经内镜放置双侧塑料胆道支架治疗肝门部胆管癌围手术期的护理

目的：探讨经内镜下放置双侧胆道塑料支架围手术期的护理方法。方法回顾性分析我科2011年9月至2013年11月18例经内镜置入双侧塑料支架的肝门部恶性梗阻患者的临床资料及围手术期的护理要点。结果18例患者成功置入双侧塑料支架,94.4%（17例）的患者引流效果好,术后3周内胆红素降至正常范围;11.1%（2例）的患者术后次日查血淀粉酶轻度升高,经处理后48 h内降至正常;5%（1例）的患者术后第5天出现高热、寒战,经皮肝穿胆道引流术（PTCD）后改善。结论经内镜下放置双侧胆道塑料支架可有效控制大部分肝门部恶性梗阻所致的黄疸和胆道感染,做好围手术期的护理,可提高患者医从性,便与ERCP操作,降低手术并发症,减轻患者的痛苦。     

经内镜逆行胆管支架置入在恶性胆管狭窄姑息性减黄 治疗中的有效性和安全性分析

目的探讨经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）置入胆管支架治疗恶性胆管狭窄所致梗阻性黄疸的有效性及安全性,筛选胆管支架引流效果预测指标。方法采用ERCP技术对106例不能手术切除的恶性胆管狭窄病人行胆管支架置入治疗。根据分析目的不同分为:恶性胆管狭窄肝门部与远端组;恶性肝门部胆管狭窄BismuthⅠ型与Ⅱ~Ⅳ型组;恶性肝门部胆管狭窄BismuthⅡ~Ⅳ型中单侧支架与双侧支架组;恶性远端胆管狭窄中塑料支架与金属支架组;支架引流有效与无效组。记录术前、术中及术后相关指标,比较术前术后及各组引流效果、术后并发症发生情况,分析筛选可能影响支架引流效果的相关指标。结果106例病人术后1周内血清总胆红素水平较术前明显下降（P < 0.05）,引流有效率70.8%。Bismuth Ⅰ型组、金属支架组引流有效率分别明显高于BismuthⅡ~Ⅳ型组、塑料支架组（P < 0.05）。恶性肝门部胆管狭窄较远端胆管狭窄的术后急性胰腺炎及急性胆管炎的发生率明显升高（P < 0.05）。术前血清白蛋白水平及术中回抽淤积胆汁量与引流效果呈明显正相关（P < 0.05）。结论经ERCP置入胆管支架的姑息性减黄治疗安全有效,但对于引流效果及术后并发症相对风险较高之BismuthⅡ~Ⅳ型组应谨慎对待。术前血清白蛋白水平及术中回抽胆汁量可预测支架引流效果。     

ERCP放置胆道内支架治疗晚期恶性胆道梗阻42例临床分析

目的 探讨通过纤维十二指肠镜逆行胆胰管造影(ERCP)放置胆道内支架姑息治疗晚期恶性胆道梗阻的临床疗效.方法 42例晚期恶性肿瘤引起的梗阻性黄疸患者,通过ERCP内镜下放置胆道内支架解除胆道梗阻性黄疸,经ERCP将导丝插入胆道并超过梗阻部位,扩张狭窄后,用推送导管将已经选择合适的引流支架推送至胆道合适部位,其近端均超过梗阻段1cm以上.结果 42例患者中插管成功36例,不成功6例,成功率85.71%(36/42).其中25例胆道内放置8F Z型自膨胀式金属支架外,其余11例行8～10F塑料内支架引流.术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻.其中27例2周内血清总胆红素下降50%以上,血清总胆红素退至40μmol/L,放置胆道内支架1周后,患者血清总胆红素由术前(334.12±66.54)μmol/L降至(89.87±53.42)μmol/L,肝功能较术前显著改善(P<0.05,P<0.01).术后1、2周,24例胆总管下端梗阻患者胆红素下降明显优于10例肝门部胆管梗阻患者(P<0.01).25例放置胆道金属支架患者中,有11例于术后2个月发生支架阻塞,再次放置塑料内支架后引流通畅,1例放置金属支架术后患者第9个月才出现支架阻塞,予以再次植入金属支架.另外11例放置塑料内支架者,有4例放置塑料内支架者于术后1～4周出现血清总胆红素再次上升,经ERCP检查发现支架移位和梗阻,予以更换内支架.结论 通过ERCP内镜下胆道放置内支架,解除晚期恶性胆道梗阻性黄疸,对缓解症状、提高患者生存质量具有满意疗效.     

