经皮肝途径胆道内支架置入术治疗恶性胆管梗阻(附57报告)

目的：经皮肝穿肝胆管内置入金属支架治疗恶性胆管梗阻并探讨其 点和影响疗效的因素。方法：57例恶性胆管梗阻，采用经皮肝穿刺肝管胆道内金属支架置入术，胆管癌25例，胰头癌9例，肝癌15例，胃癌转移8例。阻塞部位们于胆总管33例；肝门部24例，其中肝总管13例，累有右肝管5例，左、右肝管6例。结果：共置入4种类型金属支架65枚，9例病人置入双内支架。技术操作成功率98．2％。术前血清胆红素162．7－960．4μmol/l，术后53例降至18．3－55．6μmol/l。半年生存率75．4％（43．57），一年生存率47．4％（27／57）。支架置入后半年再 阻塞率43．9％（25／57）。结论：经皮肝穿胆道内支架置入术治疗恶必理管梗阻安全、有效，是临床重要姑息性治疗手段，支架再阻塞是影响远期疗效的重要因素。     

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     

胆道支架置入联合γ刀治疗复杂型肝门部胆管癌的临床分析

目的评价胆道支架置入联合γ刀治疗复杂型肝门部胆管癌的临床疗效。方法对5例Bismuth分型Ⅳ型肝门部胆管癌合并胆总管远端狭窄行胆道置入金属支架引流联合γ刀治疗,先行B超引导下左侧肝内胆管穿刺置管,再行右侧肝内胆管置管引流(PTCD),置入3枚胆道支架解除梗阻。黄疸消退后行体部γ刀治疗,观察患者胆红素、转氨酶及肿瘤控制情况。结果 5例患者治疗前血清总胆红素为289.38±101.43μmol/L,直接胆红素180.42±72.50μmol/L,丙氨酸氨基转移酶148.80±82.65U/L。术后1周、1个月患者血清总胆红素分别为94.2±20.43、27.20±14.60μmol/L,直接胆红素分别为62.37±30.41、20.58±9.33μmol/L,丙氨酸氨基转移酶分别为109.27±45.52、59.80±35.18U/L。5例患者术后生存期分别为10、13、14、17、24个月,其中3例仍存活,中位生存期15个月,无手术并发症发生。结论胆道支架置入联合γ刀是复杂型肝门部胆管癌的一种安全有效的治疗方法,对于不能手术的局部晚期病例可提高局控率和生存率。     

胆道内支架引流术结合立体定向放射治疗恶性梗阻性黄疸

目的　评价经皮肝穿刺胆道内支架置入术配合立体定向适形放射治疗对恶性梗阻性黄疸的疗效。方法　 15例恶性梗阻性黄疸采用经皮肝穿刺法置入 19个金属内支架。支架置入后随即开始立体定向适形放射治疗。结果　 15例胆道支架植入术全部成功。随访 12个月以上。 3例分别在术后 3、4、11个月无黄疸死亡 ,其余均存活超过 1年。 1年生存率 80 %。结论　胆管癌在经皮肝穿刺胆道内支架置入术有效减黄之后 ,针对肿瘤实施先进的立体定向适形放射治疗能明显延长恶性梗阻性黄疸病人的生存期     

胆管癌性阻塞内支架术后再狭窄的介入治疗

目的　探讨胆管癌性阻塞内支架术后再狭窄的介入治疗方法及其疗效。方法　 12例胆管癌性阻塞性黄疸内支架术后胆管再狭窄患者 ,采用经皮经肝穿刺胆道引流术 (PTCD)加金属内支架置入术或结合局部持续性灌注化疗术及化疗性栓塞术 ,共使用 12枚金属内支架。结果　 12例采用经皮经肝穿刺置入金属胆道内支架均获得成功 ,均一次性置入支架。术后总胆红素、丙氨酸转氨酶、谷酰转肽酶、碱性磷酸酶均有明显下降。术后 12例患者黄疸消退满意。 3例黄疸消退 ,置入内支架术后 4周在DSA下行局部持续性灌注化疗术及化疗性栓塞术。结论　经皮胆管内金属支架再置入术是姑息性治疗胆管癌性阻塞性黄疸内支架术后胆管再狭窄的安全、有效方法 ,结合局部持续性动脉灌注化疗及化疗性栓塞术 ,能提高患者的生命质量及延长生存期     

