨块型肝癌患者25例,其中男性15例,女性10例;年龄35～65岁,平均年龄48岁。因肿瘤压迫或侵蚀胆总管/肝总管合并梗阻性黄疸。在影像诊断明确病变部位和梗阻程度后,先行经皮经肝穿刺胆管(PTC),明确肝胆管侵犯和梗阻细节,酌情置入引流导管行外引流或胆管支架行内引流;术后1周患者黄疸减轻后常规进行肝动脉内介入灌注化疗与栓塞。结果 10例置入外引流管,10例置入胆道支架,5例同时置入外引流管和胆道内支架。引流术后全部外引流病例引流通畅,内引流患者大便色泽改变;血清胆红素、总胆红素下降明显,患者全身状况明显改善。5例出现右侧少量胸腔积液,其他未出现明显并发症。TAE术后肝脏肿块均不同程度缩小(t=10.00,P<0.01)。随访患者最长生存期为3年。结论 PTCD联合TAE治疗原发性肝癌引起的梗阻性黄疸疗效可靠,应根据胆管梗阻部位及程度确定治疗方案,及时施行手术可进一步提高患者生存期。     

金属胆道支架在恶性胆道梗阻治疗中的临床应用

目的：探讨金属胆道支架置人结合肿瘤区域化疗在恶性胆道梗阻治疗中的应用价值。方法：46例不能根治切除的恶性胆管梗阻患者中，42例行经皮肝穿刺胆道引流（PTCD）后支架置放术，另4例行经腹胆道支架置放术。支架置放术后，36例采用皮下埋置化疗泵化疗药物注射，8例采用分次动脉插管化疗药物灌注。结果：经PTCD成功后支架置人成功率95．2％，经腹支架置人成功率100％。结论：金属胆道支架置人成功率高，手术损伤，支架通畅率高，结合肿瘤区域化疗，可进一步提高疗效。     

胆道支架放置术治疗恶性梗阻性黄疸的体会

目的探讨胆道支架放置术治疗恶性梗阻性黄疸的安全性和有效性。方法采用自膨式胆道支架放置术治疗恶性梗阻性黄疸78例病人。术前实验室检查血总胆红素为(362.4±106.7)μmol/L,以直接胆红素升高为主[(271.9±74.3)μmol/L]。结果所有病例均成功放置支架,术中、术后无因操作原因致死病例,1～4周黄疸完全消退68例,血胆红素降到正常水平,10例血胆红素平均降至65.2μmol/L;并发症以胆道感染为主。结论胆道支架放置术治疗恶性梗阻性黄疸有效、安全。     

胆道支架联合高强度超声聚焦刀治疗胰腺癌合并梗阻性黄疸的临床观察

目的探讨胆道支架联合高强度超声聚焦刀(HIFU)治疗胰腺癌导致的梗阻性黄疸的疗效与安全性。方法选择2013年1月至2017年2月80例胰腺癌合并梗阻性黄疸经胆道支架置入治疗的患者,根据支架置入术后是否进行HIFU治疗将患者分为联合治疗组(38例)与单纯支架组(42例),对比2组患者支架通畅时间及生存期。结果 2组患者黄疸均在胆道支架置入后缓解。7例患者在胆道支架置入术后并发胆管炎。80例患者随访(5.13±2.94)个月。15例患者发生支架再狭窄。联合治疗组患者中位支架通畅时间为179 d,中位生存期为209 d;单纯支架组患者中位支架通畅时间为119 d,中位生存期为145 d;2组患者比较差异有统计学意义(P0.05)。根据单因素与多因素Cox回归分析结果,胆道支架术后进行HIFU治疗及肿瘤分期较早是延长患者生存期的因素(P0.05)。结论胆道支架联合HIFU治疗胰腺癌导致的梗阻性黄疸安全有效;HIFU能够显著延长胆道支架通畅的时间以及生存期。     

