经皮经肝置放胆道支架治疗恶性梗阻性黄疸

经皮经肝穿刺胆道内置放记忆合金支架治疗恶性梗阻性黄疸，其操作技术安全、有效，能明显提高患者的生活质量，延长患者的生存期。我科自2005年3月至2007年8月对10例恶性胆道梗阻患者，采用经皮经肝置放胆道支架进行治疗，取得了较好的临床效果，现报道如下。     

胆道支架联合引流管治疗高位恶性梗阻性黄疸疗效观察

采用经皮肝穿刺胆道主支支架植入加多侧孔引流管对12例高位恶性梗阻性黄疸患者进行多支胆管引流治疗.发现全部患者术后皮肤瘙痒症状消失,大便转黄,饮食改善,2周内血清胆红素水平由治疗前的(462.3±58.7)μmol/L降至(105.0±38.5)μmol/L,胆汁引流通畅维持时间平均达13周.认为胆道支架联合多侧孔引流管植入术的胆道疏通、引流效果好,可明显提高患者生存质量.     

经皮肝穿刺胆道内外引流术＋化疗栓塞术姑息性治疗恶性梗阻性黄疸临床体会

目的 探讨经皮肝穿刺胆道内外引流术（PTCD）＋化疗栓塞术（TALE）在恶性梗阻性黄疸姑息性治疗中的疗效。方法采用经皮肝穿刺技术胆道内外引流管植入及Seldinger穿刺技术行肿瘤动脉造影灌注化疗栓塞相结合的双介入治疗方法。结果 全部患者经皮经肝穿刺胆道内外引流手术成功，留置内外引流管13例，外引流管16例，双侧引流外引流和内外引流2例，31例患者均行动脉灌注化疗术，9例患者行动脉灌注化疗栓塞术，治疗后总胆红素明显下降。结论 经皮肝穿刺胆道内外引流术＋化疗栓塞术在恶性梗阻性黄疸临床治疗中是比较理想的姑息性治疗方法。能明显提高生活质量，延长患者的生存期。     

经皮穿刺胆道引流管及内支架置入治疗恶性阻塞性黄疸

目的分析介入性经皮穿刺胆道引流管及内支架植入术治疗恶性阻塞性黄疸的技术与疗效。方法对11例患者采用经皮肝穿刺胆道引流管及内支架置入术治疗恶性梗阻性黄疸。胆道梗阻部位位于胆总管3例、肝总管6例,左右肝管汇合部2例。结果11例共置入金属内支架6枚,5例置入引流管,其中外引流4例,内外引流1例。术后1周复查血清生化指标,总胆红素（TBil）、碱性磷酸酶及丙氨酸转氨酶均下降明显。5例于术后10月内死亡,均与胆道引流无直接因果关系。术后1个月,3项血清生化指标均有更为显著的下降。跟踪随访,平均随访5个月,5例仍存活。1例失访。期内4例TBil降至正常范围,3例TBil下降至接近正常水平。结论经皮穿刺胆道引流管及内支架植入术治疗恶性阻塞性黄疸是一种安全、有效的姑息性治疗方法,可明显缓解黄疸,改善肝脏功能,提高生存质量,并可延长生存时间。     

老年高危恶性胆道梗阻患者经皮肝穿刺胆管造影和引流及并发症的探讨

老年高危恶性胆道梗阻患者经皮肝穿刺胆管造影和引流及并发症的探讨厉振凯自７０年代初期，日本千叶大学Ｏｋｕｄａ创用了外径０．７ｍｍ细软钢针作经皮肝穿刺胆道造影（ＰＴＣ）后，经过近２０年来的不断革新，对晚期恶性梗阻性黄疸的老年高危病人，改进为经皮肝穿刺胆管...     

经皮肝穿刺胆道多支架置入治疗肝门部恶性胆管梗阻19例

经皮肝穿刺胆道支架置入术已成为肝门部恶性梗阻性黄疸的一个重要的姑息性治疗手段[1],而且可为进一步治疗创造条件[2].我科2003年1月至2008年5月对19例无法手术切除或不愿手术的肝门部恶性胆管梗阻患者放置了胆道支架.     

