肝门部胆管癌192例外科治疗及疗效分析

目的 探讨肝门部胆管癌的诊断方法和外科治疗的疗效。方法 对１９８４年至１９９９年收治的１９２例肝门部胆管癌的临床特点,诊断,手术方式和随访结果进行回顾分析。结果 本组ＭＲＣＰ对肝门部肿物显示率１００％（４４／４４）。１５３例行手术治疗,其中探查术１０例,内、外引流术８８例,均于术后３－１５个月死亡。切除术５３例,全肝切除原位肝移植术２例。手术切除率为３６.０％（５５／１５３）,行根治性切除３８例,中位生存期为３１个月,姑息性切除１７例,中位生存期为１３个月。结论 ＭＲＣＰ可以确定肝门部胆管癌病变部位及范围。术中胆道切断端应行冰冻病理检查。经根治切除术可显著延长患者生存期和改善生存质量。对于ＢismuthⅢ型、Ⅳ型无肝外转移者,行全肝切除、肝移植术不失为一种有效的治疗方法。     

梗阻性黄疸影像学诊断的选择

我院外科对 1996年 2月至 1999年 10月施行手术治疗和病理确诊的肝外梗阻性疾病 (胆道结石、胰头癌、胆总管下段及壶腹癌、肝门部胆管癌 ) 36 2例的临床资料进行回顾性分析 ,将术前Ｂ超、ＣＴ扫描与手术及病理诊断进行对比 ,以期对肝外梗阻性黄疸的影像学诊断程序进行选择 ,达到提高诊断水平、降低医疗费用的目的。临床资料本组肝外梗阻性黄疸 36 2例 ,男 198例 ,女 16 4例。年龄2 2～ 84岁 ,平均 47岁。术前 16 3例仅作Ｂ超检查 (ＨＰ 85 0 0ＧＰ) ,98例仅作ＣＴ扫描 (ＰＩＣＫＥＲＰＱ 5 0 0 0Ｖ) ,10 1例作Ｂ超和ＣＴ联合检查。全组均施…     

肝门部胆管癌的外科治疗

肝门部胆管癌或称上段胆管癌位于第一肝门，易侵犯肝、门静脉、肝动脉，手术切除率低，愈后较差，早期不易诊断。由于近几年来影像学诊断技术的发展和手术上的改进，扩大根治切除使该病的手术切除率明显提高［1］。现将我院近三年来10例肝门部胆管癌患者外科治疗情况作以介绍，重点将讨论有关手术问题。1临床资料1．1一般资料我院于1992年3月至1995年3月共收治肝门部胆管癌患者10例，其中男7例，女3例，年龄在43～70岁，平均565岁，全组10例均有黄疽，黄疽持续时间1周～2个月。肝功能分级：ChildA级6例、B级2例、C级2例。影像学检查：B超1…     

肝门部胆管癌55例的诊断和治疗

目的 探讨肝门部胆管癌的诊断和治疗方法。方法 术前５５例行Ｂ超、彩色超声、血ＣＥＡ、ＣＡ１９－９测定。４０例行ＭＲＩ和磁共振胆道成像检查,采用ＭＴＴ法对２８例肿瘤化疗药物敏感性测定。结果 根据本组病例的资料,肝门部胆管癌的术前诊断可分两步进行。用Ｂ超结合临床资料对患者进行筛选,然后进行三项检查：（１）血清ＣＡ１９－９值测定（〉２２２ＫＵ／Ｌ者３９例）;（２）彩色超声;（３）ＭＲＩ和磁共振胆道成像。     

胆道镜联合超声内镜在肝门胆管癌诊治中的应用

目的探讨肝门胆管癌的早期诊断方法。方法回顾性分析24例患者在术中及术后行胆道镜联合超声内镜检查诊断为胆管癌的临床资料。结果24例均经相应手术,无手术死亡病例。结论肝门部胆管癌早期诊断困难,胆道镜联合超内镜可提高诊断率及手术成功率。     