经皮肝穿胆道内外引流治疗上段胆管癌所致黄疸31例

目的探讨经皮肝穿胆道内外引流治疗上段胆管癌所致黄疸的疗效。方法对诊断为上段胆管癌致恶性梗阻性黄疸的患者，在X线监视下实行、经皮肝穿胆道内外引流术，并观察其疗效。结果本组患者均一次胆道引流成功，所有患者术后病情明显好转，随访1个月引流效果均较满意。结论经皮肝穿胆道内皮引流是一种姑息性方法，如能在此基础上进行根治性手术治疗或结合对肿瘤的化疗、放疗治疗，可进一步延长生命。     

68例恶性梗阻性黄疸患者ERCP诊治的分析

目的 探讨经内镜逆行胰胆管造影(ERCP)及其相关技术在恶性梗阻性黄疸患者诊断和治疗中的作用.方法 回顾性分析68例恶性梗阻性黄疸患者的ERCP诊断情况,以及ERCP相关性治疗,包括内镜下鼻胆管引流(ENBD)、内镜下胆管金属支架引流术(EMBD)、塑料支架引流术(ERBD)、超声引导下经皮肝穿刺胆道引流术(PTCD)联合ERCP支架植入术的应用情况,并对患者的预后及并发症进行总结分析.结果 68例患者均经ERCP检查,共成功发现病变显影54例(79.4％),其中壶腹癌(16/18)、乳头癌(10/12)、胆管下段癌(8/l0)、胆囊癌(5/5)、肝癌侵犯胆管(2/2)肝门部胆管癌(6/11)、胰腺癌(6/8).术后7d胆红素及ALP水平较术前均明显下降,大部分患者症状明显缓解.术后并发急性胰腺炎8例(14.8％),电解质紊乱9例(16.7％),并发消化道出血3例.49例接受为期6个月的随访,其中死亡12例(24.5％).结论 ERCP及其相关治疗手段能够减轻黄疸,缓解症状,提高生活质量,延长生存期,是姑息性治疗恶性梗阻性黄疸的重要方法.     

经皮经肝胆管引流途径胆道支架置入与姑息性胆肠内引流治疗恶性梗阻性黄疸的疗效比较

目的：探讨不能手术切除的恶性梗阻性黄疸患者行经皮经肝胆管引流（ PTCD)途径放置胆道支架与姑息性胆肠内引流减轻黄疸方式的疗效差异。方法回顾性分析蚌埠医学院第一附属医院肝胆外科2005年12月—2011年12月不能手术切除且资料完整的210例恶性梗阻性黄疸患者的临床资料,其中 PTCD 途径胆道金属支架置入术137例（支架组),男83例、女54例,年龄（67．64±12．68)岁;姑息性胆肠 Roux-en-Y 内引流术73例（引流组),男50例、女23例,年龄（64．69±12．99)岁。比较两组患者的疗效差异。结果支架组和引流组均可有效解除患者胆道梗阻、改善肝功能;在身体状况、黄疸程度及肝功能损害更严重的情况下,支架组在解除胆道梗阻、改善肝功能方面优于引流组,且不增加手术并发症和住院时间;两组术后生存时间分别为（9．25±6．24)个月和（10．36±8．02)个月,差异亦无统计学意义（P>0．05)。结论对于失去手术切除肿瘤机会的恶性梗阻性黄疸患者,可选择PTCD途径胆道金属支架置入术解除胆道梗阻、改善全身状况,其与姑息性胆肠内引流相比具有简便、安全、创伤小、可重复及可为后续治疗创造条件等优点,可作为首选。     

