肝门部胆管癌51例的外科治疗

目的探讨肝门部胆管癌的外科治疗方法和效果。方法对经手术和病理检查确定诊断的肝门部胆管癌51例的临床特征、手术方式和随访结果进行回顾性分析。结果肿瘤切除17例,其中根治性切除7例,姑息性切除10例。胆肠吻合15例,单纯探查活检6例,胆道支架置入13例。根治性切除组1,3,5年生存率分别为71%,42%和28%。姑息性切除、胆肠吻合和胆道支架置入组1年生存率分别为20%,0%和31%。结论应力争进行唯一能治愈肝门部胆管癌的根治性切除。如无法根治切除,以胆道支架置入为首选治疗方法。     

肝门部胆管癌外科治疗的研究进展

肝门部胆管癌是指发生于胆囊管开口以上的肝外胆管癌,包括肝总管、左右肝管。肝门部胆管癌占胆管癌总数的50%以上[1],在各类胆管癌中发病率最高,处理最为困难,预后亦较差。未进行治疗者通常只能生存3个月到1年[2]。1965年klatskin[3]首先描述此类肿瘤的临床病理特征。     

肝门部胆管癌的外科治疗

目的：探讨肝门部胆管癌外科治疗策略及其治疗结果。方法：回顾性分析1997—09～2004-10收治的28例肝门部胆管癌的临床资料。结果：Bismuth—CorletteⅠ型10例，Ⅱ型8例，Ⅲa型4例，Ⅲb型3例，Ⅳ型3例。手术切除16例(57．1％)，其中根治性切除11例(39．3％)，姑息性切除5例(17．8％)，外引流7例(25．6％)，剖腹探查5例(17．9％)。手术切除组、外科引流组及剖腹探查组的平均生存时间分别为20．6、7．3及1．5个月。1例术后10d因肾功能衰竭死亡。结论：治疗应以手术切除为主，根治性切除术可延长患者生存时间。对不能切除的病例应设法减轻黄疸。     

单通道双支架植入技术治疗肝门部胆管癌

目的 探讨单通道双支架植入技术治疗肝门部胆管癌的可行性和临床应用价值。方法 18例肝门部胆管癌患者，左、右肝管起始部狭窄或闭塞。采用右腋中线入路穿刺右肝管，用导丝寻找右肝管与左肝管和胆总管之间的潜在腔隙，于左右肝管间以及右肝管-胆总管间分别植入支架。结果 18例患者均从右腋中线穿刺通道成功植入右肝管-左肝管间及右肝管-胆总管间的支架，实现了胆汁经左肝管-右肝管-胆总管的完全内引流，解除梗阻疗效显著。结论 单通道双支架植入技术简化了高位胆管梗阻介入件引流的操作，减少了操作创伤，缩短了操作时间，具有较高的临床实用价值。     

肝门部胆管癌影像分型及治疗策略初探

目的 研究肝门部胆管癌的影像学分型,并探讨其临床价值与治疗方式的关系。材料与方法 男49例,女14例。全部病例均经PTC、CT和／或MRI、B超检查。采用Bismuth-CorletteⅠ－Ⅳ型分型法。结果 Ⅰ型16例,Ⅱ型7例,Ⅲ型14例（Ⅲa型5例;Ⅲb型9例）,Ⅳ型26例。13例手术切除,包括Ⅰ型8例,Ⅱ型2例,Ⅲa型1例,Ⅲb型2例,Ⅳ型均未能切除。其中根治性切除5例,姑息性切除8例;非切除组47例,包括胆－肠吻合术20例,内、外引流术23例,金属支架入术4例。CT和或／MRI显示肝动脉和／或门静脉受侵38例,伴肝转移3例,淋巴结转移2例。结论 影像学分型结合CT和／或MRI可为选择治疗方式提供依据。     

