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.     

介入治疗恶性梗阻性黄疸的临床价值

目的探讨介入治疗恶性梗阻性黄疸的临床应用价值。方法对79例恶性梗阻性黄疸患者根据具体情况给予经皮肝穿刺胆道置管外引流、内外引流或胆道内支架治疗。术后对患者的胆红素水平、一般症状等情况进行随访。结果所有患者均穿刺引流成功,单纯外引流14例、内外引流31例、置入金属支架内引流34例。术后患者一般症状、肝功能血清学指标,较术前明显改善,无严重并发症发生。结论介入治疗是治疗恶性胆道梗阻性黄疽的安全、有效的姑息治疗手段。     

恶性梗阻性黄疸微创引流及并发症的处理

目的 探索经皮肝穿刺胆道微创引流术(PTBD)治疗恶性梗阻性黄疸有效方法及常见并发症的处理.方法 对126例恶性胆道梗阻患者分别行经皮肝穿刺胆道引流术,所有病人均依据CT、MR及B超等影像资料和血液生化检查及临床体征确诊为恶性梗阻性黄疸.结果 本组经皮肝穿刺胆道成功率为98.4%(124/126),其中46例行外引流,34例行内外引流,内支架置入35例(2例双支架),3例行联合右支内外引流及左支外引流,8例因穿刺失败或肝内胆管置管困难未能行引流术.置入引流管或内支架后血清总胆红素、游离胆红素、结合胆红素、白蛋白、天门冬氨酸转移酶、丙氨酸氨基转移酶、碱性磷酸酶及γ-谷氨酰基转移酶较术前明显下降(P<0.05),患者全身状况改善.本组并发症发生率为20.2%(25/124),包括胆道感染9例,胆道出血8例,胆心反射5例,术中胆漏2例,术后胆汁腹膜炎1例.多数经保守治疗后症状消失,1例胆汁腹膜炎患者经开腹手术留置T管治疗,其中3例胆道出血患者因肝功能衰竭死亡.结论 经皮肝穿刺胆道引流术疗效可靠,单纯外引流和内外引流术具有同样减黄效果,临床工作中应根据梗阻部位和梗阻程度选择引流方法.     

胆道支架置入术姑息性治疗恶性梗阻性黄疸临床疗效观察

目的　观察经皮肝穿胆道支架置入术 ,在姑息治疗恶性梗阻性黄疸的临床疗效。方法　对恶性梗阻黄疸的 74例胆道支架 (包括 42例金属支架与 3 2例内涵管 )内引流术后临床资料作回顾分析。结果　术后对降低胆红素和改善临床症状均有明显疗效 ,胆红素以术后 1周时间下降最明显 ,术后 3周趋向正常。胆道支架以选择上段胆管梗阻为多 (占 5 2 .7% )。术后早期并发症较少 ;晚期并发症主要为支架阻塞。金属支架半年阻塞率为 19% ,平均开通时间为 2 14d ,内涵管半年阻塞率为 2 5 % ,平均开通时间为12 2d。结论　胆道支架能有效解除胆道梗阻 ,降低胆红素 ,尤其对高位胆道梗阻有较大优势 ;由于其微创性 ,适合于年老体弱者 ,估计生存期较短 (<6个月 ) ,宜选择支架引流 ,如选择金属支架 ;经济条件不许可者 ,可选用内涵管。     

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。     

胆管癌性阻塞姑息性胆肠吻合术后再发梗阻的介入治疗

目的　探讨胆管癌性阻塞姑息性胆肠吻合术后再发梗阻的介入治疗方法。方法　 10例胆管癌性阻塞姑息性胆肠吻合术后再发梗阻患者 ,9例采用经皮肝穿刺胆道引流术 (PTCD)加金属内支架置入术 ,共使用 9枚金属内支架 ,1例置入内外引流管 ,并比较介入手术前后总胆红素、谷丙转氨酶、谷氨酰转肽酶、碱性磷酸酶的变化。结果　 10例采用经皮经肝穿刺置入金属胆道内支架或内外引流管均获得成功 ,均一次性置入支架。术后总胆红素、谷丙转氨酶、谷氨酰转肽酶、碱性磷酸酶均有明显下降 ,与术前比较差异有显著性。术后黄疸消退满意。结论　经皮经肝穿刺胆管内金属支架再置入术治疗胆管癌性阻塞姑息性胆肠吻合术后再发梗阻 ,疗效满意 ,操作简单 ,并发症少     

