经皮胆道支架联合支架内外125I粒子植入治疗肝门部胆管癌研究

目的 探讨肝门部胆管癌患者在施行经皮胆道支架成形术的基础上,联合支架内外放射性125I粒子植入治疗肝门部胆管癌的疗效.方法 选择失去根治性手术时机或不愿意行外科手术治疗的23例肝门部胆管癌患者.所有患者均有明显黄疸表现,其中Ⅰ型4例,Ⅱ型7例,Ⅲ型7例,Ⅳ型5例.所有患者先行经皮穿刺胆道造影确认胆管梗阻的范围及长度并选用相匹配的胆道金属支架,准确置入胆管的狭窄段,粒子条装入塑料管,经8F胆道引流管送入所需照射部位;待黄疸减退肝功能基本正常后,行CT引导下经皮穿刺肝门部胆管癌放射性粒子植入术治疗.Ⅰ、Ⅱ、Ⅲ型患者序贯行单支架成形术+支架内粒子条及经皮穿刺支架外粒子植入;Ⅳ型患者,需要行多支架或多支引流,随后配合支架内粒子条及经皮穿刺支架外粒子植入.随访观察患者肝功能、肿瘤大小、并发症、肿瘤标志物、胆道支架通畅情况及生存期.结果 23例肝门部胆管癌患者,均成功施行经皮胆道支架成形术,中位支架通畅期为19个月,中位生存期为17个月,术后患者的胆红素均降至正常或接近正常,总胆红素值与术前相比有统计学差异(t =9.271,P=0.000),直接胆红素值与术前相比有统计学差异(=7.751,P=0.000),术后并发症少,少数仅有轻微不良反应,总体疗效高,有效率为74％.结论 经皮胆道支架成形术联合支架内外放射性125I粒子植入治疗肝门部胆管癌创伤小、安全性高,手术简单,可以治疗不同程度肿瘤并有效保持胆道支架通畅,患者生存期较长,疗效满意.     

中晚期肝门部胆管癌15例手术切除体会

目的探讨中晚期肝门部胆管癌的外科治疗方式。方法对2002年12月—2005年10月收治的15例中晚期肝门部胆管癌的外科治疗方式和随访结果进行回顾性分析,其中中期7例(BismuthⅢa型4例,Ⅲb型3例),晚期(Ⅳ型)8例。结果手术切除10例,非手术胆道支架内引流5例(Ⅳ型5例)。随访14例(14/15,93.3%),手术切除组随访10例,中位生存期14.2月(16d～32.3月);非手术胆道支架内引流组随访4例,中位生存期3.8月(1.3～7.2月),两组中位生存期差异显著(t=2.802,P<0.05)。结论对于中晚期肝门部胆管癌,联合肝切除的姑息性肝门部胆管癌切除可显著延长患者生存期、提高生活质量,必要时,辅以“架桥式”肝管空肠内引流对提高手术切除率、降低术后胆漏发生率具有重要作用。     

放射治疗在肝门部胆管癌综合治疗中的作用

肝门部胆管癌是少见的恶性肿瘤。根治性手术是肝门部胆管癌患者获得长期生存的惟一预后因素,但手术切除率很低,术后放射治疗可以提高姑息切除者的局部控制率和长期生存率。绝大多数肝门部胆管癌患者就诊时为不可切除的晚期肿瘤,并伴有不同程度的胆道梗阻症状,各种胆汁引流术可以有效地缓解胆道梗阻,但并不能延长生存期。回顾性临床分析结果表明,在胆汁引流基础上的放射治疗可以进一步缓解症状,延长生存期。放疗方式可以分为单纯外照射、外照射结合腔内放疗以及新的放射技术的应用。有效的肝门部胆管癌综合治疗手段还有待于前瞻性、随机对照的临床试验。     

