经皮内镜胃造瘘和小肠造瘘术的临床应用(附16例报告)

经皮内镜胃造瘘术（percutaneous ndoscopic astrotomy,PEG）／经皮内镜小肠造瘘术（percutaneous ndoscopic ejunosto,PEJ）是一项无需开腹手术及全身麻醉的胃及小肠造瘘新技术,具有创伤小、痛苦少、肠内营养恢复快等优点。解放军总医院第二附属医院2006年11月-2008年4月施行了11例PEG和5例PEG＋PEJ,得了满意疗效,现报告如下。     

内镜下鼻胆管引流治疗急性梗阻性化脓性胆管炎12例

急性梗阻性化脓性胆管炎是临床常见的胆道急重病，胆道引流减压是最有效的治疗措施。本文报道12例内镜下鼻胆管引流（endoscopic nasobiliary drainage，ENBD）治疗急性梗阻性化脓性胆管炎的临床结果。     

急性梗阻性化脓性胆管炎182例的内镜治疗

目的探讨内镜在急性梗阻性化脓性胆管炎治疗中应用的价值。方法回顾性分析182例急性梗阻性化脓性胆管炎患者治疗的临床资料。结果182例患者均经内镜治疗成功,在应用乳头括约肌切开术（EST）后,采用胆道内支架引流（ERBD）治疗25例,鼻胆管引流（ENBD）治疗140例,胆道金属支架引流（EMBD）治疗17例。治疗后所有病例临床症状均明显改善。结论急性梗阻性化脓性胆管炎的内镜治疗是一种快速、安全、有效和经济的治疗手段。     

内镜下逆行胰胆管造影及治疗对急性胰腺炎预后的影响

目的探讨内镜下逆行胰胆管造影(ERCP)及治疗对急性胰腺炎预后的影响。方法对我院2002年1月～2003年12月接受了ERCP诊疗的30例急性胰腺炎病例进行回顾性研究,总结其病例特点,比较ERCP前后患者的Ranson评分。结果30例患者中内镜下治疗26例,其中乳头切开24例,胆管取石9例,胆管支架2例,鼻胆管引流2例,胰管取石4例,胰管支架12例,有4例未行治疗。30例急性胰腺炎患者ERCP术前及术后的Ranson评分无明显差异(P>0.05),根据Ranson评分计算的预测病死率亦无明显差异(P>0.05)。结论胆源性胰腺炎ERCP是安全的,不会增加急性胰腺炎患者的病死率。图1ERCP术前及术后的Ranson评分经t检验(P=0.33)天数为16.5天,术前Ranson评分平均为0.71±0.19分,术后Ranson评分平均为0.53±0.15分,术后平均住院15.6天。经t检验,两组患者的术后Ranson评分均无显著差异。3讨论ERCP及其内镜治疗已成为急性胆源性胰腺炎的有效方法[4]。Soetikno等[5]总结了834例胆源性胰腺炎的治疗结果,早期内镜治疗组效果明显好于对照组,认为急性胆源性胰腺炎内镜介入治疗越早,并发症发生率与病死率越低。本组胆源性胰腺炎患者内镜下乳头切开胆管取石9例,乳头切开胆管支架2例,鼻胆管引流2例,术后无内镜治疗并发症发生,腹痛缓解,淀粉酶正常。治疗后Ranson评分与治疗前无明显差异,不会增加病死率,与文献报道一致。表明急性胆源性胰腺炎行ERCP治疗是安全有效的。Fan等[6]报道195例急性胆源性胰腺炎,在入院后24h内行ERCP及EST与常规治疗,结果显示,轻症急     

急诊内镜下逆行胰胆管造影术治疗急性梗阻性胆管炎及胆源性胰腺炎疗效分析

目的探讨急诊内镜下逆行胰胆管造影术(ERCP)治疗急性胆管炎的时机、安全性和有效性。方法回顾性分析2014年9月至2016年12月确诊或疑诊急性胆管炎或胆源性胰腺炎的90例患者临床资料,分别于术前及术后3~10 d观察腹痛、发热、皮肤黄染等症状,比较血压、血常规、肝功、血淀粉酶及脂肪酶等指标,评价感染控制、梗阻性黄疸缓解情况以及疗效。结果 90例患者中,术中诊断胆总管结石78例(86.0%);Mirrizz综合征1例(1.0%);胆道、胰腺肿瘤5例(6.0%);胆管造影未见充盈缺损6例(7.0%)。急诊ERCP手术均成功行胆管引流,单纯行鼻胆管引流61例,塑料支架引流12例,金属支架引流1例,取石16例。90例患者,腹痛缓解率100%,感染缓解率90.7%,黄疸缓解率85.2%。治疗后痊愈出院76例(84.4%);好转9例(10.0%);病死5例(5.6%)。结论诊断中、重度急性梗阻性胆管炎或胆源性胰腺炎患者,如预计其可通过积极的内镜治疗获益,尽早行急诊ERCP是安全、有效的治疗手段。     

