经皮肝穿刺胆道支架置入及引流术治疗梗阻性黄疸

目的 探讨梗阻性黄疸经皮肝穿刺胆道支架置入及引流术的治疗方法与疗效.方法 对44例胆道梗阻患者先行经皮肝穿刺胆道造影(PTC),如导丝不能越过阻塞段,则直接行外引流;如能越过阻塞段,则行支架置入或内外引流术.结果 44例患者中6例单纯外引流;7例单纯内外引流;2例仅行PTC胆道造影而未行胆道引流;29例置入支架32枚,其中19例行支架置入 外引流,10例单纯支架置入.在有完整随访资料的16例中,术后1周血清总胆红素从术前(351±142.4)μmol/L降至(143.5±97.6)μmol/L,13例血清总胆红素1个月降到正常或接近正常水平,3例血清总胆红素1个月无明显下降(＜50%).死亡9例,生存时间3～21个月,中位生存期6.8个月.结论 经皮肝穿刺胆道支架置入及引流术是治疗梗阻性黄疸的一种安全、有效的姑息性方法.     

经皮肝穿刺胆道造影在老年梗阻性黄疸病因诊断中的应用

目的 探讨经皮肝穿刺胆道造影（ＰＴＣ）在老年人梗阴黄音病因诊断的价值。方法 回顾性分析４５例老年人梗阻性黄疸的ＰＴＣ，其中３７例有完整的手术和病理检查资料。结果 ＰＴＣ穿刺成功率高，达９７．３％（３６／３７），且相当安全。ＰＴＣ对梗阻性疸中非肿瘤性病因和肿瘤性病因诊断符合率分别为９３．３％（１４／１５）和８６．４％（１９／２２），总的诊断符合率为８９．２％（３３／３７），而Ｂ超和ＣＴ的诊断条例率分     

超声引导下经皮肝穿胆管引流术穿刺应用分析

超声引导下经皮肝穿胆管引流（PTCD）是治疗梗阻性黄疸的一种姑息性疗法,可缓解因梗阻性黄疸而导致的一系列临床症状与体征,提高患者的生活质量。我院近5年来外展了48例55例次PTCD治疗,现将结果报告如下。 1 资料与方法 1．1 一般资料：2005—01～2010—05,对我院住院的48例梗阻性黄疸患者进行了55例次PTCD治疗,其中男32例36例次,女16例19例次,年龄26～75岁,平均（56．73±11．98）岁。     

恶性梗阻性黄疸患者经皮肝穿胆道引流术后胆道感染危险因素的探讨

目的 研究恶性梗阻性黄疸患者经皮肝穿胆道引流术(PTBD)后与胆道感染相关的独立危险因素.方法 因恶性梗阻性黄疸第1次行PTBD引流术,术前白细胞计数不高、无发热、不存在术前胆道感染的连续患者154例纳入研究.根据术后30 d内胆道感染发生的情况将患者分为胆道感染组和非感染组,应用单因素和多因素分析对术前20个潜在的与PTBD术后胆道感染相关的危险因素,如年龄、性别、糖尿病、肝功能分级、引流方式、是否存在未引流胆管、经内镜逆行胰胆管造影术(ERCP)或胆肠吻合手术史等进行分析.20个潜在的危险因素先行单因素分析,连续变量的比较应用Student t检验,分类变量应用x2检验;将单因素分析筛选出的可能危险因素再进行多因素Logistic分析.结果 154例患者中55例发生术后胆道感染(35.7％),即胆道感染组;99例术后未发生胆道感染,即非胆道感染组.胆道感染相关的病死率为2.6％ (4/154).154例患者中131例行术中胆汁细菌培养,胆道感染组45例,26例为阳性;非感染组86例,17例为阳性,两组差异有统计学意义(x2=19.357,P＜0.01).单因素分析显示20个潜在危险因素中,糖尿病(x2=10.470,P＜0.01)、肝功能分级(x2=36.324,P＜0.01)、存在未能引流胆管(x2=9.540,P＜0.01)、内外引流(x2=9.856,P＜0.01)、ERCP或胆肠吻合史(x2=14.196,P＜0.01)、肿瘤患者的生活质量评分(t=-3.288,P＜0.01)、Karnofsky功能状态评分(t=-2.099,P＜0.05)、丙氨酸转氨酶(t=-2.112,P＜0.05)、凝血时间(t=-3.648,P＜0.01)、血白蛋白含量(t=-2.071,P＜0.05)、白细胞计数(t=2.022,P＜0.05)、高位胆道梗阻(x2 =6.190,P＜0.05)、肝硬化病史(x2=5.439,P＜0.05)13个因素为具有统计学意义的危险因素;对这13个因素继续行多因素分析显示糖尿病(OR=5.093,P＜0.01)、肝功能分级(OR=13.412,P＜0.01)、存在未能引流胆管(OR=3.348,P＜0.05)、内外引流(OR=3.168,P＜0.05)、ERCP或胆肠吻合病史(OR=8.330,P＜0.01)为具有统计学意义的危险因素.其中糖尿病、肝功能分级、ERCP或胆肠吻合手术史为3个相关的患者因素,内外引流和存在未能引流胆管为2个与手术相关的因素.结论 PTBD是一种有效且安全的恶性梗阻性黄疸患者的姑息治疗方法.术前采取更积极的措施,如控制血糖、改善肝功能、改变引流方式、充分引流等,能够降低PTBD术后胆道感染的发生率.     