经皮经肝胆道引流术治疗肝泡球蚴病致梗阻性黄疸的临床观察

目的 探讨经皮经肝胆道引流术(PTBD)治疗肝泡球蚴病致梗阻性黄疸的价值.方法 回顾性分析肝泡状棘球蚴病致梗阻性黄疸病例12例,男4例、女8例,年龄21～56岁.所有患者经B超、CT及相关实验室检查或病理诊断确诊,经皮肝胆道穿刺造影明确梗阻部位,随后置入引流管胆道引流或胆道内支架,观察随访术前术后总胆红素、直接胆红素、血清丙氨酸转氨酶.结果 12例病例均成功穿刺并置入引流管(10例)或置入支架(2例),成功率100%,对引流术前后总胆红素、直接胆红素、血清丙氨酸转氨酶水平行配对样本t检验(P＜0.05).结论经皮经肝胆道引流术可明显改善肝泡球蚴病致梗阻性黄疸患者症状,提高生存质量,创造二次手术机会.     

恶性梗阻性黄疸的介入治疗临床价值

目的：经皮经肝穿刺放置引流管、内涵管或金属内支架作胆汁外引流、内外引流或内引流，可缓解黄疸，改善由于梗阻性黄疸引起的各种症状。提高患者的生存质量，为下一步治疗创造条件。方法：恶性梗阻性黄疸常由于胆管癌、胰头癌、原发性肝癌、肝脏转移瘤、肝门淋巴结转移等压迫和侵及胆管所致，外科手术切除率低。主要技术包括PTCD、胆管内外引流、胆管内涵管及内支架置入术。结论：可作为手术前辅助治疗，主要行经皮肝穿刺胆管引流术（PTCD）或姑息性内外引流治疗以解除黄疸。     

恶性梗阻性黄疸的微创法引流

目的　探讨微创法经皮肝穿胆道引流术 (PTBD)治疗恶性梗阻性黄疸有效方法。资料与方法　对 14 5例恶性梗阻性黄疸患者分别行微创法PTBD ,所有患者均行CT、MRI或B超等影像学及血液生化检查诊断为恶性梗阻性黄疸。男 88例 ,女 5 7例 ,平均年龄 5 8.3± 11 .7岁。PTBD穿刺成功率为 10 0 %。 131例在电视透视下穿刺右肝管 ,其中右前支 12 5例 ,右后支 6例 ;14例在B超引导下穿刺肝管 (其中 12例左肝管外支 ,2例右后支肝管 )。结果　 88例行右支内外引流 ,4 1例行单纯外引流 (其中 39例行右支外引流 ,2例行左支外引流 ) ,8例行联合右支内外引流及左支外引流 ,8例行左支内外引流 ;外引流患者中 35例经 1～ 2周外引流后 ,再成功转为内外引流。另 6例持续带管行外引流。置入引流后较术前血清总胆红素下降明显 (P <0 .0 5 ) ,患者全身状况改善 ,血清谷丙转氨酶下降具有显著性 (P <0 .0 5 ) ,外引流组与内外引流组术前、术后胆红素下降也具显著性 (P <0 .0 5 ) ,并且两组之间术前具有可比性 (P >0 .0 5 )。并发症发生率为 6 .9% ,包括胆道感染 6例 ,胆汁外漏 3例 ,胆汁瘤 1例 ,经治疗后症状消失。结论　微创法PTBD具有独到优点 ,疗效可靠 ,单纯外引流和内外引流术具有同样减轻黄疸效果 ,临床工作中应根据梗阻部位和     

金属内支架在治疗恶性胆道梗阻中的应用

目的 :探讨经皮肝穿刺胆道金属内支架置入治疗恶性胆道梗阻临床应用价值。方法 :对 2 7例恶性梗阻性黄疸患者行经皮肝穿胆道金属内支架置入术。男 18例 ,女 9例 ,其中肝癌 6例 ,胆管癌 7例 ,胰腺癌 5例 ,转移癌 9例。梗阻部位在胆总管 12例 ,肝总管肝门区 15例。结果 :经皮肝胆道内支架置入术技术成功率为 10 0 %。 2 7例共置入金属内支架31枚 ,术后 1周复查肝功能血清学指标 ,总胆红素、碱性磷酸酶和谷丙转氨酶较术前明显下降 ,P <0 .0 0 1。随访开通时间平均为 14 1天 ,半年开通率 5 5 .6 % ,并发症发生率为 2 5 .9% ,主要为胆道感染 ,胆道出血等。结论 :金属内支架置入术是治疗胆道梗阻性黄疽的安全、有效的姑息治疗手段     

Radiological interventions in malignant biliary obstruction

Malignant biliary obstruction is commonly caused by gall bladder carcinoma, cholangiocarcinoma and metastatic nodes. Percutaneous interventions play an important role in managing these patients. Biliary drainage, which forms the major bulk of radiological interventions, can be palliative in inoperable patients or pre-operative to improve liver function prior to surgery. Other interventions include cholecystostomy and radiofrequency ablation. We present here the indications, contraindications, technique and complications of the radiological interventions performed in patients with malignant biliary obstruction.     