肝门部胆管癌术前MRI及MRCP评价:手术及病理的相关性研究

本研究目的主要是评价延迟对比增强MRI在显示肝门部胆管癌的神经周围扩散,进而评价MRI/MRCP对肝门部胆管癌的肿瘤分期能力。回顾性分析15例外科手     

肝门部胆管癌的磁共振诊断和评价

肝门部胆管癌起源于肝内胆管，发生左右肝管汇合区，在肝脏恶性肿瘤中位居第二，在胆管肿瘤中位居第一，占胆管癌的58％-75％。由于肿瘤生长缓慢和隐蔽，早期影像学诊断困难；但由于肝门区有许多重要的血管，手术时多数癌肿已侵犯周围组织，手术切除难度大，预后很差。笔者搜集术前行MR检查、经手术和病理证实的肝门部胆管癌28例，旨在探讨MR在肝门部胆管癌中的诊断价值。     

49例肝门部胆管癌的手术治疗分析

目的 探讨肝门部胆管癌治疗方式及疗效.方法 回顾性分析2000年6月至2010年5月北京航天中心医院收治的49例肝门部胆管癌手术病例资料.分为单纯切除组、小范围切肝组与大范围切肝组,对比各组的并发症发生率.对临床病理资料进行单因素与多因素分析,检验对生存率的影响.结果 单纯切除组17例,小范围切肝组10例,大范围切肝组22例,各组并发症发生率依次为23.5%(4/17),30.0%(3/10)和72.7%(16/22),后者明显高于前两组(P<0.05).1,3,5年总生存率分别为73.2%,41.4%和21.3%,中位生存期30个月.单因素分析显示手术方式、切缘癌残留、淋巴结转移、T分期对生存率有影响(P<0.05).多因素分析显示淋巴结转移(RR=3.787,95% CI 0.069～25.912)和切缘癌残留(RR=2.447,95% CI 1.508～3.971)是影响肝门部胆管癌手术生存率的独立危险因素(P<0.05).结论 根据肿瘤T分期、淋巴结转移等因素选择适宜的手术方式,有望获得更大的近远期疗效.     

Animal model of bile duct dilatation created with minimally invasive surgery

RATIONALE AND OBJECTIVES: The purpose of the study was to evaluate a method of producing obstruction of the common bile duct and concomitant biliary duct dilatation in an animal model. MATERIALS AND METHODS: Laparoscopic placement of a double-balloon occlusion device was used to produce common bile duct obstruction and bile duct dilatation in pigs. RESULTS: One week after the procedure, common bile duct obstruction and dilatation of the biliary tree were demonstrated with either percutaneous transhepatic cholangiography or percutaneous cholecystography. CONCLUSION: The use of this method is technically feasible and provides a useful subacute and chronic animal model of common bile duct obstruction and dilatation of the biliary tree for percutaneous interventional training and research purposes.     

肝内胆管错构瘤5例的磁共振成像诊断及鉴别诊断简

目的：探讨成人肝脏胆管错构瘤的影像学表现,以提高对本病的认识。方法回顾性分析5例经手术、病理证实的肝内胆管错构瘤的影像学表现。对所有患者均行磁共振成像（MRI）平扫、磁共振胰胆管造影（MRCP）、增强扫描,并穿刺活检病理证实。结果 T1WI病变呈低于肝实质的信号,呈多发,沿血管胆管树分布, T2WI病灶显示清楚,呈明显的高信号,在MRCP序列上,多数病变显示为高信号,与T2WI比较,显示的病变数量有所减少。MRCP显示肝内多发类囊状高信号病变,与可见的胆管树不相通。增强扫描示各期病灶无强化,在增强扫描60 s,3 min肝实质明显强化,小囊状信号未见明显强化,形成明显的对比。结论成人肝内胆管错构瘤在影像学上无特征性表现,类似于肝转移瘤、肝脓肿、肝海绵状血管瘤等常见的肝囊性占位病变。     

Chronic bile peritonitis with progressive bile ascites: A complication of percutaneous biliary drainage

Percutaneous transhepatic biliary drainage procedures are associated with a small but definite incidence of complications. One of the most feared complications, leakage of bile, is commonly presumed to be a catastrophic clinical event. We present an unusual case in which a patient manifested only minimal abdominal symptoms associated with a massive biliary ascites. The bile leakage was first detected by diisopropyl iminodiacetic acid (DISIDA) scanning.     

