胆道良性狭窄植入金属支架3例分析

2005年3月至2005年11月我们先后对3例胆道良性狭窄植入金属支架后出现不同程度的胆道感染、胆道结石形成及肝功能损害的病人，采取保守治疗、内镜治疗及手术治疗，深感困难重重，效果有待远期观察及评价。现报告如下。     

10年胆道再手术的临床分析

目的：对胆道再手术的原因，治疗方法及疗效进行综合评价。以避免或减少再手术的发生和次数。方法：总结南开医院1990－1999年收治的外科病人中各类胆道病人治疗后的再次胆道手术病例，从胆道疾病手术后再次手术的原因，处理方法及治疗效果等方面进行系统的分析比较，结果：10年间胆道再手术病人828例，胆道再手术原因以残余和（或）再生结石为多，占73．43％，其它依次为Oddi括约肌狭窄，胆管炎性狭窄，胆肠吻合口狭窄，损伤性狭窄和肿瘤等。多次再手术的主要原因是胆管和胆肠吻合口良性狭窄，再手术方式以不同形式的胆道成形及内引流为主，38．77％的病人因胆总管结石和（或）Oddi括约肌狭窄行单纯EST及网篮取石术，胆道再手术病死率3．87％。结论：（1）胆道再手术主要原因是胆管结石。（2）多次胆道再手术的原因则以胆管和胆肠吻合口狭窄为主。（3）胆道再手术以清除结石，纠正胆管狭窄和建立通畅引流为原则。     

良性胆道狭窄的介入治疗

目的探讨良性胆道狭窄的介入治疗方法。方法1998年2月-2003年12月间采用介入方法治疗ll例良性胆道梗阻患者，均有腹腔镜和开腹胆道手术史，经超声、CT和MRI证实为胆道狭窄。结果1l例胆道狭窄共进行了19次介入治疗，其中单纯扩张15次，9例扩张后置入了塑料内涵管并在3个月后拔除，余2例扩张后放置了金属内支架治疗，2例在形成胆管结石后进行了经皮取石术。1例胆肠瘘形成后在内涵管拔除后又长期放置了内外引流管。所有患者在采取各种介入治疗方法后胆道阻塞均得到了长期缓解。结论经皮穿刺单纯扩张和放置内涵管治疗各种医源性胆管良性狭窄是一种理想的方法，其主要优点是胆管长期开通率高，创伤小，可避免进一步的外科手术。     

胆管狭窄的内镜下支架治疗

目的探讨支架对肝胆管狭窄疾病的治疗价值。方法对31例肝胆管狭窄在十二指肠镜及胆道镜下行支架治疗,其中23例恶性者行金属支架治疗,8例良性行塑料支架治疗。6例已行T管引流者通过胆道镜置入金属支架治疗。结果2例恶性者支架置入失败,余29例成功放置支架,6例发生堵塞,并发胰腺炎1例,心脏骤停死亡1例。结论内镜下胆管支架置入是治疗肝胆管良恶性狭窄的有效方法。     

胆道再次手术(胆肠吻合)的指征及术式选择

由于胆道结石复发、瘢痕狭窄以及感染等原因，胆道手术后须再次手术治疗的病人远多于腹部其他脏器须行再次手术者。多数情况下再次手术是处理胆道手术后的并发症，少数情况下是有意识安排的分期手术。胆道手术后早期出现出血、胆漏（瘘）、胆汁性腹膜炎或黄疸，需要早期再次手术。肝、胆、胰手术后远期还会出现一些并发症，如胆管良性狭窄、胆肠吻合口狭窄、胆管炎、阻塞性黄疸、胆管复发结石或残留结石、胆瘘、胆源性胰腺炎。黄志强统计4197例肝内胆管结石病人，以往曾有1次以上胆道手术史者占37．14％（1559例）。     

纤维胆道镜治疗肝胆管良性狭窄的临床探讨

目的 探讨纤维胆道镜对肝胆管狭窄的诊治价值。方法对45例肝胆管狭窄患者进行纤维胆道镜诊治，总结分析其方法的优越性。根据不同狭窄类型，治疗采取活检钳撕破狭窄膜或镜身扩张法、球囊扩张加支架支撑法。结果所有病例均成功治愈，无一例出现明显并发症。结论纤维胆道镜治疗胆管狭窄具有微创、安全、有效及方便等优点，是治疗肝胆管狭窄的有效手段。     

