经皮肝穿胆汁引流联合三维适形放射治疗肝门部胆管癌疗效分析

 目的 探讨经皮肝穿胆汁引流联合三维适形放射治疗肝门胆管癌的疗效。方法 对伴有阻塞性黄疸不能或不愿接受手术及手术不能根治的肝门胆管癌者21例，经胆汁引流后接受三维适形放射治疗，通过临床症状、影象学等指标的变化情况来评价疗效。结果 经胆汁内外引流1～3周后，患者症状明显改善，食欲增加，局部病变再配合三维适形放射治疗， 3个月有效率为76.2 %（16／21），6个月有效率为71.4 %（15／21），中位生存期为15个月。结论 对伴有阻塞性黄疸的肝门胆管癌患者，经皮肝穿胆汁引流后联合三维适形放射治疗是一种安全、无创、有效的治疗方法。     

右前叶肝管外引流治疗晚期肝门部胆管癌

本介绍右前叶肝管外引流治疗晚期肝门部胆管癌的手术方法及治疗结果。术后胆汁引流量平均300-400ml/24h,2周后血清胆红素下降平均值153.9μmol/L。通过引流管造影表明右半肝胆管扩张有不同程度改善.经1.5-2年随访观察，存活期平均9.5个月，作认为此法操作容易，安全，胆道减压引流较充分，能延长患生存期。     

肝管汇合变异在肝门胆管癌手术中的价值

目的：评价肝管汇合变异在肝门胆管癌治疗中的价值。方法：对2002年1月～2007年3月本院就诊的肝门胆管癌（或肝门部胆管癌）患者行术前磁共振胰胆管显影（MRCP）检查，发现存在左、右肝管汇合方式变异患者24例，其中16例评价有潜在手术切除可能的患者行手术探查，对该16例患者的资料进行回顾性分析。结果：16例患者术前MRCP检查发现的肝管汇合变异均经手术证实，MRCP诊断肝管汇合方式变异的准确性为100％；16例患者中右后叶支直接汇入左肝管7例（43．8％），呈“三叉戟”状5例（31.3％），右后叶支直接汇入肝总管2例（12．5％），右前叶支直接汇入左肝管2例（12．5％）；手术切除9例（56.3％）。其中R0切除5例（31．3％），R1切除3例（18．8％），R2切除1例（6.3％）；术后发生并发症2侧．1例患者死于术后胆漏，结论：肝门胆管癌患者中肝管汇合变异较常见，术前MRCP检查能较；隹确的发现这种变异；有些肝管汇合变异是对手术有利的，通过合理的手术入路，利用这些变异，能提高部分患者、尤其是Ⅲ和Ⅳ型等高位胆管癌患者手术切除的成功率。并有利于选择合适的胆肠吻合方式及避免术中胆道误损伤，提高手术切除的安全性，     

高剂量率腔内照射治疗肝门部胆管癌

肝门部胆管瘤由于病变部位高，梗阻程度严重，位置特殊，手术难以切除。我科从1994年5月以来，对不能手术切除和切除术后有残留的肝门部胆管癌，采用高剂量率（HDR）Ir－192经T型或U型胆汁引流管置施源管进行腔内照射，1例辅以外照射，共治疗6例，取得了明显的治疗作用，并结合有关文献，对肝门部胆管瘤的放疗剂量、疗效、并发症进行分析。材料与方法一般资料：1994年5月以来我科收治的肝门部胆管瘤6例，男性3例，女性3例，年龄38—64岁，中位年龄57岁。姑息切除术后5例，手术不能切除1例，胆汁引流法：T型管4例，U型管2例。术中发现肝…     

肝门部胆管癌姑息性手术的临床疗效

目的探讨不能手术切除的肝门部肝管癌姑息性手术的临床疗效。方法对1997年至2003年间11例不能手术切除的肝门部胆管癌患者行经肝管外引流十空肠造瘘术的资料进行回顾性分析，并对该手术方法进行总结。结果术后黄疸完全消退者6例，基本消退者5例。结论通过临床观察经肝管外引流 空肠造瘘术是当前临床治疗不能手术切除的肝门部胆管癌的较好方法，可以缓解症状、延长病人的生存期。     

