金属支架联合放疗治疗胆管恶性梗阻的临床观察

目的探讨应用经内镜胆道金属支架置入术（EMBE）联合放射疗法治疗晚期胆管恶性梗阻的疗效。方法12例失去手术机会的晚期胆管恶性梗阻患者,接受经内镜胆管金属支架置入术,支架置入2～3周后行放射治疗,观察随访。结果置管成功率100％,没有出现与手术有关的严重并发症。术后1周胆红素平均下降50％～60％。所有患者术后2～3周均给予放射治疗,随访6个月未再出现黄疸。有5例生存期超过1年。结论胆道金属支架置入联合放射疗法治疗晚期胆管恶性梗阻患者,可改善临床症状,提高患者的生活质量,延长生存期。是一种较好的姑息治疗手段。     

Simultaneous Duodenal Metal Stent Placement and EUS-Guided Choledochoduodenostomy for Unresectable Pancreatic Cancer

Patients with pancreatic cancer frequently suffer from both biliary and duodenal obstruction. For such patients, both biliary and duodenal self-expandable metal stent placement is necessary to palliate their symptoms, but it was difficult to cross two metal stents. Recently, endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) was reported to be effective for patients with an inaccessible papilla. We report two cases of pancreatic cancer with both biliary and duodenal obstructions treated successfully with simultaneous duodenal metal stent placement and EUS-CDS. The first case was a 74-year-old man with pancreatic cancer. Duodenoscopy revealed that papilla had been invaded with tumor and duodenography showed severe stenosis in the horizontal portion. After a duodenal uncovered metal stent was placed across the duodenal stricture, EUS-CDS was performed. The second case was a 63-year-old man who previously had a covered metal stent placed for malignant biliary obstruction. After removing the previously placed metal stent, EUS-CDS was performed. Then, a duodenal covered metal stent was placed across the duodenal stenosis. Both patients could tolerate a regular diet and did not suffer from stent occlusion. EUS-CDS combined with duodenal metal stent placement may be an ideal treatment strategy in patients with pancreatic cancer with both duodenal and biliary malignant obstruction.     

Biliary stenting with or without sphincterotomy for malignant biliary obstruction: A meta-analysis

AIM: To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs).METHODS: PubMed, EMBASE, Cochrane Library, and Science Citation Index databases up to March 2014 were searched. The primary outcome was incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and successful stent insertion rate. The secondary outcomes were the incidence of post-ERCP bleeding, stent migration and occlusion. The free software Review Manager was used to perform the meta-analysis.RESULTS: Three studies (n = 338 patients, 170 in the EST group and 168 in the non-EST group) were included. All three studies described a comparison of baseline patient characteristics and showed that there were no statistically significant differences between the two groups. Three RCTs, including 338 patients, were included in this meta-analysis. Most of the analyzed outcomes were similar between the groups. Although EST reduced the incidence of PEP, it also led to a higher incidence of post-ERCP bleeding (OR = 0.34, 95%CI: 0.12-0.93, P = 0.04; OR = 9.70, 95%CI: 1.21-77.75, P = 0.03, respectively).CONCLUSION: EST before stent placement may be useful in reducing the incidence of PEP. However, EST-related complications, such as bleeding and perforation, may offset this effect.     

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。     

内镜下胆管支架植入术结合三维适形放疗治疗晚期壶腹部恶性肿瘤

目的 评价内镜下胆管支架植入术结合三维适形放疗(简称联合治疗)治疗晚期壶腹部恶性肿瘤的疗效.方法 共165例无法手术根治的晚期壶腹部肿瘤患者纳入研究.分为联合治疗组(73例)、支架植入组(34例)及放疗组(58例).所有病人治疗后均行密切随访.结果 联合治疗组的生存期为15.6±8.2个月,显著高于支架组的10.1±5.4月及放疗组的8.5±4.3月(P均<0.01).治疗过程未出现严重的并发症.结论 内镜下胆管支架植入术结合三维适形放疗安全、有效,可显著延长晚期壶腹部恶性肿瘤患者的生存期.     

恶性胆管梗阻内支架置入后再梗阻的研究现状

通过内镜置入胆道内支架引流是目前治疗恶性胆管梗阻的首选措施,然而内支架再梗阻却是当前困扰临床的主要问题.近年来,国内外在探讨支架阻塞的机制,通过多种方法防治以延长引流时间等方面进行了广泛而深入的研究,此文就此作一综述.     