生物可降解胆道支架治疗胆道良性狭窄的研究现状

放置胆道支架是治疗胆道良性狭窄（benign biliary stricture，BBS）主要手段之一。目前常用的胆道支架是塑料支架和自膨式金属支架，但塑料支架易堵塞、移位，需要频繁更换；而金属支架价格昂贵、取出困难。生物可降解胆道支架（biodegradable biliary stent，BDBS）安全有效且无需移除，是极具应用前景的新型支架，但迄今为止临床使用经验有限。当前生物可降解支架最常用的材料是聚二恶烷酮，有限的人体试验显示其生物相容性良好。近期经内镜和经皮经肝放置自膨式聚二恶烷酮胆道支架治疗胆道良性狭窄的研究令人瞩目，初步的结果也令人鼓舞，但较高的术后胆管炎发生率也让人担忧。逐步增多的临床研究显示BDBS的安全性和有效性，初步展现出其广阔的应用前景，未来需要对长期临床效果进行进一步的大样本临床对照研究。     

采用带血管蒂胃瓣修复良性胆管狭窄

目的 观察利用带血管蒂胃瓣组织修复良性胆管狭窄术后胃瓣形态学和组织学改变及疗效.方法 选择10例良性胆管狭窄行带血管蒂胃瓣修复手术的病例,术后胆道镜检查结合病理和影像检查.结果 术后3个月胆道镜检查显示移植胃瓣黏膜形态无明显变化,病理学检查提示有轻度炎症.影像学检查显示肝外胆道形态及功能正常.随访6个月至3年,除1例因肝十二指肠韧带转移性腺癌再次手术外,其余9例术后优良率100％.结论 利用带血管蒂的胃瓣修复术可作为治疗良性胆管狭窄安全可靠的手术方式之一.     

自张性金属支架内引流在良,恶性胆道梗阻中的应用

作者从１９９４年８月以来,用国产的镍钛记忆合金金属支架,先后对２６例梗阻性黄疽病人进行了超声引导下经皮肝穿刺胆道金属支架内引流术,取得了较好的疗效。现报道如下。资料与方法ｌｌｔａ床资料本组２６例,男２０例,女６例,年龄２７～６８岁,平均５３．４岁。其中良性病变３例,２例为医源性胆管损伤修复术后胆管极痕狭窄致胆道梗阻;ｌ例为胆管泥沙样结石并胆道梗阻。恶性病变２３例,包括高位胆管癌５例,肝癌伴梗阻性黄值４例,壶腹周围癌８例,胃癌肝门区转移４例,胆囊癌侵犯肝门２例。所有病人均不宜或已不能手术治疗。出现…     

胆道内支架治疗肝门部胆管狭窄九例

肝门部胆管狭窄的处理是肝胆外科手术难题之一,尤其是恶性肿瘤所致的狭窄,过去常常因无法处理而放弃手术。1995年4月至1998年9月我们用胆道内支架治疗了9例,效果满意,现报道如下。1　临床资料1.1　一般资料　本组9例,其中男6例,女3例,年龄51～71岁。包括肝门部胆管癌6例(均为晚期患者),胆内胆管结石手术后肝门部胆管狭窄2例,肝门部胆管炎性狭窄1例。所有病人均经PTC检查确诊。血清总胆红素84.6～530μmmol/L,平均341.5μmol/L.1.2　材料与方法　选用镍钛形状记忆合金胆道内支架6例,硅胶塑料胆道内支架3例。切开胆总管后,向上插入胆道探条…     

记忆合金支架在肝门部胆管狭窄手术治疗中的应用

目的探讨镍钛记忆合金胆道支架在肝门部胆管狭窄手术治疗中的应用。方法回顾性分析2001年1月~2004年12月我院收治的肝门部胆管狭窄35例的临床资料。其中,恶性肿瘤32例,多数实施肿瘤姑息性切除术;良性病变3例,采用钛镍记忆合金辅助胆肠吻合。结果手术后1~5周黄疸消退31例。手术死亡1例。恶性肿瘤病人术后平均生存期为18.6个月,1年生存率为53.1%;胆管良性狭窄的2例,由于反复出现寒战、发热,术后1年取出支架。结论对肝门部胆管狭窄置入镍钛合金胆道支架,可明显减轻黄疸、改善肝脏功能,提高病人的生存质量和延长生存时间,是一种安全、有效的姑息性治疗方法。     

肝移植术后胆道并发症的内镜治疗

目的:探讨内镜下逆行胰胆管造影术(ERCP)在治疗肝移植术后胆道并发症方面的临床疗效.方法:回顾性分析2002年8月-2012年12月采用ERCP治疗8例肝移植术后胆道并发症患者的临床资料,其中胆道狭窄5例(吻合口狭窄4例,肝内型胆道狭窄1例),胆瘘1例,胆石和胆泥形成2例.8例患者共行ERCP治疗21次,对胆道狭窄患者行括约肌切开、胆管扩张、鼻胆管引流和内支架置放术等治疗;对胆瘘患者行鼻胆管引流及塑料内支架置放术等治疗;对结石患者行括约肌切开、鼻胆管冲洗引流术及取石网篮取石等治疗.结果:ERCP手术成功率为100％ (21/21);4例吻合口狭窄、1例胆瘘和2例结石患者均治愈,1例肝内型胆道狭窄治疗未成功,建议再次肝移植;术后胆道感染的发生率为14.3％(3/21),胰腺炎发生率为19.0％ (4/21),经对症治疗后均痊愈.结论:ERCP是治疗肝移植术后胆道并发症微创、安全和有效的方法.     

