内镜下胆道支架治疗恶性胆道梗阻85例

目的探讨内镜下胆道支架对恶性梗阻性黄疸的治疗效果和临床应用价值。方法选择85例无法手术根治性切除的恶性胆道梗阻患者,内镜下放置胆道支架。结果85例胆管恶性梗阻患者中,行经内镜逆行胰胆管造影（ERCP）操作115例次,胆道支架放置成功109例次,操作成功率为94．78％,消除黄疸总有效率为95．41％,并发症发生率为8．26％,平均存活期约为7．4个月。结论胆道支架置入术治疗恶性梗阻性黄疸疗效确切,具有创伤小、并发症少、符合生理等特点,对无法手术根治性切除的恶性胆道梗阻患者,镜下放置胆道支架是最佳的首选治疗方法。     

经内镜置放胆道支架治疗恶性胆道梗阻36例分析

恶性胆管梗阻继发梗阻性黄疸及化脓性胆管炎是临床重症 ,治疗较棘手 ,死亡率高。胆道梗阻引起胆汁淤积继发肝功能不全 ,消化吸收功能减退等是致使恶性梗阻性黄疸者死亡的主要原因 ,因此对不能手术切除的梗阻性黄疸采用非手术减黄治疗有重要的临床意义。内镜下胆道支架置入术自 1979年首次应用于临床以来 ,以其安全、方便、经济和确切的胆汁引流效果 ,确定了其在梗阻性黄疸治疗中的地位。我院1999年 1月～ 2 0 0 2年 6月共放置胆道支架治疗恶性胆管梗阻 38例次 ,现报告如下。1　临床资料1 1　一般资料　共选择 36例患者 ,男 2 1例 ,女 15例 ,…     

经内镜胆道引流治疗胆道梗阻

目的：进一步提高经内镜胆道引流术的成功率。方法：总结1998年1月至2001年9月对320例胆道梗阻患者行十二指肠镜下各种胆道引流术的经验，其中鼻胆管引流术（ENBD）242例，胆道内置管引流术（ERBD）43例，胆道金属支架术（EMBE）35例。结果：305例得到成功引流，胆道梗阻症状缓解；失败15例。其中ENBD失败10例，经调整鼻胆管位置或重新置管获得成功；ERBD失败3例，2例选用合适长度的支架后引流成功，1例经努力仍未成功改用经皮肝穿刺胆道引流；EM-BE失败2例，其中1例金属支架未超出肿瘤狭窄段，经原金属支架再套入另一金属支架而成功，另1例支架放置1月又出现胆道阻塞，经原金属支架通道再放入塑料支架而恢复通畅引流。结论：经内镜引流治疗胆道梗阻疗效确切，及早分析内镜引流失败原因并采取相应的对策，绝大多数引流失败是可以避免或补救的。     

内镜下平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻价值探讨

目的 探讨经内镜平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻的安全性和疗效.方法 2011年1月至2012年9月对11例晚期肝门部胆管恶性梗阻的病人采用内镜平行法双金属支架引流治疗,观察疗效及安全性.结果 10例成功置入左右双金属支架,全组无研究并发症及死亡病例.9例引流有效.发生2例轻微内镜相关并发症.10例双支架治疗病人中4例死亡,死亡时均无腹痛、黄疸、发热等支架阻塞迹象,生存128 ～ 185 d,失访1例,其余5例病人均在随访中.结论 内镜平行法双金属支架引流治疗晚期肝门部胆管恶性梗阻是安全可行的.     

恶性胆道梗阻的内镜下治疗进展

恶性胆道梗阻是由胆道或其他转移性恶性肿瘤导致的胆道梗阻性疾病,常以黄疸、胆汁淤积及胆管炎为表现,大于50%的患者为进展期疾病,失去根治性手术的机会。因此,缓解胆道梗阻是姑息性治疗的重要部分。内镜下胆道支架置入是一个行之有效的措施,包括塑料支架、金属支架、覆膜支架及药物洗脱支架等。其他技术如超声内镜引导下胆管引流术、内镜下射频消融术、胆管腔内近距离放射治疗、内镜下光动力治疗等,增强了内镜下逆行胰胆管造影在恶性胆道梗阻疾病中的治疗作用。此文就胆管支架的发展及内镜下恶性胆道梗阻治疗的新进展作一综述。     

内镜下胆管引流术治疗恶性胆管梗阻

目的 探讨经内镜放置胆管内支架治疗恶性胆管梗阻的效果.方法 采用胆管内支架治疗恶性胆管梗阻.结果 置管成功率91.83%,引流总有效率93.75%,并发症为8.33%.结论 内镜下置入胆管支架是解除胆管恶性梗阻的一种安全、有效、成功率高及并发症少的治疗方法.     