经皮胆道双金属支架联合125I粒子条植入治疗高位恶性梗阻性黄疸的疗效分析

目的 探讨胆道双金属支架联合125I粒子条植入治疗高位恶性梗阻性黄疸(MHBO)的疗效与安全性。方法 选取40例接受胆道双金属支架联合125I粒子条植入治疗的MHBO患者作为观察对象,分析患者手术前后肝功能、血常规变化、术后并发症、生存率及支架通畅情况。结果 所有患者均成功实施手术,共植入支架80枚,粒子608颗,无手术相关死亡。患者术后1、4、12周总胆红素(TBIL)、直接胆红素(DBIL)、天冬氨酸转氨酶(AST)、丙氨酸转氨酶(ALT)、碱性磷酸酶(ALP)、谷氨酰转肽酶(GGT)与术前比较,差异具有统计学意义(P 0. 05);患者术后4、12周白蛋白(ALB)与术前比较,差异具有统计学意义(P 0. 05);患者术后1周白细胞计数、中性粒细胞计数与术前比较,差异具有统计学意义(P 0. 05)。术后并发症发生率为10%,其中胆管炎2例,肝性脑病1例,胰腺炎1例。随访至2020年12月,中位随访时间8. 5个月,死亡33例,中位生存时间7个月,术后3、6、12个月的累积生存率分别为100%、75%和40%。2例患者分别于术后3、8个月出现支架阻塞。结论 对于MHBO患者,经皮肝穿刺胆道双金属支架联合125I粒子条植入是一种安全、可行、有效的姑息治疗方式。     

恶性胆道梗阻金属支架堵塞后再次置入金属和塑料支架的比较

背景：在堵塞的支架中再次置入金属或塑料支架可解决支架的堵塞问题,然而关于支架间如何搭配组合将使患者受益更大却一直存在着争论。 目的：对比恶性胆道梗阻金属支架堵塞后再次在其内置入不同种类支架之间的临床效果。 方法：收集在南昌大学第二附属医院行经内镜胆道金属支架置入的,且在原支架堵塞后再次在其内置入另一支架的中、低位胆道恶性梗阻患者83例,并根据原支架与再次置入支架的不同搭配组合形式,将以上患者分为3组,即覆膜金属支架组、无覆膜金属支架组和塑料支架组。 结果与结论：在原金属支架堵塞后,再次置入覆膜金属支架的通畅时间显著长于塑料支架(P < 0.05);覆膜金属支架组的支架累计通畅时间显著长于无覆膜金属支架组(P < 0.05-0.01)。提示经内镜置入胆道金属支架治疗中、低位胆道恶性梗阻时,在原金属支架和支架堵塞后再次置入金属支架时,使用≥1根覆膜支架的累计通畅时间显著长于先后2次置入无覆膜金属支架者。     

塑料与金属胆管支架的材料特征及其生物相容性

背景：经消化内镜塑料及金属胆管支架置入技术是治疗胆道良恶性梗阻的有效手段。尤其是高位梗阻胆管内支架置入治疗,对不能进行外科治疗的胆系肿瘤患者急需消除黄疸,顺应生理性引流,延长生存期,提高生活质量有极大的临床应用价值。 目的：对比经消化内镜置入塑料及金属胆管支架治疗胆道良恶性梗阻的临床效果,并探讨塑料及金属胆管支架与宿主间的生物相容性。 方法：由第一作者以“胆道梗阻,塑料胆管支架,金属胆管支架,生物相容性”为中文检索词,以“cerebrovascular disease,stent,biocompartibility”为英文检索词,在中国期刊全文数据库(CNKI：1989/2009)及Medline(1989/2009)数据库中采用电子检索的方式进行文献检索。排除Meta分析及重复性研究。筛选纳入35篇文献进行评价,探讨塑料及金属胆管支架的治疗现状、并发症和生物相容性。 结果与结论：经内镜置入胆管支架是治疗胆道良恶性梗阻的主要手段。胆管内支架主要包括金属支架和塑料支架两种。金属支架在预防细菌滋生,保持支架持久通畅等方面有很大的优势,但价格昂贵。塑料支架较易细菌附着,胆泥淤积导致支架阻塞,但具有容易更换、价格低廉的优点。塑料及金属胆管支架的生物相容性均有待于提高,对于胆管恶性梗阻的患者,胆管内支架置入与放射治疗相结合有助于预防支架梗阻。对于胆泥的形成,支架的移位和堵塞,以及支架降解产物等问题尚需要进一步的观察和研究。     