Intrahepatic artery pseudoaneurysm associated with a metallic biliary stent after living donor liver transplantation: report of a case

An intrahepatic artery pseudoaneurysm (IHAA) is a very rare but potentially lethal complication occurring after liver transplantation. This report presents a case of an IHAA associated with a metallic biliary stent after liver transplantation. A 40-year-old male underwent living donor liver transplantation (LDLT) using a left lobe graft. The bile duct reconstruction was performed with Roux-en-Y hepaticojejunostomy. He developed obstructive jaundice 5 years after LDLT, and had biliary stricture of the anastomosis area, therefore, the two metallic biliary stents were finally positioned at the stricture of the biliary tract. He suddenly developed hematemesis 8 years after LDLT, and computerized tomography scan showed an IHAA. Although seven interlocking detachable coils were placed at the neck of the aneurysm, hematemesis recurred 3 days after the initial embolization. Therefore, retransplantation was successfully performed 25 days after the embolization of IHAA using a right lobe graft from his son. In conclusion, metal stent insertion can lead to the fatal complication of HAA. The placement of a metallic stent could have been avoided in this case. Percutaneous metallic stent insertion for biliary stenosis after liver transplantation should therefore only be performed in carefully selected patients.     

Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture

OBJECTIVE: To carry out a systematic appraisal of the current status of the use of metallic endobiliary stents in the treatment of benign biliary strictures. METHODS: A computerized search of the MEDLINE and EMBASE databases identified 37 studies providing detailed clinical course data on outcome of metallic endobiliary stent placement in 400 patients. Pooled data were examined for etiology of stricture, indications for stent placement, procedure-related complications, and outcome with reference to stent patency. RESULTS: The median (range) number of patients per report was 8 (2-54) with a median recruitment period of 44 (9-126) months. The most frequent indications were postoperative biliary strictures in 123 (31%), stenosed biliary-enteric anastomoses in 79 (20%), and biliary strictures following liver transplantation in 88 (22%). During a median follow up of 31 (1-111) months, 139 (35%) stents occluded, and there are little patency data beyond 2 years after deployment, with 99 (25%) known to be patent at 3 years from stent placement. CONCLUSIONS: These pooled data on 400 patients constitute the largest collective report to date on the use of metallic endobiliary stents for benign biliary strictures. The results show a critical lack of data on long-term patency such that at the present time, metallic endobiliary stents should not be used for benign stricture in those patients with a predicted life expectancy greater than 2 years.     

胆道支架植入加介入化疗方法治疗高位恶性胆道梗阻的体会

目的:评估胆道支架植入结合介入化疗在高位恶性胆道梗阻病人中的疗效。方法:对49例植入胆道支架并辅以选择性动脉插管化疗的病人,回顾性分析血清总胆红素(SB)和碱性磷酸酶(AKP)的变化,及支架阻塞发生率和存活时间。结果:术后2周,血清总胆红素和碱性磷酸酶水平较术前明显下降。在39例植入(33.3%)可膨式金属支架病人中,13例(33.3%)发生阻塞,中位阻塞时间为10个月;10例塑料支架均在术后4个月内出现阻塞。本组病人的中位生存时间为12个月,1年生存率为55%,2年生存率为20%。结论:对高位恶性胆道梗阻病人,植入胆道支架同时辅以选择性动脉化疗是合适的治疗方法。可膨式金属支架较塑料支架的效果更好。     

Percutaneous transhepatic cholangioscopy in the treatment of complicated intrahepatic biliary strictures and hepatolithiasis with internal metallic stent

For recurrent hepatolithiasis coexisting with a complicated long-segment intrahepatic biliary stricture, repeated surgeries, balloon dilation of the stricture, and external-internal stenting may still fail to solve the problem. We tried using a Gianturco-Rosch metallic Z internal stent (Wilson-Cook Medical, Inc., Bloomington, IN, USA) with the aid of percutaneous transhepatic cholangioscopy (PTCS) to treat such patients. Eight patients had a Z stent placed through a percutaneous transhepatic biliary drainage tract. Immediately after stent placement, PTCS was inserted via the percutaneous transhepatic biliary drainage route and a part of the wire skirt not firmly anchored in one of the eight patients was detected. It was successfully repositioned using PTCS. Recurrent cholangitis developed in three patients 6, 7, and 30 months, respectively, after stent placement. PTCS was undertaken again through a reestablished percutaneous transhepatic biliary drainage route and revealed sludge in their stent lumens. We cleared it by PTCS. No further cases of cholangitis occurred in later follow-up. PTCS is useful in ensuring adequate stent position, diagnosing and treating the causes of recurrent cholangitis, and prolonging the function of stents.     