56例肝门部胆管癌外科治疗体会

目的 探讨肝门部胆管癌的诊断方法和外科治疗的疗效.方法 回顾性分析1996年1月至2006年1月间对56例肝门部胆管癌诊疗的临床资料及随访结果.结果 应用B超及MR等多种影像学技术对肝门部胆管癌的定位诊断率100%.56例行手术治疗,其中探查术5例,内、外引流术23例,均于术后2～15个月死亡.切除术28例(50.0%),行根治性切除24例(42.9%).中位生存期为29个月,姑息性切除4例,中住生存期为12个月.结论 超声检查联合MRCP能对肝门部胆管癌的定位诊断及评判手术切除有重要价值;根治性切除是改善肝门部胆管癌疗效的重要措施.     

桥式内引流术治疗恶性梗阻性黄疸26例体会

1990～ 1999年 ,我们对经手术证实不能行手术切除的胆管癌、胰头癌等恶性梗阻性黄疸病人 ,采用姑息性胆总管或左右肝内胆管插管引至空肠或十二指肠的桥式内引流术治疗方法 ,共治疗 2 6例 ,近期疗效显著 ,现总结如下。临床资料一、一般资料 :本组 2 6例 ,男 2 0例 ,女 6例。年龄 43～ 70岁。病程半个月至 2年。胆管癌 10例 ,胰头癌 12例 ,胃癌肝门浸润 2例 ,胆囊癌浸及胆总管 2例。所有病例术前Ｂ超或ＣＴ检查均证实肝门区肿块及胆总管或肝内胆管扩张。二、手术方法 :开腹探查证实癌肿无法切除后 ,于肿物上方寻找胆总管或总肝管 ,并切开 ,置…     

肝内胆管引流治疗恶性胆道梗阻

我们自 1993年 6月至 1998年 9月对 2 2例恶性胆管梗阻 ,经肝正中裂入路行肝内胆管内或外引流术。减黄效果较好 ,病人生命延长。现报道如下。临床资料1.本组 2 2例 ,男 14例 ,女 8例。年龄 30～ 79岁 ,平均 5 6 .5岁。2 .全组病人均有胆道梗阻黄疸表现。经术中探查无法根治切除 ,其中高位胆管癌 7例 ,晚期胆囊癌6例 ,胃癌肝门部转移 4例 ,结肠癌、胰腺癌肝门部转移各 2例 ,十二指肠癌肝门部浸润 1例。术前Ｂ超及ＣＴ均提示肝门肿块 ,肝内胆管扩张 ,术前血清胆红素平均 (2 0 2± 2 1)ｍｇ/ｄｌ。3.手术方式 :切断肝周韧带 ,游离肝脏 ,采…     

肝门部胆管癌52例分析

探讨肝门部胆管癌早期诊断方法和手术方式对患者预后的影响。方法 回顾性分析经手术和病理确诊的肝门部胆管癌５２例临床特征，手术方式和随访结果。结果 本组手术切全２８全我院总手术切除５３．８％，其中根治性切除１９例，姑息性切除９例，行胆管内，外引流术２４例。     

肝门部胆管癌29例手术治疗总结

肝门部胆管癌２９例手术治疗总结温州医学院外科教研室张启瑜温州医学院附一院普外科蒋飞照本院外科于１９８４年～１９９４年１０月共收治肝门部胆管癌２９例，计９１年前１６例无一例切除，９２年后１３例切除９例，全组总切除率３１％，９２年后切除率６９．２％，现就...     

Renal masses detected by general health checkup.