经皮肝穿胆道内支架置入术治疗恶性胆管梗阻

目的：探讨经皮肝穿胆道内支架置入术治疗恶性胆管梗阻的疗效及技术要点。方法：３５例恶性胆管梗阻采用经皮肝穿刺肝管胆道内支架置入术，其中胰头癌１３例，肝转移癌５例、肝门淋巴结转移压迫胆管７例、胆管癌１０例。结果：共置入３种４３枚金属内支架，其中８例采用双内支架，技术操作成功率１００％。术前血清总胆红素１７０．００～８６０．０ｕｍｏＩ／Ｌ，术后３１例降至１８．２～５３．６ｕｍｏＩ／Ｌ。半年以上生存率７７．１４％（２７／３５），１年以上生存率４８．５７％（１７／３５）。本组无严重并发症，轻度并发症未作特殊处理。结论：经皮肝穿胆道内支架置入术，是不能手术的恶性胆管梗阻安全、有效的治疗方法。配合动脉插管化疗可显著提高其疗效     

胆管癌性阻塞姑息性T管引流术后再发梗阻的介入治疗

目的　探索胆管癌性阻塞外科姑息性T管引流术后再发梗阻的介入治疗。方法　胆管癌性阻塞外科姑息性T管引流术后再发黄疸患者 7例 ,采用经皮肝穿刺胆道引流术 (PTCD) 金属内支架置入术 .共使用 7枚金属内支架。结果　 7例采用经皮经肝穿刺或经T型管通路置入胆管支架均获得成功。无并发症发生。术后总胆红素、转氨酶、谷酰转肽酶和碱性磷酸酶明显下降 ,与术前比较有显著性差异 ,7例术后黄疸消退满意。结论　经皮胆管内金属支架置入术姑息性治疗恶性阻塞性黄疸外科留置T管术后再狭窄 ,安全可靠 ,操作简单 ,费用低 ,治疗效果好 ,并发症少 ,为无法手术切除胆管癌而留置T管的患者提供了一种良好的治疗手段     

经皮穿肝经口腔双途径联合支架置入治疗胆管和十二指肠恶性梗阻

目的:探讨胆管和十二指肠恶性梗阻双途径联合支架置入介入治疗的方法和效果.方法:23 例胆管和十二指肠恶性梗阻,17例先经皮肝穿刺置入金属支架解除胆管梗阻,出现十二指肠梗阻后,再在X线透视下,经口腔置入记忆合金网状十二指肠内支架.6例因胆管与十二指肠恶性梗阻并存,先置入十二指肠内支架并同时置入胆管支架.测定术前、术后血清总胆红素水平及体重并进行t检验.结果:23例患者双途径联合支架置入成功后,术前、术后血清总胆红素水平及体重比较差异均有显著性意义(P＜0.05).十二指肠支架置入后,消化道梗阻症状迅即解除,当日即能进食,均无严重并发症发生.随访1～20个月进食情况均良好.结论:经皮肝穿经口腔双途径联合支架置入治疗胆管和十二指肠恶性梗阻是首选的有效治疗方法.     

胆管内支架治疗肝门部胆管梗阻

目的 探讨肝门部胆管梗阻置入支架治疗梗阻性黄疸的可行性和操作方法.资料与方法 28例肝门部胆管梗阻患者经皮经肝穿刺,分别在左右肝管置入支架.经单侧穿刺5例,经左右肝分别穿刺23例.2枚支架并排放置21例,经第1枚支架网眼放置第2枚支架7例.结果 手术成功率100%,无与操作有关的严重的并发症发生,血胆红素术前(19.34±15.47) mg/dl,术后1周内下降为(9.75±8.21) mg/dl.生存期25～816天(平均213天).结论 通过介入手段置入胆管内支架是缓解肝门部梗阻引起的黄疸安全、有效的方法 .     