金属内支架胆管引流与放射治疗结合治疗肝外胆管癌

目的回顾性分析局部晚期肝外胆管癌金属内支架胆管引流结合放射治疗的疗效。方法1996年1月至2002年9月收治17例不能手术切除肝外胆管癌患者,先接受金属支架行胆管引流,3例治疗1周内失访,其余14例单纯近距离放疗(近距离照射组,n=5)或外照射(外照射组,n=9,其中包括2例近距离 外照射)。Ir192高剂量率近距离放疗在金属内支架置入当天或隔天治疗。外照射的中位剂量48Gy(14～66Gy),2Gy/次。结果经金属内支架置入结合放疗后,10例黄疸患者中8例黄疸消褪,近距离和外照射对缓解黄疸症状无显著差别。全组中位生存期12个月(5～35个月),1、2年生存率分别为40.8%和8.2%。近距离治疗组与体外照射组的中位生存期、1、2年生存率分别为8个月、40.0%、20.2%和12个月、40.0%、13.3%(χ2=1.10,P=0.29)。结论金属内支架胆管引流结合放射治疗可以显著缓解黄疸症状,高剂量放射治疗可以进一步提高长期生存。     

腔内近距离放疗联合及支架植入治疗恶性胆道梗阻

目的：评价经皮植入125I粒子条及支架治疗恶性胆道梗阻的安全性及疗效。方法对2009年6月至2013年6月,在上海中山医院接受介入治疗的68例恶性胆道梗阻患者的资料进行回顾性分析,其中41例在胆道梗阻段同时植入支架和125I粒子条(联合治疗组),27例仅植入支架(传统治疗组),对两组患者的生存期、至黄疸进展时间及手术相关不良事件发生率进行比较。结果所有125I粒子条和支架植入均获成功。传统支架组和联合支架组术后7、14 d血清胆红素水平组间差异有统计学意义(P<0．05);联合支架组术后未发生明显骨髓抑制;单纯支架组和联合支架组中位生存期分别为123和215 d,差异有统计学意义(P<0．05)。结论腔内近程放疗联合支架植入治疗恶性胆道梗阻安全,疗效较单纯植入支架明显。     

胆道双金属支架植入姑息性治疗肝门胆管癌的临床价值

肝门部胆管癌起病隐匿，常以阻塞性黄疸为首发症状，由于肿瘤对肝门结构的侵犯以及转移等原因，其手术切除率低，预后不良。临床上可采用不同方式的胆道引流术以减轻黄疸，进行姑息性治疗。2001年10月以来，我们应用经皮肝穿刺胆道金属支架植入术，对8例肝门部胆管癌施行了胆道双支架植入内引流治疗，取得了较好的效果，现将结果报道如下。     

金属内支架治疗恶性梗阻性黄疸的临床研究：附33例分析

目的：总结胆管金属内支架放置术的临床经验和疗效分析。材料与方法：恶性梗阻性黄疸患者３３例，男２３例，女１０例。胆管癌１６例，胰头癌２例，原发性肝癌２例，肝转移瘤３例，肝门淋巴结转移瘤压迫胆管１０例。本组共采用金属内支架行内引流３３例，共使用６种３８枚金属内支架。１２例支架放置术后加局部放射治疗和化学治疗（简称放、化疗）。结果：３３例采用经皮经肝穿刺置入胆管支架均获得成功，其中２９例一次性植入支架，４例先行胆汁引流术（ＰＴＢＤ）后再放置金属内支架；９例因胆管梗阻复杂，金属支架置入后仍保留引流导管，其中３例在置管１５～２００天后拔除引流管。２８例（８４．８５％）黄疸消退满意。本组中位生存期７个月，支架植入后加局部放、化疗组中位生存期１０个月。结论：胆管内金属支架治疗恶性梗阻性黄疸，可用于不能手术治疗的高位胆管梗阻，支架植入后加局部放、化疗可望提高远期疗效。     

恶性梗阻性黄疸的介入治疗 (附23例报告)

目的 探讨经皮肝穿胆道内支架置入术和介入动脉灌注化疗或化疗栓塞对恶性梗阻性黄疸的临床效果并进行分析。方法 23例恶性梗阻性黄疸患，共植入胆道内支架24枚，其中：原发性肝癌3例，胰腺癌2例，胆管癌14例(肝门胆管癌10例，胆管癌4例)，胆囊癌肝门转移2例，转移癌2例。23例患支架植入术后全部行介入动脉灌注化疗或化疗栓塞。结果 23例采用经皮肝穿胆道内支架置入术治疗恶性梗阻性黄疸均获得成功，技术成功率为100％，其中20例一次性植入内支架，另3例胆汁外引流后，再放置金属内支架，全部患黄疸消退均较满意(100％)，全组病例1个月、3个月、6个月生存率分别为100％(23／23)，91．30％(21／23)，60．87％(14／23)，术后早期无严重并发症。结论 恶性梗阻性黄疸内支架置入术和介入动脉灌注化疗或化疗栓塞，方法简单，疗效确切，能提高患生存质量，延长生存期。     