BACKGROUND: A total of 60,604 persons underwent a general health checkup at Toma Hospital, Saitama, Japan, between January 1993 and June 1997, and transabdominal ultrasonography (US) was performed on all persons. We investigated the usefulness of transabdominal US in detecting renal tumors during general health checkups. METHODS: A definite diagnosis was made in cases where the re-examination by US revealed calculus with acoustic shadow or a simple cyst. Computed tomography (CT) was conducted in patients suspected of having a renal tumor, and a diagnosis of renal angiomyolipoma (AML) was made if plain CT gave evidence of a fatty component. Patients diagnosed as having a renal cell carcinoma (RCC) with non-uniform enhancement underwent nephrectomy. If a definite diagnosis could not be made even by contrast CT, the monitoring by US and contrast CT once a year was continued. RESULTS: Of 97 (0.16%) patients whose transabdominal US findings indicated a diagnosis of suspected renal tumor, 58 underwent the re-examination by US; of these, CT was conducted in 47. Detailed US revealed a hyperechoic pattern in 44 patients, a mixed pattern in nine and an isohypoechoic pattern with internal echo in five. By plain CT, 24 patients were diagnosed as having AML, and two as having renal calcification. Contrast CT enabled a diagnosis of renal cyst to be made in two patients and renal tumor in 14. All 14 patients with RCC except one underwent nephrectomy, which provided pathologic evidence supporting the diagnosis. Five patients had a tumor unidentifiable by CT, with continuing periodic follow-up by US and CT. Eleven patients underwent no CT. CONCLUSION: Of the 60,604 persons who underwent a general health checkup, we found 14 cases of RCC and 24 cases of AML. As a small RCC has a favorable prognosis, patients greatly benefit from early detection; therefore, we should recognize the importance of identifying renal masses by US screening during general health checkups.     

14例肾上腺囊肿的诊断和治疗

目的：总结肾上腺囊肿的诊断和治疗经验。方法：回顾性分析14例肾上腺囊肿的临床资料，复习文献并讨论肾上腺囊肿的诊断和治疗。结果：术前B超、CT、MRI诊断正确率分别为42．8％(6／14)，54．5％(6／11)和l00％(5／5)；联合应用B超、CT或MRI，术前诊断正确率为78．5％(11／14)；14例均行手术治疗，病理诊断假性囊肿5例，上皮性囊肿2例，内皮性囊肿4例，非特异性囊肿3例。结论：合理有序地联合应用B超、CT和MRI能提高肾上腺囊肿的诊断正确率，治疗方法取决于囊肿大小、是否有并发症，腹腔镜肾上腺囊肿切除术是外科首选的治疗方法。     

Carcinoid tumor of the biliary tract: treating a rare cause of bile duct obstruction

Biliary carcinoids are rare with fewer than 30 cases reported in the English literature. The objective of this report is to describe an additional patient found to have a biliary carcinoid and to define the presentation, diagnosis, and management of patients with this rare biliary tumor. In our case the patient initially presented with clinical jaundice and elevated transaminases. Endoscopic retrograde cholangiogram established a mass suspicious for cholangiocarcinoma (Klatskin tumor). The patient was initially managed with an endostent, which was later removed in favor of a percutaneous transhepatic cholangiogram tube. At the time of surgery successful removal of a firm nodular mass at the area of the ductal bifurcation was achieved and biliary continuity re-established with a Roux-en-Y hepaticojejunostomy. Pathology revealed carcinoid tumor of the bile duct with one lymph node positive for tumor. The patient did not receive any adjuvant radiation or chemotherapy. This case serves to highlight that extrahepatic biliary carcinoids constitute a rare but identifiable subset of bile duct tumors. Diagnostic workup should include US, CT, and cholangiography. Surgical exploration is universally indicated in physiologically fit patients with operative management to include resection and re-establishment of biliary continuity. Data on adjuvant therapy remain investigational; however, available information suggests that patients with biliary carcinoid have an overall favorable prognosis after aggressive surgical management.     

Suspected acute appendicitis: is ultrasonography or computed tomography the preferred imaging technique?

