经内镜胆道金属支架置入术后胆道感染的原因及处理

目的 探讨经内镜胆道金属支架置入术后胆道感染的原因及处理方法.方法 回顾性分析2011年1月至2012年12月47例经内镜胆道金属支架引流患者的临床资料.结果 47例均一次成功置入胆道金属支架,6例肝门部胆管癌、3例胆管癌（胆总管）、2例壶腹癌以及1例肝移植术后吻合口狭窄患者在金属支架植入术后3周～31个月发生胆道感染,发生率为25.5％,包括4例肿瘤堵塞金属支架、3例胆泥及食糜淤积、3例急性化脓性胆囊炎以及2例肝脓肿,分别采取经皮经肝胆囊穿刺置管引流（PTGBD）、经皮经肝脓肿穿刺置管引流（PTCD）、经内镜球囊取石/覆膜金属支架及鼻胆管引流治疗,12例均治愈,未发生严重并发症.结论 胆泥及食糜淤积、肝脓肿、肿瘤长入支架、胆囊颈管开口受压是胆道金属支架置入术后胆道感染的主要原因,PTGBD、PTCD及治疗性ERCP是其主要治疗方法.     

Pleural Dissemination as a Complication of Preoperative Percutaneous Transhepatic Biliary Drainage for Hilar Cholangiocarcinoma: Report of a Case

One potential risk of percutaneous transhepatic biliary drainage is tumor seeding along the catheter tract. A 57-year-old woman with obstructive jaundice due to hilar cholangiocarcinoma underwent an extended left hepatic lobectomy, a regional lymph node dissection, and a right hepaticojejunostomy 2 weeks after percutaneous transhepatic biliary drainage. Multiple right pleural masses were found on a chest radiogram 14 months after the operation. No recurrent lesions were detected in the abdominal cavity. A right panpleuropneumonectomy was performed; however, the patient died of respiratory failure due to tumor recurrence 9 months after the second operation. Preoperative percutaneous transhepatich biliary drainage was considered to have resulted in pleural implantation. Received: March 17, 2000 / Accepted: July 25, 2000     

Metastasis to the skin at the drain site after complete resection of the lower bile duct cancer: report of a case

There are extremely few reports of metastases from a lower cholangiocarcinoma to the skin except for metastatic seeding in a percutaneous transhepatic biliary drainage catheter tract. This report presents a rare case of metastases to the skin after the removal of a drain following curative pancreaticoduodenectomy for lower bile duct cancer (LBDC). A 73-year-old female had undergone subtotal stomach-preserving pancreaticoduodenectomy. Skin metastasis was noted at the site where the drain from the lower border at pancreaticojejunostomy had been removed 22?weeks postoperatively, and it was en bloc resected with the abdominal wall without exposing the carcinoma. Multiple nodules were confirmed in the axilla and chest wall 40?weeks after the initial operation. Careful discussion is necessary to avoid this mode of metastasis. The surgical field should not be exposed to pancreatic juice, even with LBDC. Nevertheless, this case is rare. Therefore, the risks and benefits of using such drains must be considered.     

Carcinoma of the hepatic hilus with superficial spreading to the intrahepatic segmental bile ducts: Report of a case

A case of superficially-spreading carcinoma of the hepatic hilus is presented. Percutaneous transhepatic biliary drainage was performed to alleviate jaundice and to evaluate the biliary system. A nodular tumor originating in the upper part of the common hepatic duct was found to be invading the confluence of the right and left hepatic ducts. Extensive superficial spread was observed in the proximal portion of the right anterior superior, right anterior inferior, right posterior superior, right posterior inferior, and caudate bile duct branches. Preoperative surgical planning was carried out on the basis of an evaluation of the findings of ultrasonography, computed tomography, percutaneous transhepatic cholangiography, and percutaneous transhepatic cholangioscopy. Absolute curative surgery, which included right hepatic lobectomy with total caudate lobectomy and bile duct resection, was performed. Bilioenteric continuity was reestablished with a Roux-en-Y jejunal loop. The histological diagnosis was well-differentiated tubular adenocarcinoma of the common hepatic duct. Postoperative recovery was very good; the patient has now enjoyed a good active social life for the past 4 years and 10 months, with no signs of recurrence. In this case report, we discuss the precise preoperative diagnosis and rational surgical treatment for carcinoma of the hepatic hilus with superficial spread.     