肝内外胆管及胆囊扩张程度和低位梗阻性黄疸病变的相关性

目的探讨肝内、外胆管及胆囊扩张程度、形式对低位梗阻性黄疸的诊断价值。方法回顾性分析105例低位阻塞性黄疸患者的CT和内窥镜逆行胰胆管造影（ERCP）的影像资料，将胆系扩张分为下列7种类型：Ⅰ型为肝内、外胆管及胆囊均重度扩张；Ⅱ型为肝外胆管、胆囊重度扩张伴肝内胆管轻度扩张；Ⅲ型为肝内、外胆管重度扩张伴胆囊不扩张或轻、中度扩张；Ⅳ型为肝外胆管重度扩张伴肝内胆管和胆囊不扩张或轻、中度扩张；Ⅴ型为肝内胆管重度扩张伴肝外胆管及胆囊不扩张或轻、中度扩张；Ⅵ型胆囊重度扩张伴肝内、外胆管不扩张或轻、中度扩张；Ⅶ型为肝内、外胆管及胆囊均不扩张或轻、中度扩张。结合手术和病理结果，分析各类型胆系扩展和其低位阻塞性黄疸病变的相关性。结果105例低位阻塞性黄疸中33例为肿瘤性病变，72例为非肿瘤性病变。肿瘤性病变中．Ⅰ型16例，Ⅱ型10例，Ⅲ型4例，Ⅳ型1例，Ⅶ型2例。非肿瘤性病变中，Ⅰ型4例，Ⅱ型4例，Ⅲ型9例，Ⅳ型33例，Ⅴ型2例，Ⅵ型11例，Ⅶ型9例。Ⅰ、Ⅱ型扩张和Ⅲ～Ⅶ型扩张在肿瘤和非肿瘤病变中差异有统计学意义（χ^2=47．33，P〈0．01）。结论低位阻塞性黄疸病变性质和肝内、外胆管及胆囊扩张程度密切相关：（1）Ⅰ型和Ⅱ型扩张提示绝大多数为肿瘤性病变，少数为嵌顿性结石。（2）Ⅲ～Ⅶ型扩张常为胆管、胆囊结石及炎症。     

Comparison of percutaneous and endoscopic retrograde removal of postoperatively retained bile duct stones

Forty-one patients underwent nonsurgical removal of postoperatively retained bile duct stones in two nonrandomized groups. The endoscopic-retrograde technique was used in 21 patients, and succeeded in 19. The percutaneous approach through the T-tube tract was used in 22 patients, including the two in whom endoscopic stone removal had failed, and was successful in 21 patients. Individual preferences and prior history introduced a selection bias against the percutaneous technique. Auxiliary extracorporeal shockwave lithotripsy (ESWL) was used in 2 patients whose stones could not be fragmented mechanically by the percutaneous basket technique. ESWL was successful in one patient but failed in the second. Because endoscopy had also failed in this case, the patient subsequently underwent repeat surgery. Procedure-related complications were minor with both techniques and were readily treated by conservative measures. We conclude that both the retrograde and the percutaneous approaches are effective and safe. The endoscopic approach appears convenient because there is no need to await maturation of the percutaneous tract, but sphincterotomy carries a small but distinctive risk. Because the percutaneous approach uses an existing tract, is only minimally invasive and leaves the sphincter of Oddi intact, it is preferable in those patients who have T-tubes of approapriate size and position in place.     

Treatment of iatrogenic biliary obstruction by balloon dilatation of a biliary jejunal fistula

Biliary obstruction and multiple hepatic abscesses occurred in a patient after ligation of a segmental branch of the right hepatic duct. The patient was successfully managed by transhepatic biliary drainage and balloon dilatation of an internal fistula that developed between the ligated duct and a Roux limb of jejunum. Internal biliary fistulas may be dilated using interventioanl radiologic techniques to permit nonobstructed bile flow. Implications for the nonsurgical treatment' of biliary strictures are discussed.     

