阻塞性黄疸:经皮穿刺胆道造影下胆道钳夹活检与毛刷活检对比研究

目的 比较胆道钳夹与毛刷活检的诊断敏感率，探索胆道疾病病理学检查新途径。方法 连续92例阻塞性黄疸接受经皮肝穿胆道造影(PTC)和经皮肝穿胆道引流(PFCD)治疗。PFCD过程中，影像监测下经皮经肝胆道穿刺，向胆道内引入活检钳和毛刷对梗阻段钳夹和毛刷活检，行组织病理学和细胞检查。结果92例钳夹活检患者90例成功获得组织块，技术成功率97．8％(90／92)。钳夹活检敏感率较毛刷活检敏感率高(88．0％比76．2％，X^2=4．251，P=0．039)。结论 PTC下胆道钳夹活检操作简单，创伤小，敏感度高，是一种值得推广的胆道病理学诊断新途径，毛刷活检在胆管癌的诊断方面也具有较高的应用价值。     

阻塞性黄疸:PTC下胆管钳夹活检的技术方法学研究

目的探索切实可行的胆管病理学检查新途径.资料与方法连续92例阻塞性黄疸患者接受经皮肝穿刺胆管造影(PTC)和经皮肝穿胆管引流(PTCD)治疗.PTCD过程中,影像监测下经皮经肝胆管穿刺,向胆管内引入活检钳对梗阻段钳夹活检,行组织病理学检查.统计学分析用χ2检验或Fisher确切概率计算法,以α=0.05作为检验水准.结果 92例钳夹活检患者90例成功获得组织块,技术成功率97.83%(90/92).钳夹活检敏感性为88.04%,63例胆管癌性恶性肿瘤钳夹活检敏感性较25例非胆管癌性恶性肿瘤高(93.65%比72.00%,P＜0.05).结论PTC下胆管钳夹活检操作简单,创伤小,敏感性高,是一种值得推广的胆管病理学诊断新途径.     

阻塞性黄疸经皮肝穿胆管造影术下胆管钳夹活检病理学诊断

目的　探索阻塞性黄疸经皮肝穿胆管造影术 (PTC)下胆管钳夹活检病理诊断的可行性和敏感性。方法　 2 0 0 1年 4月至 2 0 0 3年 3月 ,因阻塞性黄疸接受介入放射学PTC、经皮肝穿胆管引流术 (PTCD)和胆管内支架置入的连续 6 5例患者 ,男 36例 ,女 2 9例 ,年龄 33～ 88岁 ,平均 5 4岁 ,病程 7～90d ,平均 32d。PTCD减黄术中 ,在数字影像监测下经PTC途径用活检钳和毛刷对病变段胆管活检。通过经皮经肝胆管穿刺通道向胆管内送入 8F鞘至阻塞段 ,经鞘先后引入活检钳和毛刷对梗阻段胆管钳夹和毛刷活检 ,获取多个标本 ,用 10 %甲醛溶液固定后 ,行病理学检查。统计学分析用 χ2 检验或Fisher确切概率计算法 ,以P <0 0 5认为差异具有显著性意义。结果　 6 5例阻塞性黄疸 ,PTC下胆管活检技术成功率 10 0 % ,5 8例获得组织学诊断 ,分别为胆管腺癌 4 2例 ,胆管鳞癌 1例 ,胰腺癌 2例 ,肝癌 2例 ,转移癌 5例 ,纤维结缔组织增生 2例 ,硬化性胆管炎 1例 ,胆管结石 1例 ,菌团沉积 1例 ,慢性胆管炎 1例 ;阴性结果 7例。钳夹活检的病理学阳性率 89 2 3%。 4 5例胆管癌钳夹活检敏感度较 16例非胆管癌性肿瘤高 (分别为 95 5 6 %和 6 8 75 % ,χ2 =5 919,P =0 0 15 )。 5 8例毛刷活检 4 3例获得细胞学诊断 ,有胆管腺癌 36例 ,     