源头控制用于中重度急性胆道感染治疗

目的探讨源头控制原则在中重度急性胆道感染治疗中的应用价值。方法回顾性分析2004年1月至2014年6月应用外科源头控制原则处理的48例因胆石病、胆道肿瘤所致中重度急性胆道感染病人的临床资料。结果急性胆囊炎20例行经皮经肝胆囊穿刺引流术,急性胆管炎28例中6例行内镜十二指肠乳头括约肌切开术＋内镜鼻胆管引流术（endoscopic naso-biliary drainage,ENBD）,21例行ENBD,1例行胆管内支架置入术。引流术后病人寒战、发热、腹痛、腹膜炎等症状、体征迅速缓解,感染中毒症状得到有效控制,肝功能渐趋正常。全组未出现并发症,无死亡病例。结论应用源头控制原则处理中重度急性胆道感染安全、微创、有效、并发症少,为后续进一步治疗创造了有利条件,具有重要的临床应用价值。     

Double cancer of the gallbladder and common bile duct associated with an anomalous pancreaticobiliary ductal junction without a choledochal cyst: Report of a case

We report herein the case of a 37-year-old woman found to have double cancer of the gallbladder and common bile duct associated with an anomalous pancreaticobiliary ductal junction (APBDJ) without a choledochal cyst (CC). Abdominal ultrasonography showed an isoechoic mass in the gallbladder, and percutaneous transhepatic biliary drainage tubography revealed incomplete obstruction in the upper portion of the common bile duct and APBDJ. The patient underwent cholecystectomy, partial hepatic resection, pancreatoduodenectomy, and portal vein reconstruction. Pathological examination of the tumors from the gallbladder and bile duct revealed papillary carcinoma and poorly differentiated adenocarcinoma, respectively, and direct continuity was not observed between the tumors. A review of the literature on six cases of multiple primary carcinoma of the biliary tract associated with APBDJ without CC is presented following this case report. Double cancer of the biliary tract was found synchronously in five patients and metachronously in one. Gallbladder cancer showed subserosal invasion in four patients, while bile duct cancer invaded the pancreas in one patient and reached the serosa in two patients. Considering the potential for cancer to arise in the biliary tract and the difficulties associated with monitoring it, cholecystectomy and resection of the extrahepatic common bile duct may be the most appropriate treatment for patients with an APBDJ without a CC.     

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目的探讨肝细胞癌(HCC)合并胆管癌栓外科治疗的效果。方法对1984年7月至2002年12月收治的53例HCC合并胆管癌栓的治疗情况进行回顾性总结和分析。结果53例中，1例未治，6例行经皮肝穿刺胆道引流(PTCD)，46例开腹手术。开腹手术术后30d病死率为13．0％，并发症发生率为32．6％。肝切除术、胆管取癌栓及胆道引流术病人术后生存时间为5～46个月，中位生存期为23．5个月。结论黄疸不一定是肝癌的晚期表现，也不一定是手术禁忌证，对HCC合并胆管癌栓的早期诊断和手术治疗，是改善病人预后的关键。     

超声引导经皮经肝支架置入在胆道恶性梗阻中的应用

目的探讨超声引导经皮经肝支架置入技术在胆道恶性梗阻中的治疗意义。方法16例恶性胆道梗阻患者,采用B超引导经皮经肝胆管穿刺置管外引流,并胆道造影后行金属支架置入。结果胆道支架置入成功率100%,2例术后分别出现胆道及腹腔内出血,保守治疗控制。术后1~4周黄疸消除率87.5%。最短生存时间2个月,最长18个月,中位生存时间6.8个月。6例随访期间出现胆道再梗阻,其中3例经B超引导经皮经肝胆道(PTCD)外引流 胆道冲洗再通,另3例因肿瘤长入,长期PTCD外引流。结论(1)胆道金属支架减黄效果确切,并能原位恢复胆道的生理连续性;(2)超声介导技术可提高胆道金属支架置入成功率;(3)充分有效的胆汁外引流能减少支架置入的相关并发症,也为胆道再梗阻提出了解决的途径。     

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??Interventional treatment of iatrogenic bile duct injury: an analysis of 51 cases WEN Feng, MAO Xiao-nan, LU Zai-ming, et al. Department of Radiology, Shengjing Hospital of China Medical University??Shenyang110004, China
Corresponding author: LU Zai-ming, E-mail: buttervant@126.com
Abstract Objective To discuss the value of percutaneous interventional procedure in the treatment of iatrogenic bile duct injury. Methods The clinical data of 51 cases of iatrogenic bile duct injury treated with percutaneous interventional procedure initially since 2000 in Shengjing Hospital of China Medical University were analyzed retrospectively. Results Abdominal fluid collection was found in 27 cases and then treated with percutanous drainage initially. Biliary endoprosthesis implantation was attempted in 6 cases. Intrahepatic and/or extrahepatic bile duct dilatation was found in 26 cases. Percutaneous transhepatic biliary drainage was performed in 24 cases. Balloon dilatation was attempted in 3 cases. Endoscopic biliary stenting was performed in the other 2 cases. Percutaneous drainage of abdominal fluid collection was performed in 27 cases successfully. The relief of clinical symptoms and the reduction of fluid collection were represented in all cases. Bile leak immediately disappeared in 4 cases performed biliary endoprosthesis implantation and the biliary fistula finally healed in 2 cases. Percutaneous transhepatic biliary drainage was all performed successfully in 24 cases. The bilirubin decreased significantly (t= 15.61, P<0.01) 1 week later. Balloon dilatation was performed in 3 cases successfully and the biliary obstruction was relieved immediately. However, restenosis of bile duct occurred within 24 hours in 1 case. Endoscopic biliary stenting was performed in 2 cases successfully, who both represented restenosis of bile duct 6 months later. Conclusion Percutaneous interventional procedure has a great value in the initial treatment of iatrogenic bile duct injury.     