胆道支架置入联合γ刀治疗复杂型肝门部胆管癌的临床分析

目的评价胆道支架置入联合γ刀治疗复杂型肝门部胆管癌的临床疗效。方法对5例Bismuth分型Ⅳ型肝门部胆管癌合并胆总管远端狭窄行胆道置入金属支架引流联合γ刀治疗,先行B超引导下左侧肝内胆管穿刺置管,再行右侧肝内胆管置管引流(PTCD),置入3枚胆道支架解除梗阻。黄疸消退后行体部γ刀治疗,观察患者胆红素、转氨酶及肿瘤控制情况。结果 5例患者治疗前血清总胆红素为289.38±101.43μmol/L,直接胆红素180.42±72.50μmol/L,丙氨酸氨基转移酶148.80±82.65U/L。术后1周、1个月患者血清总胆红素分别为94.2±20.43、27.20±14.60μmol/L,直接胆红素分别为62.37±30.41、20.58±9.33μmol/L,丙氨酸氨基转移酶分别为109.27±45.52、59.80±35.18U/L。5例患者术后生存期分别为10、13、14、17、24个月,其中3例仍存活,中位生存期15个月,无手术并发症发生。结论胆道支架置入联合γ刀是复杂型肝门部胆管癌的一种安全有效的治疗方法,对于不能手术的局部晚期病例可提高局控率和生存率。     

经皮肝胆道支架置入术联合肝动脉化疗栓塞术及 体外放疗治疗肝门部胆管癌临床效果观察

目的观察经皮肝胆道支架置入术联合肝动脉化疗栓塞术及体外放疗治疗肝门部胆管癌患者的临床效果,并分析其预后影响因素。方法回顾性分析辽宁省肿瘤医院自2014年6月至2017年1月收治的34例肝门部胆管癌患者的临床资料。根据治疗方式不同,将患者分入A组(n=13)和B组(n=21)。A组患者仅接受经皮肝胆道支架置入术;B组患者接受经皮肝胆道支架置入术联合肝动脉化疗栓塞术及体外放疗。对患者进行随访,比较两组患者的胆道支架中位通畅时间、胆道支架中位存活期,并采用COX比例风险回归分析影响患者预后的危险因素。结果 B组胆道支架中位通畅时间为15.6个月,明显长于A组的7.0个月,差异有统计学意义(P<0.05)。B组胆道支架中位存活期为19.5个月,明显长于A组的9.6个月,差异有统计学意义(P<0.05)。COX比例风险回归分析显示:Bismuth-Corlett分型、治疗方式是肝门部胆管癌存活期的独立预测因素(P<0.05)。结论经皮肝胆道支架置入术联合肝动脉化疗栓塞术及体外放疗治疗肝门部胆管癌临床效果显著,可明显延长支架通畅时间和患者的存活期。     

射频消融导管联合支架介入治疗恶性梗阻性黄疸的临床研究

目的探讨经皮肝穿刺胆道腔内射频消融（RFA）联合支架介入治疗恶性梗阻性黄疸的效果及安全性。 方法纳入无法行手术切除的恶性梗阻性黄疸患者共13例,均接受经皮肝穿刺胆道腔内RFA联合支架植入术,观察手术并发症、黄疸缓解情况并密切随访术后1、3、6个月的支架畅通情况及生存时间。 结果所有患者均成功接受手术治疗,术后无胆道穿孔、胆漏、胆汁性腹膜炎等严重并发症发生,术后1周,患者血清总胆红素水平较术前显著降低[（95.4±83.0）μmol/L vs. （196.4±148.4）μmol/L, t=5.156,P<0.01],黄疸缓解率为61.5%。随访术后1个月、3个月支架通畅率均为100%,6个月支架通畅率为80%（8/10）。1个月存活率为100%（13/13）,3个月存活率为92%（12/13）,6个月存活率为77%（10/13）,其中2例分别于65 d、132 d后死于晚期肿瘤严重消耗,1例97 d后死于弥散性血管内凝血。2例患者在术后4~5个月内黄疸复发,再次行RFA并重新放入金属支架。 结论联合支架植入治疗在短期内能有效且安全地延长恶性梗阻性黄疸患者胆道支架通畅时间及无症状生存时间,其远期疗效尚需进一步探讨。     