Two cases of chronic pancreatitis with pseudocyst complicated by obstructive jaundice

We recently treated two cases of chronic pancreatitis with obstructive jaundice due to compression of the common bile duct by pancreatic pseudocyst. The two cases were males admitted with the complaint of icteric skin color. The first, a 46-year-old male, admitted with the complaint of icteric skin color. He was treated by operative cystojejunostomy after percutaneous drainage of the pseudocyst and percutaneous transhepatic biliary drainage. The other case was a 58 year-old male who admitted with the complaint of icteric skin color. He had an infected pseudocyst in the pancreas and was endoscopically treated. Both of them were discharged with favorable clinical course and normal laboratory findings after the treatment. The former patient remained well 11 months after treatment, but the latter patient died from necrotizing pancreatitis and septic shock 6 months after treatment. Most cases of obstructive jaundice associated with pseudocysts appear to be due to fibrotic stricture of the intrapancreatic portion of the common bile duct rather than due to compression of the bile duct by the pseudocyst. In a patient with secondary pancreatic infection or obstructive jaundice following pancreatic disease, differentiating between these two conditions is an important aspect of accurate diagnosis and therapy. Herein we report two unusual cases of chronic pancreatitis with pseudocyst complicated by obstructive jaundice.     

Percutaneous transhepatic biliary biopsy using gastrofiberscopic biopsy forceps.

To obtain a histopathologic diagnosis at the site of a biliary obstruction, we recently have performed 24 cases of biliary biopsy using gastrofiberscopic biopsy forceps (Olympus, Tokyo, Japan) via transhepatic tracts provided in the course of the procedure of percutaneous biliary drainage. Histopathologic diagnosis was successfully made at the first attempt of biopsy procedure but a second trial was made a week later in 6 cases who were negative for malignant cells on the first attempt. The histological results from the biopsy specimens were 18 adenocarcinomas, 5 chronic inflammations and one normal epithelium. Of 6 cases who were negative for malignant cells on forceps biopsy specimen, three cases were confirmed as adenocarcinoma of the ampulla of Vater, adenocarcinoma of the pancreas and chronic pancreatitis by surgical biopsy. The latter was a true negative result, which was diagnosed as chronic inflammation on forceps biopsy and verified as chronic pancreatitis by surgery. The remaining two cases were diagnosed as malignant obstructive jaundice by clinical and radiological follow-up findings. Major complications (bile peritonitis, bleeding, and hemopneumothorax) occurred in 3 patients, which mainly arose in the earlier period of study. This procedure can be performed at the same time as percutaneous transhepatic biliary drainage with low morbidity or mortality, and although the potential for perforation of bile ducts and injury to adjacent blood vessels is considered it is a useful addition to existing biopsy techniques for yielding material sufficient for histologic analysis.     

超声导航技术辅助经皮穿刺胆管置管引流术治疗

目的:探讨超声导航技术辅助经皮穿刺胆管置管引流术治疗的临床效果。方法:选择收治的60例恶性梗阻性黄疸患者,划分为30例/组,两组均行经皮穿刺胆管置管引流术,对照组采取X线辅助,观察组采取超声导航技术辅助,比较两组的穿刺成功率、穿刺时间、穿刺次数、生命体征指标、疼痛评分、舒适度评分、并发症发生率、胆汁引流量、肝功能指标。结果:（1）统计首次穿刺和首二次穿刺的成功率,观察组均较对照组高（P<0.05）;（2）统计单次穿刺和总穿刺时间,观察组均较对照组短（P<0.05）,其穿刺次数,观察组也较对照组少（P<0.05）;（3）对照组穿刺前与穿刺后的心率、血压等生命体征指标均发生明显改变（P<0.05）,而观察组穿刺前与穿刺后的生命体征指标均未发生明显改变（P>0.05）;（4）穿刺时及穿刺后,观察组的疼痛评分均较对照组更低（P<0.05）,其舒适度评分均较对照组更高（P<0.05）;（5）并发症总发生率分别为0%（观察组）、13.33%（对照组）,观察组较对照组更低（P<0.05）;（6）术后第1天、第2天、第3天,观察组与对照组的胆汁引流量比较,差异无统计学意义（P>0.05）;（7）组内AST、ALT、TBIL等肝功能指标比较,两组手术后均较手术前降低（P<0.05）。结论:利用超声导航技术,完成经皮穿刺胆管置管引流术的实施,实现对恶性梗阻性黄疸患者的胆汁予以充分引流,改善肝功能,还可提高穿刺成功率,减少穿刺耗时和次数,减轻穿刺疼痛感,减少并发症的发生。     