经皮肝穿胆道内支架置入术治疗恶性胆管梗阻的护理

为探讨恶性胆管梗阻胆道内支架置入术前、术中、术后的护理措施,我们对87例恶性胆管梗阻患者,采用经皮肝穿途径胆道内支架置入术治疗。结果共置入4种类型金属内支架96枚,9例置入双向支架。术前血清总胆红素162.7～960.4μmol/L,术后83例降至18.3～53.6μmol/L。半年以上生存率77％(67/87),一年以上生存率47％(41/87)。总的技术操作成功率100％。因此经皮肝穿胆道内支架置入术治疗恶性胆管梗阻安全、有效,而采用正确的护理措施是保证手术成功和疗效的关键。     

放置金属支架姑息性解除恶性胆道梗阻57例

目的内镜法放置胆道支架,姑息性治疗胆管恶性梗阻的最大缺陷是支架的阻塞,造成阻塞的重要原因之一是通常的塑料支架口径较小,而放置可膨式金属支架使得内引流中口径达到1cm.方法我们从1994年4月-1996年5月放置膨胀式金属道支架治疗57例无法根治的恶性梗阻性黄疸患者,其中采用内镜法置管54例,经皮肝穿刺法3例.结果导丝定位后支架放置的成功率为95%,2例发生胆管炎,经保守治疗得以控制.术后两周内黄疸完全消退21例,明显减退23例,然而9例患者在平均147d 后由于引流失效出现晚期胆管炎.全组有23例术前采用鼻胆管和3例采用内置管临时性引流,临时性引流具有可预先了解引流效果和控制炎症的优点.结论对于无法切除的恶性胆道梗阻患者,放置金属胆道支架可有效解除黄疸,改善生活质量,但欲获得最佳疗效,需严格掌握置管指证.为获得持久的引流效果.肿瘤两端支架的长度不宜短于2cm;对肝门部胆管癌,Bismuth 分型对挑选合适的引流部位有较大的参考价值.     

经皮肝穿刺胆道腔内射频消融联合胆道支架治疗恶性胆道梗阻的临床观察

目的：探讨经皮肝穿刺胆道腔内射频消融技术姑息性治疗恶性梗阻性黄疸的安全性及可行性。方法选取2013年1月－2014年3月接受治疗的20例无法切除的恶性梗阻性黄疸患者作为实验组,其中9例不能外科手术切除患者透视下行经皮肝穿刺胆道腔内射频消融术,并留置金属胆道支架;同期随机纳入11例相似病情患者作为对照组,经皮肝穿刺胆道造影（PTC）成功后仅行胆道支架置入。观察两组手术并发症及黄疸缓解情况,密切随访并比较术后3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均获得完整随访。实验组及对照组术后3个月支架通畅率分别为100％,72．7％（χ2＝2．888,P ＝0．218）,术后6个月支架通畅率分别为：87．5％、27．3％（χ2＝6．739,P ＝0．02）。随访期内射频组1例患者于术后113 d 死于消化道出血,对照组1例患者于57 d 死于肝功能衰竭,1例患者于术后142 d 死于弥散性血管内凝血。结论经皮肝穿刺胆道腔内射频消融对恶性胆道梗阻的治疗是安全和可行的,在延长自膨式金属支架通畅性方面初步疗效令人满意,但尚需大量样本随机对照研究进一步验证。     

胆道支架联合经皮肝穿刺胆管引流术治疗恶性梗阻性黄疸的临床疗效

目的观察胆道支架联合经皮肝穿刺胆管引流术(PTCD)对晚期恶性梗阻性黄疸的临床应用价值。方法 74例恶性梗阻性黄疸患者,均在DSA透视下经PTCD途径置入金属胆道支架。结果所有患者介入治疗后黄疸、皮肤瘙痒均明显减轻,术后胆红素水平显著下降(P0.01),肝功能较前好转(P0.01)。术后3个月生存率94.6%,6个月生存率60.8%,12个月生存率20.3%。结论胆道支架联合PTCD可有效缓解恶性梗阻性黄疸患者的临床症状,改善肝功能,提高生活质量,延长生存期。     

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY

Endoscopic biliary drainage (EBD) may be unsuccessful in some patients, because of failed biliary cannulation or tumor infiltration, limiting endoscopic access to major papilla. The alternative method of percutaneous transhepatic biliary drainage carries a risk of complications, such as bleeding, portal vein thrombus, portal vein occlusion and intra‐ or extra‐abdominal bile leakage. Recently, endoscopic ultrasonography (EUS)‐guided biliary stent placement has been described in patients with malignant biliary obstruction. Technically, EUS‐guided biliary drainage is possible via transgastric or transduodenal routes or through the small intestine using a direct access or rendezvous technique. We describe herein a technique for direct stent insertion from the duodenal bulb for the management of patients with jaundice caused by malignant obstruction of the lower extrahepatic bile duct. We think transduodenal direct access is the best treatment in patients with jaundice caused by inoperable malignant obstruction of the lower extrahepatic bile duct when EBD fails.     