内镜下胆道内支架置入治疗恶性梗阻性黄疸58例疗效分析

目的:探讨经十二指肠镜行胆道支架置入术以及鼻胆管引流治疗恶性梗阻性黄疸的疗效。方法:58例恶性梗阻性黄疸的患者,均行ERCP(经内镜逆行胰胆管造影)术,根据情况置入不同支架或行鼻胆管引流术,观察其疗效和3个月、6个月生存率。结果:56例病人插管成功,插管成功率97%。其中36例置入金属支架。18例置入塑料支架,2例行单纯鼻胆管引流,2例未能插管成功而放弃ERCP。并发症5例,其中急性胰腺炎2例,高淀粉酶血症2例,急性胆管炎1例,并发症率8.9%。插管成功的56名患者血清胆红素从(377.4±155.5)μmol/L下降到术后1周(146.4±54.5)μmol/L(P<0.01),支架组随访40例中总体3个月、6个月存活率分别达到94%及77%。结论:通过ERCP所进行的支架的放置术以及鼻胆管引流是姑息治疗恶性梗阻性黄疸的有效方法。     

经内镜胆道内支架术治疗恶性胆管梗阻的临床价值

目的探讨经内镜放置胆道内支架治疗胆管恶性梗阻的临床价值。方法对72例各类恶性肿瘤导致胆管梗阻的患者采用内镜胆道内支架术作胆汁引流88例次,其中胆道塑料支架引流术(ERBD)49例次,胆道金属支架置放术(EMBE)39例次。结果操作成功率为96.6%,并发症发生率为10.2%;金属支架的通畅时间为(135±14)天,明显长于塑料支架的(49±5)天(P<0.01)。结论经内镜胆道内支架术能有效解除恶性胆管梗阻患者的胆管梗阻,有良好的临床疗效,ERBD和EMBE各有其适应证。     

内镜下胆道塑料支架置入引流术治疗复发性胆总管结石的临床效果

目的探讨内镜下胆道塑料支架置入引流术治疗复发性胆总管结石的临床效果。方法回顾性分析该院2014年2月‐2015年1月行内镜下取石治疗的66例复发性胆总管结石受试者临床资料,根据其引流方式分为取石后留置胆道塑料支架引流组(研究组)和取石后留置鼻胆管引流组(对照组)。对比两组受试者术后并发症发生情况,随访1年内结石复发率、复发间隔时间、引流通畅率及脱落率。结果两组受试者术后并发症发生率比较差异无统计学意义(P0.05);随访1年,两组受试者结石复发率、复发间隔时间、引流通畅率及脱落率比较差异均无统计学意义(P0.05)。结论内镜下胆道结石清除后留置塑料胆道支架或鼻胆管均可获得较理想的引流效果,安全性较高。     

胆管恶性梗阻内镜治疗的临床价值

目的探讨内镜治疗胆管恶性梗阻的临床价值。方法对168例各类恶性肿瘤导致的胆管梗阻患者采用内镜胆道扩张和内支架术作胆汁引流196例次,其中胆道塑料支架引流术(ERBD)114例次、胆道金属支架置放术(EMBE)82例次。结果操作成功率为96.9%,并发症发生率为9.7%,比较ERBD与EMBE患者的支架通畅时间,结果金属支架的通畅时间(178&#177;21天)明显长于塑料支架(77&#177;7天)(P&lt;0.01)。结论内镜治疗恶性胆管梗阻是一种操作简单、经济有效、并发症少的方法,可以显著降低病人的创伤和痛苦,提高病人的生活质量。     

