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。     

胆道支架放置术治疗肝门部胆管癌的体会

对１１例无法手术切除的肝门部胆管癌患者在行狭窄胆管扩张的基础上经引流管或ＰＴＣＤ窦道放置自制Ｚ形胆道支架和记忆金属网状支架，效果较满意，未发现严重并发症。认为术前了解病变部位及范围，选择合适的支架，术中根据病变部位安排支架放置顺序是手术成功的关键     

经内镜鼻胆管引流术与经皮经肝胆管造影引流术用于肝门部胆管癌术前减黄的疗效对比

目的对比经内镜鼻胆管引流术(ENBD)与经皮经肝胆管造影引流术(PTCD)用于肝门部胆管癌术前减黄的疗效。方法回顾性分析2016年1月至2017年12月在内蒙古自治区人民医院接受肝门部胆管癌根治术的120例患者资料,按术前减黄方案分为ENBD组(57例)和PTCD组(63例),对比两组围术期肝功能指标、术中情况及围术期并发症发生情况。结果引流前,两组患者总胆红素(TBil)、直接胆红素(DBil)、丙氨酸氨基转移酶(ALT)、门冬氨酸氨基转移酶(AST)、白蛋白(Alb)对比,差异无统计学意义(P0.05);根治术前,ENBD组TBil、DBil、ALT、AST均明显高于PTCD组,差异有统计学意义(P0.05),两组Alb对比差异无统计学意义(P0.05);根治术后,两组TBil、DBil、ALT、AST、Alb对比,差异无统计学意义(P0.05)。ENBD组围术期胆系感染发生率明显低于PTCD组,差异有统计学意义(P0.05)。结论对肝门部胆管癌患者,根治术前行ENBD或PTCD均能够有效减黄,而后者减黄效果更可靠,能够更好地促进肝功能恢复;接受ENBD后胆系感染风险较低。     

肝门部胆管癌内镜下支架引流的研究进展

肝门部胆管癌是最常见的肝外胆管恶性肿瘤，具有起病隐匿、手术切除率低及总体预后差等临床特点，胆汁引流是当前改善黄疸症状、提高生存质量的主要治疗手段之一。内镜逆行性胆汁支架引流(ERBD)是临床上使用广泛的胆汁引流方法，本文就ERBD的优势、支架类型、数量及排列方式等研究进展进行综述。     

内镜下鼻胆管引流术与胆管支架置入术在肝门部胆管癌患者术前或姑息治疗前应用的疗效比较

目的比较内镜下鼻胆管引流术(ENBD)与胆管支架置入术(EBS)在肝门部胆管癌患者术前或姑息治疗前的应用疗效。方法选择2011-05～2019-05在河南科技大学第一附属医院内镜中心接受临时内镜下胆管引流术的肝门部胆管癌患者156例,根据患者治疗方式的不同分为ENBD组(112例)和EBS组(44例)。比较两组治疗前后的肝功能指标水平,以及术后引流管移位、导管堵塞、胆管炎、胆囊炎、肝脓肿、导管诱发的十二指肠溃疡和内镜逆行胰胆管造影术(ERCP)后胰腺炎并发症的发生率。结果两组术前碱性磷酸酶(ALP)、总胆红素(TB)、谷丙转氨酶(ALT)、γ-谷氨酰转肽酶(GGT)水平比较差异无统计学意义(P 0.05);术后两组ALP、TB、ALT、GGT水平均降低,与同组术前比较差异有统计学意义(P 0.05),但组间比较差异均无统计学意义(P 0.05)。ENBD组患者引流管移位、胆管炎的发生率低于EBS组,差异有统计学意义(P 0.05);但两组导管堵塞、胆囊炎、肝脓肿、导管诱发的十二指肠溃疡、ERCP术后胰腺炎发生率比较差异均无统计学意义(P 0.05)。结论 ENBD和EBS均可显著改善患者肝功能情况,但ENBD的术后并发症发生率更低,可作为肝门部胆管癌患者术前或姑息治疗前首选的临时内镜下胆道引流方法。     

胆道支架放置术治疗疗肝门部胆管癌的体会

对１１例无法手术切除的肝门部胆管癌患者在行狭窄胆管扩张的基础上经引流管或ＰＴＣＤ窦道放置自制Ｚ形胆道支架和记忆金属网状支架，效果较满意，未发现严重并发症。认为术前了解病变部位及范围，选择适合的支架，术中根据病变部位安排支架放置顺序是手术成功的关键。     