Polyurethane-covered metal stent for management of distal malignant biliary obstruction

BACKGROUND: The efficacy of polyurethane-covered metal expandable stents for treatment of neoplastic distal biliary obstruction was analyzed. METHODS: Twenty-one patients with unresectable malignant tumors involving the mid to distal bile duct who were seen with obstructive jaundice were consecutively enrolled. Eighteen patients underwent endoscopic implantation of a polyurethane-covered metal stent and 3 patients underwent transhepatic insertion because of duodenal obstruction. The stent patency, complications, and patient survival were analyzed. RESULTS: Effective biliary decompression was achieved in all patients. Adverse events were minor: mild pancreatitis (1) and cholecystitis (2) occurred within 7 days of stent insertion. Mean survival and stent patency were 233 days and 206 days, respectively. Stent occlusion occurred in 3 patients (14%) after a mean of 188 days. Tumor ingrowth through the stent mesh was not observed. However, 2 stents were occluded by tumor overgrowth and 1 by compacted alimentary debris. CONCLUSIONS: A polyurethane membrane may prevent tumor ingrowth and reduce the occlusion rate for expandable metal stents implanted in patients with malignant obstruction of the distal bile duct.     

Percutaneous expandable metallic stent biliary endoprostheses used inmalignant and benign obstructive jaundice

AIM To evaluate the effects of expandable metallic stent biliary endoprostheses (EMSBE) viaultrasonographic guided percutaneous transhepatic approach on the treatment of benign and malignantobstructive jaundice.METHODS Thirty-eight patients with obstructive jaundice (29 males and 9 females) aged 27 to 69 years(mean 54.7 years) were studied. Of them, 4 were benign and 34 malignant obstructions. Percutaneoustranshepatic cholangiography (PTC) was performed under ultrasonic guidance. A catheter was introducedinto the dilated bile duct via the introducer. A guide wire was inserted through the occlusive part of biliary duct after dilating with a double-lumen balloon catheter. A self-expandable metallic stent was inserted intcthe occlusive bile duct under fluoroscopic control.RESULTS The success rate of sonographic guided PTC was 100% (38/38) and the success rate of stentimplantation was 86.8% (33/ 38). Biliary obstruction was eliminated immediately, jaundice subsidedgradually and symptoms relieved after the procedure. During the 3 to 28 months fellow-up, re-occlusionoccurred in 4 malignant cases which were corrected by balloon catheter dilation and/or by stent, one patienthad secondary cholangitis and fifteen died without jaundice 6 - 28 months after the procedure. The otherswere alive with no jaundice. No severe complications or side effects were observed.CONCLUSION EMSBE via sonographic guided percutaneous transhepatic approach is a reliable and safepalliative therapy for malignant jaundice and an ideal nonoperative method for benign biliary obstruction. Ithas a definite positive impact on the quality of patient life.     

Self-expandable metallic stents for malignant biliary obstruction： Efficacy on proximal and distal tumors

AIM:To compare the efficacy of self-expandable metallicstents (EMS) in the treatment of distal and proximalstricture of malignant biliary tumors.METHODS:From March 1995 to June 2004,61 patients(40 males,21 females) with malignant biliary obstructionwho received self-expandable metallic stent implantationwere reviewed retrospectively.The stents were insertedby an endoscopic or percutaneous transhepatic method.We tried to place two stents in the biliary system in Tor Y configuration in cases of hilar tumors with bilateralhepatic duct obstruction.The end points of the studywere stent occlusion or patient death.RESULTS:The mean time of stent patency was 421±67d in the group of proximal stricture( group Ⅰ) and 168±18 d in the group of distal stricture (group Ⅱ).Thedifference was significant in borderline between thetwo groups (P=0.0567).The mean survival time was574±76 d in group Ⅰ and 182 25 d in group Ⅱ.Therewas a significant difference between the two groups(P=0.0005).CONCLUSION:EMS implantation is a feasible,palliativemethod for unresectable malignant biliary obstruction.The clinical efficacy of EMS in patients with proximal hilartumors is better than that in patients with distal tumors.     

Acute biliary conditions

Acute biliary complications may result from several medical conditions such as gallstone pancreatitis, acute cholangitis, acute cholecystitis, bile leak, liver abscess and hepatic trauma. Gallstones are the most common cause of acute pancreatitis. About 25% of theses patients will develop clinically severe acute pancreatitis, usually due to necrotizing pancreatitis. Choledocholithiasis, malignant and benign biliary strictures, and stent dysfunction may cause partial or complete obstruction and infection in the biliary tract with acute cholangitis. Bile leaks are most commonly associated with hepatobiliary surgeries or invasive procedures such as open or laparoscopic cholecystectomy, hepatic resection, hepatic transplantation, liver biopsy, and percutaneous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may have an essential role in the management of these complications.     

Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series

OBJECTIVES: Endoscopic retrograde cholangiography is an established method for treatment of common bile duct stones as well as for palliation of patients with malignant pancreaticobiliary strictures. It may be unsuccessful in the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic biliary drainage and surgery are alternative methods with a higher morbidity and mortality in these cases. Recently, endoscopic ultrasound (EUS) guided biliary stent placement has been described in patients with malignant biliary obstruction. We describe our experience with this method that was also used for the treatment of cholangiolithiasis for the first time. METHODS: The EUS guided transduodenal puncture of the common bile duct with stent placement was performed in 5 patients. In 2 of these patients, the stents were removed after several weeks and common bile duct stones were extracted. In another patient with gastrectomy, the left intrahepatic bile duct was punctured transjejunally and a metal stent was introduced transhepatically to bridge a distal common bile duct stenosis. RESULTS: Biliary decompression was successful in all 6 patients. No immediate complications occurred. One patient developed a subacute phlegmonous cholecystitis. CONCLUSIONS: Interventional EUS guided biliary drainage is a new technique that allows drainage of the biliary system in benign and malignant diseases when the bile duct is inaccessible by conventional ERCP.     

Endocoil placement after endoscopic ultrasound-guided biliary drainage may prevent a bile leak

AIM: To further reduce the risk of bleeding or bile leakage. METHODS: We performed endoscopic ultrasound guided biliary drainage in 6 patients in whom endoscopic retrograde cholangiopancreatography (ERCP) had failed. Biliary access of a dilated segment 2 or 3 duct was achieved from the stomach using a 19G needle. After radiologically confirming access a guide wire was placed, a transhepatic tract created using a 6 Fr cystotome followed by balloon dilation of the stricture and antegrade metallic stent placement across the malignant obstruction. This was followed by placement of an endocoil in the transhepatic tract. RESULTS: Dilated segmental ducts were observed in all patients with the linear endoscopic ultrasound scope from the proximal stomach. Transgastric biliary access was obtained using a 19G needle in all patients. Biliary drainage was achieved in all patients. Placement of an endocoil was possible in 5/6 patients. All patients responded to biliary drainage and no complications occurred. CONCLUSION: We show that placing endocoils at the time of endoscopic ultrasound guided biliary stenting is feasible and may reduce the risk of bleeding or bile leakage.     

Percutaneous placement of biliary stents for the treatment of high risk patients with jaundice due to common bile duct stones

OBJECTIVE: Percutaneous treatment of eight high risk patients with jaundice due to common bile duct stones who were unfit for, or refused surgery and in whom endoscopic therapy failed. METHODS: Fine needle percutaneous cholangiography was followed by catheterization of the bile duct and insertion of a 10-Fr double pigtail Teflon stent in seven cases and a metal stent in one patient with bile duct stones and noncalculous lower common bile duct obstruction. RESULTS: Stent insertion was successful in all patients. Two patients showed pus in the common bile duct. Stent insertion in these relieved the jaundice, but one patient died from sepsis at 72 h. The other patient died from renal and respiratory failure 3 wk after stent insertion with resolution of the jaundice. In six patients, stent therapy relieved the jaundice for periods up to 3 yr or death from other causes. CONCLUSIONS: These findings suggest that percutaneous transhepatic stent insertion is a reasonable alternative for the management of common bile duct stones when endoscopic stent insertion fails.     

A case of methicillin-resistant Staphylococcus aureus infection following bile duct stenting

AIM: To present a case of methicillin-resistant Staphylococcus aureus (MRSA) infection following bile duct stenting in a patient with malignant biliary obstruction. METHODS: A 78-year-old male patient was admitted to a community hospital with progredient painless jaundice lasting over two weeks, weight loss and sweating at night. Whether a stent should be implanted pre-operatively in jaundiced patients or whether these patients should directly undergo surgical resection, was discussed. RESULTS: ERC and a biopsy from the papilla of Vater revealed an adenocarcinoma. In addition, a 7-Ch plastic stent was placed into the common bile duct. Persistent abdominal pain, increasing jaundice, weakness and indigestion led to the transfer of the patient to our hospital. A pylorus-preserving pancreatoduodenectomy was performed. Intraoperatively, bile leaked out of the transected choledochus and the stent was found to be dislocated in the duodenum. A smear of the bile revealed an infection with MRSA, leading to post-operative isolation of the patient. CONCLUSION: As biliary stents can cause severe infection of the bile, the need for pre-operative placement of biliary stents should be carefully evaluated in each individual case.     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound‐guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS‐guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.