肝移植术后并发胆道狭窄和胆泥淤积影像诊断及介入治疗

目的:评价肝移植术后胆道狭窄和胆泥淤积影像诊断及介入治疗的价值。方法:对39例肝移植术后并发胆道狭窄和胆泥淤积的影像诊断及介入治疗进行回顾性分析。结果:超声、T型管胆道造影、CT和MRI检查诊断胆道狭窄伴胆泥形成39例,38例介入治疗后胆道梗阻症状明显缓解;1例介入治疗后胆道梗阻症状未明显改善,后行外科胆管修补术。结论:T型管胆道造影或直接经皮胆道造影对肝移植术后胆道狭窄和胆泥淤积诊断特异性及敏感性最高,放射介入和内镜介入技术对其均发挥重要的治疗作用。     

Inaccurate preoperative imaging assessment on biliary anatomy not increases biliary complications after living donor liver transplantation

Backgrounds and aims

Accurate assessment of graft bile duct is important to plan surgical procedure. Magnetic resonance cholangiopancreatography (MRCP) has become an important diagnostic procedure in evaluation of pancreaticobiliary ductal abnormalities and has been reported as highly accurate. We aim to estimate the efficacy of preoperative MRCP on depicting biliary anatomy in living donor liver transplantation (LDLT), and to determine whether inaccurate preoperative imaging assessment would increase the biliary complications after LDLT.

Methods

The data of 118 cases LDLT were recorded. Information from preoperative MRCP was assessed using intraoperative cholangiography (IOC) as the gold standard. The possible risk factors of recipient biliary complications were analyzed.

Results

Of 118 donors, 84 had normal anatomy (type A) and 34 had anatomic variants (19 cases of type B, 9 cases of type C, 1 case of type E, 2 cases of type F and 3 cases of type I) confirmed by IOC. MRCP correctly predicted all 84 normal cases and 17 of 34 variant cases, and showed an accuracy of 85.6% (101/118). The incidence of biliary complications was comparable between cases with accurate and inaccurate classification of biliary tree from MRCP, and between cases with normal and variant anatomy of bile duct. While cases with graft duct opening ≤5 mm showed a significant higher incidence of total biliary complications (21.1% vs. 6.6%, P = 0.028) and biliary stricture (10.5% vs. 1.6%, P = 0.041) compared with cases with large duct opening >5 mm.

Conclusion

MRCP could correctly predict normal but not variant biliary anatomy. Inaccurate assessment of biliary anatomy from MRCP not increases the rate of biliary complications, while small-sized graft duct may cause an increase in biliary complications particularly biliary stricture after LDLT.     

金属内支架治疗恶性梗阻性黄疸的临床研究：附33例分析

目的：总结胆管金属内支架放置术的临床经验和疗效分析。材料与方法：恶性梗阻性黄疸患者３３例，男２３例，女１０例。胆管癌１６例，胰头癌２例，原发性肝癌２例，肝转移瘤３例，肝门淋巴结转移瘤压迫胆管１０例。本组共采用金属内支架行内引流３３例，共使用６种３８枚金属内支架。１２例支架放置术后加局部放射治疗和化学治疗（简称放、化疗）。结果：３３例采用经皮经肝穿刺置入胆管支架均获得成功，其中２９例一次性植入支架，４例先行胆汁引流术（ＰＴＢＤ）后再放置金属内支架；９例因胆管梗阻复杂，金属支架置入后仍保留引流导管，其中３例在置管１５～２００天后拔除引流管。２８例（８４．８５％）黄疸消退满意。本组中位生存期７个月，支架植入后加局部放、化疗组中位生存期１０个月。结论：胆管内金属支架治疗恶性梗阻性黄疸，可用于不能手术治疗的高位胆管梗阻，支架植入后加局部放、化疗可望提高远期疗效。     

Radiologic approach to malignant biliary obstruction: Review and commentary

Access to the biliary tree for nonoperative intervention can be achieved endoscopically or by a direct transhepatic approach. If there is a surgical drainage tube in place this may also serve as a route for catheter insertion. Once within the ductal system, catheters can routinely be manipulated through obstructing lesions to provide biliary decompression and relieve jaundice and cholangitis. Permanent palliation can be achieved utilizing totally indwelling endoprosthesis to avoid the problems associated with external drainage catheters. The optimal management of patients with malignant biliary obstruction requires close cooperation between endoscopists and interventional radiologists.     