Ⅳ型肝门部胆管癌内镜治疗支架选择分析

目的 探究Bismuth分型Ⅳ型肝门部胆管癌内镜治疗支架的选择方法及经验。方法 回顾性分析2010年9月—2018年9月在兰州大学第一医院普外科就诊并接受经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography, ERCP）治疗的65例Ⅳ型肝门部胆管癌患者临床资料。按照内镜引流方式不同分为3组:经内镜胆道内支架放置术（endoscopic retrograde biliary drainage,ERBD）组38例、ERBD+内镜下胆道金属支架置入 (endoscopic metal biliary endoprosthesis, EMBE)组23例、EMBE组4例;根据胆道造影方式不同分为造影剂组(n=26)、空气造影组（n=22）及无胆道造影组(n=17）。比较术后急性胆管炎发生率、总胆红素显著下降率及住院期间死亡率等指标。结果 3种引流方式相比,ERBD组、ERBD+EMBE组和EMBE组的急性胆管炎发生率分别为23.7%（9/38）、52.2%（12/23）和75.0%（3/4）,差异有统计学意义（χ2=7.499,P=0.006）。3组住院期间死亡率分别为5.3%（2/38）、13.0%（3/23）和50.0%（2/4）,差异有统计学意义（χ2=7.729,P=0.021）;两两比较,ERBD组和EMBE组之间差异有统计学意义（χ2=8.406,P=0.004）。3种造影方式相比,造影剂组、空气造影组和无胆道造影组的急性胆管炎发生率分别为57.7%（15/26）、27.3%（6/22）和17.6%（3/17）,差异有统计学意义（χ2=8.407,P=0.015）;两两比较,造影剂组和无胆道造影组之间差异有统计学意义（P=0.012）。结论 对于Ⅳ型肝门部胆管癌,胆道双塑料支架置入能显著降低患者术后急性胆管炎发生率及住院期间死亡率,可作为首选支架方案;术中造影剂的使用会增加术后急性胆管炎发生率,应慎用造影剂。     

塑料胆管支架置入方式对不可切除肝门部胆管癌伴梗阻性黄疸治疗效果的影响

目的　对比塑料胆管支架3种末端开口留置方式在解除不可切除肝门部胆管癌梗阻性黄疸方面的临床应用效果。方法　回顾性分析2014年4月—2020年12月在中国医学科学院肿瘤医院内镜科行塑料胆管支架置入减黄治疗的不可切肝门部除胆管癌患者61例，其中胆管支架末端开口胃内留置18例（胃内留置组），十二指肠乳头留置31例（十二指肠乳头留置组），十二指肠水平部留置12例（十二指肠水平部留置组）。对随访2周发热率、围手术期死亡率、术后90 d支架梗阻率、支架中位通畅时间进行分析。结果　胃内留置组、十二指肠乳头留置组和十二指肠水平部留置组3组患者术后2周内发热率比较［66.7%（12/18），58.1%（18/31）和16.7%（2/12），χ2=7.30，P=0.026］差异有统计学意义，围手术期死亡率［0（0/16），3.2%（1/31）和0（0/10），χ2=1.09，P=1.000］、术后90 d内支架梗阻率［52.9%（9/17），48.3%（14/29）和40.0%（4/10），χ2=1.91，P=0.589］和支架中位通畅时间（66.0 d，91.5 d和94.0 d，Z=4.96，P=0.084）比较差异无统计学意义。结论　与胆管支架末端开口胃内留置和十二指肠乳头留置比较，十二指肠水平部留置术后2周发热率低，但支架中位通畅时间、术后90 d支架梗阻率及围手术期死亡率相似。支架末端开口留置于十二指肠水平部可作为首选置入方式。     

经内镜置入金属支架结合局部放疗治疗肝门部胆管癌12例临床分析

近年来,我们采用经内镜置入金属支架及局部放疗治疗肝门部胆管癌,取得较好疗效。现报告如下。     

T管架桥内引流术治疗老年肝门部胆管癌8例体会

1965年由Klatskin首先报道肝门部胆管癌(Klatskin瘤) ,占肝外胆管癌的5 8%～75 % ,早期诊断困难,发现时大多属晚期。本院自1996年1月至2 0 0 2年1月间共收治8例年龄>60岁的肝门部胆管癌患者,均行胆道内引流术,取得了良好疗效,现报道如下。1　临床资料1 1　一般资料　本组男5例,女3例。年龄60～87岁,平均(71 3±6 3 )岁,其中>70岁者5例。术前所有患者均有黄疸和不同程度的肝功能损害,肾功能受损4例。伴有心肺疾病4例,糖尿病1例。术前B超或CT均提示肝内胆管明显扩张,其中5例B超及CT均提示肝门部肿块影,增强CT显示肿块与门静脉浸润。2例有…     

Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma

AIM: To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma. METHODS: In total, 118 patients with hilar cholangiocarcinoma underwent endoscopic management [endoscopic nasobiliary drainage (ENBD) or endoscopic biliary stenting] as a temporary drainage in our institution between 2009 and 2014. We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment. The risk factors for biliary reintervention, post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis, and percutaneous transhepatic biliary drainage (PTBD) were also analyzed using patient- and procedure-related characteristics. The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage. RESULTS: In total, 137 complications were observed in 92 (78%) patients. Biliary reintervention was required in 83 (70%) patients. ENBD was significantly associated with a low risk of biliary reintervention [odds ratio (OR) = 0.26, 95%CI: 0.08-0.76, P = 0.012]. Post-ERCP pancreatitis was observed in 19 (16%) patients. An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis (OR = 3.46, 95%CI: 1.19-10.87, P = 0.023). PTBD was required in 16 (14%) patients, and Bismuth type III or IV cholangiocarcinoma was a significant risk factor (OR = 7.88, 95%CI: 1.33-155.0, P = 0.010). Of 102 patients with initial unilateral drainage, 49 (48%) required bilateral drainage. Endoscopic sphincterotomy (OR = 3.24, 95%CI: 1.27-8.78, P = 0.004) and Bismuth II, III, or IV cholangiocarcinoma (OR = 34.69, 95%CI: 4.88-736.7, P < 0.001) were significant risk factors for bilateral drainage. CONCLUSION: The endoscopic management of hilar cholangiocarcinoma is challenging. ENBD should be selected as a temporary drainage method because of its low risk of complications.     

Intrahepatic cholangiocarcinoma diagnosed via endoscopic retrograde cholangiopancreatography with a short double-balloon enteroscope

Endoscopic retrograde cholangiopancreatography (ERCP) using a double-balloon enteroscope (DBE) in patients with bowel reconstruction due to a previous abdominal surgery is now widely accepted. In particular, a short DBE, which has a 2.8-mm working channel and 152-cm working length, is useful for ERCP because of its good rotational and straightening ability and the availability of various conventional ERCP accessories through the working channel. Herein we report a case of intrahepatic cholangiocarcinoma via ERCP with a short DBE. This is the first report in which the pre-cutting and the brush cytological examination were performed successfully under a DBE to diagnose intrahepatic cholangiocarcinoma pathologically. The short DBE allowed us to perform all diagnostic and therapeutic procedures accepted in conventional ERCP in patients with surgically altered anatomies.     

儿童胰腺炎ERCP术后并发症研究

目的 分析儿童胰腺炎患者经内镜逆行胰胆管造影(endoscopic retrograde cholangiop-ancreatography,ERCP)术后高淀粉酶血症、胰腺炎及出血等并发症的发生率,探讨其安全性。方法 回顾分析1997年2月～2002年2月间入住我科确诊为儿童胰腺炎并行ERCP术的27例患者的临床资料,其中急性胰腺炎(acute pancreatitis,AP)14例,慢性胰腺炎(chronic pancreatitis,CP)13例;诊断性ERCP 9例,治疗性ERCP18例。结果 27例患者ERCP术后总体并发症发生率为51.85％(l4/27),其中,高淀粉酶血症发生率22.22％(6/27),术后4、24h血清淀粉酶水平分别为(410.75±230.31)U/L、(367.25±233.90)U/L,48～72h后均恢复正常;胰腺炎发生率22.22％(6/27),均为轻型胰腺炎;乳头切开处出血、黑便发生率7.41％(2/27),均发生于胆总管结石行十二指肠乳头括约肌切开(endoscopicsphincterotomy,EST)+取石术后;诊断性ERCP组并发症的发生率低于治疗性ERCP组,但无统计学意义。结论 儿童胰腺炎患者ERCP术后具有较高的并发症发生率,内镜医师于ERCP术中应高度重视,采取必要的预防措施以减少并发症的发生。     

