三种方式同期放置双侧金属支架治疗肝门胆管恶性梗阻的比较研究

目的:探讨内镜下3种方式同期平行放置双侧金属支架治疗无法手术切除肝门胆管恶性梗阻的疗效。方法:回顾性分析2012年1月—2019年2月期间上海东方肝胆外科医院采用内镜下同期平行放置双侧金属支架治疗无法手术切除肝门胆管恶性梗阻(Bismuth Ⅱ～Ⅳ型)的118例患者资料。按照支架放置方式分为3组：双侧支架均跨越十二指肠...     

内镜支架引流治疗不可切除肝门胆管恶性梗阻临床成功影响因素的多中心研究

目的　探讨不可切除的肝门胆管恶性梗阻患者行内镜支架引流临床成功的影响因素。方法　回顾性分析2002年1月至2019年1月期间在3所内镜中心（海军军医大学第三附属医院502例、空军军医大学西京医院92例和上海交通大学附属第一人民医院39例）成功接受支架引流的肝门胆管恶性梗阻（Bismuth Ⅱ~Ⅳ型）的633例患者资料。主要观察指标为临床成功率,次要观察指标为支架通畅期和总体生存时间。临床成功患者和临床失败患者单因素比较中P<0.1的变量,纳入多因素logistic 回归,筛选出患者临床成功的独立影响因素。临床成功患者和临床失败患者支架通畅期和总体生存期使用Kaplan‑Meier曲线展示,两组间的差异比较使用log‑rank方法。结果　共有503例患者临床引流成功,有130例患者临床引流失败,总体患者的临床成功率为79.5%。单因素分析显示性别、疾病类型、Bismuth分型、肝硬化、支架类型、支架数量、支架跨越十二指肠乳头和肝脏引流体积可能是影响引流临床成功的因素（P<0.05）。进一步的多因素回归分析确定Bismuth分型（Bismuth Ⅱ~Ⅲ型比Bismuth Ⅳ型：OR=3.308,95%CI：1.772~6.176,P<0.001）、支架类型（金属比塑料：OR=3.297,95%CI：1.829~5.942,P<0.001）和支架数量（双边比单边：OR=2.335,95%CI：1.463~3.727,P<0.001）均为引流临床成功的独立预测因素。临床成功和临床失败患者的支架通畅期分别为6.5（95%CI：5.6~7.4）个月和1.2（95%CI：0.9~1.5）个月（P<0.001）,生存时间分别为5.1（95%CI：4.6~5.6）个月和1.2（95%CI：0.9~1.6）个月（P<0.001）。结论　内镜支架引流治疗不可切除的肝门胆管恶性梗阻患者时,Bismuth Ⅳ型的患者临床成功率较低; 使用金属支架或者双边引流的患者可以提高临床成功率。     

跨越十二指肠主乳头平行放置双侧金属支架治疗肝门部胆管恶性狭窄的临床研究(含视频)

目的:探讨内镜下跨越十二指肠主乳头平行放置双侧胆管金属支架治疗肝门部胆管恶性狭窄的成功率和疗效。方法:回顾性纳入2012年1月—2018年12月在上海东方肝胆外科医院内镜中心采用改良内镜引流技术(内镜下跨越十二指肠主乳头平行放置双侧金属支架)治疗的肝门部胆管恶性狭窄(Bismuth Ⅱ～Ⅳ型)患者共55例,分析技术成功...     

超细推送系统金属支架在肝门胆管恶性狭窄中的应用

目的　探讨超细金属支架治疗肝门胆管恶性狭窄的可行性、有效性和安全性。方法　2014年1月—2021年6月在东方肝胆外科医院消化内科根据影像学或组织学和（或）细胞学诊断为Bismuth Ⅱ型以上肝门胆管恶性狭窄的30例患者,使用超细推送系统金属支架,采用同步并行置入法置入胆管双侧金属支架。分析其技术成功率、临床疗效及并发症发生率。结果　技术成功率为100.0%（30/30）,临床成功率为93.3%（28/30）,操作时间（55.7±20.7）min, 金属支架置入时间（28.3±18.2） min。早期不良事件包括轻度急性胰腺炎2例和胆管炎5例。支架半数通畅时间为243 d （95%CI： 186.6~299.4 d）,患者半数生存期为237 d （95%CI：149.0~325.0 d）。晚期胆管炎发生率为36.7% （11/30）。14例患者出现支架失效,其中5例接受内镜下再介入。双侧金属支架腔内再置入支架技术成功率为4/5,操作时间为（49.8±6.9）min。结论　内镜下同步并行放置双侧超细金属支架治疗肝门胆管恶性狭窄是安全、可行、有效的。 结果 技术成功率100%（30/30例）,临床成功率93.3%(28/30例),操作时间55.7±20.7分, 金属支架置入时间28.3±18.2分。早期不良事件包括轻度急性胰腺炎2例和胆管炎5例。支架中位通畅时间为243 d (95% CI 186.6-299.4 d),中位生存期为237 d (95% CI 149.0-325.0 d)。晚期胆管炎发生率为36.7% (11/30)。14例患者出现支架失效,其中5例受内镜下再介入。双侧金属支架腔内再置入支架技术成功率为80%（4/5）,操作时间为49.8±6.9分。 结论 内镜下同步并行放置双侧超细推送系统金属支架治疗肝门胆管恶性狭窄是安全、可行、有效的。     

