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。     

恶性胆道梗阻的肝脏病理组织学观察

恶性胆道梗阻是指由肿瘤堵塞或压迫胆汁流出道,使胆汁排出受阻,胆道内压力增高,引起肝脏继发性损害而产生梗阻性黄疸。恶性胆道梗阻导致肝脏组织学及超微结构的改变,国内未见报道,本研究旨在对此进行探讨。材料与方法标本来自1986年1～11月我院收治的恶性胆道梗阻病人,共32例。年龄30～78岁,平均54.5(±1.7)岁。男性22例,女     

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。     

金属内支架治疗胃十二指肠恶性梗阻体会（附28例报告）

目的探讨金属内支架治疗胃十二指肠恶性梗阻的临床疗效、操作技术及技巧。方法28例胃十二指肠恶性梗阻患者,其中男性19例,女性9例;年龄48．96岁,平均年龄72．4岁。包括胰腺癌12例．胃癌9例．肝癌3例．十二指肠癌1例,胃癌术后狭窄3例。在数字减影血管造影（DSA）引导下经导丝及导管通过狭窄段后造影证实狭窄部位及长度．选择合适的金属内支架置入。结果28例中27例一次置入成功,成功率96．4％。1周后复查支架位置及膨胀良好。置入后给予补液、止血及对症治疗,3d内进流食,后逐渐进半流食及普食。结论金属内支架置入介入治疗十二指肠恶性狭窄是安全右斯的姑皂-件治疗青浩对不厶匕丰术的＋一指隔驻性柄阳右稆杯的缮懈作田     

B超引导下应用PTCD治疗胆道梗阻23例临床分析

目的分析B超引导下经皮肝胆管引流术(PTCD)优缺点,为临床治疗胆道梗阻提供参考。方法回顾性分析23例胆道梗阻患者,使用国产PTCD F8-F9套管针,在B超引导下行PTCD,在右腋中线第7~9肋间或剑突下为穿刺点,局麻后皮肤戳孔3 mm,置入肝穿针,经肝行胆管穿刺,选择直径在5 mm以上且离肝下缘较远的扩张胆管。结果23例经皮肝插管外引流均获得成功,1次穿刺成功17例,2次穿刺成功6例,无1例发生并发症,21例引流获得较好效果。结论PTCD是一种比较安全、简便的诊断和治疗胆道疾病的方法。     

低场MRCP在胆道梗阻疾病的临床应用

目的探讨低场磁共振MRCP技术临床应用价值。方法回顾2004～2008年怀疑胆道梗阻59例临床资料。36例行CT检查。10例B超检查，全部行MRCP及B超检查。结果胆总管结石20例，肝门部胆管癌3例，胆总管癌12例，胰头癌5例，壶腹部癌8例，因胆管炎症所致胆总管下段狭窄者3例。结论MRCP作为无创性技术，结合MRI对胆道梗阻疾病的术前诊断有很大的价值。     

老年胆道梗阻手术治疗90例报告

随着我国人口结构逐步趋向老龄化,老年人胆道梗阻的治疗,在外科领域里越来越受到重视,我院普外科自1984年1月至1996年10月对90例65岁以上的胆道梗阻病人进行了手术治疗,现就其临床特征和治疗体会报告如下。     

低张饮水MRCP技术在低位胆道梗阻诊断中的应用

目的探讨低张饮水MRCP技术在低位胆道梗阻诊断中的价值。方法180例低位胆道梗阻患者均进行了低张饮水MRCP与常规MRCP检查,所有病例均经手术或内镜活检病理证实。比较两种方法对低位胆道梗阻性病变的显示及正确诊断率。结果低张饮水MRCP对低位胆道梗阻性病变的显示明显优于常规MRCP（P〈0．05）;低张饮水前后MRCP对低位胆道梗阻的定性诊断准确率分别为72．8％（131／180）、92．8％（167／180）。结合MR其它成像序列,对低位胆道梗阻的定性诊断准确率分别为91．1％（164／180）、96．1％（173／180）。两位诊断医师之间的意见一致性明显提高（K=0．687、0．812）。结论低张饮水MRCP对低位胆道梗阻的诊断具有一定的优势,可作为低位胆道梗阻MRI诊断与鉴别诊断的一种补充手段。     

上海长征医院采用特殊支架治疗十二指肠梗阻

据2006年8月4日上海长征医院报道．该院专家用一根特制的长8cm，直径2cm的抽丝式可拆除金属支架为62岁的女患者的治疗胰腺炎引起的十二指肠梗阻，取得成功。医生在胃镜直视下配合X线．准确地将金属支架置入到患者的十二指肠梗阻部位，耗时20min。     