ERCP放置胆管内支架姑息治疗难以切除的恶性胆管梗阻

目的探讨ERCP放置胆管内支架对难以切除的恶性胆管梗阻的临床治疗效果。方法对54例恶性肿瘤引起的梗阻性黄疸患者,经ERCP将导丝插入胆管并超过梗阻部位,扩张狭窄处,用推送导管将已经选择合适的引流支架置于胆管适当部位,其两端均超过梗阻段2cm以上。结果54例患者中51例插管成功,3例插管不成功的患者中1例乳头开口于憩室内,另2例肿瘤完全阻塞导丝无法通过。成功率为94.44%(51/54)。34例胆管内放置8FZ型自膨胀式金属支架,其余20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39例2周内血清总胆红素下降50%以上,血清总胆红素退至34μmol/L以下。放置胆管内支架1周后,患者血清总胆红素由术前235.45±56.67μmol/L降至78.36±37.58μmol/L,肝功能较术前显著改善(P<0.05,P<0.01)。31例胆总管下段梗阻患者与12例肝门部胆管梗阻患者相比,放置胆管内支架引流治疗1周、2周后,其胆红素下降明显优于肝门部胆管梗阻患者(P<0.01)。34例放置胆管金属支架患者中,有12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10个月出现支架阻塞予以再次植入金属支架。另外20例放置塑料内支架者,有3例于术后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阻塞,予以更换内支架,其中1例植入塑料双支架。结论经ERCP内镜下胆管放置内支架,对解除恶性胆管梗阻性黄疸、缓解症状、提高患者生存质量具有满意疗效,对胆总管下段梗阻性黄疸的疗效优于肝门部胆管梗阻。     

经皮联合内镜放置支撑物内引流治疗恶性胆道梗阻

对４４例失去手术机会并经内镜途径胆汁引流失败的恶性胆道梗阻病人做经皮联合内镜放置支撑物内引流，成功３７例（８４．１％）。并发症和３０天内死亡率在低位总胆管梗阻和肝门梗阻者分别为４６．７％、１６．７％和５０．０％２１．４％，总并发症和３０天死亡率为４７．７％１８．２％．经皮联合内镜放置支撑物内引流提供了恶性胆道梗阻姑息治疗的另一非手术途径，对单纯内镜放置ｓｔｅｎｔ失败是一种补救。     

经皮肝穿刺胆道内支架植入治疗恶性胆道梗阻64例

目的：总结经皮肝穿刺胆道内支架植入治疗恶性梗阻性黄疸的经验，探讨其临床疗效及价值。方法：64例患者均采用X线透视下经皮肝穿刺胆道内支架植入术治疗恶性梗阻性黄疽。根据梗阻部位的不同解剖决定放置支架的方式。结果：64例患者中，50例植入单支支架于肝总管或(和)胆总管，14例植入2支以上支架于总管和分支胆管，其中2例肝内胆管支架的桥接通过肝实质。58例患者2周内血清胆红素降低75％以上。结论：经皮肝穿刺刺内支架植入是治疗恶性胆道梗阻性的有效方法。     

可膨式金属胆道支架解除恶性胆管梗阻的中长期疗效

为总结经内镜放置可膨式金属胆道支架（ＥＭＢＥ）的中远期疗效，回顾了７６例恶性胆管梗阻接受ＥＭＢＥ治疗患者的资料，并与同期５３例次放置普通塑料支架的疗效进行对比。结果前者操作成功率９３．８％，与操作有关的并发症发生率６．６％，黄疸消除率为８７．０％，金属支架的平均通畅期为３１０天，明显高于塑料支架的８５天（Ｐ＜０．０１），患者平均存活期为２１０天。随访患者中有１６例（３４．８％）发生支架阻塞，平均发生时间１８５．５天。结果表明可膨式金属胆道支架的平均通畅性能显著优于普通塑料支架，可持久有效解除恶性肿瘤所致的肝外胆管梗阻，为提高ＥＭＢＥ的疗效必须严格掌握适应证     

Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents.