内镜下多塑料支架置入治疗活体肝移植术后胆管狭窄

目的探讨内镜下多塑料支架置入治疗活体肝移植术后胆管狭窄的安全性与长期疗效。方法 2005年6月至2012年6月,共31例活体肝移植术后胆管狭窄患者接受内镜逆行胆胰管造影(ERCP)及多塑料支架置入治疗,记录内镜治疗技术成功率和ERCP相关并发症,对患者进行随访并观察支架维持时间、狭窄消除率和狭窄持续消除率。结果 ERCP证实单纯胆管吻合口狭窄22例,胆管吻合口狭窄合并胆漏9例。27例成功置入塑料支架,内镜治疗技术成功率为87.1%(27/31)。ERCP并发症包括急性胰腺炎1例,急性胆管炎2例,支架部分移位2例,无操作相关死亡发生,支架中位维持时间为9.6个月,狭窄消除率为95%(19/20),狭窄持续消除率为88.2%(15/17;随访5～43个月,中位随访期38个月)。结论内镜下多塑料支架置入治疗活体肝移植术后胆管狭窄是安全、有效的方法,其长期疗效满意,可成为活体肝移植术后胆管狭窄的一线治疗方法。     

支架置入治疗27例恶性梗阻性黄疸的疗效

目的:探讨支架置入治疗恶性胆道梗阻的临床价值。方法:对27例不宜手术治疗的恶性胆道梗阻患者,通过内镜、经皮经肝两种方式行胆道支架置人术。回顾其支架通畅、胆红素下降、并发症发生等情况。结果:应用内镜治疗23例,经皮经肝穿刺4例。14例放置金属支架的患者中3例术后2个月支架阻塞,经过放置塑料支架后引流通畅,其他11例置入支架后平均通畅266 d。13例放置塑料支架的患者中2例术后4周内支架移位或梗阻,重新置入塑料支架,其他11例支架通畅平均110 d。治疗中所有患者均未发生严重并发症。所有患者放置内支架1周后,血清总胆红素、AST、ALT均显著下降,临床症状明显改善。随访26个月,存活3个月以上18例。结论:胆道支架置入治疗恶性胆道梗阻疗效确切,适用于不宜手术的患者,对于恶性胆道梗阻性黄疸症状的缓解、提高患者生存质量效果令人满意。     

经内镜下逆行胰胆管造影置入支架治疗恶性胆管梗阻的分析

目的探讨经内镜下逆行胰胆管造影置入支架治疗恶性胆管梗阻的疗效。方法收集我院恶性胆管梗阻患者,分为:研究组(接受金属支架治疗)和对照组(接受单塑料支架治疗)。对比(1)两组术后不同时间总胆红素、直接胆红素、碱性磷酸酶及谷氨酰转肽酶。(2)两组术后并发症及支架通畅时间。结果两组术前总胆红素、直接胆红素、碱性磷酸酶及谷氨酰转肽酶比较无差异(P0.05);两组术后1周总胆红素、直接胆红素、碱性磷酸酶及谷氨酰转肽酶比较有差异(P0.05);两组术后并发症及支架通畅时间比较有差异(P0.05)。结论经内镜下逆行胰胆管造影置入金属支架可以有效改善恶性胆管梗阻患者实验室指标,延长支架使用时间。     

Are self-expandable metal stents superior to plastic stents in palliating malignant distal biliary strictures? A meta-analysis and systematic review

BackgroundPalliation for inoperable malignant distal biliary strictures can be achieved with self-expandable metal stents (SEMS) and plastic stents (PS). This is a meta-analysis to compare PS and SEMS. The aim of the study is to compare clinical outcomes in patients with SEMS and PS.MethodsStudy selection criteria were studied using SEMS and PS for palliation in patients with malignant distal biliary stricture. For data collection and extraction, articles were searched in Ovid journals, Medline, Cochrane database, and Pubmed. Pooled proportions were calculated using both Mantel–Haenszel method and DerSimonian Laird method for statistical analysis.ResultsInitial search identified 1376 reference articles, of which 112 were selected and11 studies (N = 947) were included in this analysis. Pooled analysis showed SEMS patency to be 167.7days (95% CI = 159.2–176.3) compared to 73.3days (95% CI = 69.8–76.9) in PS. SEMS have lower odds of occlusion when compared to PS with an odds ratio of 0.48 (95% CI = 0.34–0.67). SEMS has a lower odds of cholangitis compared to SP, with an odds ratio of 0.46 (95% CI = 0.30–0.69).ConclusionSEMS seem to be superior to PS with better patency periods and survival duration. SEMS have lower occlusion rates, re-intervention rates, and cholangitis.     