Metallic biliary endoprostheses

In patients with obstructive jaundice caused by unresectable malignant tumors, biliary endoprostheses insterted percutaneously or endoscopically can provide excellent palliation. Conventional plastic stents are associated with a relatively high rate of occlusion caused by biliary sludge. Migration is another significant problem. Self expandable, metallic stents can be inserted percutaneously via a small transhepatic track but expand to achieve a relatively large internal diameter. This minimizes the problem of occlusion due to encrusted bile and reduces the rate of reintervention. Migration rarely occurs. Metallic stents have also been employed in the management of recurrent benign biliary strictures unsuitable for surgery. In those patients in whom the frequency of radiological intervention is unacceptably high, such endoprostheses can provide a means of preventing restenosis.     

合理选择介入方式治疗高位胆道梗阻的探讨

目的:探讨高位胆道梗阻介入治疗方法的选择及临床疗效。方法:2005年1月~2008年1月,我科治疗高位胆道梗阻患者45例。13例行胆道内外引流加支架置入术,17例行支架置入后肝动脉化疗和/(或)栓塞,6例行单纯经皮胆道内外引流,3例行射频治疗后置入胆道支架,3例肝动脉栓塞后置入支架,2例行单纯射频治疗,1例行肝动脉灌注化疗栓塞。结果:39例患者术后1周黄疸减轻或消失(总胆红素<100μmol/L),总有效率87%;患者术后生存时间1~17月,平均7.2月;术后出现胆道感染5例,胆道出血3例,胆汁性腹膜炎1例,均经保守治疗后好转。结论:根据具体情况选择合理的介入治疗方法能够有效治疗高位胆道梗阻,减轻黄疸,改善患者生活质量,延长生存时间。     

Percutaneous imaging-guided interventions for acute biliary disorders in high surgical risk patients

AIM: To evaluate the efficacy of percutaneous imaging-guided biliary interventions in the management of acute biliary disorders in high surgical risk patients.METHODS: One hundred and twenty two patients underwent 139 percutaneous imaging-guided biliary interventions during the period between January 2007 to December 2009. The patients included 73 women and 49 men with a mean age of 61 years (range 35-90 years).Fifty nine patients had acute biliary obstruction, 26 patients had acute biliary infection and 37 patients had abnormal collections. The procedures were performed under computed tomography (CT)- (73 patients), sonographic- (41 patients), and fluoroscopic-guidance (25 patients). Success rates and complications were determined. The χ² test with Yates’ correction for continuity was applied to compare between these procedures. A P value < 0.05 was considered significant.RESULTS: The success rates for draining acute biliary obstruction under CT- , fluoroscopy- or ultrasound-guidance were 93.3%, 62.5% and 46.1%, respectively with significant P values (P = 0.026 and 0.002, respectively). In acute biliary infection, successful drainage was achieved in 22 patients (84.6%). The success rates in patients drained under ultrasound- and CT-guidance were 46.1% and 88.8%, respectively and drainage under CT-guidance was significantly higher (P = 0.0293). In 13 patients with bilomas, percutaneous drainage was successful in 11 patients (84.6%). Ten out of 12 cases with hepatic abscesses were drained with a success rate of 83.3%. In addition, the success rate of drainage in 12 cases with pancreatic pseudocysts was 83.3%. The reported complications were two deaths, four major and seven minor complications.CONCLUSION: Percutaneous imaging-guided biliary interventions help to promptly diagnose and effectively treat acute biliary disorders. They either cure the disorders or relieve sepsis and jaundice before operations.     

胆道支架与十二指肠支架联合应用治疗胆道消化道梗阻

目的评价联合应用双支架治疗胆道及十二指肠梗阻的疗效。方法20例患者实施治疗。16例患者先经过经皮肝穿刺置入胆道支架解决胆道梗阻,患者出现十二指肠梗阻的症状后,14例患者经口腔、2例患者经胃造瘘口置入十二指肠支架。有4例患者同时有胆道和十二指肠梗阻的症状,同时置入胆道和十二指肠支架。结果所有患者都成功置入了双支架,没有出现并发症和再梗阻的表现。生存期1~14个月,平均5个月。结论联合双支架置入是治疗胆道和十二指肠梗阻的有效的方法。     

经皮肝胆管穿刺金属内支架植入治疗恶性梗阻性黄疸

目的：探讨经皮肝胆管穿刺金属内支架植入治疗恶性梗阻性黄疸临床应用价值。方法：108例患者中的9r7例均采用X线透视下经皮肝穿刺胆道内支架植入术治疗恶性梗阻性黄疸。根据梗阻部位的不同解剖决定放置支架的方式。结果：108例患者中,90例植入单支支架于肝总管或（和）胆总管,7例植入2支以上支架于总管和分支胆管,11例行外引流。全部患者2周内血清胆红素从（436±314）mol／L降低到（53±31）mol／L。结论：经皮肝穿刺内支架植入是治疗恶性胆道梗阻性的有效方法。