内镜支架引流治疗Bismuth Ⅳ型肝门部胆管癌的疗效分析：一项大型回顾性研究

目的探究内镜支架引流治疗Bismuth Ⅳ型肝门部胆管癌患者的疗效。方法回顾性分析2002年1月—2019年1月在海军军医大学第三附属医院内镜科治疗的无法手术切除且内镜支架成功置入的229例Bismuth Ⅳ型肝门部胆管癌患者资料。观察指标包括临床成功率、并发症发生率、支架通畅期和总体生存时间。使用Kaplan-Meier曲线估算支架通畅期和患者总体生存期。采用多因素Cox比例回归模型分析患者支架通畅期和总体生存期的独立预测因素。结果患者的临床成功率为78.2%(179/229)。内镜逆行胰胆管造影术后早期胆管炎发生率为20.5%(47/229)。患者的中位支架通畅时间和总体生存时间分别为5.7(95%CI:4.8～6.7)个月和5.1(95%CI:4.2～6.0)个月。进一步Cox回归分析显示金属支架(P<0.001, HR=0.452, 95%CI:0.307～0.666)和双边造影双边支架(P=0.036, HR=0.644, 95%CI:0.427～0.971)是患者支架通畅期的独立预测因素。总胆红素>200 μmol/L(P=0.001, HR=1.627, 95...     

内镜支架引流治疗肝细胞肝癌所致肝门部胆管恶性梗阻的疗效分析

目的　评估无法手术切除的肝细胞肝癌所致肝门部胆管恶性梗阻患者的内镜支架引流疗效。方法　回顾性分析2012年1月—2019年1月在海军军医大学第三附属医院因无法手术切除的肝细胞肝癌导致肝门部胆管恶性梗阻而行内镜支架引流的106例患者的临床资料。根据置入支架类型的不同,分为金属支架组（30例）和塑料支架组（76例）。观察指标包括临床成功率、并发症发生率、支架通畅期及总体生存时间。采用多因素Cox回归模型分析患者支架通畅期和总体生存时间的独立预测因素。结果　患者的总体临床成功率为67.9%（72/106）,术后胆管炎发生率为29.2%（31/106）。金属支架组与塑料支架组的临床成功率分别为93.3%（28/30）和57.9%（44/76） （χ2=12.40,P<0.001）,术后胆管炎发生率分别为13.3%（4/30）和35.5% （27/76）（χ2=5.12,P=0.024）。中位支架通畅期为5.2（95%CI：3.7~6.0）个月,中位总体生存时间为3.0（95%CI：2.5~3.7）个月。多因素Cox回归分析显示肝脏引流体积<30%是支架通畅期的独立预测因素（HR=2.12, 95%CI：1.01~4.46,P=0.048）。BismuthⅣ型（HR=2.06, 95%CI：1.12~3.77,P=0.020）、Child⁃Pugh C级（HR=4.09, 95%CI：2.00~8.39,P<0.001）、塑料支架（HR=1.87,95%CI：1.21~2.90,P=0.005）是总体生存时间的独立预测因素。结论　肝细胞肝癌一旦累及肝门部胆管预后不良。与塑料支架相比,金属支架引流在临床成功率、术后胆管炎发生率方面均具有一定优势。肝脏引流体积<30%是支架通畅期的独立预测因素,而Bismuth Ⅳ型、Child⁃Pugh C级、塑料支架为总体生存时间的独立预测因素。     