经皮肝穿刺胆道内钳夹活检诊断恶性阻塞性黄疸胆肠吻合术后吻合口狭窄

目的探讨经皮肝穿刺胆道造影(PTC)术中胆道钳夹活检诊断恶性阻塞性黄疸胆肠吻合术后吻合口狭窄的可行性和优越性,获取病变部位的组织病理学,指导临床治疗。资料与方法 PTC术中引入活检钳对18例恶性阻塞性黄疸胆肠吻合术后复发黄疸患者于梗阻部位活检,判断狭窄的良恶性,采取相应的减黄措施并观察其疗效。结果全部病例PTC造影显示梗阻部位均位于胆肠吻合口处,行钳夹活检,技术成功率100%,敏感性为94.4%(17/18),其中14例钳夹到肿瘤组织,证实为肿瘤复发;3例病理为纤维组织增生和(或)炎症,结合影像学及实验室检查,考虑瘢痕性狭窄;另1例钳夹阴性,但影像学、实验室检查及术后随访证实为肿瘤复发。所有患者钳夹术中均未出现消化道出血、穿孔等并发症。活检术后行内外引流管和(或)内支架置入,术后患者黄疸消退明显(P<0.05),精神状态及生活质量较术前均有不同程度改善。结论 (1)PTC术中胆道钳夹活检诊断胆管癌术后胆肠吻合口狭窄操作简单,安全,敏感性高;(2)采取介入方法降黄效果明显,操作简单,并发症少。     

基层医院开展PTC的体会

经皮经肝穿刺胆道造影(PTC)，作为胆道系统检查方法之一，早已在临床广泛应用。尤其当患者胆道梗阻黄疸严重时，胆汁不能分泌，各种胆道造影均不能显影，此时PTC检查更为必需。它不仅能清晰显示肝内胆管结石的部位，大小，而且能较好显示肝外胆管阻塞的部位、性质(结石或肿瘤)，这不仅对决定治疗和手术方案能起指导作用，     

胃癌术后阻塞性黄疸钳夹活检病理学及介入治疗疗效研究

目的探讨胃癌术后阻塞性黄疸钳夹活检病理学及介入治疗的疗效。方法分析21例胃癌术后阻塞性黄疸患者的临床资料,右侧腋中线经皮经肝穿刺入路20例,剑突下左侧胆道穿刺入路1例,21例患者均成功施行了胆道引流术,其中18例打通胆道阻塞段后施行了胆道钳夹活检,介入术前1天血清胆红素与术后3天、1周、2周胆红素水平进行重复测量数据的方差分析。结果 18例胆道钳夹活检病理学诊断为高分化腺癌3例,中分化腺癌2例,低分化腺癌8例,慢性炎症并纤维组织增生5例;引流术前血清胆红素与术后3天、1周、2周胆红素水平比较有统计学意义(P<0.05),术后显著下降。结论胃癌术后阻塞性黄疸患者钳夹活检病理学对患者的病情、预后判断及后期治疗提供了依据;经皮经肝穿刺胆道引流术疗效显著,可显著缓解黄疸,改善肝功能,延长患者生存时间。     

经皮经肝胆道后装放疗导管预置术治疗胆道壶腹癌10例

目的 探讨经皮肝穿刺胆道后装放疗导管预置技术的可行性和安全性.方法 选择10例壶腹癌患者,在经皮肝穿刺技术行胆道支架植入术后,经导引导丝送入后装放疗导管,依据病变部位对导管头端及通过导管置入的假源进行定位,每次内照射前CT或透视下复位,给与足量内照射.结果 10例患者均顺利完成经皮肝穿胆道支架置人术和假源定位,并于术后5～7 d内完成足量内照射,治疗过程中未发生严重并发症.结论 经皮肝穿胆道后装放疗导管预置技术安全可行,其成功率高、并发症少,能有效提高胆道支架通畅率,适用于姑息治疗的壶腹癌患者,值得应用和推广.     