盐酸哌替啶联合山莨菪碱在梗阻性黄疸介入干预术中的应用

目的 探讨盐酸哌替啶与山莨菪碱配伍应用在晚期恶性梗阻性黄疸患者肝穿胆道引流术(PTCD)及支架植入术(PTBS)中的应用效果.方法 因恶性梗阻性黄疸行PTCD及PTBS的100例患者,随机分成对照组与研究组,每组50例.研究组于术前30 min联合分别肌注盐酸哌替啶100 mg与山莨菪碱10 mg,对照组术前术中不用镇痛药及解痉药,观察患者血压和心率,记录胆心反射发生率及手术时间,应用疼痛评分量表评定患者疼痛程度.结果 与对照组相比,盐酸哌替啶与山莨菪碱配伍应用能稳定研究组患者生命体征、缩短手术时间、减少胆心反射发生率、缓解疼痛,提高患者舒适度.结论 盐酸哌替啶与山莨菪碱配伍应用于晚期恶性梗阻性黄疸患者PTCD或PTBS介入术中,可缓解疼痛,节省手术时间,方法简便易行、安全有效、费用低廉,可以作为PTCD或PTBS介人手术前的常规用药.     

A novel combination of percutaneous stenting with iodine-125 seed implantation and chemotherapy for the treatment of pancreatic head cancer with obstructive jaundice

PurposeInsertion of radioactive strips through the biliary stent has been reported to offer longer survival and patency than an uncovered conventional self-expanding metal stent in patients with unresectable malignant biliary obstruction. The aim of this study was to investigate the safety and effectiveness of intraluminal brachytherapy combined with ¹²⁵I seed implantation and transarterial infusion chemotherapy for the treatment of pancreatic head cancer with obstructive jaundice.MethodFrom October 2012 to January 2018, 21 consecutive patients diagnosed with biliary obstruction caused by locally advanced, nonmetastatic pancreatic cancer with cytologically or histologically confirmed by biopsy were enrolled and receive treatment with intraluminal brachytherapy using ¹²⁵I seed strand and CT-guided percutaneous radioactive seed implantation therapy. The procedure-related and radiation complications were assessed. The outcomes were measured in terms of stent patency, patient survival, complications related to the procedure.ResultOne of the 22 patients (4.5%, 1/22) with pancreatic head cancer failed to perform the above procedure because the guidewire was unable to pass through the obstruction segment. The remaining 21 patients (95.5%, 21/22) with pancreatic head cancer with obstructive jaundice were successfully placed with biliary stents and radioactive strips through drainage tubes. The median number of ¹²⁵I seeds loaded was 15, ranging from 12 to 17. After the chemotherapy with gemcitabine and cisplatin, no adverse reaction of Grade Ⅲ ～ Ⅳ occurred in all cases. Median stent patency was 12.50 months (95% CI: 10.26, 14.74). By May 2019, all 21 patients had died, with overall survival of 5.2–23.3 months, with a median survival of 13.20 months (95% CI: 10.96, 15.44).ConclusionPercutaneous ¹²⁵I seed implantation combined with insertion of radioactive strips through the biliary stent has the characteristics of less trauma, fewer complications, simple operation, and so on. These procedures bring remission of obstructive jaundice combined with the increased survival for the treatment of obstructive jaundice caused by unresectable pancreatic head cancer if follow-up chemotherapy is carried out. The long-term efficacy of this treatment combination needs to be confirmed by further multicenter, large sample size prospective randomized controlled studies.     