原因不明胃肠道出血的DSA

目的：进一步提高消化道出血的诊断率，探讨ＤＳＡ的应用价值。材料和方法：对３０例原因不明胃肠道出血病例行选择性腹腔动脉和肠系膜上、下动脉造影。在常规ＰＵＣＫ快速摄片后，再行ＤＳＡ，比较两种方法所见。结果：３０例中２４例发现病理血管，检出病变，检出率为８０％。其中肿瘤６例（胃肠平滑肌瘤或肉瘤５例，腺瘤１例），血管病变１１例（ＡＶＭ６例，小肠毛细血管扩张症４症，胃底静脉曲张１例）；炎症性病变６例（麦克尔憩室２例，胆道出血１例，胃溃疡或糜烂３例）和十二指肠粘膜异位１例。ＤＳＡ较常规血管造影片显示病变更清楚，血管结构更仔细。２例小肠毛细血管扩张症在常规血管造影片上仅见小血管密集，紊乱，而ＤＳＡ则能清楚显示病变肠段较正常肠段染色异常增浓，因此术前得以确诊。本组资料显示ＤＳＡ对于提高胃肠道出血的病变检出率和诊断正确率很有价值。１例小肠毛细血管扩张症出血第一次检查阴性。一周后采用山莨菪碱药物血管造影，ＰＵＣＫ及ＤＳＡ见造影剂外溢及肠管异常染色而得到诊断。结论：胃肠道出血的血管造影检查结合应用ＤＳＡ，可进一步提高病变检出率和诊断正确率。     

经皮肝穿胆汁引流术后胆道出血的临床分析

目的回顾经皮肝穿胆道引流术后胆道出血发生与处理措施。方法无法或不能耐受手术的梗阻性黄疸患者139例,经常规经皮肝穿胆管造影后,一步法或二步法穿刺扩张胆道,放置外引流管或内外引流管及金属内支架留置,临床观察治疗前后总胆红素指标改变及手术相关并发症,处理胆道出血。结果全部患者经皮经肝穿刺胆道引流手术成功,治疗后总胆红素明显下降,由360μmol/L降至158.2μmol/L,使用止血药物43例,11例轻微胆道出血,调整引流管及应用止血药后停止,5例严重胆道出血,4例肝动脉损伤,其中3例肝动脉栓塞治疗成功,1例失败。结论经皮经肝穿刺胆汁引流可并发胆道出血,能及时有效控制,术者应不断提高穿刺水平,减少胆道出血并发症发生。     

肝门区恶性梗阻性黄疸不同经皮经肝穿刺胆道引流术疗效对比

目的比较经皮经肝穿刺胆道引流术（PTBD）不同引流方式治疗肝门区恶性梗阻性黄疸的近期疗效。 方法回顾性分析154例肝门区恶性梗阻性黄疸患者的临床资料,根据接受的不同PTBD引流方式分为壶腹上内外引流、跨壶腹内外引流、外引流及双侧PTBD引流四组,同时将外引流组分为横跨引流组及单纯外引流组两个亚组,利用单因素方差分析或卡方检验比较近期疗效的差异。 结果肝门区梗阻性黄疸不同引流方式在缓解TBIL、DBIL、TBA、ALT、AST、ALP、rGGT及术后肾功能损害发生率方面彼此之间没有差异。跨壶腹内外引流术后胆道感染发生率明显高于其他引流方式。 结论不同PTBD引流方式对肝门区恶性梗阻性黄疸在减黄和缓解肝功能方面效果相当。     

