放置金属支架姑息性解除恶性胆道梗阻57例

目的内镜法放置胆道支架,姑息性治疗胆管恶性梗阻的最大缺陷是支架的阻塞,造成阻塞的重要原因之一是通常的塑料支架口径较小,而放置可膨式金属支架使得内引流中口径达到1cm.方法我们从1994年4月-1996年5月放置膨胀式金属道支架治疗57例无法根治的恶性梗阻性黄疸患者,其中采用内镜法置管54例,经皮肝穿刺法3例.结果导丝定位后支架放置的成功率为95%,2例发生胆管炎,经保守治疗得以控制.术后两周内黄疸完全消退21例,明显减退23例,然而9例患者在平均147d 后由于引流失效出现晚期胆管炎.全组有23例术前采用鼻胆管和3例采用内置管临时性引流,临时性引流具有可预先了解引流效果和控制炎症的优点.结论对于无法切除的恶性胆道梗阻患者,放置金属胆道支架可有效解除黄疸,改善生活质量,但欲获得最佳疗效,需严格掌握置管指证.为获得持久的引流效果.肿瘤两端支架的长度不宜短于2cm;对肝门部胆管癌,Bismuth 分型对挑选合适的引流部位有较大的参考价值.     

恶性胆道梗阻金属内支架治疗后堵塞的处理

不能手术切除的恶性胆道梗阻通常采用放置胆道自膨式金属内支架治疗。经内镜和经皮经肝途径放置金属内支架成功率高、疗效好。放置金属内支架能有效缓解皮肤瘙痒，消除黄疸，改善肝功能，给化疗和手术提供机会。然而，远期存在的主要问题是金属内支架发生堵塞。现将我院采用十二指肠镜处理的45例金属内支架堵塞病例的经验介绍如下．     

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。     

金属支架治疗胆道恶性梗阻

目的 探讨金属支架治疗胆道恶性梗阻的价值和适应证。方法 回顾性分析15例植入胆道金属支架治疗不能手术切除的胆道恶性梗阻患者的临床转归，其中胰头癌8例，肝门胆管癌5例，胆囊癌2例。结果 15例患者金属支架均植入成功，术后2周内血清胆红素恢复正常8例（53．3％）、明显减退3例（20．0％）、缓慢减退4例（26．7％）。中位生存时间为12个月，一年生存率46．7％，两年生存率13．3％。结论 对不能切除的胆道恶性梗阻患者放置胆道金属支架操作较简单、痛苦少、并发症少，而且减黄效果好，是一种较为理想的姑息性疗法。     

不同内镜介入引流与外科手术治疗恶性胆管梗阻的疗效分析

目的 探讨不同内镜介入引流与外科手术治疗胆管恶性梗阻的疗效.分析影响因素与提高疗效手段.方法 回顾性分析98例外科手术治疗、ERBD和EMBE治疗胆管恶性梗阻的随访资料.结果 1997～2004采用塑料、金属胆道支架经内镜主乳头置入胆管引流和外科姑息引流恶性胆管梗阻98例,其中男66例,女32例,平均63.8岁.ERBD46例,成功率94.34%.总有效率78.27%.失访5例,随访的41例患者生存期为13～264天,平均135±39天,并发症2.5%.EMBE组35例,成功率100%,总有效率94.29%,失访2例,随访的31例患者生存期为91～542天.平均生存时间为258±112天,并发症14.86%.两者比较差异显著(P<0.01).术后并发症包括轻度胰腺炎、胆管炎、上消化道出血,无严重并发症与相关死亡发生.结论 EMBE是胆管恶性梗阻的一种安全有效的治疗手段,其疗效尤于ERBD.合理选择病例,采用不同手段力求导丝通过狭窄部、双支架引流等方法可改善疗效.     

内镜下胆道支架置入术治疗恶性胆道梗阻122例

目的:探讨经内镜逆行胰胆管造影技术(ERCP)在恶性胆道梗阻中的应用.方法:收集2003-07/2007-12临床确诊为恶性胆道梗阻患者122例,均采用ERCP及留置内支架,比较手术前后血清总胆红素变化情况.结果:全组122例胆管恶性梗阻中,行ERCP操作138例次,置管成功128例次,操作成功率92.75%.消除黄疸总有效率96.88%,并发症发生率为7.97%.108例置管成功且治疗有效者全部跟踪随访,其中86例在随访期内死亡,存活期为7.14±5.13 mo,22例至今仍存活,全组生存中位时间7.2 mo.结论:胆道支架置入术治疗恶性梗阻性黄疸疗效确切,安全性高,能提高患者生活质量.     