术前胆道引流对恶性阻塞性黄疸患者免疫和炎症状况的影响

目的探讨术前胆道引流对恶性阻塞性黄疸患者免疫和炎症状况的影响。方法选择于我院就诊的31例恶性阻塞性黄疸患者作为研究对象,对患者进行术前胆道引流,比较引流前后患者的免疫和炎症状况。结果引流后患者的IL-6、IL-8、CRP、CD4+、CD8+与引流前比较,差异均无统计学意义(P0.05);引流后患者的TNF-α明显低于引流前,差异有统计学意义(P0.05)。结论术前胆道引流能够明显改善患者的TNF-α水平,TNF-α是恶性阻塞性黄疸患者免疫、炎症的敏感因子。     

Unilobar Versus Bilobar Biliary Drainage: Effect on Quality of Life and Bilirubin Level Reduction

Background:

Percutaneous biliary drainage is an accepted palliative treatment for malignant biliary obstruction.

Purpose:

To assess the effect on quality of life (QOL) and bilirubin level reduction in patients with inoperable malignant biliary obstruction treated by unilobar or bilobar percutaneous transhepatic biliary drainage (PTBD).

Materials and Methods:

Over a period of 2 years, 49 patients (age range, 22–75 years) of inoperable malignant biliary obstruction were treated by PTBD. Technical and clinical success rates, QOL, patency rates, survival rates, and complications were recorded. Clinical success rates, QOL, and bilirubin reduction were compared in patients treated with complete (n = 21) versus partial (n = 28) liver parenchyma drainage. QOL before and 1 month after biliary drainage were analyzed retrospectively between these two groups.

Results:

Biliary drainage was successful in all 49 patients, with an overall significant reduction of the postintervention bilirubin levels (P < 0.001) resulting in overall clinical success rate of 89.97%. Clinical success rates were similar in patients treated with whole-liver drainage versus partial-liver drainage. Mean serum bilirubin level before PTBD was 19.85 mg/dl and after the procedure at 1 month was 6.02 mg/dl. The mean baseline functional score was 39.35, symptom scale score was 59.55, and global health score was 27.45. At 1 month, mean functional score was 61.25, symptom scale score was 36.0 4, and global health score was 56.33, with overall significant improvement in QOL (<0.001). There was a statistically significant difference in the improvement of the QOL scores (P = 0.002), among patients who achieved clinical success, compared with those patients who did not achieve clinical success at 1 month. We did not find any significant difference in the QOL scores in patients according to the amount of liver drained (unilateral or bilateral drainage), the type of internalization used (ring biliary or stent). Overall, minor and major complications rates were 14.3% and 8.1%, respectively.

Conclusion:

Percutaneous biliary drainage provides good palliation of malignant obstructive jaundice. Partial-liver drainage achieved results as good as those after complete liver drainage with significant improvements in QOL and reduction of the bilirubin level.     