注气造影——一种肝门部胆管癌ERCP检查治疗的新方法(附随机对照临床试验)

目的 探讨经十二指肠镜行肝门都胆管癌(HCC)造影的新方法.方法 选择CT、磁共振胆管胰腺造影术(MRCP)诊断明确的HOC患者36例,随机分为注气造影组和碘造影剂组,每组18例.两组均正常插入十二指肠镜,找到十二指肠乳头,在透视观察下,利用导丝技术经乳头插管成功后,顺导丝送导管人左(或右)肝内胆管,行造影观察.碘造影剂组按常规注入35%安碘醇,调整导丝至左(或右)肝内胆管主干,置入7Fr或8.5Fr一体式塑料内支架,抽出造影剂后释放支架;注气造影组注入空气,透视下观察,调整导丝至左(或右)肝内胆管主干,置入7Fr或8.5Fr塑料内支架,抽出注入气体后释放支架.重新插管至另一侧肝内胆管,分别注入碘造影剂或空气透视观察后置入8.5Fr塑料内支架.术后常规给予抗感染及对症支持治疗,观察黄疸消退、发热、腹痛等情况.结果 36例HOC患者行内镜逆行胆总管胰腺造影术(ERCP)塑料内支架置入术均一次成功.碘造影剂组中6例术后出现发热,其中3例黄疸未消退患者再次行ERCP,调整支架引流位置,引流出脓性胆汁后体温降至正常、黄疸消退,另3例发热患者经抗感染治疗后体温降至正常、黄疸消退.注气造影组中未出现术后发热和化脓性胆管炎病例,黄疸消退理想.结论 经十二指肠镜注气造影并支架引流治疗HCC更加安全,疗效满意.     

VCT三期增强结合ERCP后扫描诊断肝门胆管癌的价值

目的:探讨VCT增强扫描结合ERCP后扫描在肝门胆管癌诊断中的价值。材料和方法:分析20例肝门胆管癌三期增强扫描及ERCP术后VCT扫描图像,并对原始图像进行后处理,判断肿瘤的部位和侵及范围,肝门部血管受侵情况,局部淋巴结及脏器转移情况;将分型及术前评估结果与手术结果进行对照分析。结果:20例患者均行VCT三期增强扫描及ERCP术后扫描,诊断与病理结果一致20例,定位分型准确16例。结论:应用VCT三期增强结合ERCP后扫描行胆系及血管重建可作为肝门胆管癌诊断及术前评估的有效方法。     

内镜下鼻胆管引流术联合中药治疗急性梗阻性化脓性胆管炎的临床应用

目的观察内镜下鼻胆管引流术(ENBD)联合中药治疗急性梗阻性化脓性胆管炎(AOSC)的临床疗效。方法对65例AOSC患者行胰胆管造影(ERCP)明确梗阻部位后,行ENBD留置鼻胆管至梗阻上方,术后给予清热解毒、消炎利胆中药治疗。结果 65例ENBD成功率100%,治疗后黄疸、发热、腹痛等临床症状、体征均迅速减轻或消失。结论 ENBD合并清热解毒、消炎利胆中药治疗AOSC安全、有效、可靠。     

肝移植术后并发胆道狭窄的内镜下治疗

 目的:初步探讨内镜在肝移植术后胆道狭窄治疗中的临床应用价值.方法:通过十二指肠镜逆行胆管造影(endoscopic retrograde cholangiography,ERC)检查对肝移植术后胆道狭窄进行诊断,并根据检查结果做相应的内镜下介入治疗.结果:肝移植术后胆道狭窄38例,其中21例为吻合口狭窄(10例合并有胆瘘),17例为非吻合口胆道狭窄.针对不同情况进行鼻胆管引流术及塑料支架引流术等治疗,非吻合口胆道狭窄的患者内镜治疗较困难,需要多次进行内镜治疗.所有患者治疗后临床症状均明显改善,无严重并发症发生.结论:内镜对于肝移植术后胆道狭窄并发症的诊断与治疗安全而有效,胆道狭窄并发症的较快发现及时处理可使患者较快治愈.     