肝内记忆金属支架介入术治疗肝门部胆管癌的应用研究

目的：探讨经皮经肝置入记忆金属内支架术，在治疗肝门部胆管癌的作用。方法：20例估计不能手术切除的肝门部胆管癌患者，置入记忆金属内支架（PMSE）20例，观察其减黄效果、并发症发生率、再梗阻时间及生存率。结果：全组术后2-3月的减黄有效率92.85%；引流效果与Bismuth分型有密切关系。引流维持通畅平均时间7.3个月。术后随访平均存活期7.3个月。结论：对无切除可能的肝门部胆管癌，经皮经肝记忆金属内支架置入术可作为首选的安全有效的姑息性治疗手段。     

塑料内支架治疗难取性胆总管结石的疗效分析

目的评价塑料内支架治疗难取性胆总管结石的疗效。方法采用常规方法行ERCP造影，对58例难取性胆总管结石患者（41例为巨大结石，10例结石伴下端胆管狭窄、7例结石伴乳头过小），在导丝引导下放置一根8．5Fr塑料胆道内支架进行治疗。结果3个月后第二次ERCP检查时，发现15例结石消失；27例结石直径变小1／2以上或成碎片状经网篮或气囊顺利取出；16例结石无明显变化，行更换塑料内支架治疗并B超随访，一旦发现结石明显变小，即再次ERCP＋取石。经平均2．3次内镜下治疗，96．5％患者结石取净。期间未发生与ERCP或留置支架相关的严重并发症。结论留置塑料内支架是治疗难取性胆总管结石简单有效的方法。     

Clinical outcomes of serolimus-eluting stents versus bare metal stents in ST-segment elevation myocardial infarction patients: a meta-analysis

Background The benefits and safety of sirolimus-eluting stent （SES） have not been systematically quantified in different trials in ST-segment elevation myocardial infarction （STEMI） patients with primary or rescue percutaneous coronary intervention （PCI）. A meta-analysis of randomised trials comparing SES and bare-metal stent （BMS） was performed. Methods A systematic literature search was conducted to identify all randomized clinical trials. The primary outcome was the rate of major adverse cardiac events （MACEs）. The secondary outcomes included death, recurrent myocardial infarction, recurrent revascularization, and stent thrombosis.
Results Totally, 1973 STEMI patients were enrolled in seven eligible randomized trials comparing SES with BMS. The pooled rate of major adverse cardiac events was significantly lower in the SES group than in the BMS group （9.7% vs 20.3%, OR 2.45, 95% Cl 1.88-3.19, P 〈 0.00001）. No significant difference in all causes of death was found between the SES and BMS groups, as well as in the pooled recurrent myocardial infarction rates. The pooled recurrent revascularization rate was significantly lower in the SES group than in the BMS group （5.1% vs 14.8%, OR 3.30, 95%CI 2.37-4.60, P 〈 0.00001）. No significant difference was found between the pooled rates of stent thrombosis （1.2% in the SES group and 2.0% in the BMS group, OR 1.61, 95%CI 0.79-3.26, P = 0.19）.
Conclusions SES is associated with a decreased risk of major adverse cardiac events compared with BMS by the greater reduction in repeat revascularization in STEMI patients. Larger trials with longer follow up are warranted to better define the role of SES in STEMI.     