金属支架置入术治疗左半结肠癌合并梗阻疗效分析

目的 探讨经内镜自膨式金属支架置入术在左半结肠癌合并梗阻术前的应用价值。方法 选择2009年1月~2015年1月我院收治的左半结肠癌合并肠梗阻患者84例,根据随机数字表法分为两组,每组42例。观察组采取术前支架置入术,对照组采用传统手术治疗,对比两组的手术时间、术中出血量、术后排气时间、术后并发症发生率、平均住院时间、腹腔引流时间以及生存期死亡率。结果 观察组腹腔镜手术率为90.47%（38/42）,Ⅰ期切除吻合率为97.61%（41/42）,均高于对照组（P＜0.05）;两组手术时间比较无统计学差异（P＞0.05）,观察组术中出血量（68.41±20.47）ml少于对照组的（125.25±20.13）ml （P＜0.05）,术后排气时间（2.81±0.42）d短于对照组（4.50±0.33）d（P＜0.05）;观察组并发症发生率（14.29%）低于对照组（40.48%）（P＜0.05）;观察组腹腔引流时间短于对照组（P＜0.05）。对照组3年、5年死亡率分别为14.29%、30.95%,平均生存期（48.20±13.13）个月,高于观察组的4.76%、11.90%、（67.41±15.93）个月,（P均＜0.05）。结论 左半结肠癌合并梗阻,术前采用经内镜自膨式金属支架置入术,可以有效提高I期吻合率,减少术中出血量,并显著降低并发症发生率,促进术后恢复。     

急性胆源性胰腺炎的临床治疗探讨

目的:探讨提高急性胆源性胰腺炎(acute biliary pancreatitis,ABP)疗效的治疗方法.方法:本组共48例ABP患者,其中胆道梗阻性11例、非梗阻性37例.对梗阻性ABP患者采取早期急诊手术治疗,手术方式为胆囊切除、胆总管切开取石、T管引流,胰腺包膜切开引流、胰腺坏死组织和感染灶清除;对非梗阻性ABP患者早期采取非手术治疗.结果:非梗阻性ABP 37例,其中34例经非手术治疗痊愈;3例出现体温升高、病情恶化者急诊手术,2例痊愈,1例死于多器官功能衰竭.11例梗阻性ABP行急诊手术治疗,发生并发症5例,均治愈.结论:急性胆源性胰腺炎的治疗应遵循个体化原则,对伴有胆道梗阻者早期宜行急诊手术,其它类型的急性胆源性胰腺炎早期宜非手术治疗.选择正确的治疗方法,把握恰当的手术时机,可提高治愈率,降低病死率.     

抗反流胆道支架研究现状及进展

胆道支架是治疗恶性胆道梗阻的有效手段,而常规胆道支架术后普遍存在肠胆反流,从而引发胆道逆行感染、支架堵塞等并发症,严重降低了患者生存质量.目前,抗反流胆道支架被认为是兼顾引流与抑制肠胆反流功能的具有前景的姑息性治疗手段.对抗反流胆道支架的研究现状进行综述,重点对抗反流瓣膜的功能设计与评估、瓣膜与本体支架连接设计、抗反流...     

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.     

Ampullary Neuroendocrine Tumor Presenting with Biliary Obstruction and Gastric Outlet Obstruction

Neuroendocrine tumors of the ampulla of Vater are extremely rare cause of extrahepatic biliary obstruction and further rarer cause of duodenal obstruction, and only a few cases have been reported in the literature. Herein we report a case of ampullary neuroendocrine tumor in a 75-year-old woman who presented with biliary obstruction and gastric outlet obstruction palliated with metal biliary and duodenal stenting with relief of jaundice and vomiting at 1 month of follow-up.     

A Systematic Review and Meta-Analysis of Randomized Trials and Prospective Studies Comparing Covered and Bare Self-Expandable Metal Stents for the Treatment of Malignant Obstruction in the Digestive Tract

