经鼻胆管冲洗胆道+灌注高浓度抗生素治疗急性梗阻性化脓性胆管炎

目的：探讨B超监视下经内镜鼻胆管引流术(ENBD),用生理盐水冲洗胆道+局部灌注高浓度抗生素,治疗急性梗阻性化脓性胆管炎的疗效及安全性。方法：对22例急性梗阻性化脓性胆管炎的患者,采取B超监视下行ENBD术、术后经鼻胆管行胆道冲洗及灌注高浓度抗生素为主的非手术综合治疗,对比患者治疗前后的血清总胆红素水平、肝功能、胆总管内径变化,并对患者临床资料进行回顾性分析。结果：本组22例患者除1例因壶腹癌行保守治疗外,其余21例内镜下鼻胆管引流术成功,胆汁引流通畅,经胆道冲洗+灌注高浓度抗生素治疗后治愈。结论：急性梗阻性化脓性胆管炎在B超监视下行ENBD术较X监视行ENBD术,胰腺炎并发症发生率降低。经鼻胆管用生理盐水冲洗胆道+局部灌注高浓度抗生素为主的综合治疗是有效的、安全的。     

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.     

肝移植术后胆道并发症的内镜治疗

目的探讨内镜治疗在肝移植术后胆道并发症中的作用。方法对我院2006年1月至2009年6月期间经内镜诊治的55例肝移植术后胆道并发症患者的临床资料进行回顾性分析。结果55例肝移植术后出现胆道并发症的患者共行内镜治疗98例次,治疗成功46例(83.6%),其中单纯胆瘘11例,胆管狭窄合并胆瘘4例,单纯胆管狭窄21例,胆管狭窄伴结石12例,单纯胆管结石3例,胆管扭曲2例,十二指肠乳头狭窄2例。针对不同的胆道并发症,采取了胆管扩张、鼻胆管引流、乳头切开取石、胆道支架置放等不同的治疗方式,发生内镜相关并发症13例次(13.3%)。结论内镜处理肝移植术后胆道并发症是一种安全、有效的方法,应该作为首选方法在临床上推广应用。     

经内镜鼻胆管引流联合腹腔镜、胆道镜完成胆总管探查后一期缝合的探讨

目的探讨术前经内镜鼻胆管引流(endoscopic nasobiliary drainage,ENBD)在腹腔镜胆囊切除、胆总管切开、胆道镜取石后一期缝合胆总管代替术后T形管引流的可行性. 方法对18例胆囊结石合并胆总管结石(不伴有完全性胆道梗阻)腹腔镜手术之前行鼻胆管引流,术中一期缝合胆总管. 结果手术时间70～120 min,平均85 min.术后住院7～10 d,平均8 d.术后5 d经鼻胆引流管行胆道造影显示胆总管愈合良好,全组病人无胆漏、胆总管狭窄、肝内外胆总管残余结石、引流管脱落、胆汁性胰腺炎等并发症.18例随访6个月,1例胆总管内小结石经内镜括约肌切开取石,余17例未见胆总管明显扩张或狭窄. 结论腹腔镜胆囊切除、胆总管探查、胆道镜取石网取石手术之前行鼻胆管引流,完全可以替代T形管体外引流,缩短了住院时间.     

经T管腔内胆道支架治疗胆道探查术后胆汁漏1例报道并文献复习

目的探讨经T管腔内行胆道支架置入和肝内胆管置入鼻胆管胆道引流治疗胆道探查术后胆汁漏的临床疗效。方法回顾性分析南充市中心医院肝胆外科于2016年12月收治的1例胆总管探查术后胆汁漏患者的临床资料。结果对该例患者采用经T管腔内置入胆道支架和肝内胆管置入鼻胆管行胆道引流。经T管腔内隧道插入导丝至肝门部,向肝门部置入鼻胆管引流;另经T管再置入导丝1根,进入十二指肠,向十二指肠内置入8.5F塑料支架1根,支架一端置于胆总管内,一端于肠腔内,行胆道引流。引流术后患者胆汁漏停止,腹腔感染得到控制,于胆道支架置入术后10 d顺利出院,术后20 d夹闭T管和鼻胆管,2个月后行T管造影和腹部B超发现胆总管下段支架已脱落,拔除T管。门诊随访2年,患者完全康复。结论经T管腔内行胆总管下段支架置入术和肝门鼻胆管引流术是治疗胆汁漏的有效方法之一,方法简单,易于操作。     