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。     

Clinical Outcomes and Patency of Self-expanding Metal Stents in Patients with Malignant Upper Gastrointestinal Obstruction

This study was performed to evaluate clinical outcomes and factors associated with patency of self-expanding metal stents (SEMS) in patients with malignant upper gastrointestinal (UGI) obstruction. In 83 patients with malignant UGI obstruction, 118 SEMS placements were performed. Obstruction sites were esophagus/gastro-esophageal junction (GEJ) and gastric outlet (GO) in 41 and 42 patients, respectively. Technical success was achieved in 99.2% and clinical success in 90.5%, with no procedure-related complications. Re-obstruction and migration occurred in 38.1% during a mean follow-up of 137 days; both occurred significantly more often with GO than esophageal/GEJ obstruction (49.2% vs 23.9%). Patency rates of esophageal/GEJ obstruction were 93.5, 78.1 and 67.0% at 30, 90 and 180 days, respectively, and were significantly higher than those of GO obstruction—71.7, 51.8 and 32.5%. Palliative chemotherapy or radiation therapy was not associated with stent patency. Endoscopic SEMS placement is a safe and effective palliative treatment for malignant UGI obstruction, and complications or stent patency differed according to obstruction site.     

胆汁型碱性磷酸酶同工酶在恶性肝外胆道阻塞诊断中的价值

目的 探讨胆汁型碱性磷酸酶同工酶在恶性肝外胆道阻塞论断中的价值。方法 用改良琼脂糖电泳对30例健康体检者和105例肝胆疾病患者血清中的碱性磷酶同工酶（ALP）进行分离和定量分析。结果 恶性肝外胆道阻塞的胆汁型ALP显著高于非恶性肝外胆道阻塞、肝内梗阻性黄疸以及原发性肝癌,正常体验者血清中不存在胆汁型ALP;若以100U／L的胆汁型ALP区分恶性肝外胆道阻塞和其他肝胆疾病,则它对恶性外胆道阻塞的诊断灵敏度为82．9％,特异性为95％,阳性预示值为85．3％,阴性预示值为94．1％,实验总有效率为91．9％。结论 胆汁型ALP可作为恶性肝外胆道阻塞的有用诊断指标。     

Endoscopic Palliation and Survival in Malignant Biliary Obstruction

Malignant biliary obstruction is a common problem that is regarded as having a poor prognosis and is usually managed with palliation. Our aim was to investigate the survival of 182 consecutive subjects with malignant biliary obstruction where management was palliative within endoscopically placed biliary stent. We undertook a retrospective longitudinal study with date of death or confirmed survival of at least 23 months, as the primary end point. Diagnosis and blood indices from the 24 hr prior to first ERCP were obtained from hospital records. Of the 182 eligible subjects follow-up of date of death or confirmed survival of at least 23 months was obtained in 181 (99.5%). Of these 181 patients, 37 (20.4%) survived for more than one year. Histological confirmation was obtained in 47 of 182 subjects (25.8%). Increased age at first ERCP predicted increased survival (P < 0.05). In conclusion, in patients with malignant biliary obstruction, where management was endoscopic and palliative, 20.4% survived for more than one year with increased age at diagnosis being the only significant predictive marker.     

Endoscopic biliary stent insertion through specialized duodenal stent for combined malignant biliary and duodenal obstruction facilitated by stent or PTBD guidance

Objectives: Endoscopic stenting for combined malignant biliary and duodenal obstruction is technically demanding. However, this procedure can be facilitated when there is guidance from previously inserted stent or PTBD tube. This study aimed to evaluate the feasibility and clinical success rate of endoscopic placement of biliary self-expandable metal stent (SEMS) through duodenal SEMS in patients with combined biliary and duodenal obstruction due to inoperable or metastatic periampullary malignancy.

Materials and methods: A total of 12 patients with combined malignant biliary and duodenal stricture underwent insertion of biliary SEMS through the mesh of specialized duodenal SEMS from July 2012 to October 2016. Technical and clinical success rate, adverse events and survival after completion of SEMS insertion were evaluated.

Results: The duodenal strictures were located in the first portion of the duodenum in four patients (Type I), in the second portion in three patients (Type II), and in the third portion in five patients (Type III). Technical success rate of combined metallic stenting was 91.7%. Insertion of biliary SEMS was guided by previously inserted biliary SEMS in nine patients, plastic stent in one patient, and PTBD in two patients. Clinical success rate was 90.9%. There were no early adverse events after the procedure. Mean survival period after combined metallic stenting was 91.9 days (range: 15–245 days).