经T管造瘘口下空肠输出袢切开胆道镜取石术治疗肝内胆管术后复发结石

目的研究肝内胆肠吻合术后肝内胆管复发结石的治疗。方法 287例肝内胆道结石病人行胆管空肠Roux-en-Y吻合术后,将引出T管的输出袢肠壁缝合在T管腹壁戳孔处的腹膜下。其中25例发生术后复发结石,切开T管腹壁戳孔下空肠输出袢肠壁,使用电子胆道镜经腹壁下空肠输出袢进入胆道取石。结果本组25例均通过电子胆道镜取石成功,手术效果满意,无术后并发症。结论经T管造瘘口下输出袢切开胆道镜取石术是一种治疗胆肠吻合术后复发结石的较为简单有效的方法。     

Staging of Klatskin tumours (hilar cholangiocarcinomas): comparison of MR cholangiography, MR imaging, and endoscopic retrograde cholangiography

The aim of the study was to compare prospectively magnetic resonance cholangiography (MRC) and magnetic resonance imaging (MRI) with endoscopic retrograde cholangiography (ERC) in the diagnosis and staging of Klatskin tumours of the biliary tree (hilar cholangiocarcinomas). Forty-six patients with suspected Klatskin tumours of the biliary tract underwent MRI and heavily T2-weighted, non-breathhold, respiratory-triggered fast spin-echo MRC. Forty-two patients underwent ERC within 24 h; in four patients, ERC was not feasible, and percutaneous trans-hepatic cholangiography (PTC) was carried out instead. Two independent investigators evaluated imaging results for the presence of tumour, bile duct dilatation, and stenosis. Clinical and histopathological correlation revealed Klatskin tumours in 33 patients. MRI revealed a slightly hyperintense signal of infiltrated bile ducts in T2-weighted fast spin-echo sequences. The malignant lesion was regularly visualized as a hypointense area in T1-weighted gradient-echo sequences with substantial contrast enhancement along the involved bile duct walls. MRC revealed the location and extension of the tumour in 31 of 33 cases correctly (sensitivity 94%, specificity 100%, diagnostic accuracy 95%). In 27 of 31 cases, ERC enabled accurate staging and diagnosis of Klatskin tumours with a sensitivity of 87%. ERC and PTC combined yielded a sensitivity of 84% and a specificity of 97%. Tumours were grouped according to the Bismuth classification, with MRC allowing correct identification of type I tumour in seven patients, type II tumour in four patients, type III tumour in 12 patients, and type IV tumour in ten patients. MRC provided superior visualization of completely obstructed peripheral systems. MRC in combination with MRI is a reliable non-invasive diagnostic method for the pre-therapeutic staging of Klatskin tumours.     

A case of choledochocele mimicking choledocholithiasis on MR cholangiography: A new differential diagnosis of pseudo-filling defect

We present the case of a 79-year-old female with acute cholangitis and cholecystitis who presented with right upper quadrant pain. Thin-collimation MR cholangiogram showed a filling defect measuring 1 cm, which was less prominent on single-slab images. Endoscopy showed dynamic ballooning and collapsing of the ampulla of Vater, and a cholangiogram showed characteristic bulging at the distal common bile duct, which led to the diagnosis of choledochocele. It is important to differentiate choledochocele as a cause of filling defect of the lower common bile duct on the MR cholangiogram.     

经ERCP取胆汁检测淀粉酶在胰胆管合流异常诊治中的意义

目的：探讨经ERCP取胆汁进行淀粉酶检测在胰胆管合流异常诊断与治疗中的作用。方法：通过B超筛选，对我中心部分行ERCP的病人在造影剂注入前，取胆汁进行淀粉酶测定，同时对其中部分病人在造影前行血清淀粉酶测定。根据造影结果将病人分成胰胆管合流异常组（PBM）．长共同通道组（LCC）与短共同通道组（SCC）3组。对PBM组患者在术后通过T管取胆汁行淀粉酶检测。结果：PBM组术前胆汁淀粉酶水平（2207．8±654．7）U／L显著高于LCC组（181．6±55．3）U／L及SCC组（46．1±10．3）U/L，而LCC组胆汁淀粉酶显著高于SCC组。PBM组胆汁淀粉酶显著高于血清淀粉酶（381．2±85．6）U／L，同时术前胆汁淀粉酶水平也显著高于术后（240．2±64．7）U／L。结论：胆汁淀粉酶水平高低与胰胆管共同通道长度有关，共同通道较长者胆汁淀粉酶水平较高。胆汁高淀粉酶水平是诊断胰胆返流的可靠证据，检测胆汁淀粉酶可做为诊断PBM的重要辅助手段。对那些共同通道长度未达到PBM诊断标准，但胆汁淀粉酶明硅高于血清水平者，应视为PBM处理。     