内镜下金属支架引流术治疗肝门部胆管癌和肝外恶性胆道梗阻临床观察

临床上恶性胆道梗阻性疾病预后较差。对于不能手术切除者,通常选择内镜下置人胆道支架以解除梗阻,然而该技术对进展期肝门部肿瘤的疗效报道不一。目的：探讨内镜下金属支架引流术对肝门部胆管癌和肝外恶性胆道梗阻的疗效和并发症发生情况。方法：纳入上海交通大学附属第一人民医院2006年6月～2009年6月收治的82例接受ERCP下置入自膨式金属胆道支架引流治疗的恶性胆道狭窄患者,根据病变部位分为肝门部胆管癌组和肝外恶性胆道梗阻组,对其ERCP参数和术后6个月随访记录进行回顾性分析,并分析随访期间急性胆管炎发生的危险因素。结果：两组支架置入成功率均为100％。与肝外恶性胆道梗阻组相比,肝门部胆管癌组术后1周总胆红素降低显效率较低,术后6个月内急性胆管炎发生率增高,初次发生时间提前,支架再狭窄率增高（P=0．000）。ERCP术中括约肌切开为随访期间发生急性胆管炎的危险因素（P=0．004,OR：8．196）。结论：内镜下金属支架引流术对肝门部胆管癌的疗效不及肝外恶性胆道梗阻,且更易早期发生急性胆管炎和支架再狭窄,术中括约肌切开可增加术后急性胆管炎的发生风险。     

经内镜放置胆管金属支架联合鼻胆管引流治疗恶性胆管梗阻

目的探讨经内镜放置胆管金属支架联合鼻胆管引流对恶性胆管梗阻的治疗效果。方法 115例失去手术机会的恶性胆管梗阻患者行经内镜逆行胰胆管造影下放置胆管支架,其中48例行胆管塑料支架引流术,30例行胆管金属支架引流术,37例行胆管金属支架联合鼻胆管引流术;分析各组引流效果、成功率、早期并发症和胆管再堵塞发生情况。结果塑料支架组、金属支架组及金属支架联合鼻胆管组的谷丙转氨酶(ALT)、总胆红素(TBIL)、直接胆红素(DBIL)和碱性磷酸酶(AKP)在手术后均有明显降低(P0.05);手术后1周金属支架联合鼻胆管组的TBIL和DBIL明显低于塑料支架组、金属支架组(P0.05),塑料支架组和金属支架组相比,差异无统计学意义(P0.05);术后3个月内金属支架组和金属支架联合鼻胆管组再堵塞的发生率明显低于塑料支架组(P0.05),金属支架组和金属支架联合鼻胆管组相比,差异无统计学意义(P0.05);塑料支架组的手术成功率与金属支架组及金属支架联合鼻胆管组相比,差异无统计学意义(P0.05),塑料支架组的早期并发症发生率明显高于金属支架联合鼻胆管组,差异有统计学意义(P0.05)。结论经内镜逆行胰胆管造影下放置胆管金属支架联合鼻胆管对于恶性胆管梗阻有确切的引流效果。     

肝门部胆管恶性梗阻的内镜引流

肝门部胆管恶性梗阻的早期诊断困难，多数患者发现时已处于疾病晚期，失去了外科手术根治性切除的机会。解除胆道梗阻能有效控制黄疸和胆管炎症状并为放化疗创造机会，是姑息治疗的关键所在。内镜引流是如今解除胆管梗阻的一线选择，但由于肝门部所处的解剖位置复杂，引流操作技术要求高且术后并发症多，内镜引流依然具有较大的挑战性。本文结合目前的相关研究进展，就内镜操作技术、引流策略制定以及引流导管类型选择等问题作一综述。     

Y型金属支架引流治疗肝门部恶性胆管梗阻

肝门部恶性肿瘤患者在出现症状后就诊时，仅有不到20%的患者可以行手术切除治疗，大多数患者因局部浸润或广泛转移而失去了手术切除的时机，因此姑息性治疗肝门部恶性肿瘤成为临床医生所关注的焦点，而其中对于黄疸的治疗又成为关键与重点。     

Unilateral versus bilateral endoscopic metal stenting for malignant hilar biliary obstruction

Background and Aim: The extent of liver drainage for palliative treatment of malignant hilar biliary obstruction is controversial. The aim of this study was to compare endoscopic unilateral versus bilateral drainage in patients with malignant hilar biliary obstruction using a self‐expanding metal stent (SEMS). Methods: We carried out a retrospective review of 46 consecutive patients with malignant hilar biliary obstruction who were treated by endoscopic biliary drainage using SEMS between 1997 and 2005. Unilateral metal stenting (group A) was performed in 17 patients between 1997 and 2000, and bilateral metal stenting (group B) was performed in 29 patients between 2001 and 2005. The successful stent insertion, successful drainage, early complications, late complications, stent patency, and survival rate for groups A and B were evaluated and compared retrospectively. Results: There were no significant differences between the two groups in successful stent insertion (100% vs 90%, group A vs B, respectively), successful drainage (100% vs 96%), early complications (0% vs 10%), or late complications (65% vs 54%). Cumulative stent patency was significantly better in group B than in group A (P = 0.009). In cases of cholangiocarcinoma, cumulative stent patency was significantly better in group B than in group A (P = 0.009), whereas there were no inter‐group differences for gallbladder carcinoma. Cumulative survival did not differ significantly between the groups. Conclusions: Endoscopic bilateral drainage using SEMS for malignant hilar biliary obstruction is more effective than unilateral drainage in terms of cumulative stent patency, especially in cases of cholangiocarcinoma.     