U管引流在晚期肝门部胆管癌治疗中的应用体会

目的 探讨U管引流在不能切除肝门部胆管癌姑息治疗中的应用价值。方法 对8例晚期肝门部胆管癌行U管引流姑息治疗病例的方法，疗效进行分析。结果 除1例术后死于肝衰，其余7例均黄疸消退，营养改善。5例存活1年，3例存活2年，存活率分别为62．5％(5／8)及31．5％(3／8)。治疗效果明显。结论 U管引流在晚期肝门部胆管癌的应用可取得良好的治疗效果，提高病人生存质量及延长患存活期。     

肝门部胆管癌内置管肝内胆管十二指肠吻合术四例报告

我院自1988年以来,采用带支撑内置管的肝内胆管十二指肠吻合术治疗肝门部胆管癌四例,收到较好的效果,报道如下。例1.男,58岁。因上腹隐痛、日渐消瘦8个月、进行性黄疸20多天入院。手术探查,发现除肝脏有中度硬化改变及明显淤胆外,于肝总管、胆囊三角以及胆囊壶腹部处有—约5×4×4cm包块,向上浸润肝门大部致无法显露肝门。但于肝圆韧带入肝处的右前方有一2×1.5cm呈囊状隆起的扩张胆管,切开后大量胆汁涌出。乃用一长5cm、外径5mm的硅胶管行支撑内置     

肝门胆管癌手术切除26例疗效分析

肝门胆管癌，７０年代以前大多数病例难以切除，视为手术禁区。随着医学科学技术的快速发展，早期病例诊断率明显提高，手术切除率也提高至６０％左右。从１９８８～１９９６年共施行肝门胆管癌手术切除２６例取得较好效果。Ⅰ型（肝总管癌）１０例，Ⅱ型（肝管汇合部癌）７例，Ⅲ型（左肝管及肝总管癌）４例，Ⅳ型（右肝管及肝总管癌）３例，Ⅴ型（左、右肝管和肝总管癌）２例。手术方法为单纯肝门胆管癌切除，肝门胆管及半肝切除，肝中央部切除，扩大半肝切除后与空肠行Ｒｏｕｘ－ｅｎ－Ｙ吻合术。作者对手术切除方法，禁忌证，治疗效果等进行了详细讨论。所有病例均行胆管或肝断面与空肠吻合术，术后并发症少，再次手术少，疗效满意。     

肝门部胆管癌的外科治疗

目的　评价肝门部胆管癌手术治疗效果。方法　回顾性分析 4 0例肝门部胆管癌的临床资料。结果　 4 0例胆管癌中 ,11例行治愈性切除术 ,10例行姑息性切除术 ,19例行内外引流术 ,手术切除率为 5 2 .5 %。根治术者 1、3、5年生存率为 82 .5 %、2 5 %、15 .5 % ,姑息性切除 1、3年生存率分别为 35 .5 %和 9.5 %。非切除性胆道内、外引流者生存期均未超过 2年 ,1年生存期分别为 3/ 11和 2 / 8,无 2年生存者。术后并发症 15例 (37.5 % ) ,术后死亡率 7.5 % (3/ 4 0 )。结论　治愈性切除是治疗肝门癌胆管最佳手段 ,姑息性切除也能延长病人生存时间。     

原发性胆囊癌六例外科治疗的体会

我院1979～1989年共收治原发性胆囊癌6例,其中:男性1例,女性5例:年龄:49岁1例,50～60岁2例,61～70岁3例;病理检查:腺癌5例,鳞状细胞癌1例。B型超声波检查:提示胆囊炎胆囊结石5例,胆囊结石伴胆囊肿瘤可能1例。手术:行胆囊切除十肝门部淋巴结清除2例,胆囊单纯切除2例,未能切除胆囊2例。术后半年内死亡4例,术后8个月死亡1例,1例术后至今5个月,B超检查提示肝胰已     

