胆肠吻合术后再发梗阻性黄疸的介入治疗

目的 探讨胆肠吻合术后再发梗阻性黄疸的介入治疗方法及疗效.资料与方法 回顾性分析胆肠吻合术后再发梗阻性黄疸而行介入治疗的43例患者,行经皮经肝胆管穿刺置管引流术,并选择胆肠吻合口或原发梗阻部位进一步行经皮胆道金属支架植入术.结果 本组经皮经肝胆管造影显示胆肠吻合口狭窄32例,吻合口狭窄并肠袢成角、张力过高7例,吻合口未见狭窄4例.最终单纯行经皮经肝胆管穿刺置管引流术16例,包括单纯外引流9例,内外引流7例;行胆道金属支架植入术27例,其中经胆肠吻合口留置支架22例,经原梗阻部位留置支架5例.术后1周内复查,37例黄疸消退满意,6例黄疸消退不明显,其中4例再次行外科手术治疗.本组43例术中、术后均无严重并发症发生.结论 胆肠吻合术后再发梗阻性黄疸可行经皮经肝胆管穿刺置管引流术或经皮胆道金属支架植入术,此法安全、微创、可靠、有效,值得推广应用.     

渐进性球囊扩张联合胆道持续引流治疗胆肠吻合术后吻合口良性狭窄

目的 评价渐进性球囊扩张联合胆道持续引流治疗胆肠吻合术后吻合口良性狭窄的安全性和可行性.方法 回顾性分析2008年1月至2014年3月收治的49例胆肠吻合术后吻合口良性狭窄患者临床及影像学资料.所有患者术前均行彩色超声、MR和/或增强CT及内镜下或DSA下吻合口活检病理证实为吻合口良性狭窄,其中23例患者采用经皮肝穿渐进性球囊(初始直径8 mm;第2个月直径10 mm;第3个月直径12 mm)扩张联合引流管持续引流(6个月)方式治疗(研究组);26例患者采用单次经皮肝穿球囊(直径6或8 mm球囊)扩张联合引流管置入(6个月)治疗(对照组).比较两组患者术后临床症状缓解情况,术后并发症的发生率以及吻合口通畅时间.结果 所有患者手术操作均顺利完成,未见手术相关并发症,如胆道出血,穿孔等发生.术后1周两组患者的血清胆红素下降明显,组间比较未见明显差异(P＜0.05).3个月时两组患者吻合口通畅率未见明显差异,但在6、12和24个月时研究组的吻合口通畅率显著高于对照组(P＜0.05).研究组中,3例患者分别于11.2、14.3和17.6个月出现复发黄疸,MRI及增强CT证实吻合口狭窄复发,给予再次的球囊扩张和引流管置入治疗.对照组16例患者在球囊扩张术后3.1至17.1个月再次出现黄疸,其中1例患者死于播散性血管内凝血,余15例患者给予再次的球囊扩张和引流管置入治疗.结论 渐进性球囊扩张联合胆道持续引流是治疗胆肠吻合术后吻合口良性狭窄的安全、有效的微创手术.     

经皮经肝球囊扩张治疗胆肠吻合术后吻合口狭窄

目的：探讨经皮经肝胆管穿刺引流术（ PTCD）联合球囊扩张术治疗胆肠吻合术后吻合口狭窄的可行性及疗效。方法回顾性分析军事医学科学院附属医院普外科2009年3月至2011年12月采用PTCD联合球囊扩张术治疗胆肠吻合术后吻合口狭窄23例的疗效,评估胆道通畅程度、黄疸指数及肝功能。结果本组行PTCD联合球囊扩张术23例,19例治疗效果明显,1例植入金属支架。术后胆肠吻合口狭窄、黄疸指数及肝功能均明显改善,无严重并发症发生。结论 PTCD联合球囊扩张术治疗胆肠吻合术后吻合口狭窄疗效好,并发症发生率低,是较为安全可行的微创治疗措施。     

逐级更换胆肠吻合口支撑管治疗胆肠吻合口良性狭窄3例

<正>胆肠吻合术是治疗胆道疾病的常用术式,其中,尤以胆管空肠Roux-en-Y吻合术常用。笔者从事介入工作,临床中常遇到胆肠吻合术后反复发热,多数为胆肠吻合口狭窄所致。本研究应用经皮肝穿胆道引流术(percutaneous transhepatic cholangiodrainage,PTCD)构建内外引流,逐渐更换更粗的引流导管,扩张吻合口狭窄处,最终拔除引流管,治疗3例胆肠吻合口良性狭窄患者,取得良好疗效。现报道如下。     