OBJECTIVE: To compare the sensitivity and specificity of unenhanced spiral computed tomography (CT) and ultrasonography (US) in patients with suspected acute appendicitis. DESIGN: Prospective study. SETTING: University hospital, Germany. SUBJECTS: 120 consecutive patients with acute appendicitis as a differential diagnosis, whose clinical findings were not enough to make operation essential, but were too severe to send home. INTERVENTIONS: CT and US of the appendix. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive value. RESULTS: The results were correlated with surgical and histopathological findings at appendicectomy or clinical follow-up. 93 patients had acute appendicitis, 27 patients did not. The sensitivity of CT was 95% and of US 87%. The corresponding specificities were 89% and 74%, positive predictive values 97% and 92%, negative predictive values 83% and 63%. In the 27 patients who did not have acute appendicitis, the correct diagnosis was established with CT in 14 patients and with US in eight. CONCLUSION: CT is more sensitive and specific than US in patients suspected of having acute appendicitis, but in whom the presentation is equivocal. The use of unenhanced spiral CT led to a significant improvement in the accuracy of preoperative diagnosis and a lower negative appendicectomy rate.     

Percutaneous aspiration of peripancreatic fluid collections: a safe method to detect infection

During the past 5 years, we have used percutaneous aspiration of peripancreatic fluid collections guided by computed tomography (CT) or ultrasonography (US) to facilitate diagnosis of infection in selected cases. Fifteen of 18 patients undergoing guided needle aspiration had persistent fevers (greater than 38.3 degrees C). The three afebrile patients all had abdominal pain and leukocytosis, and two of the three also had elevated serum amylase levels. Percutaneous aspiration was guided by CT in 14 patients and by US in four. On the basis of aspirate Gram stains and cultures, as well as surgical (15) and percutaneous drainage (1) findings, the final diagnosis was pancreatic abscess in nine patients, infected pseudocyst in four, uninfected pseudocyst in four, and cystadenoma in one. Diagnosis based on percutaneous aspiration was correct in 17 of 18 patients (94%), and no complications could be directly attributed to the procedure. We conclude that CT- or US-guided percutaneous aspiration is a safe and accurate diagnostic procedure for patients with peripancreatic fluid collections in whom secondary infection is suspected.     

Differential diagnosis of sclerosing cholangiocarcinomas of the common hepatic duct (Klatskin tumors).

Although it is recognized that some other lesion may be the cause, a presumptive diagnosis of Klatskin tumor is usually made when a focal stenotic lesion of the common hepatic duct is seen on a cholangiogram of a jaundiced patient. Biopsy is so often nondiagnostic that decisions about therapy are usually made on the basis of the imaging tests and lack of evidence for some other disease. Because the accuracy and consequences of this strategy have never been tested, we contrasted the preoperative diagnosis of Klatskin tumor with the final diagnosis in 98 consecutive patients treated from 1985 to 1990. Preoperative investigations included ultrasound and computed tomographic scans, percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, and angiography. Sclerosing cholangiocarcinomas of the bile duct were correctly diagnosed in 68 cases. The final diagnosis was other than a sclerosing adenocarcinoma in 30 (31%) cases. There were 5 papillary bile duct carcinomas, 12 gallbladder carcinomas invading the bile duct, 5 metastatic tumors to the bile duct, 2 cases of Mirizzi syndrome, 3 granulomas, and 3 cases of idiopathic benign focal stenosis. Patients with papillary adenocarcinomas had an extensive filling defect of the duct, which was often thought to be unresectable. However, four of these five lesions could be completely excised, and the tumor was confined to the duct wall in all four. The outcome of surgical treatment of the other eight patients with benign lesions was good in most cases. These findings demonstrate the pitfalls of assuming that a focal stenosis of the hepatic duct represents a sclerosing adenocarcinoma. The diagnosis is much less specific than is generally thought, so there is considerable opportunity for mismanaging such patients.     

Biliary cystadenocarcinoma. A case report

The authors report a case of cystadenocarcinoma of the biliary tract, an uncommon tumor of the liver. A 68 aged white Caucasian jaundiced male subwent intervention for a tumor of the 4th hepatic segment. Forty-two months after discharge he is still alive without any secondary lesion. On the 16th follow-up month a prostatic malignancy was diagnosed. Differential diagnosis with other cystic lesion is an exacting and difficult target. Usual techniques such as US, CT, NMR infrequently get a correct diagnosis. Often only in surgical room a real diagnosis is achieved. In the aim to avoid tumor relapse the best surgical procedure is a large hepatic resection.     