生物可吸收支架与药物洗脱支架治疗心血管疾病的比较：临床试验meta分析

目的 比较生物可吸收支架与药物洗脱支架治疗心血管疾病的安全性和有效性。方法 计算机检索中国生物医学文献服务系统（SinoMed）、万方、中国知网（CNKI）、维普（VIP）、PubMed、Medline、Embase数据库,检索年限为1980年1月至2018年10月,筛选出符合纳入标准的临床试验研究文献,采用R 3.5.1软件计算评价指标比值比（OR）及95%置信区间（CI）,评估生物可吸收支架与药物洗脱支架治疗心血管疾病的安全性和有效性。结果 最终纳入22项研究,包含33 570名研究对象。在合并的心脏冠状动脉疾病的临床试验随访结果中,生物可吸收支架相对于药物洗脱支架,主要的安全性指标、有效性指标差异均无统计学意义（P均>0.05）,其中心源性死亡率合并OR（95% CI）为1.01（0.88,1.16）、总体死亡率合并OR（95% CI）为0.97（0.88,1.08）、心肌梗死发生率合并OR（95% CI）为0.98（0.87,1.10）、靶病变血运重建率合并OR（95% CI）为0.99（0.89,1.09）、靶血管血运重建率合并OR（95% CI）为1.03（0.95,1.13）。针对生物可吸收支架的应用目的对各时期支架内血栓发生率的合并分析中,临床确诊或疑似支架内血栓发生率合并OR（95% CI）为0.80（0.65,0.99）,差异有统计学意义（P=0.042）;早期支架内血栓发生率合并OR（95% CI）为0.97（0.69,1.37）,差异无统计学意义（P=0.906）;晚期支架内血栓发生率合并OR（95% CI）为0.61（0.43,0.86）,差异有统计学意义（P=0.004）。结论 在冠心病的治疗中,不能认为生物可吸收支架与药物洗脱支架存在安全性或有效性的差异,但生物可吸收支架可降低支架内血栓尤其是晚期血栓的发生风险。     

Below knee drug eluting stents

Restenosis and occlusion after endovascular intervention of lower limb arteries remain the main problem in obtaining better results for patients with critical limb ischemia (CLI) and claudication.Improved angioplasty balloons,catheters,guide-wires,and operator skill have enabled ＞90％ of stenotic and ＞80％ of occluded arteries to be successfully cleared.However,percutaneous transluminal angioplasty (PTA) rarely results in sustained patency with most studies showing a ＜50％ patency at 12 months.1,2 Drug eluting stents (DES)were originally designed to reduce the risk of restenosis in coronary arteries.While there has been concern about acute thrombosis in the medium term follow-up,DES has clearly been shown to reduce the risk of restenosis compared with similar bare metal stents (BMS) by over 50％ at 12 months and later.4     

Multilayer stents, a new progress in the endovascular treatment of aneurysms

Objective To review the recent progress of multilayer stents in treating arterial aneurysms and to draw an initial conclusion about its paradigm.Data sources PubMed database and ELSEVIER database were ...     

Pharmacokinetics of rapamycin-eluting stents in miniswine coronary model

Background The results of clinical trials of rapamycin-eluting stents reduce restenosis have been quite promising. The main purpose of this study was to characterize the in vivo pharmacokinetics of high dose rapamycin (Rapa)-eluting stents in a miniswine coronary model.Methods Ten miniswines underwent placement of 18 high dose Rapa-eluting stents in the left anterior descending and right coronary arteries. At the planned times of the 1.5th, 12th, 24th hour, 3th, 7th and 28th day, the animals (n=1, 1, 2, 2, 2, and 2, respectively) were euthanized after completion of coronary angiography. Blood samples were obtained at 0, 10, 20, 30 minutes; 1, 2, 6, 24 hours; and 3, 7, 28 days to determine systemic Rapa levels. Rapa levels in whole blood, arterial wall, heart, renal and liver tissues were determined by high-performance liquid chromatography/mass spectroscopy.Results Peak whole blood concentration (Cmax), time to peak concentration (tmax), elimination half-life (t1/2β), area under the curve (AUC), and apparent systemic clearance (Cl/F) were (10.91±1.28) ng/ml, (2.0±0.2) hours, (7.25±0.63) hours, (1.15±0.11) ng·h·ml（-1）, and (180±12) ml·h（-1）·kg（-1）, respectively. More than 95% Rapa detected is localized in the coronary artery surrounding the stent and heart.Conclusion Stent-based delivery of Rapa via a copolymer stent is feasible and safe. This strategy holds promise for the prevention of stent restenosis.     

生物可降解冠状动脉支架的研究进展

在如今的老龄化社会中，冠心病已成为人类健康的一大杀手，血管支架作为心血管介入治疗的最主要的器械，其效能决定了介入手术的成败。冠状动脉冠脉支架的发展先后经历了裸金属支架、药物洗脱支架和生物可降解支架3个时代。该文通过归纳目前使用的生物可降解支架的临床试验，来阐述可降解冠脉支架大体的发展历程，指出目前疗效及所面临的难题，并对支架发展的未来作一展望。