囊肿型胆道闭锁MRI和MRCP特征

目的 分析囊肿型胆道闭锁（CBA）的MRI和MR胰胆管造影（MRCP）表现。方法 回顾性分析24例经手术病理证实的CBA患儿术前MRCP及MRI资料,结合术中造影及病理结果,分析CBA的影像学特点。结果 24例CBA,MRI均显示肝门区囊状结构,11例出现肝门区门静脉周围T2WI高信号,23例显示胆囊宽径明显小于长径,1例胆囊未显示;5例显示肝门区纤维斑块。24例CBA患儿MRCP均可见肝外胆总管区囊性结构,位于肝门区22例,位于左右肝管区2例;18例肝门区囊肿与胆囊管相通。结论 肝门区囊肿及纤维斑块、胆囊大小、形态及MRCP显示的肝外胆管情况是诊断CBA的重要征象。MRCP对于早期诊断CBA具有一定价值。     

声辐射力脉冲成像技术术前评估胆道闭锁患儿肝硬化

目的 探讨声辐射力脉冲（ARFI）成像技术术前评估胆道闭锁患儿肝硬化的价值。方法 选取64例经胆道造影检查确诊的胆道闭锁患儿,于Kasai手术前3天内行ARFI检查,并在术中行肝组织活检,根据活检病理结果分为肝硬化组和非肝硬化组。于声触诊组织量化模式下测定肝脏剪切波速度（SWS）值,比较2组间SWS值的差异,并绘制ROC曲线,评价SWS值术前诊断胆道闭锁患儿肝硬化的价值。结果 64例胆道闭锁患儿中,肝硬化组8例,SWS值为（2.51±0.50） m/s;非肝硬化组56例,SWS值为（1.74±0.31） m/s,肝硬化组SWS值明显高于非肝硬化组（t=6.039,P<0.001）。ROC曲线分析显示ARFI技术诊断肝硬化的最佳临界值为2.16 m/s,曲线下面积为0.930（P<0.001）,诊断敏感度、特异度分别为87.50%、92.86%。结论 ARFI成像技术在无创评价预测胆道闭锁患儿术前肝硬化中有一定的价值,可为临床选择治疗方案和判断疾病预后提供指导信息。     

超声鉴别诊断小儿常见病理性黄疸性疾病

目的 探讨超声早期鉴别诊断婴儿病理性黄疸的应用价值。方法 回顾性分析74例病理性黄疸患儿,包括婴儿肝炎综合征28例、胆道闭锁32例、先天性胆总管囊肿8例、胆管发育不全3例、新生儿肾上腺出血3例,对其声像图表现进行总结分析。结果 胆道闭锁患儿高频超声检查多表现为胆囊收缩不良(31/32,96.88%)、TC征(30/32,93.75%)及空腹胆囊充盈不良(24/32,75.00%),婴儿肝炎综合征中空腹胆囊充盈不良(16/28,57.14%)多见,先天性胆总管囊肿患儿肝门区无回声包块(8/8,100%)多见,胆管发育不良者空腹胆囊充盈不良(3/3,100%)多见,新生儿肾上腺出血者肾上腺区包块(3/3,100%)多见。结论 超声可用于鉴别诊断婴儿病理性黄疸,可于早期为临床提供较可靠的诊断线索。     

高频超声与MRI鉴别诊断胆管闭锁

目的 探讨高频超声与MRI对胆管闭锁及非胆管闭锁性黄疸的鉴别诊断价值。方法 对47例黄疸患儿进行高频超声检查,观察TC征、肝右动脉和胆囊等;对其中23例患儿行MR检查,观察胆总管、肝总管和胆囊。以肝穿刺组织学检查、术后病理检查结果或临床痊愈为金标准,对比两种方法诊断小儿黄疸的敏感度、特异度及准确率。结果 47例患儿中,胆管闭锁19例、非胆管闭锁28例。高频超声观察指标中,TC征阳性、肝右动脉增宽和异常胆囊对诊断胆管闭锁的诊断价值较高,以其中两项阳性诊断胆管闭锁的敏感度、特异度及准确率分别为94.47%(18/19)、92.86%(26/28)和93.62%(44/47)。MRI观察指标中,以胆总管、肝总管未显示或不连续(伴或不伴胆囊未显示)诊断胆管闭锁的敏感度、特异度及准确率分别为44.44%(8/18)、80.00%(4/5)和52.17%(12/23)。结论 高频超声对鉴别胆管闭锁及非胆管闭锁性黄疸有较高的准确率,可作为首选检查方法。     