经皮肝穿胆道引流术后肝动脉出血的介入治疗

目的 分析经皮肝穿胆道引流术后肝动脉出血的原因及临床表现,总结诊疗经验,以降低其发生率及病死率.方法 2007年6月至2010年6月622例接受经皮肝穿胆道引流术患者中有11例患者肝动脉出血(均经血管造影证实),其中胆道出血6例,腹腔出血3例,胆道及腹腔合并出血2例.该文回顾性分析肝动脉出血患者的临床表现及治疗结果.结...     

Arterial complications of percutaneous transhepatic biliary drainage

Purpose: To report on the frequency and treatment of arterial complications due to percutaneous transhepatic biliary drainage (PTBD). Materials: Lesions of the intrahepatic artery were encountered in 10 of 525 patients treated by PTBD (2%). Hemobilia followed in 9 patients and subcapsular hematoma in 1. Seven patients had a benign biliary stenosis and 3 had a malignant stenosis. Results: The bleeding resolved spontaneously in 3 patients. In 7 it required arterial embolization, which was successfully achieved either through the percutaneous catheter (n= 3) or by arteriography (n= 4). Conclusion: Arterial bleeding is a relatively rare complication of PTBD that can easily be treated by selective arterial embolization when it does not resolve spontaneously. In this series its frequency was much higher (16%) when the stenosis was benign than when it was malignant (0.6%). Received: 0/00/000 Accepted: 0/00/00     

Prognostic factors after percutaneous transhepatic biliary drainage

The authors reviewed the clinical charts and the radiographic files of 93 patients with obstructive jaundice--in 86 cases due to neoplasm--treated with PTBD. The test of differences from survival curves was used to identify the clinical parameters predictive of short survival after PTBD. The difference in survival curves was significant relative to serum indirect bilirubin (cut point: 7.6 mg%), to serum cholinesterase (cut point: 1290 mU/ml), to white blood cell counts (cut point: 8600/mm3), to blood urea nitrogen (BUN) levels (cut point: 60 mg%). Because of the marked negative prognostic value of high BUN levels, our data seem to indicate that PTBD should not be performed when severe renal insufficiency is present. Other parameters correlated with a short survival after PTBD were the histotype of metastasis (in comparison with the other ones), and large neoplastic volume (in comparison with a small and a medium ones). Through pre-PTBD radiological and laboratory data analysis, a group of patients can be selected in whom the procedure will increase neither well-being nor survival, as plotted against those patients who are likely to benefit from biliary drainage.     

经皮肝穿刺胆道引流术及胆管内支架植入术在恶性梗阻性黄疸治疗中的应用

目的 评价经皮肝穿刺胆道引流(FTBD)及胆管内支架植入术(PTIBS)治疗恶性梗阻性黄疸的疗效.方法 对56例恶性梗阻性黄疸患者采取PTBD或PTIBS,所有患者均经B超、CT或MRI明确诊断,并确定梗阻部位,其中高位梗阻19例,低位梗阻37例.梗阻原因包括肝癌14例,胆管癌11例,胆囊癌5例,胃癌伴淋巴结转移14例,壶腹部占位1例,胰头癌11例.术中根据造影结果选择合适方案.结果 所有56例均成功完成手术.其中行PTBD 11例,PTIBS 40例,PTBD并PTIBS 5例.TBIL由术前(295.65 ±152.86)μmol/L降至术后(151.05 ± 107.36)μmol/L(P<0.01).术后感染对黄疸消退有影响(P<0.01).梗阻部位与黄疸消退情况比较差异无统计学意义(P=0.063).结论 经皮肝穿刺胆道引流及支架植入术治疗恶性梗阻性黄疸安全有效,可明显减轻黄疸,改善患者生活质量,延长生存期.     

Tumor extension along percutaneous transhepatic biliary drainage tracts

Percutaneous Transhepatic Biliary Catheterization is commonly employed in the diagnosis and management of obstructive jaundice associated with malignant lesions. Tumor manipulation as an effort to obtain a histological diagnosis or to establish short or long-term internal-external biliary drainage is liable to disseminate the malignancy along the catheter tract. Two cases of malignant seeding of the catheter tract after biliary drainage have been observed.     