金属支架治疗胆道恶性梗阻

目的 探讨金属支架治疗胆道恶性梗阻的价值和适应证.方法 回顾性分析15例植入胆道金属支架治疗不能手术切除的胆道恶性梗阻患者的临床转归,其中胰头癌8例,肝门胆管癌5例,胆囊癌2例.结果 15例患者金属支架均植入成功,术后2周内血清胆红素恢复正常8例(53.3%)、明显减退3例(20.0%)、缓慢减退4例(26.7%).中位生存时间为12个月,一年生存率46.7%,两年生存率13.3%.结论 对不能切除的胆道恶性梗阻患者放置胆道金属支架操作较简单、痛苦少、并发症少,而且减黄效果好,是一种较为理想的姑息性疗法.     

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。     

BILIARY STENTING FOR MALIGNANT STRICTURE OF THE BILE DUCT

Biliary stenting is used as a standard procedure for the relief of jaundice in patients with non‐resectable malignant stricture of the bile duct. The stents available in the market are variously characterized, and surgeons must select an appropriate one for each disease status. For the stricture of the middle and/or lower part of the bile duct, covered metallic stent is superior to plastic stent in the patency period, however, there are questions as to the use of metallic stents in light of cost‐effectiveness and development of complications of stenting. And, the stent selection for the stricture of the hilar part of the bile duct has not been fully studied, which remains a problem yet to be resolved. In the use of metallic stent, it is difficult to manage when stent occlusion or complication occurs, and it holds the risk of developing a very serious complication. In the use of plastic stent, however, long‐term patency cannot be expected, which is also a problem yet to be resolved.     

FACTORS AFFECTING THE PATENCY OF EXPANDABLE METALLIC STENT FOR MALIGNANT BILIARY OBSTRUCTION

Although placement of expandable metallic stent (EMS) is an established method for palliation of malignant biliary obstruction, it remains unclear which factors affect the patency of the stent. We retrospectively analyzed the patency of EMS according to the following four factors: location of the stenosis (distal vs. hilar bile duct stenosis); uncovered vs. covered EMS; position of the distal end of EMS (intra bile duct vs. intra duodenal placement); and stent design (Diamond stent vs. Wallstent). The median stent patency was comparable in each group, but there was a trend that it was longer in covered EMS and intraduodenal placement group.     

PLASTIC STENT PLACEMENT FOR UNRESECTABLE MALIGNANT BILIARY STRICTURE

Background: Endoscopic stent placement is an efficacious treatment for patients with malignant biliary stricture. We investigated the indications for plastic stent placement in patients with unresectable malignant biliary stricture. Patients and methods: Eighty‐three patients with unresectable malignant biliary stricture who had undergone endoscopic placement of either a plastic stent or a covered metal stent in our department between February 1997 and September 2002 were reviewed retrospectively. Results: Metal stents had significantly longer patency (273 ± 99 days) than plastic stents (155 ± 52 days) (P = 0.0292). The two groups showed similar patency curves up to 150 days. Conclusions: The indication for plastic stent placement as palliative therapy for unresectable malignant biliary stricture is drainage for patients with an expected survival of less than 5 months.     

MALIGNANT BILIARY OBSTRUCTION: A COMPARISON OF COST FOR A USE OF METAL OR PLASTIC STENT FOR PALLIATION IN JAPANESE HEALTH CARE SYSTEM

Endoscopic treatment with endoprosthesis for obstructive jaundice is a well‐accepted method for palliation of obstructive jaundice and its associated symptoms. Yet, there is no consensus whether a plastic stent or metal stent to be used. The longer patency period with metal stent is a definite advantage but its high cost limits its routine use. The best use of metal stent is accomplished with consideration of patients’ predicted prognosis and a medical cost in Japan. We used a simulated case scenario to calculate a cost for metal stent and non‐metallic stent. Metal stent use would cost about 437 000 yen per patient at 6 months compared with 276 000–329 000 for non‐metallic stents, and thus metal stent use appears to be more costly in current Japanese medical system. Longer patency rate with covered metal stent would make metal stent more favorable, and less frequent procedure would be beneficial for patients who are at their terminal stage of diseases. Alternatively, many patients would not need stent replacement after first biliary stent placement due to the nature of underlying diseases. In addition to a development of an ideal stent and an appropriate technique, our research should also aim at determining who would benefit most for each stent in our own practice, preferably in prospective randomized trial.     

ENDOSCOPIC RETRIEVAL OF MIGRATED PLASTIC STENT INTO BILE DUCT OR PANCREATIC PSEUDOCYST

Proximally migrated biliary plastic stent and migrated stent in the pancreatic pseudocyst are relatively rare complications. A migrated stent causes poor drainage conditions, which leads to secondary complications such as infection, abscess, perforation and, moreover, becomes a foreign object in the body, and retrieval or re‐stenting is therefore necessary. The retrieval of a migrated stent includes surgical, percutaneous and endoscopic approaches, and the most non‐invasive method is endoscopic retrieval. However, because very few devices are exclusively designed for retrieval, the current situation is that the available devices are used while taking advantage of various ideas and techniques. From previously reported cases and our experiences of such cases, we herein describe the methods of endoscopic retrieval for stents that have migrated into a bile duct or pancreatic pseudocysts.     

