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。     

A comparison of bilateral stenting methods for malignant hilar biliary obstruction

Background/Aims: Despite common use of stent-instent methods for endoscopic bilateral metal stenting in malignant hilar obstruction, the longevity of these stents and clinical outcomes of patients who receive them are less well known than for the side-by-side method. We aimed to compare treatment outcomes according to bilateral stenting method. Methodology: A total of 41 patients were divided into two groups: a bilateral side-by-side metal stenting group (side-by-side group, n=19) and a bilateral stent-in-stent metal stenting group (stent-in-stent group, n=22). Results: During the study period, successful drainage was achieved in 15 of 19 patients (78.9%) with the side-by-side placement, which did not differ significantly from the proportion with the stent-in-stent placement (18 of 22 patients, 81.8%). The two groups did not differ significantly in rates of early complications (31.6% vs. 22.7%, p=0.725), late complications (36.8% vs. 50.0%, p=0.531) or death (47.4% vs. 54.5%, p=0.647). Comparing stent patency and survival curves according to bilateral stenting type, patients with stent-in-stent placement and those with side-by-side placement did not differ significantly (p=0.771 and p=0.769). Conclusions: Our results show no significant difference in clinical outcomes, including stent patency and overall survival, between side-by-side and stent-in-stent bilateral metal stenting in patients with malignant hilar obstruction.     

肝门部高位恶性胆管梗阻的多支架引流治疗

目的探讨多支架植入技术治疗肝门部高位多发性恶性胆道梗阻的治疗方法及临床应用价值。方法高位胆管梗阻127例。梗阻部位：肝总管上端距左、右肝管汇合部1cm以内66例，左、右肝管及肝总管上端同时梗阻45例．肝内右肝管多发性梗阻5例，肝内左、右肝管梗阻11例。采用五种支架植入方法。66例经右腋中线右肝管一胆总管途径植入支架；37例经腋中线和剑突下’分别穿刺左、右肝管。植入2个支架呈“Y”型排列。7例左肝管一右盯管问植入支架，再在右肝管一胆总管间植入支架．2支架呈“Г”行排列。3例右肝内肝管多发梗阻。先存右肝内盯管问放置支架，再在右肝管-肝总管问放置支架。12例右盯管放置支架．左肝管放置外引流。2例右盯内肝管多发梗阻病例，单纯放置多点位外引流。测定术前、术后血清总胆红素水平。结果127例高他胆管梗阻患者经植入支架。实现胆汁内引流。J2J例患者的总胆红素由术前平均（283．4±175．4）μmol，／L下降至（63．2±111．8）／μmol／L．差异有统计学意义（P〈0．05）。术后随访1～28个月．患者生存率大于6个月者占67．3％（85/127）。1年者占46．5％（59／127）。结论对无法手术治疗的肝门部高位多部位恶性胆管梗阻．采用双点传双通道双支架植入或单点位单通道双支架植入,能有效实现胆汁的全面充分内引流．临床效果显著。     

全国酒精性肝病的多中心调查分析

目的对全国酒精性肝病发病情况、临床特征等进行多中心回顾研究。方法按酒精性肝病诊疗指南标准，将全国7家医院2000—2004年902例确诊为酒精性肝病患者纳入研究。回顾调查酒精性肝病患者占同期住院肝病患者的构成比，分析酒精性肝病的易感因素。结果2000-2004年,酒精性肝病患者占同期住院肝病患者的病例构成比分别为2．4％、2．7％、2．8％、3．4％和4．3％；酒精性肝病以40～49岁者居多，每日摄入乙醇量为80～159g。饮酒年限以20～29年者居多；轻症酒精性肝病101例（11．2％）。酒精性脂肪肝204例（22．6％），酒精性肝炎260例（28．8％），酒精性肝硬化337例（37．4％）。酒精性肝硬化组的饮酒量、饮酒年限与其他三组差异有统计学意义（P〈0．05）。酒精性肝病患者常见临床表现为乏力、纳差、黄疸、腹胀、腹痛等；血清学改变以天冬氨酸转氨酶、丙氨酸转氨酶、了谷氨酰转肽酶、胆红素升高为主。约19．7％患者出现乙醇相关性精神障碍表现，11．9％出现乙醇戒断综合征．10．8％有乙醇性肌病表现；乙醇性心肌和胰腺损害分别占4．6％和3．1％；0．3％有乙醇性性功能障碍表现。结论酒精性肝病占同期住院肝病患者构成比呈逐年上升趋势,肝脏损害程度与饮酒量、饮酒年限相关．长期大量饮酒可造成多器官功能受损。     

Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction

Background and Aim: The extent of liver drainage for palliative treatment of malignant hilar biliary obstruction is controversial. The aim of this study was to compare endoscopic unilateral versus bilateral drainage in patients with malignant hilar biliary obstruction using a self‐expanding metal stent (SEMS). Methods: We carried out a retrospective review of 46 consecutive patients with malignant hilar biliary obstruction who were treated by endoscopic biliary drainage using SEMS between 1997 and 2005. Unilateral metal stenting (group A) was performed in 17 patients between 1997 and 2000, and bilateral metal stenting (group B) was performed in 29 patients between 2001 and 2005. The successful stent insertion, successful drainage, early complications, late complications, stent patency, and survival rate for groups A and B were evaluated and compared retrospectively. Results: There were no significant differences between the two groups in successful stent insertion (100% vs 90%, group A vs B, respectively), successful drainage (100% vs 96%), early complications (0% vs 10%), or late complications (65% vs 54%). Cumulative stent patency was significantly better in group B than in group A (P = 0.009). In cases of cholangiocarcinoma, cumulative stent patency was significantly better in group B than in group A (P = 0.009), whereas there were no inter‐group differences for gallbladder carcinoma. Cumulative survival did not differ significantly between the groups. Conclusions: Endoscopic bilateral drainage using SEMS for malignant hilar biliary obstruction is more effective than unilateral drainage in terms of cumulative stent patency, especially in cases of cholangiocarcinoma.     

Contrast-free air cholangiography-assisted unilateral plastic stenting in malignant hilar biliary obstruction

BACKGROUND:Endoscopic palliation in malignant hilar biliary obstruction requires endoscopic retrograde cholangiopancreatography (ERCP),whereas contrast injection leads to cholangitis.Contrast-free metal stenting with or without magnetic resonance cholangiopancreatography (MRCP) has shown encouraging results,but MRCP and metal stents are costly.There have been no reports on the use of air cholangiography.METHODS:We prospectively evaluated the role of air cholangiography-assisted unilateral plastic stenting i...     

内镜双支架引流术治疗晚期肝门部胆管恶性梗阻的疗效评价

目的评价内镜下双支架引流术治疗晚期肝门部胆管恶性梗阻的疗效。方法2007年1月至2010年12月接受内镜下双支架引流治疗的晚期肝门部胆管恶性梗阻患者28例（双支架组）,男15例、女13例,年龄44—88岁,中位年龄66．4岁,其中BismuthII型9例,Ⅲa型8例,IIIb型5例,Ⅳ型6例;同期接受内镜下单支架引流治疗的晚期肝门部胆管恶性梗阻患者23例（单支架组）作为对照,男11例、女12例,年龄42～83岁,中位年龄65．8岁,其中Bismuth11型7例,IIa型5例,IIIb型6例,Ⅳ型5例。对2组引流成功率、并发症发生率、平均支架通畅时间及平均生存时间进行对比分析。结果2组支架均成功置入,无死亡病例。引流有效率、并发症发生率双支架组分别为96．4％（27／28）和17．9％（5／28）,单支架组分别为87．0％（20／23）和13．0％（3／23）,2组比较差异无统计学意义（P〉0．05）。双支架组失访5例,随访率82．1％（23／28）;单支架组失访4例,随访率82．6％（19／23）。双支架组随访的23例患者的平均支架通畅时间、平均生存时间分别为（129±48．5）d和（187±94．5）d,单支架组随访的19例患者的平均支架通畅时间、平均生存时间分别为（102±37．8）d和（103±98．5）d,双支架组均明显优于单支架组（P〈0．05）。结论BismuthII型以上的肝门部胆管恶性梗阻行内镜下双支架引流是安全可行的,其平均支架通畅时间和平均生存时间均优于内镜下单支架引流。     

Technical tips and troubleshooting of endoscopic biliary drainage for unresectable malignant hilar biliary obstruction