肝外胆管癌的放射治疗：附12例分析

During the past 8 years, 12 patients with extrahepatic bile duct adenocarcinoma which was contra-indicated to operation or who underwent conservative resection wer treated by radiotherapy in our hospital. Five patients were given post-operative radiation of 60-70 Gy/7-9 weeks, 3 patients received 12 Mev beta beam of one single 30 Gy intra-operative radiotherapy and 4 were treated by intra-operative radiotherapy of 20 Gy plus external irradiation of 40 Gy/5 weeks after the operation. The results indicated that most of the patients died around 1 year and 2 are still alive for over 2 years. The present results are more favorable as compared with those treated before 1980 because biliary drainage had been done before timely high dose radiotherapy after the operation. The author considers that intra-operative radiotherapy or its combination with external irradiation might be helpful to improve the prognosis in extrahepatic bile duct cancer.     

恶性梗阻性黄疸姑息手术术式选择探讨

 目的　探讨对恶性梗阻性黄疸姑息手术术式的选择。方法　对112例姑息性手术治疗的恶性梗阻性黄疸患者临床资料进行回顾性分析。结果　手术死亡率7.1 %（8／112）;术后复发性胆管炎发生率17.3 %（13／75）;术后生存期：胆肠Roux-en-Y吻合术组［（9.4±1.6）个月］与开腹支架内引流术组［（9.8±12.5）个月］、经皮经肝胆和引流（PTCD）内支架引流术组[（9.0±3.1）个月]差异无统计学意义（均P＞0.05）,与开腹桥式内引流术组［（6.8±1.7）个月］差异有统计学意义（P＜0.05）,与逆行胰胆管造影（ERCP）内支架引流术组［（3.5±2.2）个月］和单纯开腹探查术组［（2.8±2.7）个月］比较差异有统计学意义（P＜0.01）。结论　胆肠Roux-en-Y吻合术式适用于胆管中、下段梗阻,开腹内支架引流术式适用于肝门胆管梗阻患者,ERCP内支架术式仅适用于胆管下段的梗阻,PTCD内支架术式适用于任何一段的梗阻。胆管空肠Roux-en-Y吻合术、开腹支架内引流术和PTCD内支架引流术能够延长患者术后生存期和提高生活质量。     

超声引导经皮经肝胆管置管引流术在胆道梗阻疾病中的应用

目的评价超声引导经皮经肝胆管置管引流术在无手术适应证胆道梗阻疾病中的应用价值及疗效判断。方法本组39例,男22例,女17例。平均年龄51.2岁。使用自制穿刺辅助装置,日本八光S型引流套管（8F）。选择内径≥10 mm、走行较平坦、无扭曲的胆管为穿刺点,胆管周围加以彩色血流成像并注意避开血管。成功置管的38例中33例行左胆管置管,5例右胆管置管。结果39例除1例因术中出血未成功外,38例均成功置管,随访未发现胆漏、出血、感染等并发症。引流胆汁后患者症状明显改善,血清胆红素逐渐下降,其中6例降至正常。本组胆汁日引流量380～1400 ml。38例中术后生存2～5个月8例、〉6个月15例、〉9个月11例、〉1年4例,最长生存期17个月。结论超声引导肝胆管置管引流,操作简便、痛苦小、成功率高,使患者得到了持续性胆汁引流的机会,对改善梗阻导致的黄疸,减轻由其产生的损害和症状,延长患者生存期及提高晚期生存质量将起到重要的积极作用。     

Intraluminal low-dose-rate 192Ir brachytherapy combined with external beam radiotherapy and biliary stenting for unresectable extrahepatic bile duct carcinoma