BILIARY STENTING FOR MALIGNANT BILIARY OBSTRUCTION

Management of patients with malignant biliary obstruction remains controversial. We reviewed our current status of biliary stenting for malignancy. The initial step in our management is endoscopic nasobiliary drainage, which is used not only for preoperative drainage but also to decide whether or not surgery is appropriate treatment. Although a metal stent has a longer patency time than a plastic stent, it costs up to thirty‐fold more than the latter in Japan. Therefore, stent selection, metal or plastic, should be dependent on the expected prognosis of each patient with malignant biliary strictures. In the present paper, we also discuss the efficacy of the covered metal stent and stenting for malignant hilar obstruction.     

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。     

SHORT‐TERM METAL STENTING FOR TREATMENT OF MAIN PANCREATIC DUCT STRICTURES ASSOCIATED WITH CHRONIC PANCREATITIS

Background: Stricture of the main pancreatic duct associated with chronic pancreatitis is a cause of pain due to ductal high pressure and the formation of pancreatic stones, but there is no established non‐surgical therapeutic procedure. We attemped a new method for treating this condition, called short‐term metal stenting. Methods: In three patients who had experienced recurrent stones and pancreatitis attacks several times after extracorporeal shock wave lithotripsy, a self‐expandable metal stent was placed into the pancreatic duct for 2–7 days. Results: Dilatation was successful in all cases. Over observation periods of 18–25 months (mean, 22 months) following stent withdrawal, no recurrence of stones or attacks of pancreatitis was observed. Conclusion: Short‐term metal stenting is an effective procedure for dilating stricture of the main pancreatic duct. It is also promising as a method for preventing recurrence of stones or episodes of pancreatitis.     

COVERED WALLSTENT FOR PALLIATION OF MALIGNANT COMMON BILE DUCT STRICTURE: PROSPECTIVE MULTICENTER EVALUATION

Background: Occlusion due to tumor ingrowth is a major drawback in self‐expandable metallic stents. Covering the stent is a probable solution to prevent tumor ingrowth. A manufactured covered self‐expandable metallic stent, Covered Wallstent, has become commercially available. We evaluated the Covered Wallstent in a prospective uncontrolled multicenter setting. Methods: Between October 2001 and October 2003, 97 patients with common bile duct strictures deemed unfit for surgical resection underwent placement of a single Covered Wallstent, and were followed prospectively until April 2004. Results: Placement of the stent was successful in all the patients attempted. As a procedure‐related complication, acute pancreatitis developed in four patients, in one of whom obstruction of the pancreatic duct orifice with the stent body seemed to be a major cause. The 30‐day mortality was 9.3% (nine patients). Stent occlusion occurred in 22 patients as a late (greater than 30 days) complication, due to either tumor overgrowth (14 patients) or encrustation (eight patients). Distal migration of the stent was demonstrated in two other patients. No stent occlusions due to tumor ingrowth were observed. Patency rates of the stent for 3‐, 6‐, and 12‐month periods were, respectively, 90.7, 82.5, and 45.9%. Conclusions: The present results in a large series suggest that placement of the Covered Wallstent is feasible and effective in the palliation of patients with malignant common bile duct strictures. The Covered Wallstent seems to be reliable in eliminating tumor ingrowth. The role of stent covering in promoting stent function should be examined in a prospective comparative study between covered‐ and uncovered Wallstents.     

SUCCESSFUL TREATMENT USING A SELF‐EXPANDABLE METALLIC STENT IN THE PALLIATION FOR UNRESECTABLE MALIGNANT OBSTRUCTION OF THE COLON AND RECTUM

Background: We attempted the placement of a self‐expandable metallic stent (SEMS) for unresectable malignant obstruction of the proximal colon as well as obstruction of the distal colon and rectum, using a technical device. Patients and methods: Thirty patients were selected to place SEMS. The procedure was performed under endoscopic and fluoroscopic guidance. As a technical device, we used an angiographic introducer to straighten the rectosigmoid region. Moreover, we used a transparent hood to easily obtain a front view of the stricture. Results: Of 30 cases of attempted SEMS placement, SEMS was successfully placed in 26 (87%). The technical success rate was 82% (9/11) in strictures of the proximal colon, while it was 89% (17/19) in those of the distal colon or rectum. According to complications, stent migration occurred in one patient (3%) and restenosis was also observed in one patient (3%). Conclusion: Placement of SEMS is a feasible and effective adjunct and alternative to stoma in malignant large bowel obstruction.