Brachytherapy and percutaneous stenting in the treatment of cholangiocarcinoma: a prospective randomised study

PURPOSE: To evaluate the effect of radiation therapy including intraluminal brachytherapy with iridium-192 on survival of patients with malignant biliary strictures (cholangiocarcinoma, histologically improved) treated with metallic stent in a prospective randomised study. METHOD AND MATERIALS: In the prospective randomised study, 21 patients with cholangiocarcinoma were treated with implantation of percutaneous stents followed with intraluminal Ir-192 brachytherapy (mean dose 30 Gy) and external radiotherapy (mean dose 50 Gy) and 21 patients were treated only with stents insertion. We did not find any statistically significant differences in age and tumor localization between these two groups of patients. RESULTS: All the patients died. In the group of patients treated with brachytherapy and with stent implantation, the mean survival time was 387.9 days. In the group of patients treated only with stent insertion the mean survival was 298 days. In effort to eliminate possible effect of external radiotherapy we treated the control group of eight patients with cholangiocarcinoma by stent insertion and brachytherapy only. CONCLUSION: Our results show that combined radiation therapy could extend the survival in the patients with cholangiocarcinoma obstruction.     

Percutaneous Placement of Self-Expandable Metallic Stents in Patients with Obstructive Jaundice Secondary to Metastatic Gastric Cancer after Gastrectomy

Objective

To evaluate the outcomes of patients undergoing percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy.

Materials and Methods

Fifty patients (mean age, 62.4 years; range, 27-86 years) who underwent percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy were included. The technical success rate, clinical success rate, complication rate, stent patency, patient survival and factors associated with stent patency were being evaluated.

Results

The median interval between the gastrectomy and stent placement was 23.1 months (range, 3.9-94.6 months). The 50 patients received a total of 65 stents without any major procedure-related complications. Technical success was achieved in all patients. The mean total serum bilirubin level, which had been 7.19 mg/dL ± 6.8 before stent insertion, decreased to 4.58 mg/dL ± 5.4 during the first week of follow-up (p < 0.001). Clinical success was achieved in 42 patients (84%). Percutaneous transhepatic biliary drainage catheters were removed from 45 patients (90%). Infectious complications were noted in two patients (4%), and stent malfunction occurred in seven patients (14%). The median stent patency was 233 ± 99 days, and the median patient survival was 179 ± 83 days. Total serum bilirubin level after stenting was an independent factor for stent patency (p = 0.009).

Conclusion

Percutaneous transhepatic placement of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy is a technically feasible and clinically effective palliative procedure.     

肝癌伴下腔静脉癌栓行TACE联合下腔静脉放射性支架或裸支架治疗的对照研究

目的 探讨TACE联合下腔静脉放射性支架植入治疗肝细胞肝癌伴下腔静脉癌栓的安全性及有效性.方法 对61例肝细胞肝癌伴下腔静脉癌栓患者的资料行回顾性分析,放射性支架采用125I粒子条捆载裸支架的方法,共对33例患者采用此方法(A组),28例患者植入裸支架(B组).采用倾向性评分匹配(propensity score matching)对原数据进行后随机化分析以减少选择性偏倚,对两组患者的生存期,症状缓解率及不良反应进行对照分析.结果 两组患者术后不良反应发生率相仿,均采用内科对症处理.A组患者较B组显示更长的生存期优势,A组中位生存时间(203.0±28.1)d,B组(93.0±24.3)d(P=0.006),倾向性评分匹配后(24对)A组(200±31)d,B组(66.0±23) d(P=0.019),A组水肿缓解率97.0％,B组为96.4％,多因素分析显示放射性支架植入与肿瘤客观有效率为患者预后好的独立性影响因素.结论 TACE联合放射性支架植入对治疗肝细胞肝癌伴下腔静脉癌栓安全有效,可能延长患者生存时间.     