输卵管导管联合腹腔镜治疗胆总管结石的临床体会

目的 探讨采用输卵管导管联合腹腔镜治疗胆总管结石的临床技巧。方法 回顾性分析该院2017年2月－2018年1月48例因胆总管结石行输卵管导管联合腹腔镜胆总管切开探查的患者的临床资料。结果 所有患者均在腹腔镜下成功取出并取尽胆总管内结石,一期胆总管缝合43例,放置T管引流5例;手术时间45～180 min,平均116 min。术后住院时间为6～14 d,平均8 d。术后发生胆瘘1例,保守引流9 d后痊愈;5例放置Ｔ管引流者,术后4～6周行Ｔ管造影,均无结石残留,拔除T管。术后随访3个月～１年,未见胆管狭窄及残留结石等情况发生。结论 输卵管导管联合腹腔镜治疗胆总管结石是安全、可行和有效的,娴熟的输卵管导管冲洗取石技巧、丰富的腹腔镜经验及术中细致的操作是手术成功的关键。     

弥散张量成像诊断新生儿和婴儿胆道闭锁

目的 探讨弥散张量成像（DTI）对新生儿和婴儿胆道闭锁（BA）的诊断价值。方法 收集疑诊为BA或其他胆道疾病的患儿46例,以手术探查、腹腔镜探查、术中造影、病理检查或临床治疗结果作为金标准,将患儿分为BA组与非BA组（non-BA组）。对所有患儿应用1.5T MR扫描仪,采用单次激发自旋回波平面成像DTI序列（b值为1000 s/mm²）行肝脏扫描,经后处理获得平均扩散系数（AvgDC）图及FA图,测量AvgDC值及FA值。结果 46例中,BA组24例,non-BA组22例,BA组的AvgDC值显著低于non-BA组［（1.27±0.16）×10^-3 mm²/s vs （1.43±0.15）×10^-3 mm²/s,P=0.001)］。在BA组中,不同肝脏纤维化分级患儿间AvgDC值、FA值的差异均无统计学意义（P>0.05）;INF1~INF3级炎症分级患儿AvgDC值逐渐降低,但差异无统计学意义（F=2.15, P=0.14）,FA值差异有统计学意义（F=5.51, P=0.01）。应用AvgDC、FA值诊断BA的ROC曲线下的面积分别为0.80±0.07、0.60±0.09;AvgDC界限值为1.33×10^-3 mm²/s时,诊断敏感度为75.00%（18/24）,特异度为77.27%（17/22）。结论 DTI的AvgDC值可用于诊断新生儿和婴儿BA,但其诊断敏感度与特异度仍有待提高。     

腹腔镜在婴幼儿阻塞性黄疸病因诊断中的应用

目的探讨腹腔镜在婴幼儿阻塞性黄疸病因诊断中的应用。方法阻塞性黄疸患者30例,男20例,女10例,年龄60~180 d;术前行血生化、B超、CT等检查未能确定病因。在腹腔镜下行胆囊置管造影术、胆道冲洗及肝活检术。结果20例患儿炎性阻塞,其胆囊充盈,造影显示肝外胆道通畅,术中用生理盐水冲洗胆道,术后黄疸迅速消退,肝功能多项升高指标明显下降;10例患儿为先天性肝外胆道闭锁,其胆囊干瘪,造影肝外胆道不显影,肝大、表面布满结节,绿褐色,胆总管为纤维索块。30例患儿肝脏均有不同程度硬化,其中炎性阻塞患儿明显较轻。结论腹腔镜胆道探查能早期确诊婴幼儿阻塞性黄疸,对部分患儿术中行胆道冲洗治疗,争取了治疗时机,避免了肝脏进一步硬化,其技术微创,诊断准确,操作简便。     

逆行胰胆管造影诊治肝包虫囊肿破入胆总管1例并文献复习

  目的  研究逆行胰胆管造影(endoscopic retrograde cholangiopancreatography, ERCP)对肝包虫囊肿破入胆总管的诊疗价值。  方法  报告1例肝包虫囊肿破入胆总管患者的ERCP诊治经过并复习文献。  结果  该患者临床表现类似急性化脓性胆管炎, 经ERCP确诊, 且治疗后好转。  结论  肝包虫病患者突发急性胆系感染, 应怀疑肝包虫囊肿破入胆道。围手术期ERCP对提高该病的诊治水平有重要价值。     