梗阻性黄疸患者胆道内、外引流手术前后血清白细胞介素的表达及临床意义

了解梗阻性黄疸胆道内、外引流术式对血清白细胞介素-6(IL-6)和白细胞介素-12(IL-12)含量的影响。方法：43例由恶性肿瘤引起的梗阻性黄疸中，胆道内引流32例，胆道外引流术11例，43例患者术前、术后均测得血清IL-6和IL-12含量。结果显示，梗阻性黄疸内、外引流术前血清IL-6和IL-12低于正常组，行胆道内引流术后血清IL-6、IL-12的值与正常组比较无显著性差异，表明其免疫功能有所恢复，而胆道外引流术后血清IL-6、IL-12的值低于正常组，表明免疫功能仍受损。该结论提示在临床上对于一般情况差，不能行根治手术的梗阻性黄疸病人，应尽可能行胆道内引流术。     

Pulmonary bile emboli. Sequelae of iatrogenic trauma

A 58-year-old man manifested obstructive jaundice secondary to adenocarcinoma of the common hepatic duct. The markedly icteric patient underwent multiple diagnostic and therapeutic procedures, including percutaneous needle biopsy of the liver, curettage, catheterization and washing of the hepatic ducts, and percutaneous transhepatic cholangiography. Three months later the patient died of a bleeding gastric ulcer. Autopsy confirmed the presence of adenocarcinoma of the common hepatic duct. Microscopic examination of the lungs disclosed numerous bile emboli in the smaller arteries, arterioles, and in a few alveolar capillaries. Histochemical reaction of the emboli was positive for bilirubin. Organizing fibrin was seen around occasional bile emboli, but most were without microscopic reaction. Review of the literature disclosed nine cases of pulmonary bile embolism, six of which had a history of marked cholestasis and trauma to the liver, like the present patient. Bile reaches the systemic circulation through a biliary-venous fistula that, in our case, was probably iatrogenic.     

Leakage of jejunal end of roux limb after total gastrectomy: management with a placement of a covered metallic stent: case report

Postoperative leakage is a serious complication in patients after gastric surgery. It can lead to a rapid deterioration in the patient's condition and quality of life. Treatment is guided by the type of anastomosis and the patient's clinical status. The role of interventional radiology in gastrointestinal tract is evolving. Metallic stent placement has shown encouraging results for the palliation of gastrointestinal tract obstruction and fistula in malignant patients. We encountered a case of the leakage of jejunal end of Roux limb after total gastrectomy. This patient required a drainage procedure with long-term parenteral nutrition. We performed peroral placement of a covered metallic stent to avoid surgery and long-term parenteral nutrition, and he resumed adequate oral intake immediately after stent placement. This minimally invasive procedure is very promising for the treatment of a gastrointestinal fistula to avoid surgery and long-term parenteral nutritional support in selected cases.     

De novo perihilar cholangiocarcinoma arising in the allograft liver 15 years post‐transplantation for biliary atresia

Most primary liver cancers diagnosed in allograft livers are recurrent tumors of the native liver origin, while donor‐derived primary liver cancers are markedly less common. A 21‐year‐old woman who had liver transplantation for post‐Kasai biliary atresia was recently referred for post‐transplant biliary stricture. Her transplantation was performed at the age of 6 years using the whole liver graft from a 10‐year‐old donor and choledocho‐jejunostomy. The post‐transplant course was uneventful in the first 15 years until she presented with obstructive jaundice. The stricture was located at the level of the hepaticojejunostomy, and required percutaneous transhepatic drainage and bile duct dilatation. She underwent an exploratory laparotomy, which suggested a neoplastic process widely involving the extrahepatic and intrahepatic large bile ducts. The histological examination of the resected extrahepatic bile duct confirmed infiltrating moderately differentiated adenocarcinoma. Molecular tests of multiple short tandem repeat loci confirmed the donor origin of the tumor. After four cycles of chemotherapy with gemicitabine and cisplatin, she is currently on radiotherapy in view of potential re‐transplantation. De novo, post‐transplant cholangiocarcinoma of graft origin is extremely uncommon with only three other cases reported. Two were associated with recurrent primary sclerosing cholangitis, and all had choledocho‐jejunostomy at the time of transplantation.