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography(ERCP)in patients with surgically altered anatomy must be performed by a highly experienced endoscopist.The challenges are accessing the afferent limb in different types of reconstruction,cannulating a papilla with a reverse orientation,and performing therapeutic interventions with uncommon endoscopic accessories.The development of endoscopic techniques has led to higher success rates in this group of patients.Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction;however,these success rate is lower in long-limb reconstruction.ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length;however,it must be performed by a highly experienced and skilled endoscopist.Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography,but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy.Laparoscopic-assisted ERCP has an almost 100%success rate in longlimb reconstruction because of the use of a conventional side-view duodenoscope,which is compatible with standard accessories.This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy.This review focuses on the advantages,disadvantages,and outcomes of various procedures that are suitable in different situations and reconstruction types.Emerging new techniques and their outcomes are also discussed.     

Diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography in biliary rhabdomyosarcoma

Biliary rhabdomyosarcoma （BRMS） is an uncommon childhood malignancy which has been managed surgically. We present a case of a 3-year-old boy with BRMS, in whom endoscopic retrograde cholangiopancreatography （ERCP） was successfully used both diagnostically and therapeutically, thus obviating the need for surgery and its attendant risks of morbidity and mortality. We conclude that ERCP is an effective alternative to surgery for BRMS in some patients.     

Diaanostic and therapeutic role of endoscopic retrograde cholangiopancreatography in biliary rhabdomyosarcoma

Biliary rhabdomyosarcoma (BRHS) is an uncommon childhood malignancy which has been managed surgically.We present a case of a 3-year-old boy with BRHS,in whom endoscopic retrograde cholangiopancreatography (ERCP) was successfully used both diagnostically and therapeutically,thus obviating the need for surgery and its attendant risks of morbidity and mortality.We conclude that ERCP is an effective alternative to surgery for BRHS in some patients.     

Portal vein cannulation: an uncommon complication of endoscopic retrograde cholangiopancreatography

Portal vein cannulation is a rare complication of endo-scopic retrograde cholangiopancreatography(ERCP).It has been reported that it usually occurs after endo-scopic sphincterotomy,whereas in cases without prior sphincterotomy,the presence of portobiliary fistulas has been shown.Here,we present a case in which cannulation of the portal vein occurred despite careful wire-guided cannulation and the absence of sphinc-terotomy.Although fatal cases of cerebral and pulmo-nary air and/or bile embolism have been re...     

ERCP结合EPT对胆囊切除术后患者诊治价值的探讨

目的 回顾性研究逆行性胰胆管造影（ERCP）结合乳头肌切开术（EPT）对胆囊切除术后患者的诊治价值。方法 170例胆囊切除术后症状再发或反复发作患者，接受ERCP检查和EPT等治疗，诊断结果与B超作对照。同时动态观察内镜下介入诊治术后临床表现的改变。不良反应及血清淀粉酶的变化及高淀粉酶血症的分布情况。结果 经ERCP结合EPT等术后患者临床症状显著改善；与B超对照ERCP对胆囊切除术后胆总管残余结石的诊断率显著提高（P＜0．001），对胆总管扩张程度的诊断价值显著优于B超（P＜0．05），并能发现许多B超检查不能发现的胆胰病变；术后主要不良反应表现为出血、高淀粉酶血症，ERCP结合EPT等治疗组高淀粉酶的发生率显著高于单纯ERCP操作组（P＜0．01）。经积极地处理后短期内出血控制，血清淀粉酶多在3日内转为正常。结论 对胆囊切除术后患者，ECRP结合EPT不失为一项非常有价值、安全的诊治措施。     

经内镜诊治肝移植术后胆道远期并发症

目的：探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植患者胆道远期并发症中的应用。方法：肝移植术后出现胆道远期并发症患者6例，共行ERCP 12次，根据患者的情况进行扩张、内镜下乳头切开取石、内支架置入等治疗。结果：1例胆总管结石行乳头切开后取石成功，1例胆道狭窄在胆道扩张后胆道梗阻症状解除，4例胆道狭窄合并胆总管结石的狭窄近端结石经乳头切开取出，狭窄远端结石行胆道扩张、内支架置入等治疗后取出。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度的下降，无严重并发症发生。结论：ERCP是诊断和治疗肝移植患者胆道远期并发症安全、有效的手段。