经皮肝穿刺胆道引流在恶性肝外阻塞中的应用

1937年Huard等报道了经皮肝穿刺肝内扩张胆管,注入造影剂行诊断性胆道造影.15年后,Carter等首次报道用水溶性造影剂行经皮肝穿刺胆道造影(PTC).1952年Leger等报道一例恶性肿瘤致肝外阻塞行PTC,并接着作术前胆汁外引流.在操作时用细针穿刺可减少并发症,并提高PTC诊断的可靠性. 近年来进一步改进经皮肝穿刺胆汁引流     

CT引导下经皮肝穿刺诊断和治疗的临床应用

目的:提高CT引导下经皮肝穿刺抽吸活检及介入治疗的技术水平,并评价其临床应用价值。方法:26例肝内病变行经皮肝穿刺术,其中19例肝占位和弥漫性病变行活检术,7例临床确诊病例行相应介入治疗术。穿刺部位:肝左叶14例,肝右叶12例。病灶直径1.3～12.5cm。结果:26例患者均一次穿刺成功,穿刺成功率100%。其中19例行活体组织病理学检查,活检诊断符合率94.74%,1例未得出正确病理结果;7例行穿刺后介入治疗,操作成功率100%,并送细胞学检查,诊断符合率达100%。结论:CT引导下经皮肝穿刺为基础进行的抽吸活检及介入治疗对肝脏疾病诊断、鉴别诊断及治疗具有重要临床意义。     

经皮肝穿刺胆管内射频消融联合金属支架植入治疗恶性胆道梗阻的短期疗效及安全性

目的 探讨经皮肝穿刺胆管内射频消融联合金属支架植入术治疗恶性梗阻性黄疸的安全性和有效性.方法 回顾性分析了156例无法手术的恶性胆道梗阻患者的资料.这些患者首先接受经皮肝穿刺胆管内射频消融术,随后联合胆道内金属支架植入进行内引流.结果 经联合治疗后,患者除血清白蛋白下降外,其他主要肝功能指标均显著改善,TBil由治疗前的(325.6±182.3) μmol/L下降到(211.0±153.2)μmol/L,均未发生肝功能不全,30 d内无一例患者死亡.术后发生严重并发症8例,其中胆漏2例(1.3％),出血6例(3.9％);发生轻微并发症88例,其中胆道感染22例(14.3％),疼痛36例(23.4％),呕吐30例(19.5％).结论 经皮肝穿刺胆管内射频消融联合金属支架植入术治疗恶性胆道梗阻是安全,有效的.     

Percutaneous Transhepatic Biliary Drainage in the Management of Postsurgical Biliary Leaks in Patients with Nondilated Intrahepatic Bile Ducts

Purpose To assess the feasibility of percutaneous transhepatic biliary drainage (PTBD) for the treatment of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts, its efficacy in restoring the integrity of bile ducts, and technical procedures to reduce morbidity. Methods Seventeen patients out of 936 undergoing PTBD over a 20-year period had a noncholestatic liver and were retrospectively reviewed. All patients underwent surgery for cancer and suffered a postsurgical biliary leak of 345 ml/day on average; 71% were in poor condition and required permanent nutritional support. An endoscopic approach failed or was excluded due to inaccessibility of the bile ducts. Results Established biliary leaks and site of origin were diagnosed an average of 21 days (range 1–90 days) after surgery. In all cases percutaneous access to the biliary tree was achieved. An external (preleakage) drain was applied in 7 cases, 9 patients had an external–internal fistula bridging catheter, and 1 patient had a percutaneous hepatogastrostomy. Fistulas healed in an average of 31 days (range 3–118 days ) in 15 of 17 patients (88%) following PTBD. No major complications occurred after drainage. Post-PTBD cholangitis was observed in 6 of 17 patients (35%) and was related to biliary sludge formation occurring mostly when drainage lasted >30 days and was of the external–internal type. Median patient survival was 17.7 months and in all cases the repaired biliary leaks remained healed. Conclusions PTBD is a feasible, effective, and safe procedure for the treatment of postsurgical biliary leaks. It is therefore a reliable alternative to surgical repair, which entails longer hospitalization and higher costs.     