内镜在腹腔镜胆囊切除术后胆漏治疗中的应用

目的:探讨内镜在腹腔镜胆囊切除术(LC)术后胆漏治疗中的应用价值。方法:10例胆漏患者均先行内镜下十二指肠乳头切开经鼻胆管引流术,继续保留原有胆道、腹腔引流。胆道、腹腔引流停止1~2周且证实胆漏愈合后拔管。结果:10例胆漏患者经鼻胆管引流2~3周后,胆漏处均闭合,无严重并发症发生。结论:内镜治疗可作为LC术后胆漏早期治疗的有效方法。     

逆行胰胆管造影在肝移植中的应用

目的探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植术后胆道并发症中的应用。方法对本院肝移植术后出现胆道并发症的16例患者进行ERCP检查,并根据情况分别行鼻胆管引流(ENBD)和/或内镜下乳头切开取石(EST)等治疗。结果ERCP确诊16例肝移植术后胆道并发症,发生率为9.47%,其中胆道结石6例,胆道狭窄3例,吻合口漏2例,胆道结石伴左肝管狭窄1例,吻合口胆漏伴胆道结石3例,1例示供受体胆管比例不一致,供体胆管相对狭窄,所有患者都得到有效治疗。结论内镜下ERCP是诊断和治疗肝移植术后胆道并发症的一种安全而有效的手段,可作为非手术治疗中的首选。     

肝移植胆系并发症的防治

目的 探讨原位肝移植胆系并发症的预防及治疗。方法 回顾性分析1999年2月至2002年12月完成的95例次原位肝移植。门静脉、下腔静脉转流下原位肝移植12例,背驮式肝移植78例,活体部分肝移植5例。胆道重建：胆管对端吻合91例,放置胆道外引流55例,36例未放置胆道引流。胆管空肠Roux-en-Y吻合4例。胆管吻合及胆肠吻合应用5旬或6-0 Vicryl缝线或PDS缝线间断或连续缝合。术后以血清学检查、超声、胆道造影等手段随访。结果 共发生胆系并发症7例,发生率7．3％。2例术后7、10d吻合口胆漏,致胆汁性腹膜炎,再次手术引流。1例术后1个月胆管吻合口狭窄,内窥镜下支架内支撑治愈。2例拔除T管时胆漏,1例保守治愈,1例腹腔镜下缝合窦道、腹腔引流治愈。1例术后5个月因胆管消融、胆管炎死亡。1例术后10d因肝动脉血栓形成继发胆管坏死后死亡。74例随访1-42个月(平均11．4个月),胆道造影及(或)超声检查未见肝内外胆管狭窄,无胆泥、胆石形成,血清学检查提示肝功能状态良好。结论供肝切取时保护胆管黏膜及肝外胆管动脉供给,实现精细胆管黏膜对黏膜无张力对端吻合是预防胆系并发症的关键。内窥镜下狭窄段胆管扩张、内支撑是治疗肝移植肝外胆管狭窄的有效手段。     

内镜乳头括约肌切开治疗术后胆漏

目的 探讨内镜乳头括约肌切开（EST）治疗肝胆术后漏的效果。方法 对肝胆术后胆漏病人结合逆行胆道造影（ERCP）,实施内镜乳头括约肌切开术（EST）联合鼻胆管负压引流。结果 3例肝叶切除术后肝创面胆漏和4例腹腔镜－胆囊切除术后胆囊管或胆囊床胆漏经采用此方法治疗后,均治愈无并发症。结论 内镜乳头括约肌切开术（EST）后,胆道内压降,利于胆汁引流入十二指肠,促使胆漏愈合。创伤小,成功率高,治愈时间短,为术后胆漏治疗的首选方法。     