Biliary stenting for hilar malignant biliary obstruction

Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced high-grade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques. However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent-in-stent vs stent-by-stent).     

Revision of bilateral self-expandable metallic stents placed using the stent-in-stent technique for malignant hilar biliary obstruction

Background

Endoscopic biliary decompression using bilateral self-expandable metallic stent (SEMS) placed using the stent-in-stent (SIS) technique is considered favorable for unresectable malignant hilar biliary obstruction (MHBO). However, occlusion of the bilateral SIS placement is frequent and revision can be challenging. This study was performed to investigate the efficacy, the long-term patency and the appropriate approach for revision of occluded bilateral SIS placement in unresectable MHBO.

Safety and efficacy of metallic stent for unresectable distal malignant biliary obstruction in elderly patients

AIM To study the safety of insertion of metallic stents in elderly patients with unresectable distal malignant biliary obstruction.METHODS Of 272 patients with unresectable distal malignant biliary obstruction, 184 patients under the age of 80 were classified into Group A, and 88 subjects aged 80 years or more were classified into Group B. The safety of metallic stent insertion, metal stent patency period, and the obstruction rate were examined in each group.RESULTS In Group B, patients had a significantly worse per-formance status, high blood pressure, heart disease, cerebrovascular disease, and dementia; besides the rate of patients orally administered antiplatelet drugs or anticoagulants tended to be higher(P 0.05). Metallic stents were successfully inserted in all patients. The median patency period was 265.000 ± 26.779(1-965) d; 252.000 ± 35.998(1-618) d in Group A and 269.000 ± 47.885(1-965) d in Group B, with no significant difference between the two groups. Metallic stent obstruction occurred in 82 of the 272(30.15%) patients; in 53/184(28.80%) patients in Group A and in 29/88(32.95%) of those in Group B, showing no significant difference between the two groups. Procedural accidents due to metal stent insertion occurred in 24/272(8.8%) patients; in 17/184(9.2%) of patients in Group A and in 7/88(8.0%) of those in Group B, with no significant difference between the two groups, either.CONCLUSION These results suggested that metallic stents can be safely inserted to treat unresectable distal malignant biliary obstruction even in elderly patients aged 80 years or more.     

肝门胆管恶性梗阻患者肝脏有效引流体积对总体生存时间的影响：一项多中心研究

目的探讨无法手术切除的肝门胆管恶性梗阻患者的肝脏引流体积对其总体生存时间的影响。方法回顾性分析2002年1月—2019年5月期间在3所内镜中心接受支架引流的633例肝门胆管恶性梗阻(Bismuth Ⅱ-Ⅳ型)患者的临床资料。主要观察指标包括临床成功率、支架通畅期、总体生存时间、有效肝脏引流体积、并发症发生率。结果肝脏引流体积<30%、30%～50%、>50%患者的临床成功率分别为56.8%(25/44)、77.3%(201/260)和84.2%(277/329);早期胆管炎发生率分别为31.8%(14/44)、18.8%(49/260)和16.1%(53/329);中位支架通畅期分别为4.5(95%CI:1.8～7.2)个月、5.6(95%CI:5.0～6.2)个月、6.6(95%CI:5.2～8.0)个月;总体生存时间分别为2.4(95%CI:1.8～3.0)个月、4.0(95%CI:3.4～4.6)个月和4.9(95%CI:4.4～5.4)个月。30%～50%肝脏引流体积组的临床成功率(χ2=8.28, P=0.012)、中位支架通畅期(χ2=18.87, P=0.01...     

Current status of endoscopic biliary drainage for unresectable malignant hilar biliary strictures

The management of jaundice and cholangitis is important for improving the prognosis and quality of life of patients with unresectable malignant hilar biliary strictures (UMHBS). In addition, effective chemotherapy, such as a combination of gemcitabine and cisplatin, requires the successful control of jaundice and cholangitis. However, endoscopic drainage for UMHBS is technical demanding, and continuing controversies exist in the selection of the most appropriate devices and techniques for stent deployment. Although metallic stents (MS) are superior to the usual plastic stents in terms of patency, an extensive comparison between MS and “inside stents”, which are deployed above the sphincter of Oddi, is necessary. Which techniques are preferred remains as yet unresolved: for instance, whether to use a unilateral or bilateral drainage, or a stent-in-stent or side-by-side method for the deployment of bilateral MS, although a new cell design and thin delivery system for MS allowed us to accomplish successful deployments of bilateral MS. The development of techniques and devices for re-intervention after stent occlusion is also imperative. Further critical investigations of more effective devices and techniques, and increased randomized controlled trials are warranted to resolve these important issues.