Unresectable malignant hilar biliary obstruction (MHBO) occurs in various diseases, such as cholangiocarcinoma, gallbladder carcinoma, hepatocellular carcinoma, pancreatic cancer, and lymph node metastasis of the hilum of the liver. The majority of patients with advanced MHBO are not candidates for surgical resection because of the tumor location in the hepatic hilum and adjacent areas, advanced tumor stage, or comorbidities. Therefore, these patients often have a poor prognosis in terms of survival and quality of life. Most of these patients will require non‐surgical, palliative biliary drainage. To date, various biliary drainage techniques for unresectable MHBO (UMHBO) have been reported. Of these techniques, endoscopic biliary drainage is currently considered to be the most safe and minimally invasive procedure. However, endoscopic biliary drainage for UMHBO is still not standardized regarding the optimal stent, drainage area, stenting method, and reintervention technique. Recently, towards standardization of this technique for UMHBO, clinical research and trials including randomized controlled trials have been performed. In this article, we reviewed the most important issues regarding endoscopic biliary drainage for UMHBO, focusing on prospective studies. We also described in detail the techniques and future perspectives of endoscopic biliary drainage in patients with UMHBO.     

Management of malignant hilar biliary obstruction by endoscopy results and prognostic factors

Between January 1983 and December 1987, 103 patients who had hilar biliary obstruction (59 men, 44 women, median age 73 years) were referred to our institution. The causes of hilar biliary obstruction were carcinoma of the bile ducts (55), hepatic metastases or hepatocellular carcinoma (30), and carcinoma of the gallbladder (18). When endoscopic retrograde cholangiography was performed, the stricture was classified as type I in 28%, type II in 41%, and type III in 31% of the patients. In 92 patients, we tried to insert endoscopically a 10, 11, or 12 F Amsterdam type prosthesis; it proved possible in 66 (74%), and the prosthesis proved functional without further procedure in 49 cases (53%); no combined percutaneous and endoscopic method was used. At death or discharge, 45 patients (49%) had a successful drainage. Cholangitis was the main procedure-related complication and occurred in 25 patients. The 30-day mortality was 43%. Results varied according to type of stenosis: successful drainage was performed in 15% of the patients with type III stenosis, compared with 86% when the stenosis was of type I. Under a multivariate analysis the independent prognostic factors of 30-day mortality were: (1) development of infectious complications after endoscopic attempt at drainage (P<0.0001), and (2) absence of successful drainage (P<0.0001). In conclusion, endoscopic endoprosthesis placement allows a sufficient drainage in 53% of the cases. In type III stenosis, the high rate of 30-day mortality leads us the conclusion that endoscopic drainage must be avoided.     

Contrast-free unilateral endoscopic palliation in malignant hilar biliary obstruction: new method

BACKGROUND: Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast-free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast-free unilateral metal stenting in type II malignant hilar biliary obstruction. METHODS: We prospectively studied the results of unilateral metal stenting in type II malignant hilar biliary obstruction without contrast injection in 18 patients. RESULTS: A successful endoscopic drainage was achieved in 100% (18/18) of patients with hilar strictures. Cholangitis and 30-day mortality occurred in none. CONCLUSIONS: Unilateral endoscopic metal stenting without contrast in type II malignant hilar biliary obstruction is a safe and effective method of palliation.     

内镜下平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻价值探讨

目的 探讨经内镜平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻的安全性和疗效.方法 2011年1月至2012年9月对11例晚期肝门部胆管恶性梗阻的病人采用内镜平行法双金属支架引流治疗,观察疗效及安全性.结果 10例成功置入左右双金属支架,全组无研究并发症及死亡病例.9例引流有效.发生2例轻微内镜相关并发症.10例双支架治疗病人中4例死亡,死亡时均无腹痛、黄疸、发热等支架阻塞迹象,生存128 ～ 185 d,失访1例,其余5例病人均在随访中.结论 内镜平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻是安全可行的.     

Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents

BACKGROUND: Endoscopic management of malignant hilar biliary obstruction is controversial with respect to optimal types of stents and extent of drainage. This study evaluated outcomes of selective MRCP and CT-targeted drainage with self-expanding metallic stents. METHODS: Consecutive patients undergoing attempted palliative ERCP for malignant hilar biliary obstruction were prospectively followed. Whenever possible, management strategy included evaluation and staging for potential resectability before ERCP, with primary placement of metallic stents at the first ERCP in nonsurgical candidates, and early conversion to a metallic stent when a tumor proved to be unresectable. MRCP and/or CT were used to plan selective guidewire access, opacification, and drainage only of the largest intercommunicating segmental ducts. Unilateral stent placement was intended in all cases except for selected patients with Bismuth II cholangiocarcinoma. RESULTS: Thirty-five patients were included. Bismuth classification was I, 10; II, 6; III, 8; and IV, 11. Tumor origin was bile duct (17), gallbladder (5), and metastatic (13). Metallic stents were placed in 27 patients as the initial stent, and in 8 after plastic stent placement. Initial stents were placed endoscopically in 33 patients and percutaneously in 2 patients in whom lumenal tumor precluded ERCP. Stent placement was unilateral in 31 patients and bilateral in 4 patients. There were no episodes of cholangitis or other complications within 30 days after any procedures. Initial metallic stents were clinically effective in 27 (77%) of the 35 patients. Additional percutaneous drainage in 3 patients who did not respond to initial stent placement did not resolve jaundice. Median patency of first metallic stents was 8.9 months for patients with primary bile duct tumors and 5.4 months for all patients, and was not related to Bismuth classification. No further intervention was needed in 25 (71%) patients. CONCLUSIONS: Unilateral metallic stent placement by using MRCP and/or CT to selectively target drainage provides safe and effective palliation in most patients with malignant hilar biliary obstruction.     

肝门部恶性胆道梗阻单、双侧引流的荟萃分析

目的 评价肝门部恶性胆道梗阻单、双侧引流的有效性与安全性. 方法 联合检索PubMed、Embase、Cochrane Library数据库,检索年限均从1975年至2013年8月,纳入单、双侧引流的随机对照和非随机对照试验.用RevMan5.0软件进行荟萃分析,用相对危险度(RR)值及95％可信区间(CI)对单、双侧引流进行比较.在荟萃分析中用RR及其95％CI比较两组差异.混合性的数据资料采用固定效应模型和随机效应模型,当研究间出现显著异质性时,荟萃分析采用随机效应模型.研究之间的异质性检验采用卡方检验(P＜ 0.10为异质性有统计学意义)和I2分析(I2＞ 50％为异质性有统计学意义).对于异质性的来源采用亚组分析和敏感性分析,潜在的发表偏倚采用漏斗图分析. 结果 经过筛选共纳入3个随机对照试验和7个观察性研究,合计894例患者.荟萃分析结果显示主要观察重点:单、双侧引流的支架通畅率优于单侧(RR=2.03,95％CI:1.16 ～ 3.56,P=0.01);而引流的有效性(RR=1.07,95％CI:0.97～1.18,P=0.20)和患者的生存率(RR=-0.16,95％CI:-0.40 ～ 0.08,P=0.20)差异无统计学意义.次要观察重点:单双侧引流的技术成功率(RR=1.05,95％CI:0.98 ～ 1.17,P=0.34)、早期并发症(RR=1.15,95％CI:0.75 ～ 1.76,P=0.52)、晚期并发症(RR=1.09,95％CI:0.75 ～ 1.60,P=0.65)、30 d病死率(RR=0.68,95％CI:0.38 ～ 1.23,P=0.20)同样差异没有统计学意义. 结论 虽然双侧引流支架通畅率较单侧好,现存循证医学证据还不足够支持双侧引流,期待更多严格设计前瞻性随机对照研究出现来验证.     

肝门部胆管恶性梗阻双支架引流22例临床应用

目的探讨肝门部胆管恶性梗阻双侧支架引流的疗效、安全性。方法回顾性分析首都医科大学附属北京友谊医院、北京市消化疾病中心2002年10月至2003年12月肝门部胆管恶性梗阻患者22例双侧支架引流的有效率、并发症发生率、支架畅通时间及生存时间。结果22例肝门部胆管恶性梗阻患者均一次置入双侧支架成功,引流有效率81.8%(18/22),并发症发生率22.7%,其中胆管炎4例、胰腺炎1例,中位支架畅通时间113d,中位生存时间138d。结论对于BismuthⅡ、Ⅲ型肝门部恶性梗阻,双侧支架引流是安全有效的;对于BismuthⅣ型,双侧支架引流需慎重。     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound‐guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS‐guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.