胆道双支架置入治疗肝门部胆管癌

目的　探讨肝门部胆管癌胆道双支架置入的方法、术式和临床疗效。方法　 6例肝门部BismuthⅣ型胆管癌患者 ,采取经皮肝穿刺胆道双支架置入治疗 ,根据左右肝管分叉角度的不同采取不同的双支架置入术式。当分叉呈钝角时 ,仅通过右肝管单一穿刺通道置入双支架 ;当分叉呈锐角时 ,2个穿刺通道都在右腋中线进行 ,方便了操作和术后护理。结果　术后患者黄疸明显减轻或消退 ,血清胆红素水平较术前平均下降了 (10 4± 2 9) μmol L(P <0 .0 1) ,收到了较好的近期治疗效果。 6例中有 2例分别于术后 4和 6个月支架再阻塞。结论　胆道双支架置入对于肝门部BismuthⅣ型胆管癌疗效可靠 ,根据左右肝管分叉角度采取不同的双支架置入术式 ,方法可行。     

金属内支架和局部治疗相结合治疗肝门部胆管癌

目的：提高肝门部胆管癌疗效，延长生存时间、改善生存质量。材料与方法：２４例非手术肝门部胆管癌患者先行ＰＴＣＤ减黄术，其中１８例再行局部治疗（胆道内照射或局部化疗）并留置金属内支架１周后拔去引流管，另６例仅行ＰＴＣＤ治疗。结果：２４例行ＰＴＣＤ治疗后，２２例总胆红素下降，未见改变的２例在１个月内死亡。１８例行局部治疗并留置金属内支架的病例，平均生存１０个月，最长２４个月。平均无管（指拔去引流管）生存为５．５个月，最长为１７个月。另６例平均生存２个月，最长为６个月。结论：（１）行局部治疗并留置金属内支架病例的生存时间明显长于单纯ＰＴＣＤ治疗的病例。（２）ＰＴＣＤ后胆红素未见改变或上升者预后不佳。（３）ＰＴＣＤ后的胆道内留置金属内支架与局部治疗相结合是非手术治疗肝门部胆管癌的有效方法。     

经皮肝穿刺胆管腔内射频消融联合植入支架治疗肝门胆管癌伴恶性梗阻临床疗效研究

目的探讨经皮肝穿刺胆管腔内射频消融联合植入支架治疗肝门胆管癌伴恶性梗阻患者的临床应用价值。方法选取自2013年1月至2014年6月收治的肝门胆管癌伴恶性梗阻患者36例,行经皮肝穿刺胆管腔内射频消融联合植入支架进行治疗,观察患者术后并发症发生与肝功能变化情况。所有患者每月随访1次至术后1年,记录患者的存活率与支架通畅率。结果所有患者均手术成功,成功率为100.0%(36/36)。术后发生出血1例(2.7%),胆道感染4例(11.1%),腹泻5例(13.9%),呕吐6例(16.7%),疼痛10例(27.8%),对症治疗后均好转。术后1周,患者总胆红素、直接胆红素、谷氨酰转肽酶与碱性磷酸酶均明显低于术前,差异有统计学意义(P<0.05)。术后3、6、12个月的支架通畅率分别为91.7%(33/36)、69.4%(25/36)、38.9%(14/36);存活率分别为97.2%(35/36)、80.6%(29/36)、66.7%(24/36)。结论经皮肝穿刺胆管腔内射频消融联合植入支架治疗肝门胆管癌伴恶性梗阻安全有效,值得临床推广应用。     

双介入治疗肝门部胆管癌的临床应用研究

目的：观察经皮肝胆管引流（PTCD）金属内支架植入术联合125I放射性粒子永久性植入术对肝门部胆管癌的临床治疗效果。方法：回顾性研究确诊为肝门部胆管癌的患者67例,分为两组：A组35例（PTCD金属内支架植入组）、B组32例（PTCD金属内支架植入＋125I放射性粒子植入组）,通过观察术后减黄效果、肿瘤大小变化、生存率及再梗阻时间,分析PTCD金属内支架植入术联合125I放射性粒子植入术治疗肝门部胆管癌的临床效果。结果：术后15天A、B两组总胆红素均下降且两组差异无显著性（P〉0.05）;术后3月A组总胆红素水平升高,B组未发现回升;术后6个月A、B两组总体有效率（CR＋PR）分别为15%（3/20）,72.4%（21/29）,A、B两组差异有显著性（P〈0.05）;术后6个月、12个月、36个月生存率,B组为90.6%（29/32）,74.3%（26/32）,40%（14/32）,明显高于A组的57.1%（20/35）,34.3%（12/35）,8.6%（3/35）（P〈0.05）。结论：PTCD金属内支架植入术为姑息性治疗;PTCD金属内支架植入术联合125I放射性粒子永久性植入术能达到较理想的治疗效果,并发症少,且提高患者的生存期,具有较高的临床价值。     