Twenty patients with chronic pancreatitis and signs of biliary obstruction were treated by endoscopic placement of self expandable metal mesh stents, and followed up prospectively. Eleven had been treated previously with plastic endoprostheses. All had persistent cholestasis, seven patients had jaundice, and three overt cholangitis. Endoscopic stent placement was successful in all cases. No early clinical complication was seen and cholestasis, jaundice or cholangitis rapidly resolved in all patients. Mean follow up was 33 months (range 24 to 42) and consisted of clinical evaluation, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 18 patients, successive ERCPs and cholangioscopies have shown that the metal mesh initially embeds in the bile duct wall and is rapidly covered by a continuous tissue by three months. The stent lumen remained patent and functional throughout the follow up period except in two patients who developed epithelial hyperplasia within the stent resulting in recurrent biliary obstruction, three and six months after placement. They were treated endoscopically with standard plastic stents with one of these patients ultimately requiring surgical drainage. No patient free of clinical or radiological signs of epithelial hyperplasia after six months developed obstruction later. This new treatment could become an effective alternative to surgical biliary diversion if further controlled follow up studies confirm the initial impression that self expandable metal mesh stents offer a low morbidity alternative for longterm biliary drainage in chronic pancreatitis without the inconvenience associated with plastic stents.     

A case of choledochoduodenal fistula as a delayed complication after biliary metallic stent placement in distal cholangiocarcinoma]

Biliary drainage in patients with malignant biliary obstruction relieves jaundice and prevents the development of cholangitis or hepatic failure from biliary obstruction. Therefore, this may result in better quality of life along with survival prolongation. Biliary stent placement is an effective and safe measure for biliary decompression and is preferred than bypass surgery in high risk patients. Entero-biliary perforation-communication is one of the rare complications of biliary stent. We herein report a case of duodeno-biliary perforation-communication in patient with distal cholangiocarcinoma who presented with duodenal ulcer and obstruction, occurring 4 years later from the metallic biliary stent insertion. Patient was managed with a pyloric metal stent and conservative care.     

WHICH TYPES OF DRAINAGE TUBE SHOULD WE SELECT FOR ENDOSCOPIC BILIARY DRAINAGE? CURRENT STATUS

Biliary drainage is a standard procedure for cholangitis or obstructive jaundice due to biliary obstruction. However, criterion for the selection of types of drainage tube is not established. The authors analyzed the types of drainage tube used in the University of Tokyo, Tokyo, Japan, during the month of June 2005, and they treated 63 cases. For drainage for cholangitis (31), the authors used endoscopic naso‐biliary drainage (ENBD) tube in 74.1% and plastic stent in 25.9%. In contrast, for the cholestesis cases (16), the authors used ENBD tube in 37.5% and plastic stent in 63.5%. For the unresectable biliary malignancy cases (8) with improved jaundice, the authors used covered metallic stent in seven distally stricture cases and uncovered metallic stent in one proximally stricture case. The remaining eight cases received plastic stent placement. There were six cases of residual common bile duct stones and two cases of prevention of cholangitis after papillectomy. For the patients with unresectable biliary malignancies at distal portion, the authors consider that covered metallic stent is a standard endoprosthesis. For drainage for cholangitis, the authors used ENBD tube because bile juice flow is able to be checked any time. However, the authors used plastic stent rather than ENBD tube for the drainage of cholestesis. A larger study for selection of drainage tube for these aspects is needed in the future.     

Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas

Together with biliary drainage, which is an appropriate procedure for unresectable biliary cancer, biliary stent placement is used to improve symptoms associated with jaundice. Owing to investigations comparing percutaneous transhepatic biliary drainage (PTBD), surgical drainage, and endoscopic drainage, many types of stents are now available that can be placed endoscopically. The stents used are classified roughly as plastic stents and metal stents. Compared with plastic stents, metal stents are of large diameter, and have long-term patency (although they are expensive). For this reason, the use of metal stents is preferred for patients who are expected to survive for more than 6 months, whereas for patients who are likely to survive for less than 6 months, the use of plastic stents is not considered to be improper. Obstruction in a metal stent is caused by a tumor that grows within the stent through the mesh interstices. To overcome such problems, a covered metal stent was developed, and these stents are now used in patients with malignant distal biliary obstruction. However, this type of stent has been reported to have several shortcomings, such as being associated with the development of acute cholecystitis and stent migration. In spite of these shortcomings, evidence is expected to demonstrate its superiority over other types of stent.     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound‐guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS‐guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.     