PTC对梗阻性黄疸诊断价值之探讨（附114例分析）

目的本文旨在探讨PTC对梗阻性黄疸的诊断价值。方法本组共114例梗阻性黄疸，均经手术病理证实，术前均行PTC检查及B超检查，其中56例做了CT检查。结果114例梗阻性黄疸的PTC检查，诊断正确者103例，符合率90.3%；B超诊断明确者86例，符合率75.4%；56例CT检查，诊断正确者46例，符合率82%。结论PTC对梗阻性黄疸具有相当重要的诊断价值，尤其是基层医院术前行此项检查非常必要。     

经皮肝穿刺螺旋CT三维胆系造影对阻塞性胆管病变诊断价值的探讨

目的 :研究三维螺旋CT经皮肝穿刺胆系造影 (3D SCT PTC)对胆管梗阻性病变的临床应用价值。方法 :对 31例胆管扩张的患者 ,常规CT扫描图像选择穿刺胆管和针道。螺旋CT扫描从膈顶至胰腺钩突区 ,以MIP、SSD和曲面重建法合成三维胆管树影像。结果 :31例病人中 ,30例 (96 .8%)经皮肝穿刺胆系造影成功。 30例螺旋CT胆系造影均显示了胆管梗阻的部位、原因、程度及范围 ,2 7例 (90 %)胆管解剖和异常在MIP和曲面重建图像比轴位图像显示清楚。结论 :螺旋CT经皮肝穿刺胆系造影可避免常规X线PTC穿刺的盲目性 ,对比剂使用伊索显 ,用量少 ,并发症少 ,对梗阻的部位、原因、程度判断准确可靠 ,对明显胆管梗阻性病变的患者不失为一种有用的检查方法。     

Sonograhic-radiologic evaluation of obstructive jaundice (author's transl)]

Retrospective evaluation of indication and technical procedure and its value in sonography of 110 patients with jaundice. A correct diagnosis (by ultrasound) of hepatogenic jaundice was made in 36/38 patients (94%) and of obstructive jaundice in 69/72 patients (96%). In additional 31/72 patients (43%) ultrasound gave important diagnostic clues by demonstrating dilated bile ducts as well as the location of obstruction. For verification and for the demonstration of morphologic changes, sonographically guided fine needle aspiration puncture, percutaneous transhepatic cholangiography with a fine puncture neede (Chiba-needle) and ERCP are indicated.     

Treatment of malignant biliary obstruction by percutaneous transhepatic insertion of expandable metallic stents

A group of 55 patients with jaundice secondary to malignant biliary obstruction were treated with percutaneous transhepatic insertion of self-expandable metal stents (Wallstents). Obstruction was caused by pancreatic carcinoma in 22 patients, cholangiocarcinoma in 21 patients, and other malignancies in 12 patients. A total of 16 patients were treated for hilar obstruction, 35 patients for obstruction of the bile duct below the hilum, and 4 patients for obstruction in a bilioenteric anastomosis. Stent insertion was performed as a two-step procedure in 37 patients, but as a one-step procedure in 18 patients. Adequate bile drainage was achieved in all patients. Procedure-related complications occured in 9 % of cases. After 24 months of observation time 46 patients had died (mean survival 4.6 months). The 30-day mortality rate was 5.5 %. A total of 14 patients (25.5 %) developed recurrent jaundice after an average of 5.3 (0–13) months. Percutaneous insertion of Wallstents ensures good palliation, is relatively safe, and may be performed as a one-step procedure. Correspondence to: P. Hannesson     

胆管癌性阻塞姑息性T管引流术后再发梗阻的介入治疗

目的　探索胆管癌性阻塞外科姑息性T管引流术后再发梗阻的介入治疗。方法　胆管癌性阻塞外科姑息性T管引流术后再发黄疸患者 7例 ,采用经皮肝穿刺胆道引流术 (PTCD) 金属内支架置入术 .共使用 7枚金属内支架。结果　 7例采用经皮经肝穿刺或经T型管通路置入胆管支架均获得成功。无并发症发生。术后总胆红素、转氨酶、谷酰转肽酶和碱性磷酸酶明显下降 ,与术前比较有显著性差异 ,7例术后黄疸消退满意。结论　经皮胆管内金属支架置入术姑息性治疗恶性阻塞性黄疸外科留置T管术后再狭窄 ,安全可靠 ,操作简单 ,费用低 ,治疗效果好 ,并发症少 ,为无法手术切除胆管癌而留置T管的患者提供了一种良好的治疗手段     

Isolated Right Segmental Hepatic Duct Injury Following Laparoscopic Cholecystectomy