经皮穿肝胆管引流术指南的建议

经皮穿肝胆管引流术是治疗梗阻性黄疸的有效手段,随着各种新颖的穿刺器械不断开创、操作技术的提高及医学理念的更新,该方法在临床上被广泛地应用于缓解胆道梗阻。为更好地应用此项技术,本文就经皮穿肝胆管引流术的适应证、禁忌证、操作方法、术后处理、并发症及预防、注意事项等方面提出一些建议,作为制订经皮穿肝胆管引流术指南讨论的基础。     

经皮肝穿刺胆管-胃引流治疗梗阻性黄疸动物实验

目的 探讨经皮肝穿刺胆管-胃引流(PTCGD)治疗顽固性胆道梗阻黄疸的可行性、安全性和有效性.方法 健康杂种家猪20只,行胆总管结扎,建立梗阻性黄疸动物模型.动物于术后14 d随机分成两组:①PTCGD组(A组,n=10):行PTCGD,置入内引流管.②对照组(B组,n=10):在胆总管结扎后不予治疗.两组在不同时间段内观察血清总胆红素(TBIL)、直接胆红素(DBIL)、丙氨酸转氨酶(ALT),白蛋白(ALB)变化,比较2组间及内引流前后差异,观察肝脏病理学和影像学改变.结果 A组技术成功率为100%,行PTCGD后肝内胆管扩张明显减轻,肝功能显著改善,病理表现显示肝组织明显修复好转.B组动物分别死于胆总管结扎术后23～32 d,TBIL、DBIL、ALT在胆总管结扎后持续升高,并且随梗阻时间延长逐步加重,胆管造影显示肝内外胆管重度扩张,病理显示肝小叶出现大片状坏死,小叶间胆管胆汁淤滞,扩张明显,肝细胞崩解.结论 PTCGD是梗阻性黄疸动物模型,特别是常规介入放射学技术不能成功的顽固性胆道梗阻又一较为安全、有效、微创的治疗方法.     

Thoracic paravertebral block for percutaneous transhepatic biliary drainage

Percutaneous transhepatic biliary drainage is a painful procedure most commonly performed after intravenous sedation. Despite systemic opiates and benzodiazepines, most patients experience significant pain during the procedure and in the recovery period. Paravertebral blocks allow the spinal nerve roots and sympathetic chain in the paravertebral space to be anesthetized, and their role in providing analgesia for thoracic and upper abdominal surgical procedures is well-established. Herein a case is described in which thoracic paravertebral blockade dramatically reduced standard intra- and postprocedural analgesic needs and provided superior pain control.     

经皮经肝胆道引流术后胆道感染的相关因素分析

目的探讨经皮经肝胆道引流（PTCD）术后胆道感染的相关因素,更好地防治术后的胆道感染。方法对我院78例因梗阻性黄疽接受PTCD治疗的患者资料进行回顾性分析,以术前和术后的临床和实验室指标作为观察对象,分析影响术后胆道感染的相关因素并行多元非条件Logistic回归分析。结果术后胆道感染25例,感染率为32.05%。X²检验表明患者年龄、术前黄疸天数、术前有无胆道感染、术前生活质量评分（KPS）ALT、ALP、GGT、TBIL、引流方式、每日平均引流量与术后胆道感染率有关,进行非条件多元logistic分析,采取向前逐步选择自变量的方式,并选择有主要作用的影响因素,并得出方程:P=(e^{-0.296+2.003X₃+2.860X₂-3.957X1})/(1+e^{-0.296+2.003X₃+2.860X₂-3.957X₁})其中X₁为每日平均引流量,X₂为ALP,X₃为术前黄疸天数。结论术后的平均引流量、ALP、术前黄疸的天数是PTCD术后胆道感染的相关因素。因此,对不能手术的梗阻性黄疸患者应及早行PTCD术,同时积极调整肝功能,术后紧密观察引流量的多少。只有这样才能更好地预防术后胆道感染。     

Biliary leaks: treatment by means of percutaneous transhepatic biliary drainage

PURPOSE: To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks. MATERIALS AND METHODS: Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect. RESULTS: In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma. CONCLUSION: Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.