经皮介入技术在胆肠吻合口狭窄处理中的价值

胆肠吻合术在建立胆汁引流通路方面具有重要临床意义,胆肠吻合口狭窄为影响手术预后的严重并发症之一,由于胆肠吻合术后局部组织结构的紊乱和吻合术式的影响,再手术及内镜处理存在其自身的局限性。经皮介入技术对病人身体条件要求不高,并且具有操作相对简单、长期随访再狭窄率低、并发症少等特点,在胆肠吻合口狭窄处理中具有独特优势。对于顽固性良性胆肠吻合口狭窄及恶性胆肠吻合口狭窄可选择置入胆道金属支架。     

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。     

高位恶性胆道梗阻行内支架成形术与胆肠吻合术疗效比较北大核心CSCD

目的:探讨开腹胆-肠吻合及经皮胆道双支架植入在恶性高位梗阻性黄疸患者临床治疗中的应用价值。方法:回顾分析49例不能根治切除的高位恶性梗阻性黄疸患者的临床资料及随访情况,按手术方式分为支架组(n=28)和胆肠吻合组(n=21)。结果:所有患者均一次性完成胆-肠吻合术或胆道双支架植入以达到内引流的目标。2组肝功能指标:总胆红素(TBIL)、谷草转氨酶(ALT)、谷丙转氨酶(AST)、碱性磷酸酶(AKP)均在术后l周出现明显下降(P<0.05),组间比较差异无统计学意义(P>0.05)。2组中胆肠吻合组平均生存时间(22.96±7.83)周,胆道支架植入组平均生存时间(28.67±1.69)周,差异无统计学意义(P>0.05);2组住院天数、单次住院费用比较,差异有统计学意义(P<0.05),其中胆肠吻合组平均住院时间为(27.55±31.35)d,胆道支架植入组为(12.62±4.17)d,胆肠吻合组平均住院费用为(54881.99±16816.57)元,胆道支架植入组为(42650.00±11450.08)元。围手术期死亡1例(胆肠吻合组),死亡率2.04%,考虑为术后感染性休克导致多器官功能衰竭。术后主要并发症有胆管炎、胰腺炎、胆道支架移位或堵塞、胆道感染、肝功能衰竭。结论:开腹胆肠吻合及经皮胆道支架植入均可有效解除恶性胆道梗阻,改善肝功能,延长生存期。但从住院天数、费用等经济学指标来观察,胆道支架植入更具优势。     

胆道镜协助高位胆肠吻合口良性狭窄扩张后置管支撑引流的临床观察

目的　探讨在胆道镜协助下通过扩张、置管支撑、引流治疗高位胆肠吻合术后良性吻合口狭窄的效果。方法　将吻合肠管戳创 ,置入胆道镜协助 ,在肠内寻找胆肠吻合口并将其扩张后 ,进行胆道镜检查、取石或冲洗 ,然后纵切吻合口并置入U形管支撑、外引流。结果　 5例患者均在 6～ 12月内成功拔管 ,最长随访 3年无复发 ,治疗效果满意。结论　胆道镜协助下 ,扩张纵行切开的狭窄的高位胆肠吻合口后置管支撑引流可以有效地解决狭窄的问题 ,同时费用低廉、对机体损伤较小     

经皮经肝胆管引流术治疗胆肠吻合术后梗阻性黄疸疗效分析

 目的 评价经皮经肝胆管引流术(PTBD)治疗胆肠吻合术后梗阻性黄疸的临床效果.方法 回顾分析了5年来因梗阻性黄疸行PTBD治疗的胆肠吻合术后患者39例.男25例,女14例,年龄平均(52.51±12.38)岁.患恶性疾病23例,良性疾病16例;狭窄部位分为胆肠吻合口12例,肝门部12例、胆总管8例、肝内外胆管广泛累及7例.均经PTBD进行穿刺引流或置管引流.结果 行PTBD术39例,37例成功.左右肝管外引流分别12例、5例、双侧4例,左右肝管放置内外引流管3例,通过狭窄段至胆总管或小肠放置内外引流管13例.术后患者临床症状在3～5 d内得到明显改善,总胆红素于1周内下降52.76%.术后除发热外无其他严重并发症发生.结论 PTBD是治疗胆肠吻合术后梗阻性黄疸的良好方法,具有临床推广价值.     

125I放射性粒子条联合胆管金属支架植入术在恶性胆肠吻合口狭窄中的应用

目的 评估125I放射性粒子条联合胆管金属支架植入术在恶性胆肠吻合口狭窄患者治疗中的有效性及安全性.方法 回顾性分析21例恶性胆肠吻合口狭窄并且行125I放射性粒子条联合胆管金属支架植入术的患者,统计分析手术成功率、支架通畅时间、生存时间及手术并发症.结果 胆肠吻合术后出现胆肠吻合口狭窄的中位时间为8(3～78)个月;...     