B型超声检查对肾上腺肿瘤的诊断价值

目的　提高腹部超声对肾上腺肿瘤诊断的准确性。方法　对照分析57例肾上腺肿瘤的超声检查和手术病理结果。结果 57例患者中超声未显示肿瘤的为5例(8.8%),超声显示肿瘤的为52例(91.2%);超声的定位诊断符合率为89.5%(51/57),定性诊断 合率为73.7%(42/57)。结论　超声检查是肾上腺肿瘤定位诊断的首选可靠方法,并对定性诊断有一定的帮助。     

Is a preoperative multidiagnostic approach to predict surgical resectability of periampullary tumors still effective?

BACKGROUND: Multimodality staging is recommended in patients with periampullary tumors to optimize preoperative determination of resectability. We investigated the potency of currently used diagnostic procedures in order to determine resectability. METHODS: Ninety-five consecutive patients with periampullary tumors prehospitally staged resectable underwent preoperative diagnostic tests: helical-computed tomography (CT) with maximum intensity projection of arterial vessels (MIP), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreaticography (MRCP), endoscopic ultrasonography (EUS), endoscopic retrograde cholangiopancreaticography (ERCP), digital subtraction angiography (DSA), and positron emission tomography (PET). Diagnoses were verified by surgery and histopathology. RESULTS: In 45 patients with benign and 50 patients with malignant periampullary tumors sensitivity for tumor diagnosis was 89% to 96% in CT, MRI, EUS, and PET. Small tumors were best diagnosed by EUS (100%). Diagnosis of malignancy was made with 85% (EUS), 83% (CT), 82% (PET), and 72% (MRI) accuracy. Arterial vessel infiltration was best predicted by CT/MIP with an accuracy of 85%. For venous vessel infiltration MRI reached 85% accuracy. Accuracy rates for local nonresectability were 93% (EUS), 92% (MRI), and 90% (CT). Two and 4 of 8 patients with distant metastases were identified by CT and PET, respectively. The correct diagnosis of malignancy and determination of resectability was made by CT in 71% and by MRI in 70%. Biliary stenting reduced accuracy of CT diagnosis of malignancy from 88% to 73%. CONCLUSIONS: CT obtained before stenting was the single most useful test, providing correct diagnosis in 88% and resectability in 71% of patients. If no tumor is depicted in CT, EUS should be added. Uncertain venous vessel infiltration can be verified by MRI or EUS. Angiography should no longer be a routine diagnostic procedure. Equivocal tumors or possible metastasis may be further examined with PET.     

多排螺旋CT三维成像技术在胆系的临床应用

目的：探讨多排螺旋CT三维成像技术对胆系疾病的诊断价值。方法：146例胆系疾病患者，其中胆系肿瘤73例，胆系阴性结石87例，胆肠吻合术后12例，先天性胆总管囊肿1例。CT容积扫描所获图像数据送工作站处理，选择合理的成像方法，胆系成像方法包括最大密度投影法（MIP），最小密度投影法（MinP)，仿真内窥镜（CTVE），表面遮盖法（SSD）和Raysum。对比分析胆系成像，常规CT，US及ERCP对各疾病的诊断准确率。结果：各疾病在胆系成像上均有较特征性的表现；胆系成像是一种评价胆肠吻合术的新手段；对胆系结石，胆总管癌，胆管癌栓，胰头癌，壶腹周围癌的诊断，胆系成像优于常规CT，US，ERCP；对于肝门部胆管癌的诊断,胆系成像优于常规CT，US，与ERCP相当；对胆囊癌的诊断，不如常规CT，US。结论：胆系成像是一种诊断胆系疾病的无创，敏感的新方法，确诊率高，将极大地提高胆系疾病的术前诊断水平。