Magnetic resonance cholangiography of biliary strictures after liver transplantation: a prospective double-blind study

PURPOSE: To compare magnetic resonance cholangiography (MRC) with endoscopic retrograde cholangiography (ERC) in quantitatively evaluating biliary strictures in liver transplant recipients. MATERIALS AND METHODS: Eight liver transplant recipients with suspected biliary complications were referred for ERC and also underwent MRC within 24 hours using a combination of single-shot rapid acquisition with relaxation enhancement (SS-RARE) and three-dimensional (3D)-RARE sequences. The studies were independently interpreted by two blinded radiologists and a single blinded endoscopist who recorded the presence of a stricture and/or upstream dilatation, the ratio of recipient-to-donor duct diameters at the anastomosis, as well as the proximal duct diameter, length, and percent stenosis of any stricture detected. RESULTS: Using ERC as the standard of reference, MRC had a sensitivity and negative predictive value of 100%, mean specificity of 83.3%, and mean positive predictive value of 92.9% in the detection of six strictures. Compared with ERC, MRC obtained accurate measurements of recipient-to-donor duct diameter ratios (r, 0.91; P < 0.01), proximal duct diameters (r, 0.83, P < 0.05), stricture lengths (r, 0.58; P = 0.06), and percent stenosis (r, 0.78; P = 0.06). CONCLUSION: MRC can provide equivalent imaging to ERC and can reliably identify and quantitatively evaluate biliary strictures in post-orthotopic liver transplantation (OLT) patients.     

Contrast-enhanced MRI combined with MR cholangiopancreatography for the evaluation of patients with biliary strictures: differentiation of malignant from benign bile duct strictures

PURPOSE: To determine imaging criteria for the combined use of contrast-enhanced (CE)-MRI and MR cholangiopancreatography (MRCP) to differentiate malignant from benign biliary strictures. MATERIALS AND METHODS: A total of 44 patients with biliary stricture who had undergone unenhanced, MRCP, and dynamic MRI were identified from radiological and surgical databases. Two radiologists analyzed MR features for asymmetry, luminal irregularity, abrupt narrowing, outer margin, signal intensity (SI) on T2-weighted (T2W) images, and hyperenhancement relative to liver parenchyma during portal phase. The wall thickness and length of the narrowed segment were measured. MR findings relevant as predictors were identified using a Chi-square or Fisher's exact test and the odds ratio (OR). RESULTS: The presence of hyperenhancement relative to liver parenchyma, length > 12 mm, wall thickness > 3 mm, indistinct outer margin, luminal irregularity, and asymmetry of strictured bile duct were significant factors for malignancy (P < 0.05). Malignant strictures were significantly thicker (5.0 +/- 2.0 mm) and longer (27.0 +/- 13.6 mm) than benign strictures. When any three or more of these six criteria were used in combination, we could identify 100% of malignant strictures and 87.0% of benign strictures. CONCLUSION: The combined use of CE-MRI and MRCP helped to define the criteria for differentiating malignant from benign biliary strictures in our data.     

Minimally invasive catheter implantation for regional chemotherapy of the liver: A new percutaneous transsubclavian approach

Purpose Development of a percutaneously implantable catheter system for regional chemotherapy of liver metastases and its application in patients with surgically implanted but dislocated catheters. Methods Thirty-three patients with liver metastases of colorectal tumors were submitted to percutaneous puncture of the subclavian artery and insertion of a catheter whose tip was placed in the proper hepatic artery and whose end was subcutaneously connected with an infusion pump. Results The mean duration of therapy via the percutaneously inserted catheter was 27 weeks (±14 weeks). The most frequent complication was disconnection of the therapy catheter from the tube of the infusion pump. Eighty percent of all complications were corrected by reintervention. The therapy drop-out rate due to catheter-associated complications was 9%. Conclusion Percutaneous insertion of a catheter for regional chemotherapy of the liver is a relatively uncomplicated method with high patient acceptance and simple access for reintervention.     

Iatrogenic Portobiliary Fistula following Endoscopic Biliary Stent Placement: A Case Series and Review of the Literature

Iatrogenic portobiliary fistula is a rare adverse event following endoscopic biliary stent placement. Damage to the portal vein following endoscopic biliary stent placement has previously only been reported as single case reports. Management has ranged from conservative monitoring to surgery. Here, the authors present 4 cases of inadvertent endoscopic placement of a biliary stent into the portal vein. Interventional radiology was called to assist in the management of each of these cases. The experience presented here in conjunction with review of the previously reported cases helps shed light on potential management strategies if this adverse event is encountered in the future.