盆部MRI诊断原发性闭经

目的 探讨MRI对原发性闭经的诊断价值。方法 回顾性分析16例经手术证实病因的原发性闭经患者的盆部MRI资料,并与手术结果对照。结果 手术证实16例原发性闭经患者包括1例阴道下1/3闭锁、12例苗勒管畸形（MDA）、1例完全性雄激素不敏感综合征（AIS）和2例先天性肾上腺皮质增生（CAH）。14例（14/16,87.50%）术前MRI诊断与术后诊断相符。2例（2/16,12.50%）术前MRI误、漏诊,均为MDA患者,其中1例术中见2个始基子宫,术前MRI漏诊左侧始基子宫,另1例合并宫颈缺如,术前MRI误诊为阴道闭锁。结论 通过MRI可较为准确地观察阴道、子宫、卵巢结构及发育情况,对原发性闭经患者术前行MR检查有助于及时诊断。     

磁共振胆管成像和动态十二指肠液检查鉴别诊断婴儿肝炎与胆道闭锁

目的探讨磁共振胆管成像(MRC)和十二指肠液引流对婴儿期胆道闭锁(EHBA)与婴儿肝炎综合征(IHS)的鉴别诊断价值。方法应用磁共振和婴儿十二指肠引流管对52例婴儿期持续性阻塞性黄疸行MRC和十二指肠液检查,以胆总管、肝总管显影和十二指肠液检查有胆汁(胆汁酸阳性)并经随访黄疸消退诊断为婴儿肝炎综合征;以胆总管、肝总管未显示,十二指肠液检查无胆汁(胆汁酸阴性)且经外科手术探查诊断为胆道闭锁;并将胆道闭锁MRC及十二指肠检查结果与手术、病理结果对比分析。结果52例患儿中最后有34例确诊为婴儿肝炎综合征,18例确诊为胆道闭锁。34例婴儿肝炎综合征中30例MRC能清楚显示胆总管、肝总管结构,2例显示较小胆囊,2例胆总管、肝总管未显示。首次十二指肠液检查有胆汁31例,3例无胆汁。18例胆道闭锁中13例胆囊、胆总管和肝总管未显示,4例仅显示较小胆囊,1例仅显示较大胆囊,十二指肠液检查均无胆汁。18例确诊为胆道闭锁的患儿中,17例与MRC及十二指肠引流诊断相符。结论十二指肠引流液检查能直接观察有无胆汁,诊断胆道闭锁的敏感性为100%,特异性为91.1%;MRC能显示肝外胆道结构,诊断胆道闭锁的敏感性为94.4%,特异性88.24%;十二指肠与MRC联合诊断胆道闭锁的敏感性94.4%,特异性97.06%,因此二者结合应用能较准确鉴别诊断婴儿肝炎与胆道闭锁。     

螺旋CT胆道造影及MRCP对先天性胆总管囊肿的诊断

目的：评价螺旋ＣＴ胆道造影及ＭＲＣＰ对胆总管囊肿的诊断价值。材料与方法：胆总管囊肿的病人先进行上腹部螺旋ＣＴ胆道造影检查，ＣＴ检查后第二天进行ＭＲＣＰ检查，于ＣＴ检查后第三天进行手术治疗，并行术中胆道造影，将ＣＴ胆道造影及ＭＲＣＰ结果与术中所见进行比较。结果：螺旋ＣＴ胆道造影及ＭＲＣＰ准确地做出胆总管囊肿的诊断，利用ＳＳＤ及ＭＩＰ重建的方法，囊肿与胆总管之间的关系被清楚地显示出来，并且可以更加直观地显示出肝内、外胆管扩张的有无及其扩张程度，其结果与术中所见一致。结论：螺旋ＣＴ胆道造影及ＭＲＣＰ可以作为一种无创性的，准确的方法用于胆总管囊肿的诊断。     

MRI manifestations of adult choledochal cysts associated with biliary malignancy: a report of ten cases

Background

To retrospectively review the MRI imaging features of adult choledochal cysts associated with biliary malignancy.

Patients and methods

Ten out of 72 cases of adult choledochal cysts were found to be associated with biliary malignancy between January 1, 2003 and April 1, 2011 in our hospital database. The following MRI findings of these ten patients were retrospectively reviewed: the type of choledochal cysts, the presence of anomalous union of the pancreaticobiliary duct (AUPBD), manifestations of biliary malignancy, and concomitant findings.