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY

Endoscopic biliary drainage (EBD) may be unsuccessful in some patients, because of failed biliary cannulation or tumor infiltration, limiting endoscopic access to major papilla. The alternative method of percutaneous transhepatic biliary drainage carries a risk of complications, such as bleeding, portal vein thrombus, portal vein occlusion and intra‐ or extra‐abdominal bile leakage. Recently, endoscopic ultrasonography (EUS)‐guided biliary stent placement has been described in patients with malignant biliary obstruction. Technically, EUS‐guided biliary drainage is possible via transgastric or transduodenal routes or through the small intestine using a direct access or rendezvous technique. We describe herein a technique for direct stent insertion from the duodenal bulb for the management of patients with jaundice caused by malignant obstruction of the lower extrahepatic bile duct. We think transduodenal direct access is the best treatment in patients with jaundice caused by inoperable malignant obstruction of the lower extrahepatic bile duct when EBD fails.     

One-step percutaneous transhepatic insertion of a balloon-expanding metallic stent for obstructive jaundice

Background and Aim: The aim of this study was to evaluate the efficacy and safety of one‐step percutaneous transhepatic insertion of the Express LD stent, a balloon‐expanding stainless steel stent used for the management of distal artery stenosis in the treatment of obstructive jaundice caused by various inoperable malignancies. Methods: Seventy‐one consecutive patients with unresectable malignant biliary obstruction who underwent Express LD stent placement between 2007 and 2010 at our institute were reviewed. Results: Mean stent patency was 165 ± 144 days and mean patient survival was 180 ± 156 days, while the cumulative stent patency rate and patient survival rate at 6 and 12 months were 79% and 65%, and 38% and 16%, respectively. Stents were successfully placed in all cases without any stent migration or misplacement. Stent failure occurred in 14 patients (20%), and 16 complications were observed, including 12 cholangitis (17%), two cholecysitis (3%), and two pancreatitis (3%). Y‐configuration stenting for hilar bile duct obstruction was the only independent prognostic factor for stent failure. Conclusions: One‐step percutaneous transhepatic insertion of the Express LD stent is effective and safe for the management of obstructive jaundice caused by inoperable malignancies.     

Polyurethane-covered metal stent for management of distal malignant biliary obstruction

BACKGROUND: The efficacy of polyurethane-covered metal expandable stents for treatment of neoplastic distal biliary obstruction was analyzed. METHODS: Twenty-one patients with unresectable malignant tumors involving the mid to distal bile duct who were seen with obstructive jaundice were consecutively enrolled. Eighteen patients underwent endoscopic implantation of a polyurethane-covered metal stent and 3 patients underwent transhepatic insertion because of duodenal obstruction. The stent patency, complications, and patient survival were analyzed. RESULTS: Effective biliary decompression was achieved in all patients. Adverse events were minor: mild pancreatitis (1) and cholecystitis (2) occurred within 7 days of stent insertion. Mean survival and stent patency were 233 days and 206 days, respectively. Stent occlusion occurred in 3 patients (14%) after a mean of 188 days. Tumor ingrowth through the stent mesh was not observed. However, 2 stents were occluded by tumor overgrowth and 1 by compacted alimentary debris. CONCLUSIONS: A polyurethane membrane may prevent tumor ingrowth and reduce the occlusion rate for expandable metal stents implanted in patients with malignant obstruction of the distal bile duct.     

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent(PS) or nasobiliary catheter(NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedurerelated adverse events, stent/catheter dysfunction(occlusion or migration of PS/NBC, developmentof cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution(bilirubin level 3.0 mg/d L) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study(PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients(46%), bile duct cancer in 172(41%), gallbladder cancer in three(1%), and ampullary cancer in 50(12%). The median serum total bilirubin was 7.8 mg/d L and 324 patients(77%) had ≥ 3.0 mg/d L. During the median time to surgery of 29 d [interquartile range(IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio(SHR) = 4.76; 95%CI: 2.44-10.0, P 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method(PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.     

Management of simultaneous biliary and duodenal obstruction: the endoscopic perspective

Obstructive jaundice often develops in patients with unresectable malignancy in and around the head of the pancreas. Duodenal obstruction can also occur in these patients, and usually develops late in the disease course. Palliation of both malignant biliary and duodenal obstruction is traditionally performed with surgical diversion of the bile duct and stomach, respectively. With the advent of nonsurgical palliation of biliary obstruction using endoscopic transpapillary expandable metal stent placement, a similar approach can be used to palliate duodenal obstruction by placement of expandable metal gastroduodenal stents. Endoscopic palliation can be achieved in patients who require relief of both biliary obstruction and duodenal obstruction, although this can be technically difficult to achieve depending on the level of duodenal obstruction in relation to the major papilla. This article reviews the endoscopic approaches for combined palliative relief of malignant biliary and duodenal obstruction.