经皮肝穿刺胆道造影术下胆管活检的临床研究

目的　探索经皮肝穿刺胆道造影术 (PTC)下胆道活检的可行性和敏感性。方法　 31例阻塞性黄疸患者 ,在行经皮经肝穿刺胆道内外引流术 (PTCD)中 ,进行PTC下胆道活检。通过经皮经肝胆道穿刺通道向胆道内送入 8F鞘 ,活检钳经鞘内送入并对病变狭窄段行胆道钳夹活检 ,获取多个标本 ,行组织病理学检查。结果　 31例患者 30例获得组织病理学诊断 (敏感性 96 .8% )。结论　PTC下胆道活检是一种简单易行、准确可靠的获取组织学病理检查途径     

Non-surgical palliative treatment of patients with malignant biliary obstruction--the place of endoscopic and percutaneous drainage

Non-surgical methods to treat patients with inoperable malignant biliary obstruction are endoscopic retrograde biliary drainage and ultrasound guided percutaneous transhepatic biliary drainage. During a 2 year evaluation a total of 144 patients were admitted with malignant biliary obstruction: 93 with a mid- or distal common bile duct stenosis; 51 patients with a perihilar stenosis. Endoscopic biliary drainage was performed in 123 patients and ultrasound guided percutaneous biliary drainage in 57 patients. An effect on jaundice was seen in more patients after percutaneous biliary drainage (91%) than with endoscopic biliary drainage (70%). However with the percutaneous method only 63% of patients were drained internally. The site of the stenosis seemed to be an important factor. In patients with perihilar obstruction early complications after endoscopic biliary drainage occurred in 41% of drained patients compared with 3% procedure-related and 28% catheter-related complications with ultrasound guided drainage. A major complication of the endoscopic method in perihilar disease was cholangitis due to inadequate drainage.     

经皮肝穿胆道造影术靶胆管定位穿刺方法的应用

目的 精确测定肝内扩张胆管位置.设计穿刺途径,提高经皮肝穿胆道造影术(PTC)成功率.方法 对73例恶性阻塞性黄疸患者进行PTC,其中30例采用经皮肝穿靶胆管定位方法穿刺为实验组,43例采用传统法为对照组.实验组:在CT或MRI片上,取肝内胆管扩张最明显的层面,选择外周直径合适,与预计针道走行方向呈锐角的肝内胆管分支为靶胆管,靶胆管中点作为穿刺进入点,测量穿刺进入点至背部体表的距离为h值,h值为确定穿刺层面的参考值;分别测量靶胆管两端至腹部(矢状面)正中线距离为a值和b值,(a-b)值为靶胆管体表投影区的参考值;穿刺点定在h值层面与右侧肋膈角下2个肋间隙肋骨上缘相交点,针尖对准靶胆管体表投影区进行水平穿刺.对照组:取右侧腋中线肋膈角下2个肋间隙(常为第8～10肋间隙肝脏中部)肋骨上缘为穿刺点,针尖指向胸10～胸12椎体之间进行水平穿刺,至接近椎体右缘2～6 cm处.结果 实验组穿刺次数为1～4次,共62次,每例平均2.07次,成功率为48.4%;对照组穿刺次数为1～9次,共186次,每例平均4.33次,成功率为23.1%;两组比较具有显著性差异(χ2=14.294,P<0.01).结论 经皮肝穿胆道造影术靶胆管定位穿刺准确测定可提高穿刺成功率,减少肝脏损伤等并发症,对PTC是一种有效方法.     

Clinical experience of expandable metallic stent placement for malignant biliary obstruction]

Expandable metallic stents of modified Gianturco design were used in nine cases of malignant biliary obstruction. Stents were placed through a percutaneous transhepatic approach without any severe complications. Initial patency was obtained seven of nine patients. Of these seven patients, recurrent jaundice was observed in three within four weeks. One patient had recurrent stenosis after four months due to ingrowth of the tumor. Although the expandable metallic stent offers several theoretical advantages over currently available stents, a disadvantage is that tumors may grow through the spaces between the legs of the wire or grow over the stent. We found that multi-modal treatment combined with radiation therapy was indispensable to maintain the patency of the stent in malignant biliary obstruction.     