PURPOSE: To evaluate the results of combined-modality therapy, including external beam radiotherapy, intraluminal (192)Ir, and biliary stenting for extrahepatic bile duct carcinoma. MATERIALS AND METHODS: Between 1988 and 1998, 93 patients with unresectable extrahepatic bile duct carcinoma underwent definitive radiotherapy. The dose of external beam radiotherapy was 50 Gy in 25 fractions. Low-dose-rate (192)Ir was delivered at a dose of 27-50 Gy (mean 39.2) at 0.5 cm from the source. An expandable metallic endoprosthesis was used to establish an internal bile passage. RESULTS: The median survival was 12 months, with a 1-, 3-, and 5-year actuarial survival rate of 50%, 10%, and 4%, respectively. Tumor length, hepatic invasion, and distant metastasis significantly affected survival. Ninety-six percent of patients could successfully remove external drainage catheters. The actuarial biliary patency rate for these patients at 1, 3, and 5 years was 52%, 29%, and 18%, respectively. Tumor length, tumor diameter and T stage were significantly associated with the patency rate. Mild-to-severe gastroduodenal complications were observed in 32 patients and were significantly associated with the active length of (192)Ir and linear source activity. Eight patients had treatment-related biliary fistula. CONCLUSIONS: Our combined-modality therapy provided reasonable local control and improved the quality of life of patients with extrahepatic bile duct carcinoma. Because none of the treatment characteristics had any impact on survival or biliary patency, lower dose levels and/or a localized target volume are recommended to minimize morbidity.     

支架置入术治疗恶性低位胆道梗阻的临床价值

目的 探讨金属胆道支架置入术治疗恶性低位胆道梗阻的有效性、安全性.方法 32例恶性胆道低位梗阻患者(中位年龄61岁),术前经CT和磁共振胰胆管造影(magnetic resonance cholangiopancreatography,MRCP)证实为恶性胆道低位梗阻.其中,胆管癌12例,胰头癌11例,壶腹癌5例,转移癌2例,胆囊癌2例.32例患者行经皮经肝胆道穿刺,于胆总管中下端置入32枚自膨式金属胆道支架.结果 32例患者手术成功率100.0％,支架位置良好,胆汁引流通畅.术中无胆道出血、胆汁渗漏及胆道破裂等严重并发症.32例患者于术后7天复查肝功能,其血清总胆红素(total bilirubin,TB)由术前的(378.11±134.53) μmol/L下降至(166.10 ±74.37) μmol/L(P＜0.05);血清直接胆红素(direct bilirubin,DB)由术前的(219.14±86.37) μmol/L下降至(98.26 ±53.68) μmol/L(P＜0.05).29例于术后30天复查肝功能,其血清TB由术前的(356.78±118.21) μmol/L下降至(56.10±44.37)μmol/L;血清DB由术前的(219.14 ±86.37) μmol/L下降至(38.26±43.68) μmol/L,均P＜0.05.30例获得随访,随访1-42月(平均25.4月),9例再发支架内梗阻(30.0％),其中4例再行支架治疗,3例行导管引流治疗,2例未治疗死亡.十二指肠梗阻1例,行十二指肠支架治疗后缓解.生存期1-33月,平均生存期(11.56±2.14)月,中位生存期10.0月.结论 金属胆道支架置入术是治疗恶性低位胆道梗阻的安全、有效的方法.     

经导管~(192)Ir近距离放射治疗局部晚期肝门部胆管癌

目的：观察局部晚期肝门部胆管癌姑息性引流术后１９２Ｉｒ腔内放疗的疗效。方法：先行手术探查尽可能刮除肿瘤并放置Ｕ型管引流，术后再经导管腔内放疗。参考点距离放射源中心轴１０ｍｍ，总量２４～３０Ｇｙ／３次。３例配合肝动脉区域性灌注化疗，１例配合外照射ＤＴ４５Ｇｙ／４．５周。结果：生存期６～２６个月，中位生存期１１．５月。１５例死亡，１例目前存活８个月。全组１年生存率３７．５％，２年生存率６．０％，结论：局部晚期肝门部胆管癌姑息性引流术后腔内放疗可提高生存期及生活质量     

Metachronous bile duct cancer in a patient surviving for a decade and undergoing curative surgery twice.