Background: Self-expandable metal stents (SEMS) are widely used for the palliative treatment of malignant gastrointestinal obstruction. Our aim was to evaluate the evidence comparing covered and bare SEMS in the digestive tract using meta-analytical techniques.Methods: A literature search was performed using PubMed, Cochrane Library, and Embase databases for comparative studies assessing the two types of stents. The primary outcomes of interest were stent patency and patient survival; second outcomes included technical success, clinical success, tumor ingrowth, tumor overgrowth, and stent migration. A random-effects model was conducted. Pooled analysis was done separately based on the different segments of the digestive tract.Results: Eleven studies (8 randomized controlled trials and 3 prospective cohort studies) including a total of 1376 patients were identified. Covered SEMS were equivalent to bare SEMS in terms of technical success, clinical success, stent patency (gastroduodenal obstruction: HR =0.87, 95% CI 0.53-1.42; colorectal obstruction: HR =0.89, 95% CI 0.18-4.45; biliary obstruction: HR =0.73, 95% CI 0.41-1.32) and survival rates (esophageal obstruction: HR =1.80, 95% CI 0.73-4.44; gastroduodenal obstruction: HR =0.83, 95% CI 0.55-1.26; biliary obstruction: HR =0.99, 95% CI 0.77-1.28), although bare stents were more prone to tumor ingrowth (esophageal obstruction: RR =0.10, 95% CI 0.01-0.77; gastroduodenal obstruction: RR =0.12, 95% CI 0.03-0.55; colorectal obstruction: RR =0.21, 95% CI 0.06-0.70; biliary obstruction: RR =0.21, 95% CI 0.06-0.69), whereas covered stents had the higher risk of stent migration (gastroduodenal obstruction: RR =5.01, 95% CI 1.53-16.43; colorectal obstruction: RR =11.70, 95% CI 2.84-48.27; biliary obstruction: RR =8.11, 95% CI 1.47-44.76) and tumor overgrowth (biliary obstruction: RR =2.03, 95% CI 1.08-3.78).Conclusion: Both covered and bare SEMS are comparable in efficacy for the palliative treatment of malignant obstruction in the digestive tract. Each type of the stents has its own merit and demerit relatively.     

关于肠梗阻的临床治疗研究

目的：分析肠梗阻的临床治疗研究。方法选取我院收治的肠梗阻患者共70例,随机将其分成观察组和对照组各35例,其中对照组患者使用传统开腹手术进行治疗;观察组患者采用腹腔镜手术治疗,对两组患者的术中出血量、手术时间、住院时间进行对比分析。结果与对照组患者相比,观察组患者术中出血量少,手术时间以及住院时间均短于对照组,(P<0.05)具备统计学意义。结论在对肠梗阻患者进行治疗的过程中,采用腹腔镜手术治疗,具有术中出血量少、住院时间短以及手术时间短等优点,且在临床治疗中效果显著,值得推广使用。     

胆道梗阻后胆汁中自由基反应及其在胆石形成中的作用

作者通过临床标本及动物实验,观察胆汁中超氧化物歧化酶(SOD)、过氧化脂质(LPO)、β-葡萄糖醛酸苷酶(β-G)、总胆红素(TB)及总蛋白(P)等的变化,对胆道梗阻后胆汁中自由基反应及其在胆石形成中的作用进行了研究。结果发现:原发性肝胆管结石和/或胆道梗阻病人术中胆汁的SOD和LOP升高,显示自由基反应增强,切除病灶或解除梗阻后则逐渐下降。动物实验证明,兔胆道梗阻后,同样使胆汁中SOD和LPO显著上升,并伴随有组织性β-G,TB,及P的含量明显增加。组织性β-G和TB变化与SOD相关。提示胆道梗阻,胆管内压增高,可通过增强自由基反应途径使胆汁成份发生变化,导致胆石形成。     

慢性胆道梗阻时肝脏病理变化的立体学研究

用立体学方法测得大鼠胆总管结扎后1W、2W、3W，其汇管区周围肝窦横径较对照组明显扩张（P＜0．01），增大幅度分别为67．34％、86．26％和94．81％。单位体积肝窦表面积较对照组明显减小（P＜0．01），减小幅度分别为31．07％、32．94％和36．21％。各结扎组中，肝细胞体积比较对照组肝细胞体积比减小（P＜0．05）；肝内纤维组织体积比较对照组肝内纤维组织体积比增加（P＜0．05）；肝内小血管体积比虽较对照组肝内小血管体积比增加，但无统计学差异（P＞0．05）。本实验证实：慢性肛道梗阻后肝内分流途径是汇管区周围扩张的肝窦。     

大肠癌合并急性梗阻的临床治疗探讨

目的:探讨大肠癌致急性梗阻病例的外科处理原则、方法及预后。方法:回顾性分析46例大肠癌致急性梗阻的外科临床资料。结果:46例患者均行手术治疗,45例治愈,1例死亡,20例右半结肠行根治性切除,Ⅰ期吻合,11例左半结肠行根治性左半结肠切除,Ⅰ期吻合5例,6例行改良Hartmann术,7例中高位直肠癌,3例行Dixon,3例行改良Hartmann术,1例行乙状结肠单纯造口,8例低位直肠癌,行Dixon3例,Miles2例,改良Hartmann2例,死亡1例。结论:手术治疗大肠癌致肠梗阻是唯一办法,具体方法需根据患者全身情况及肿瘤的局部情况选择合理方式,置入内支架,变急诊为限期手术,是大肠癌合并急性梗阻治疗的未来发展方向。