胆道内支架治疗胆胰恶性肿瘤

目的探讨胆道内支架引流治疗胆胰恶性肿瘤的临床疗效。方法无手术指征的103例胆胰恶性阻塞性黄疸患者,行内镜下胆管支架引流,包括:经内镜鼻胆管引流术(ENBD组)11例,经内镜逆行塑料导管胆管引流术(ERBD组)45例,经内镜金属支架逆行引流术(EMBD组)47例。结果胆道引流效果满意91.3%,一般6.8%,无效1.9%;103例平均生存时间(227±135)d,ENBD组(184±56)d,ERBD组(226±73)d,EMBD组(238±136)d,3组比较无显著差异(P>0.05)。胆道引流术后通畅时间EMBD组为(214±120)d,明显优于ERBD组的(143±46)d和ENBD组的(152±74)d(P<0.05)。结论应用胆道支架治疗胆胰恶性肿瘤引起的梗阻性黄疸是一种简便、安全、有效的姑息性治疗手段。     

The management of T tube leaks in orthotopic liver transplant recipients with endoscopically placed nasobiliary catheters

Biliary tract problems remain an important cause of complication following orthotopic hepatic transplantation. We describe 12 liver transplantation patients who developed bile peritonitis secondary to a biliary leak after T tube removal. Each of these patients underwent an urgent ERCP that exhibited leakage outside the T tube tract and nondilated intrahepatic ducts. At the time of the ERCP, a nasobiliary catheter was inserted to divert the bile flow. All of these patients resolved their symptoms and closed their leak. We advocate endoscopic placement of a nasobiliary catheter as first-line therapy for significant T tube tract leaks after liver transplantation.     

Randomized controlled trial of oral itraconazole solution versus intravenous/oral fluconazole for prevention of fungal infections in liver transplant recipients

BACKGROUND: Liver transplant recipients at high risk for serious fungal infections frequently receive fluconazole or an amphotericin B preparation for antifungal prophylaxis. Because of concerns about fungal resistance with fluconazole, safety with amphotericin B, and the cost of lipid formulations of amphotericin, alternative prophylactic regimens are needed. In this randomized, controlled trial, we compared the efficacy and safety of oral itraconazole solution with intravenous/oral fluconazole for prevention of fungal infections. METHODS: Adult liver transplant recipients were randomized to receive either oral itraconazole solution (200 mg every 12 hr) or intravenous/oral fluconazole (400 mg every 24 hr). Each study drug was started immediately before transplant surgery and continued for 10 weeks after transplantation. Patients were evaluated for fungal colonization, proven invasive or superficial fungal infection, drug-related side effects, and death. RESULTS: Fungal colonization decreased from baseline to week 8 after transplantation in both the itraconazole patients (67% to 25%, P<0.001) and the fluconazole patients (77% to 30%, P<0.001). Proven fungal infection developed in 9 (9%) of 97 itraconazole patients and in 4 (4%) of 91 fluconazole patients (P =0.25). The number of proven invasive fungal infections (seven with itraconazole [7%], three with fluconazole [3%]) and proven superficial fungal infections (two with itraconazole [2%], one with fluconazole [1%]) were also similar in both groups of patients. Organisms causing infection were (four patients), (three patients), and species (two patients) in the itraconazole group and (two patients), (one patient), and species (one patient) in the fluconazole group. Mortality from fungal infection was very low and occurred in only 1 (0.5%) of 188 patients. Except for more frequent gastrointestinal side effects (nausea, vomiting, diarrhea) with itraconazole, both itraconazole and fluconazole were well tolerated and not associated with any hepatotoxicity. Mean trough plasma concentrations of itraconazole were greater than 250 ng/mL throughout the study and were not affected by H -receptor antagonists or antacids. CONCLUSION: Oral itraconazole solution has adequate bioavailability in liver transplant recipients for effective antifungal prophylaxis. Similar to fluconazole, prophylactic oral itraconazole decreases fungal colonization and is associated with a low incidence of serious or fatal fungal infections. Except for gastrointestinal side effects, oral itraconazole solution is well tolerated and has no significant hepatotoxicity.     

Endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations.

OBJECTIVE: This study was undertaken to prospectively evaluate the efficacy and safety of endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations. SUMMARY BACKGROUND DATA: Surgical therapy has been the traditional approach to large or unresolving biliary fistulas complicating liver transplantation. Although endoscopic management is rapidly becoming an acceptable alternative to surgery for the treatment of biliary fistulas complicating non-liver transplant hepatobiliary operations, it has received limited attention in the liver transplant setting. METHODS: During a 15-month period, 146 adults underwent liver transplantation with biliary reconstruction by end-to-end choledochocholedochostomy over a T-tube. Inadvertent T-tube migration or intentional T-tube removal resulted in bile peritonitis in 18 patients. The patients were treated with a nasobiliary tube (n = 13), internal stent plus endoscopic sphincterotomy (n = 3), or internal stent alone (n = 2). Thirteen patients had a biliary fistula after other hepatobiliary operations and underwent endoscopic therapy during a similar period. All 13 had an endoscopic sphincterotomy with removal of obstructing stones when present (n = 6). Twelve patients also had stents placed. All patients were prospectively followed after hospital discharge and assessed for recurrent symptoms suggestive of biliary tract disease and procedure-related complications. RESULTS: Endoscopic retrograde cholangiopancreatography (ERCP) identified a biliary fistula at the T-tube insertion site into the bile duct in all 18 liver transplant patients. Seventeen patients had resolution of their symptoms within 12 hours of therapy. The fistula sealed in 94.4%. In the other hepatobiliary operation group, ERCP demonstrated contrast extravasation from the biliary tree in 12 of 13. The biliary fistula closure rate was 92.3%. The endoscopic complication rate for the two groups was 3.2%. During a mean follow-up of 9 months, recurrent biliary tract complications occurred in 11.1% of the liver transplant group and 0% in the other hepatobiliary operation group (p > 0.05). The 30-day mortality rate was 0%. CONCLUSIONS: The results of this study support the application of endoscopic management of biliary fistulas complicating orthotopic liver transplantation and other hepatobiliary operations. This approach was relatively safe and obviated the need for surgical intervention.     

肝移植术后胆道并发症的防治

目的探讨肝移植术后胆道并发症的防治措施。方法回顾性研究2002年4月至2007年2月我中心249例肝移植的临床资料。结果249例肝移植患者中,31例发生胆道并发症(12.45%),其中胆漏16例(早期14例、晚期2例),吻合口狭窄9例,非吻合口狭窄6例。并发胆漏患者中,3例经ERCP放置鼻胆管引流治愈,4例在B超引导下行腹腔穿刺置管引流治愈,7例轻度胆漏患者经延长腹腔引流管放置时间治愈,2例晚期胆漏患者充分引流后治愈。吻合口狭窄患者中,5例行PTCD球囊扩张术,4例行ERCP球囊扩张术,共有3例放置了胆道支架,现均存活良好。非吻合口狭窄患者中,2例二次肝移植后治愈,另4例行PTCD联合胆道镜治疗,2例治愈,2例恢复不佳。结论完善手术技术、缩短移植物冷热缺血时间及保护胆道血供是预防肝移植术后胆道并发症的重要措施,个体化治疗,多可取得良好疗效。     

原位肝移植术后真菌感染的诊治

目的 探讨原位肝移植术后真菌感染的诊断和治疗。方法 58例肝移植患者术后怀疑真菌感染时，行体液（痰、血、尿、胆汁、引流液等）或导管真菌培养，结合胸腹部CT影像学检查、活组织检查及诊断性治疗结果综合判断，一旦诊断确定，即给予氟康唑治疗，无效者改用伊曲康唑和两性霉素B，同时调整免疫抑制治疗方案。结果 58例患者中，16例术后并发真菌感染21例次（5例患者发生两次以上、不同部位或不同菌株的感染），感染发生率为27．6％（16／58），感染发生在术后4～38d，感染好发部位依次为肺（28．6％）、肠道（19．0％）、泌尿系统（14．3％）、腹腔（14．3％）、切口（9．5％）、血液（4．8％）、胆管（4．8％）及肝脏（4．8％）。在21例次真菌感染中，念珠菌感染占85．7％，曲霉菌感染占14．3％。氟康唑治疗有效者占66．7％，伊曲康唑治疗有效者占14．3％，两性霉素B治疗有效者占14．3％，1例（4．7％）各种抗真菌药物治疗均无效，治疗总有效率为95．2％。结论 肝移植术后真菌感染的发生率较高，依据影像学检查、病原学检查及活组织检查综合判断真菌感染，及时选用氟康唑、伊曲康唑及两性霉素B治疗。     