Percutaneous transhepatic intraductal biliary sonography for lymph node staging at 12.5 MHz in malignant bile duct obstruction: Work in progress

Purpose To assess the value of intraductal ultrasound (US) for lymph node staging in malignant biliary obstruction. Methods Eighteen patients with malignant extrahepatic obstruction were imaged during percutaneous bile duct drainage with a mechanically rotating US transducer at 12.5 MHz. Detectable lymph nodes were classified as malignant when two of three criteria (hypoechoic, rounded, conspicuous margins) were fulfilled. The results were compared with histopathological data in 8 patients and follow-up CT findings in 10 patients. Results In 15 of 18 patients (83%) malignant lymph node involvement was suspected at intraductal US and in 5 of 18 patients (28%) during CT. Histopathological investigation after operation (n=8) and follow-up CT studies (n=10) revealed the presence of malignant nodal involvement in 13 of 18 (72%) patients. The sensitivity, specificity, and accuracy of transhepatic intraductal biliary US in determining merely the presence or absence of malignant lymph nodes without specific topographic assignment were 92%, 40%, and 78%, respectively. Conclusion These preliminary results suggest that intraductal US may develop into a promising adjunctive modality during percutaneous bile duct drainage in patients with suspected malignant regional lymph node involvement.     

Percutaneous transhepatic stenting by wallstents of portal vein and bile duct stenoses caused by immunoblastic sarcoma in a liver transplantation

Posttransplant lymphoproliferative disorders are infrequent tumors related to chronic immunosuppressive therapy. We present a liver transplant recipient who developed such a tumor in the porta hepatis that provoked obstruction of the entire portal triad. Treatment consisted of systemic chemotherapy, percutaneous dilatation, and placement of Wallstent endoprostheses across both biliary and portal vein stenoses. The patient died 3 weeks later of pneumonia and sepsis. At necropsy, the tumor was completely necrosed and the prostheses in both the common bile duct and the portal vein were patent.     

Isolated Right Segmental Hepatic Duct Injury Following Laparoscopic Cholecystectomy

Purpose Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. There is an increased incidence of bile duct injuries in LC compared with the open technique. Isolated right segmental hepatic duct injury (IRSHDI) represents a challenge not only for management but also for diagnosis. We present our experience in the management of IRSHDI, with long-term follow-up after treatment by a multidisciplinary approach.Methods Twelve consecutive patients (9 women, mean age 48 years) were identified as having IRSHDI. Patients demographics, clinical presentation, management and outcome were collected for analysis. The mean follow-up was 44 months (range 2–90 months).Results Three patients had the LC immediately converted to open surgery without repair of the biliary injury before referral. Treatments before referral included endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage and surgery, isolated or in combination. The median interval from LC to referral was 32 days. Eleven patients presented with biliary leak and biloma, one with obstruction of an isolated right hepatic segment. Post-referral management of the biliary lesion used a combination of ERCP stenting, percutaneous drainage and stent placement and surgery. In 6 of 12 patients ERCP was the first procedure, and in only one case was IRSHDI identified. In 6 patients, percutaneous transhepatic cholangiography (PTC) was performed first and an isolated right hepatic segment was demonstrated in all. The final treatment modality was endoscopic management and/or percutaneous drainage and stenting in 6 patients, and surgery in 6. The mean follow-up was 44 months. No mortality or significant morbidity was observed.Conclusion Successful management of IRSHDI after LC requires adequate identification of the lesion, and multidisciplinary treatment is necessary. Half of the patients can be treated successfully by nonsurgical procedures.     

肝外胆管梗阻的磁共振胆胰管造影诊断

目的 评价磁共振胆胰管造影（ＭＲＣＰ）对肝外胆管梗阻性疾病的临床诊断价值。方法 对５４例肝外胆管梗阻性疾病（肝外胆管结石３０例,恶性胆管梗阻２４例）进行ＭＲＣＰ检查,并与临床诊断或手术和病理结果对照分析。ＭＲＣＰ采用不屏气快速自旋回波（ＴＳＥ）序列重工Ｔ２ＷＩ扫描,结合呼吸触发及脂护抑制技术,原始图像以最大信号强度投影（ＭＩＰ）法进行三维重建。结果 全部５４例ＭＲＣＰ检查均一次成功,５２例胆胰管显