Results

Among the ten patients, there were five type I and five type IVA choledochal cysts. AUPBD was noted in four cases. The biliary malignancy was diagnosed as cholangiocarcinoma in seven cases (70.0%) and as gallbladder cancer in three cases. Cholangiocarcinoma manifested with irregularly thickened cyst wall (n = 2), mass with irregularly thickened cyst wall (n = 4), or multiple papillary nodules without thickened cyst wall (n = 1). Most of them showed mark enhancement (n = 4) after contrast administration. Gallbladder cancer appeared as mass with irregular thickening of the gallbladder wall with inhomogeneous enhancement. Concomitant findings included liver invasion or metastases in five cases, lymph node metastases in two cases, cholangitis and/or hepatic abscess in two cases, biliary stones in three cases. The type of choledochal cysts and the extent of malignant tumor invasion revealed by MRI were consistent with the surgical findings.

Conclusion

Most malignancies associated with choledochal cysts are cholangiocarcinoma and gallbladder cancer. MRI is a reliable method for the detection of choledochal cysts with biliary malignant changes. MR features such as irregular thickening of the gallbladder wall or cyst wall, mass or papillary nodules are suggestive of biliary malignant changes.     

钆贝葡胺增强MRC与3D-SPACE-T2WI-MRC显示活体肝移植供体胆管的比较

目的 比较钆贝葡胺(Gd-BOPTA)CE-MRC与3D-SPACE-T2WI-MRC对活体肝移植供体胆管解剖及变异的显示.方法 32名肝移植供体,术前接受Gd-BOPTA CE-MRC与3D-SPACE-T2WI-MRC.以术中胆管造影为标准,分析并比较两种方法诊断胆管变异情况.结果 两种方法对胆总管、肝总管、左肝管及右肝管的显示差异有统计学意义(P＜0.05),CE-MRC优于3D-SPACE-T2WI-MRC;对胆囊管,左前、后肝管,右前、后肝管及3级以上胆管的显示差异无统计学意义(P＞0.05).术中胆管造影诊断胆管变异17例,3D-SPACE-T2WI-MRC诊断14例,CE-MRC诊断15例,两者联合诊断17例.结论 3D-SPACE-T2EI-MRC与CE-MRC均可用于评估术前肝移植供体胆管解剖,CE-MRC对部分胆管的显示优于3D-SPACE-T2WI-MRC,二者联合应用效果更佳.     

Choledochal cysts: Ultrasonographic findings and correlation with other imaging modalities

In the past, choledochal cysts had been infrequently diagnosed prior to surgical exploration for obstructive jaundice. However, with the advance of imaging modalities, preoperative diagnosis is usually apparent. We evaluated the radiological findings of choledochal cysts in 14 patients in whom ultrasonography (US) or computed tomography (CT) were mainly used for diagnosis. In addition, oral cholecystography, intravenous (IV) cholangiography, scintigraphy, and percutaneous transhepatic cholangiography were performed in some of them. The diagnosis was confirmed surgically in all patients. Ultrasonographic examinations were diagnostic in 13 of 14 patients. Preoperative specific diagnosis of choledochal cyst was possible with the demonstration of direct entrance of the extrahepatic bile ducts into the cyst in most cases. When US fails to show relation of cystic mass with biliary system, other imaging modalities can be used to clarify the findings.     

比较99mTc-EHIDA SPECT/CT肝胆动态显像各时相诊断价值

目的 比较^99mTc-EHIDA肝胆动态显像不同时相诊断肝胆疾病的价值。方法 回顾性分析经病理学或临床综合确诊的387例接受^99mTc-EHIDA肝胆动态显像的肝胆疾病患者,根据肠道显像情况将其分为排泄正常组（n=65,均为非肝胆系疾病或肝胆系疾病痊愈者）和排泄异常组。观察排泄正常组早期相和延迟相代表排泄通畅的影像学表现是否一致;计算排泄异常组延迟各时相对疾病的检出率。结果 排泄正常组中,62例早期相与延迟相的影像学表现一致,3例延迟相可确认排泄通畅。排泄异常组中,延迟相2 h与4 h、4 h与6 h对婴儿先天性BA、IHS及胆总管囊肿检出率差异均有统计学意义（P均<0.008）,延迟相6 h与24 h对婴儿先天性BA、IHS及胆总管囊肿检出率差异均无统计学意义（P均>0.008）;延迟各时相对胆汁漏的检出率均较高,2 h与4 h、4 h与6 h、6 h与24 h比较差异均无统计学意义（P均>0.008）。结论 ^99mTc-EHIDA肝胆动态显像对多种肝胆系疾病具有较好的诊断价值。     