Purpose Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. There is an increased incidence of bile duct injuries in LC compared with the open technique. Isolated right segmental hepatic duct injury (IRSHDI) represents a challenge not only for management but also for diagnosis. We present our experience in the management of IRSHDI, with long-term follow-up after treatment by a multidisciplinary approach.Methods Twelve consecutive patients (9 women, mean age 48 years) were identified as having IRSHDI. Patients demographics, clinical presentation, management and outcome were collected for analysis. The mean follow-up was 44 months (range 2–90 months).Results Three patients had the LC immediately converted to open surgery without repair of the biliary injury before referral. Treatments before referral included endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage and surgery, isolated or in combination. The median interval from LC to referral was 32 days. Eleven patients presented with biliary leak and biloma, one with obstruction of an isolated right hepatic segment. Post-referral management of the biliary lesion used a combination of ERCP stenting, percutaneous drainage and stent placement and surgery. In 6 of 12 patients ERCP was the first procedure, and in only one case was IRSHDI identified. In 6 patients, percutaneous transhepatic cholangiography (PTC) was performed first and an isolated right hepatic segment was demonstrated in all. The final treatment modality was endoscopic management and/or percutaneous drainage and stenting in 6 patients, and surgery in 6. The mean follow-up was 44 months. No mortality or significant morbidity was observed.Conclusion Successful management of IRSHDI after LC requires adequate identification of the lesion, and multidisciplinary treatment is necessary. Half of the patients can be treated successfully by nonsurgical procedures.     

胆管癌性阻塞姑息性胆肠吻合术后再发梗阻的介入治疗

目的　探讨胆管癌性阻塞姑息性胆肠吻合术后再发梗阻的介入治疗方法。方法　 10例胆管癌性阻塞姑息性胆肠吻合术后再发梗阻患者 ,9例采用经皮肝穿刺胆道引流术 (PTCD)加金属内支架置入术 ,共使用 9枚金属内支架 ,1例置入内外引流管 ,并比较介入手术前后总胆红素、谷丙转氨酶、谷氨酰转肽酶、碱性磷酸酶的变化。结果　 10例采用经皮经肝穿刺置入金属胆道内支架或内外引流管均获得成功 ,均一次性置入支架。术后总胆红素、谷丙转氨酶、谷氨酰转肽酶、碱性磷酸酶均有明显下降 ,与术前比较差异有显著性。术后黄疸消退满意。结论　经皮经肝穿刺胆管内金属支架再置入术治疗胆管癌性阻塞姑息性胆肠吻合术后再发梗阻 ,疗效满意 ,操作简单 ,并发症少     

犬胆管金属支架诱导p16、p53基因扩增的实验研究

目的 探讨胆道金属支架在诱导抑癌基因扩增方面的价值.方法 健康成年实验犬24只,采用经皮经肝穿刺胆囊的方法于犬胆总管下段植入支架1枚,术后正常喂养平均半年,再次麻醉后活体开腹取支架覆盖段胆管壁与支架上段胆管壁组织,通过逆转录聚合酶链反应(RT-PCR)方法检测所取组织p16、p53、p15、Bcl-2及K-ras基因的表达情况,计算两个部位胆管壁目的 基因表达阳性率,采用X~2检验进行统计学分析.结果 共20只实验犬建模成功.支架覆盖段胆管壁p16、p53基因表达阳性率分别为80%(16/20)、45%(9/20),支架上段胆管壁p16、p53基因表达阳性率分别为15%(3/20)、0,以上差异具有统计学意义(X~2值分别为16.94、9.17,P值均＜0.05).支架覆盖段胆管壁p15、Bcl-2、K-ras基因表达阳性率分别为60%(12/20)、100%(20/20)、0,支架上段胆管壁p15、Bcl-2、K-ras基因表达阳性率分别为70%(14/20)、100%(20/20)、0,两个部位间差异均无统计学意义(P值均＞0.05).结论 胆管壁p16、p53的扩增加强与胆道金属支架的植入有一定的相关性,对于不存在胆道支架植入禁忌证的恶性梗阻性黄疸患者建议行胆道支架植入术治疗.