经皮肝穿刺胆道支架植入后再狭窄分析及介入治疗

目的探讨恶性胆道梗阻性黄疸经皮肝穿刺胆道支架置放术后支架再狭窄原因及介入治疗。方法20例胆道支架再狭窄患者,根据术后引流量及黄疸消退情况,于2周,1个月,2个月,3个月复查肝功、血、尿、粪及B超、CT、经引流管胆道造影,确认支架再狭窄性质、部位后,利用外置引流管途径行介入再通治疗。支架均为国产普通镍钛合金胆道支架,直径10mm,长度40~80mm。结果20例支架再狭窄中,9例为肿瘤浸润压迫所致,3例为支架上端成角致阻塞,4例为胆泥及食物残渣或陈旧性凝血块阻塞支架,2例为胆管炎性狭窄,2例为肉芽组织增生引起阻塞。全部再狭窄病例经引流管抽吸、药物灌注、冲洗、导管导丝疏通、球囊扩张、支架再植入予以复通,生存期超过6个月。结论经皮肝穿刺胆道支架植入术治疗恶性胆道梗阻,术后支架再狭窄率仍较高,应引起重视。     

盐酸哌替啶联合山莨菪碱在梗阻性黄疸介入干预术中的应用

目的 探讨盐酸哌替啶与山莨菪碱配伍应用在晚期恶性梗阻性黄疸患者肝穿胆道引流术(PTCD)及支架植入术(PTBS)中的应用效果.方法 因恶性梗阻性黄疸行PTCD及PTBS的100例患者,随机分成对照组与研究组,每组50例.研究组于术前30 min联合分别肌注盐酸哌替啶100 mg与山莨菪碱10 mg,对照组术前术中不用镇痛药及解痉药,观察患者血压和心率,记录胆心反射发生率及手术时间,应用疼痛评分量表评定患者疼痛程度.结果 与对照组相比,盐酸哌替啶与山莨菪碱配伍应用能稳定研究组患者生命体征、缩短手术时间、减少胆心反射发生率、缓解疼痛,提高患者舒适度.结论 盐酸哌替啶与山莨菪碱配伍应用于晚期恶性梗阻性黄疸患者PTCD或PTBS介入术中,可缓解疼痛,节省手术时间,方法简便易行、安全有效、费用低廉,可以作为PTCD或PTBS介人手术前的常规用药.     

恶性梗阻性黄疸介入治疗并发症分析及其防治的探讨

目的探讨经皮经肝胆管引流和置入内支架治疗恶性梗阻性黄疸的方法及并发症的预防。方法65例恶性梗阻性黄疸患者接受经皮经肝胆管引流和置入内支架治疗。其中肝门部肝癌18例,胆管癌16例,胆囊癌累及胆总管3例,胃癌肝门淋巴结转移16例,胰腺癌8例,胆肠吻合术后吻合口狭窄4例。结果20例放置了胆管支架,其中2例因左右肝总管梗阻各放置了2枚金属内支架;15例放置了内外引流管;29例单纯放置外引流管;1例右侧胆管放置支架,左侧放置内外引流管。与操作有关的并发症为胆管出血2例,其中胆管出血致出血性休克1例;感染4例,2例出现败血症;肝功能损害5例;局限胆汁性腹膜炎并发反应性胸腔积液1例;电解质紊乱1例;引流管部分移位或脱出8例;引流管阻塞2例;支架置入后早期发生再狭窄1例。结论恶性梗阻性黄疸介入治疗方法简单、疗效确切,正确选择适应证、规范操作技术可以减少并发症的发生。     

Evaluation of percutaneous cholangiography and percutaneous biliary drainage in obstructive jaundice

104 patients with obstructive jaundice were referred for percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD). The effects of PTBD on postoperative morbidity and mortality were evaluated as well as the occurrence of complications. The results were compared to a group of 33 patients with malignant bile duct obstruction operated without preoperative bile drainage. There was no significant difference in the rate of postoperative complications and mortality between these two groups.     

The role of interventional radiology in biliary complications after orthotopic liver transplantation: a single-center experience

This study evaluated interventional radiological experience in the management of biliary complications of OLT at the National Cancer Institute of Milan. Seventeen patients who had undergone orthotopic liver transplantation in various hospital were referred to our unit with biliary complications. Group I consisted of 8 patients with anastomotic biliary fistula who came to our attention a short time after transplantation. Group II consisted of 9 patients with anastomotic strictures who came to our attention in a longer period. Two different interventional radiological approaches were used: (a) percutaneous transhepatic biliary drainage (PTBD) in the presence of fistulas in patients of group I; and (b) percutaneous transhepatic biliary drainage combined with dilatation of the strictures with a balloon catheter in patients of group II. On the whole resolution of the biliary complications was achieved in 13 of the 17 cases treated (76.5%), 5 of 8 in group I and 8 of 9 in group II. No secondary stenosis after PTBD were observed in group I, whereas two patients of group II needed a second dilatation. Percutaneous biliary drainage is indicated as a valid treatment in the management of biliary complications, either to allow closure of the fistula either to perform balloon dilatation of stenosis.