Cholangiojejunostomy for multiple biliary ducts in living donor liver transplantation: A case report

BACKGROUNDLaparoscopic living donor hepatectomy (LLDH) has been successfully carried out in several transplant centers. Biliary reconstruction is key in living donor liver transplantation (LDLT). Reliable biliary reconstruction can effectively prevent postoperative biliary stricture and leakage. Although preoperative magnetic resonance cholangiopancreatography and intraoperative indocyanine green cholangiography have been shown to be helpful in determining optimal division points, biliary variability and limitations associated with LLDH, multiple biliary tracts are often encountered during surgery, which inhibits biliary reconstruction. A reliable cholangiojejunostomy for multiple biliary ducts has been utilized in LDLT. This procedure provides a reference for multiple biliary reconstructions after LLDH.CASE SUMMARYA 2-year-old girl diagnosed with ornithine transcarbamylase deficiency required liver transplantation. Due to the scarcity of deceased donors, she was put on the waiting list for LDLT. Her father was a suitable donor; however, after a rigorous evaluation, preoperative magnetic resonance cholangiopancreatography examination of the donor indicated the possibility of multivessel variation in the biliary tract. Therefore, a laparoscopic left lateral section was performed on the donor, which met the estimated graft-to-recipient weight ratio. Under intraoperative indocyanine green cholangiography, 4 biliary tracts were confirmed in the graft. It was difficult to reform the intrahepatic bile ducts due to their openings of more than 5 mm. A reliable cholangiojejunostomy was, therefore, utilized: Suture of the jejunum to the adjacent liver was performed around the bile duct openings with 6/0 absorbable sutures. At the last follow-up (1 year after surgery), the patient was complication-free.CONCLUSIONIntrahepatic cholangiojejunostomy is reliable for multiple biliary ducts after LLDH in LDLT.     

Intraoperative fluorescent cholangiography using indocyanine green for laparoscopic fenestration of nonparasitic huge liver cysts

Bile duct injury is one of the known serious complications of laparoscopic fenestration for nonparasitic liver cysts. Herein, we report the case of a huge liver cyst for which we performed laparoscopic fenestration using intraoperative fluorescent cholangiography with indocyanine green. A 71‐year‐old woman with abdominal distention was referred to our hospital. CT demonstrated a 17 × 11.5‐cm simple cyst replacing the right lobe of the liver, so laparoscopic fenestration was performed. Although the biliary duct could not be detected because of compression by the huge cyst, fluorescent cholangiography with indocyanine green through endoscopic naso‐biliary drainage tube clearly delineated the intrahepatic bile duct in the remaining cystic wall. The patient had no complications at 3 months after surgery. Fluorescent cholangiography using indocyanine green is a safe and effective procedure to avoid bile duct injury during laparoscopic fenestration, especially in patients with a huge liver cyst.     

Application of near-infrared fluorescent cholangiography using indocyanine green in laparoscopic cholecystectomy

ObjectiveNear-infrared fluorescence cholangiography (NIRF-C) can help to identify the bile duct during laparoscopic cholecystectomy. This retrospective study was performed to investigate the effect of NIRF-C in laparoscopic cholecystectomy.MethodsConsecutive patients who underwent NIRF-C-assisted laparoscopic cholecystectomy (n = 34) or conventional laparoscopic cholecystectomy (n = 36) were enrolled in this study. Identification of biliary structures, the operation time, intraoperative blood loss, and postoperative complications were analyzed.ResultsLaparoscopic cholecystectomy was completed in all patients without conversion to laparotomy. The median operation time and intraoperative blood loss were not significantly different between the two groups. No intraoperative injuries or postoperative complications occurred in either group. In the NIRF-C group, the visualization rate of the cystic duct, common bile duct, and common hepatic duct prior to dissection was 91%, 79%, and 53%, respectively. The success rate of cholangiography was 100% in the NIRF-C group. NIRF-C was more effective for visualizing biliary structures in patients with a BMI of <25 than >25 kg/m².ConclusionsNIRF-C is a safe and effective technique that enables real-time identification of the biliary anatomy during laparoscopic cholecystectomy. NIRF-C helps to improve the efficiency of dissection.