Antifungal prophylaxis in liver transplant recipients: a randomized placebo-controlled study

The aim of this study was to evaluate the efficacy of two antifungal prophylaxis regimens in liver transplant recipients. One hundred and twenty-nine consecutive recipients were randomized to receive sequential treatment with intravenous liposomal amphotericin B + oral itraconazole, intravenous fluconazole + oral itraconazole, or intravenous and oral placebo. Frequency and incidence of mycotic colonization, local and systemic infection of mycotic origin, causes of death, and possible risk factors for mycotic infection were evaluated. The incidence of mycotic colonization was higher in the placebo group ( P<0.01), but there was no significant difference in the incidence of infection between the three groups. Pre-transplant colonization, severity of liver disease, and graft rejection were all risk factors for the development of fungal infection. The routine use of antifungal prophylaxis for all liver transplant recipients does not seem to be justified.     

原位肝移植术后48例次真菌感染的诊治体会

目的探讨原位肝移植术后真菌感染的诊断及治疗方法。方法回顾性分析147例肝移植受体术后发生真菌感染的诊治情况。结果147例患者中，29例发现真菌感染48例次，感染率为19．73％（29／147）。感染好发的部位依次为肺（33．34％，16／48），肠道（22．92％，11／48），泌尿系统（20．83％，10／48）。其中白色念珠菌感染占52．08％，光滑念珠菌感染占22．92％，热带念珠菌感染占12．50％，曲霉菌感染占8．34％，毛霉菌感染占4．17％。氟康唑治疗有效者占41．38％，伊曲康唑治疗有效者占27．59％，科赛斯治疗有效者13．79％，24例感染患者治愈，总有效率为82．76％。5例死亡，病死率17．24％。结论肝移植术后真菌感染的发生率较高，依据影像学检查和病原学检查等可早期诊断真菌感染，及时选用氟康唑、伊曲康唑及科赛斯等早期治疗是治愈真菌感染的关键。     

鼻胆管胆汁细菌培养及抗生素敏感性分析

目的:分析ERCP鼻胆管胆汁的微生物检测及细菌对抗生素的敏感性。方法:对2012年1月至2013年8月的112例病人ERCP后临床无感染征象时行鼻胆管胆汁细菌培养和抗生素敏感试验。结果:在123次鼻胆管胆汁微生物培养中52次检测结果阳性,阳性率为42.3%,其中细菌10种,真菌3种。所有胆汁培养共检出细菌58株,其中革兰阴性菌6种42株,革兰阳性菌4种11株,真菌3种5株。胆汁革兰阴性菌对碳青霉烯类抗生素(亚胺培南、厄他培南)和氨基糖苷类抗生素(阿米卡星、庆大霉素)的敏感性最高,对头孢曲松、头孢他啶等第三代头孢菌素和左氧氟沙星、哌拉西林/三唑巴坦中度敏感,对环丙沙星、氨苄西林/舒巴坦等抗生素较不敏感,对头孢唑林均不敏感。革兰阳性菌对万古霉素仍较敏感,对喹努普汀/达福普汀、利奈唑胺、替加环素高度敏感,但对苯唑西林等青霉素和克林霉素、红霉素等敏感性不高。结论:临床无感染症状病人的鼻胆管胆汁具有较高的细菌感染率。本研究对于ERCP后胆道感染复发病人早期使用抗生素,控制病情进展提供了参考。