Postoperative percutaneous choledochoscopy

Postoperative percutaneous choledochoscopy (PC) is becoming an important aid to surgeons in the diagnosis and treatment of complex biliary tract disease. The authors retrospectively examined the results of 27 PCs performed on 22 patients at the University of Louisville Affiliated Hospitals from 1980 to 1987. Indications for PC included: suspected choledocholithiasis stricture, sclerosing cholangitis, and cholangiocarcinoma. The biliary tree was accessed through a T-tube tract in 18 patients, and through a biliary-enterocutaneous fistula in four patients. The patient population included 11 men and 11 women with a mean age of 62 years. T-tubes varied in size from #16F to #24F. The time allowed for T-tube tract maturation ranged from four weeks to five months. Percutaneous choledochoscopy was performed 16 times in 13 patients for possible choledocholithiasis. Stones were present in 13, and 11 of 13 attempted extractions were successful. Two patients underwent PC for stent placement. Nine procedures were performed on eight patients to obtain biopsies or to evaluate possible strictures. Four studies were normal, two patients had sclerosing cholangitis, one had a stricture of the Sphincter of Oddi, and one patient had benign ductal tissue on biopsy after an iridium implantation for cholangiocarcinoma. Two minor complications occurred in this series. The authors conclude that by using PC the surgeon may safely manage complicated biliary problems and avoid re-operation in selected cases.     

经皮经肝胆道支架术在肝移植术后胆管狭窄中的应用

目的 评价经皮经肝胆道支架术治疗肝移植术后胆管狭窄的疗效.方法 肝移植术后胆管狭窄患者23例,其中吻合口狭窄7例,肝门区狭窄6例,多发性狭窄10例.确诊后均行经皮经肝胆道支架术.术前均给予经皮经肝胆管引流术(percutaneous transhepatic biliary drainage,PTBD),同时对狭窄部位...     

再次肝移植的胆道重建及其术后并发症的防治:附99例临床分析

目的探讨再次肝移植（ROLT）的胆道重建方式及其术后并发症的防治。方法回顾性分析1999年11月至2005年11月间99例再次肝移植病人胆道重建及术后并发症的防治情况。99例病人胆道重建过程中有88例行胆管端端吻合，全部放置T管引流；11例行胆肠Roux-en-Y吻合，5例放置外支撑管引流、5例内支撑管引流、1例未放置支撑管。术后胆道并发症的诊断主要依据临床表现、B超、T管造影、胆道镜、ERCP、MRCP等检查。结果99例再次肝移植病人围手术期（术后2个月）平均死亡率20．1％；存活1年病人胆道并发症的发生率为11．1％（5／45），其中2例为术后早期胆漏，1例为拔除T管后胆漏，经非手术治疗治愈；1例为术后6个月吻合口狭窄，经内镜球囊扩张、安放内支架处理后治愈；1例为胆肠吻合口漏，经吻合口周围放置的冲洗套管冲洗、引流1个月后治愈。结论再次肝移植胆道重建的关键是良好的受体胆道血供、胆道吻合确切、无张力。术后积极控制胆道感染、选择恰当的介入方法是诊断和治疗胆道并发症的有效手段。     

经皮,经肝放置EMS治疗恶性胆道狭窄

作者以经皮，经肝介入法放置胆道ＥＭＳ（ＥｘｐａｎｄａｂｌｅＭｅｔａｌｌｉｃＳｔｅｎｅｔｓ）成功地治疗６例胆道狭窄病人（恶性５例，良性１例），共放置ＥＭＳ８枚（Ｗａｌｌｓｔｅｎｔ２枚，Ｇ－ＲＺ－ｓｔｅｎｔ５枚，改良了Ｚ－ｓｔｅｎｔ２枚）首次放置ＥＭＳ技术成功率７５％，发生支错位２例次，发生错位的病人均经追加ＥＭＳ得以纠正，最终效果良好，随访５例恶性狭窄病人存活１－７个月，退黄效果满意，１例良性狭窄病