高位胆管梗阻的介入治疗和近期疗效分析

目的回顾性分析高位梗阻性黄疸患者介入治疗方法及近期疗效。方法100例接受经皮肝穿刺胆汁引流或胆道支架置入治疗的高位梗阻性黄疸患者,其中胆管癌39例,转移瘤22例,肝移植后胆管病变18例,原发性肝癌15例,胆囊癌6例。测定术前,术后3～7d、8～14d血胆红素水平并进行显著性检验。结果79例行单纯外引流或内外引流,21例行胆道支架置入术,所用支架4种31枚。术前血清胆红素含量与术后3～7d胆红素水平差别有显著性(P<0.05),与术后8～14d胆红素水平比较有非常显著的差异(P<0.01)。结论介入治疗高位梗阻性黄疸方法简单、近期疗效满意。     

Brachytherapy and percutaneous stenting in the treatment of cholangiocarcinoma: a prospective randomised study

PURPOSE: To evaluate the effect of radiation therapy including intraluminal brachytherapy with iridium-192 on survival of patients with malignant biliary strictures (cholangiocarcinoma, histologically improved) treated with metallic stent in a prospective randomised study. METHOD AND MATERIALS: In the prospective randomised study, 21 patients with cholangiocarcinoma were treated with implantation of percutaneous stents followed with intraluminal Ir-192 brachytherapy (mean dose 30 Gy) and external radiotherapy (mean dose 50 Gy) and 21 patients were treated only with stents insertion. We did not find any statistically significant differences in age and tumor localization between these two groups of patients. RESULTS: All the patients died. In the group of patients treated with brachytherapy and with stent implantation, the mean survival time was 387.9 days. In the group of patients treated only with stent insertion the mean survival was 298 days. In effort to eliminate possible effect of external radiotherapy we treated the control group of eight patients with cholangiocarcinoma by stent insertion and brachytherapy only. CONCLUSION: Our results show that combined radiation therapy could extend the survival in the patients with cholangiocarcinoma obstruction.     

胆道支架联合抗肿瘤治疗对肝外胆管癌治疗疗效分析

目的探讨胆道支架联合抗肿瘤方法治疗肝外胆管癌疗效。 方法搜集2013年1月至2014年3月我科收治并于经皮肝穿刺胆道造影术（PTC）中行胆道内钳夹活检病理证实为肝外胆管癌的123例梗阻性黄疸患者临床及影像学资料。60例患者行金属自膨式金属支架置入联合后续抗肿瘤治疗。将此60例患者随机分为A、B、C三组,每组20例患者,其中A组患者行动脉灌注化疗;B组患者行胆道内125I粒子链置入;C组患者行动脉灌注化疗+胆道内125I粒子链置入。同期纳入62例仅行胆道支架置入患者作为对照组。观察对照组、治疗组及不同治疗方式各亚组间手术并发症及黄疸缓解情况,密切随访并比较术后3个月和6个月支架的通畅性。 结果所有患者术后通过门诊或电话随访均获得完整随访。术后所有患者总胆红素及直接胆红素均明显下降。治疗组及对照组术后3个月支架通畅率分别为56/60、51/62（P=0.06）,其中A、B、C三亚组支架通畅率分别为：18/20、19/20、19/20（P=0.7684）。术后6个月支架通畅率分别为：42/60、27/62（P=0.0032）,其中A、B、C三亚组支架通畅率分别为：13/20、11/20、18/20（P=0.0477）。 结论支架置入术联合抗肿瘤治疗能明显延长支架通畅时间。而不同抗肿瘤治疗方式之间,灌注化疗联合粒子链内照射治疗的综合治疗方式对延长支架通畅时间更有优势。     

T-configured dual stent placement in malignant biliary hilar duct obstructions with a newly designed stent