We report a 75-year-old woman with metachronous bile duct cancer who underwent curative resection twice and has survived for a decade. In 1989, she was admitted because her serum alkaline phosphatase level was elevated. Computed tomography (CT) showed a low-density mass, 2 cm in diameter, at the left hepatic duct and intrahepatic bile duct dilatation in the left lobe. We diagnosed the lesion as an intrahepatic bile duct cancer and performed extended left hepatic lobectomy with systematic lymph node dissection. The histological diagnosis was a well differentiated cholangiocellular carcinoma with hepatic hilar and celiac lymph node metastases (T1N2M0, Stage IVB). In 1996, she was re-admitted with obstructive jaundice. CT showed a slightly enhanced mass, 4 cm in diameter, in the pancreatic head. After reducing the jaundice by percutaneous transhepatic biliary drainage, pancreatoduodenectomy was performed. The histological diagnosis of this lesion was a moderately differentiated adenocarcinoma originating from the intrapancreatic bile duct. Ten years after the first operation, she is leading a normal daily life with no cancer recurrence. These findings suggest that repeated curative surgery can result in a long-term survival of patients with metachronous bile duct cancer.     

肝细胞癌合并胆管癌的临床分型及手术方式对其远期疗效的影响

目的 对肝细胞癌合并胆管癌患者进行临床分型,采取不同手术方式,分析其对患者的生存期及生存率的影响.方法 选取肝癌合并胆管癌栓的患者100例,对入组患者进行分型,分别采用五种不同的手术方式,并根据治疗方式不同分为1~5组,每组20例.随访并记录其生存期,分析不同分型及治疗方式对预后的影响.结果 对入组患者采取不同的治疗方式,术后出现腹腔积液、黄疸、感染、出血等并发症,5种不同治疗方式之间比较,患者的术后并发症发生率差异均无统计学意义(P>0.05);采用根治性肿瘤切除术联合胆管癌栓取出术组,较其他4组生存期明显延长,生存率明显提高,差异有统计学意义(P<0.05);4种不同分型患者的生存期、生存率之间比较,差异均无统计学意义(P>0.05).结论 对肝癌合并胆管癌栓的患者,采取根治性肿瘤切除术联合胆管癌栓取出术,能够明显延长生存期,提高生存率,而不同的临床分型对术后生存期及生存率均无显著影响.     

Percutaneous transhepatic hybrid biliary endoprostheses using both plastic and metallic stents for palliative treatment of malignant common bile duct obstruction

To evaluate clinical safety and efficacy of percutaneous transhepatic hybrid biliary prostheses for palliative treatment in patients with common bile duct obstruction caused by advanced malignancies. A total of 13 consecutive patients was treated with percutaneous transhepatic biliary endoprostheses concurrently using both plastic and metallic stents. Serum total bilirubin levels before and after stent placement were evaluated. The technical success rate, the period with no obstructive jaundice, patient survival and complications were also assessed. Median bilirubin levels decreased from 3.8 mg/dL before to 1.2 mg/dL after stent placement, and this difference was statistically significant. The median no‐jaundice period after bile duct stent placement was 6.0 months (range: 2–11 months), and overall survival time was 7.0 months. Of the 13 patients, nine did not have recurrent jaundice by the time of death, whereas four (31%) had recurrent jaundice. A second intervention was performed in these four patients. A new plastic stent was placed and jaundice did not recur up to the time of death. No serious complications such as cholangitis, pancreatitis or bile duct perforation developed. Percutaneous transhepatic hybrid biliary endoprostheses using both plastic and metallic stents can be useful as non‐invasive palliative treatment to relieve jaundice in patients with malignant obstructive jaundice.     

Obstructive jaundice caused by hepatocellular carcinoma

Hepatocellular carcinoma can be complicated by obstructive jaundice with tumor growing into the extrahepatic bile duct. This complication is an autopsy finding in most reported cases and, rarely, is recognized ante mortem. We report two patients with hepatocellular carcinoma who presented initially with obstructive jaundice. Clotted blood and tumor, which caused bile duct obstruction, was removed operatively and the biliary tract was drained in both patients. We conclude that blood clot and fleshy debris removed from the common bile duct at operation for obstructive jaundice suggests the possibility of hepatocellular carcinoma; the differential diagnosis of jaundice and fever in patients known to have hepatocellular carcinoma should include intrabiliary tumor causing obstruction and cholangitis; and the association of obstructive jaundice and hepatocellular carcinoma may occur more often than previously recognized.