Conclusions: Endoscopic placement of biliary SEMS through duodenal SEMS is feasible with high success rates and relatively easy when there is guidance. This method can be a good alternative for palliation in patients with combined biliary and duodenal obstruction.     

Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device

Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.     

经内镜金属支架治疗肠道恶性梗阻性疾病的I临床应用

目的探讨金属自膨式支架治疗肠道恶性梗阻的临床疗效及意义。方法对1999年至2009年我院消化科门诊和住院31例肠道恶性梗阻患者进行金属自膨式支架置入术。结果31例均放置成功,患者恶心、呕吐、排便困难等梗阻症状得到缓解,患者生活质量得到提高。结论金属自膨式支架无论是在肠道恶性梗阻无法手术、恶性肠道肿瘤手术后复发还是在肿瘤切除术后吻合13狭窄等情况下,均可解决梗阻,达到提高患者生存质量的目的。     

恶性胆总管梗阻合并胃出口-十二指肠梗阻的内镜治疗价值分析

目的 探讨经内镜置入胆管及肠道支架联合治疗胆总管恶性梗阻合并胃出口-十二指肠梗阻的临床价值.方法 对17例同时存在胆管及胃出口-十二指肠梗阻的恶性肿瘤患者在完成胆管金属支架置入术后再行肠道金属支架置入.观察操作成功率、胆管及消化道梗阻缓解情况、并发症发生情况、支架再阻塞情况以及患者生存期.结果 17例患者经内镜下置入胆管支架和肠道支架,成功率100％;术后7天患者血清总胆红素[(263.4±62.5)μmol/L降至(157.6±25.1)μmol/L]、直接胆红素[(233.2±66.5)μmol/L降至(130.9±27.7) μmol/L]和碱性磷酸酶[(534.2±78.7)IU/L降至(216.3±23.3)IU/L]均明显下降(P＜0.O1),胃出口梗阻评分[(0.9±1.1)分升至(2.1±0.7)分]明显上升(P＜0.01).所有患者均未出现严重并发症,生存70～332 d,中位生存时间192 d.结论 联合双支架置入是治疗胆管合并胃出口-十二指肠恶性梗阻的安全有效的方法.     

New antireflux plastic stent for patients with distal malignant biliary obstruction

BACKGROUND Endoscopic biliary stenting is a well-established palliative treatment for patients with unresectable distal malignant biliary obstruction(MBO). However, the main problem with stent placement is the relatively short duration of stent patency.Although self-expanding metal stents(SEMSs) have a longer patency period than plastic stents(PSs), the higher costs limit the wide use of SEMSs. A PS with an antireflux valve is an attractive idea to prolong stent patency, but no ideal design for an antireflux PS(ARPS) has been proposed. We developed a new ARPS with a "duckbilled" valve attached to the duodenal end of the stent.AIM To compare the patency of ARPSs with that of traditional PSs(TPSs) in patients with unresectable distal MBO.METHODS We conducted a single-center, prospective, randomized, controlled, double-blind study. This study was conducted at the West China Hospital of Sichuan University. Consecutive patients with extrahepatic MBO were enrolled prospectively. Eligible patients were randomly assigned to receive either an ARPS or a TPS. Patients were followed by clinic visits or telephone interviews every 1-2 mo until stent exchange, death, or the final study follow-up in October 2018. The primary outcome was the duration of stent patency. Secondary outcomes included the rate of technical success, the rate of clinical success,adverse events, and patient survival.RESULTS Between February 2016 and December 2017, 38 patients were randomly assigned to two groups, with 19 patients in each group, to receive ARPSs or TPSs. Stent insertion was technically successful in all patients. There were no significant differences between the two groups in the rates of clinical success or the rates of early or late adverse events(P = 0.660, 1.000, and 1.000, respectively). The median duration of stent patency in the ARPS group was 285 d [interquartile range(IQR),170], which was significantly longer than that in the TPS group(median, 130 d;IQR, 90, P = 0.005). No significant difference in patient survival was noted between the two groups(P = 0.900).CONCLUSION The new ARPS is safe and effective for the palliation of unresectable distal MBO,and has a significantly longer stent patency than a TPS.     

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...