胆道支架与十二指肠支架联合应用治疗胆道消化道梗阻

目的评价联合应用双支架治疗胆道及十二指肠梗阻的疗效。方法20例患者实施治疗。16例患者先经过经皮肝穿刺置入胆道支架解决胆道梗阻,患者出现十二指肠梗阻的症状后,14例患者经口腔、2例患者经胃造瘘口置入十二指肠支架。有4例患者同时有胆道和十二指肠梗阻的症状,同时置入胆道和十二指肠支架。结果所有患者都成功置入了双支架,没有出现并发症和再梗阻的表现。生存期1~14个月,平均5个月。结论联合双支架置入是治疗胆道和十二指肠梗阻的有效的方法。     

Treatment of common bile duct obstruction by pancreatic cancer using various stents: single-center experience

PURPOSE: To compare the effectiveness of various means of stenting in patients with biliary obstruction caused by pancreatic cancer in a retrospective analysis. METHODS: Sixty-two patients with biliary obstruction due to unresectable pancreatic cancer underwent biliary stenting. On the basis of the findings obtained by percutaneous transhepatic cholangiography (10 patients) and endoscopic retrograde cholangiography (52 patients), the site of obstruction was distal to the hilar confluence, predominantly especially in the middle to lower third of the common bile duct. Polyurethane-covered Wallstents (9 mm in diameter) were inserted in 13 patients, while uncovered Wallstents (10 mm in diameter) were used in 10 patients and plastic stents (10 Fr and 12 Fr) were used in 39 patients. RESULTS: Stenting was successful in 34 patients (87.2%) treated with plastic stents and in 22 patients (95.7%) treated with Wallstents. Effective biliary drainage was achieved in 32 out of 34 patients (94.1%) treated with plastic stents and in 21 out of 22 patients (95.5%) treated with Wallstents. The cumulative patency rate was significantly higher for the uncovered and covered Wallstents compared to plastic stents, but was not significantly higher for covered than for uncovered Wallstents. Stent occlusion occurred in 23 patients (70%; all by clogging) from the plastic stent group, in two patients (22%; by tumor ingrowth) from the uncovered Wallstent group, and in one patient (9%; by clogging) from the covered Wallstent group. The survival rate showed no significant difference among the three stent groups. CONCLUSION: The Wallstent is effective for long-term palliation in patients with obstruction caused by pancreatic cancer invading the middle to lower part of the common bile duct. The covered Wallstent can prevent tumor ingrowth, a problem with the uncovered Wallstent. However, it may be necessary to take measures to prevent the migration or clogging of covered Wallstents.     

经皮肝穿刺胆管腔内射频消融联合植入支架治疗肝门胆管癌伴恶性梗阻临床疗效研究

目的探讨经皮肝穿刺胆管腔内射频消融联合植入支架治疗肝门胆管癌伴恶性梗阻患者的临床应用价值。方法选取自2013年1月至2014年6月收治的肝门胆管癌伴恶性梗阻患者36例,行经皮肝穿刺胆管腔内射频消融联合植入支架进行治疗,观察患者术后并发症发生与肝功能变化情况。所有患者每月随访1次至术后1年,记录患者的存活率与支架通畅率。结果所有患者均手术成功,成功率为100.0%(36/36)。术后发生出血1例(2.7%),胆道感染4例(11.1%),腹泻5例(13.9%),呕吐6例(16.7%),疼痛10例(27.8%),对症治疗后均好转。术后1周,患者总胆红素、直接胆红素、谷氨酰转肽酶与碱性磷酸酶均明显低于术前,差异有统计学意义(P<0.05)。术后3、6、12个月的支架通畅率分别为91.7%(33/36)、69.4%(25/36)、38.9%(14/36);存活率分别为97.2%(35/36)、80.6%(29/36)、66.7%(24/36)。结论经皮肝穿刺胆管腔内射频消融联合植入支架治疗肝门胆管癌伴恶性梗阻安全有效,值得临床推广应用。     

恶性梗阻性黄疸的双介入治疗

目的：本文通过双介入法（经皮经肝胆道引流术和经动脉化疗栓塞术）在恶性梗阻性黄疸病人治疗中的研究，对双介入法作一评价。材料和方法：我院从１９８７年至１９９６年共有８２例恶性梗阻性黄疸病人接受了介入治疗。其中２８例为单纯的经皮经肝道引流术（ＰＴＢＤ），归为Ａ组；另外５４例在ＰＴＢＤ术后２周左右接受了经动脉化疗术（ＴＡＩ）和／或化职栓塞术（ＴＡＩ＋ＴＡＥ），归为Ｂ组。所有病人都通过多种影象学，外科或生物