PURPOSE: To evaluate the technical success and clinical efficacy of T-configured dual stent placement in the management of malignant biliary hilar duct obstructions with a newly designed stent. MATERIALS AND METHODS: Between January 2001 and July 2002, 57 patients with malignant biliary hilar duct obstruction were treated with percutaneous transhepatic placement of two self-expandable metallic endoprostheses in a T configuration with use of a newly designed stent. The patients ranged in age from 46 to 85 years and included 37 men and 20 women. RESULTS: Stent placement with two endoprostheses was successful in all patients. The mean survival and stent patency times were 193.6 days (range, 7-442 days) and 170.3 days (range, 7-305 days), respectively. There were no statistical differences in age, sex, or Bismuth type. CONCLUSION: T-configured dual stent placement with a newly designed stent is simple, safe, and reliable in achieving bilateral internal bile drainage in patients with malignant biliary hilar obstructions.     

Intraluminal brachytherapy with metallic stenting in the palliative treatment of malignant obstruction of the bile duct

PURPOSE: To describe the outcome of intraluminal high-dose-rate (HDR) brachytherapy with metallic stenting in patients with obstructing extrahepatic cholangiocarcinoma. MATERIALS AND METHODS: Eight patients with inoperable and/or unresectable extrahepatic bile duct carcinomas were treated with intraluminal brachytherapy (ILBT) followed by self-expandable metallic stent placement. Following percutaneous transhepatic drainage, ILBT was delivered by an HDR-Ir-192 source using the Micro-Selectron afterloading device. Two treatments were planned one week apart, with each treatment consisting of a single 10 Gy fraction. Biliary patency and palliative effect were assessed by serial labs (including bilirubin/alkaline phosphatase), symptomatic improvement, and/or cholangiography. RESULTS: All eight patients tolerated the first application of ILBT well, and five of them completed two-intraluminal treatments. Six of eight had satisfactory control of jaundice until death. Pain relief was observed in four of five (80%) and pruritis in six of seven (86%) patients experiencing such symptoms. The mean and median times of stent patency were 6.9 and 5 months (range, 4-14), respectively. Gastrointestinal bleeding and/or cholangitis occurred in three patients. CONCLUSION: HDR ILBT with metallic stenting for patients with obstructive jaundice from extrahepatic bile duct carcinoma appears to be feasible and associated with acceptable toxicity. These treatments may lead to an improved quality of life in these patients.     

Percutaneous unilateral placement of biliary covered metallic stent in patients with malignant hilar biliary obstruction and contralateral portal vein occlusion

Background Unilateral biliary metallic stent placement in the lobe with patent portal vein seemed to be a safe and effective palliative treatment of patients with contralateral portal vein occlusion caused by advanced hilar malignancy, obviating bilateral stent placement in these patients, because the hepatic lobe with portal vein occlusion ceases to produce bile due to interruption of enterohepatic circulation. Purpose To investigate the safety and efficacy of percutaneous unilateral expanded polytetrafluoroethylene (ePTFE)-covered stent placement in malignant hilar biliary obstruction with contralateral portal vein occlusion. Material and Methods From February 2008 to March 2011, 24 consecutive patients with malignant hilar biliary obstruction and unilobar portal vein occlusion were enrolled in this prospective study. All patients were treated by percutaneous placement of ePTFE-covered stents. Results Stent deployment was technically successful in all patients. Two (8%) patients experienced minor self-limiting hemobilia. No major complication was noted. Successful internal drainage was achieved in 22 (91.6%) patients. Mean serum bilirubin level, which was 12.5 mg/dl ± 8.4 before drainage, decreased significantly to 2.7 mg/dl ± 3.4, 1 month after stent placement (P < 0.001). Median survival was 191 days (95% CI, 94-288 days) and cumulative stent patency rates at 1, 3, 6, 9, and 12 months were 100%, 95%, 95%, 95%, and 71%, respectively. Two (8%) patients presented with stent occlusion due to sludge incrustation. Aside from two patients who had died within 30 days after stent placement, the other 22 patients demonstrated slight decrease in diameter of undrained lobe and did not experience cholangitis nor jaundice. Conclusion Unilateral placement of ePTFE-covered stent in the lobe with patent portal vein seems to be a safe and effective method for palliative treatment of patients with contralateral portal vein occlusion. In addition, ePTFE-covered stent placement can prevent tumor ingrowth without functional occlusion of segmental bile ducts.