Small pancreatic carcinoma misdiagnosed as superficially spreading cholangiocarcinoma

We report a case of small pancreatic carcinoma misdiagnosed as superficially spreading cholangiocarcinoma using percutaneous transhepatic cholangioscopy (PTCS). The patient was a 72-year-old man admitted to a local hospital with obstructive jaundice. The patient underwent percutaneous transhepatic biliary drainage and PTCS. He was referred to our hospital with a diagnosis of superficially spreading cholangiocarcinoma. Cholangiography revealed a stenosis of the common bile duct, and also revealed some irregularities from the common hepatic duct to the left hepatic duct, suggesting a superficial spread of cancer. No pancreatic tumor was identified by endoscopic retrograde pancreatography or by enhanced computed tomography. Cholangioscopy disclosed an elevated tumor with torsional vessels and granular mucosal lesions, which were extended to the left hepatic duct. Repeated cholangioscopic biopsies of the bile duct mucosa revealed adenocarcinoma. The patient was diagnosed with superficially spreading cholangiocarcinoma extending to the left hepatic duct and the right anterior hepatic duct. Left trisectionectomy combined with pancreatoduodenectomy was performed. The cut surface of the resected specimen showed a pancreatic head tumor that was 8 mm in diameter. Histological findings of the resected specimen revealed adenocarcinoma arising from the pancreatic head with invasion in the common bile duct. Additionally, extensive inflammatory granulation tissue was observed along the surface of the bile duct, without any evidence of carcinoma. This case implies to us that the results of PTCS, even after repeated biopsies, should be interpreted with great caution.     

经PTC或ERC两种途径放置胆道支架治疗恶性胆管梗阻对比分析

目的比较经PTC或ERC两种途径放置胆道支架治疗恶性胆管梗阻的疗效。方法 PTC途径:在超声引导下选择胆管走行与胆总管夹角较大、扩张的左右肝内胆管,穿刺置管引流,1周后再置入支架,共68例(其中有2例系ERC途径失败者)。ERC途径:在十二指肠镜下逆行插入引流管于胆总管内,经造影显示梗阻部位,其引导丝通过梗阻部位,然后沿引导丝置入支架,共53例。结果 经PTC或ERC途径放置支架成功率分别为100%(68/68)和96.2%(51/53),2组均未发生出血及漏胆并发症。全部患者获随访1～18个月(平均12.4个月),结果PTC组和ERC组放置支架后6个月内死亡者分别为7和5例,18个月仍存活者分别为17和9例。结论对失去手术机会或不能耐受手术的恶性胆管梗阻患者采取支架置入是有效解除梗阻、延长生存时间和提高生存质量的最佳方法。位于胆总管下端和壶腹部的梗阻首选ERC途径放置支架;位于肝门部及以上的梗阻应以PTC途径放置支架为宜。     

Is preoperative biliary drainage necessary according to evidence-based medicine?

Preoperative biliary drainage has been in use for a long time and is still being performed today in some institutions, but there has been a long-standing issue as to whether the necessity of this procedure has been proven medically. Many problems existed previously, such as systemic complications due to the difficulty in diagnosing and differentiating obstructive jaundice from jaundice left untreated for a long time, or surgeon-based problems such as a lack of surgical skill or undeveloped surgical techniques, or even inexperience in perioperative patient management. These problems, however, are being overcome with time, and the advantages of preoperative biliary drainage are now being questioned according to evidence-based medicine. Several recent controlled trials have clearly shown that preoperative biliary drainage is not necessary for lower bile duct obstruction, although it was noted that surgery after reduction of jaundice by percutaneous transhepatic cholangial drainage (PTCD) was very easily performed. It is important to understand that preoperative biliary drainage is unnecessary for lower bile duct obstruction, whether the technique follows a percutaneous approach, an endoscopic apporach, or stenting. Although it is still being debated, there have already been several reports regarding whether preoperative biliary drainage is necessary for upper bile duct obstruction, such as hilar bile duct carcinoma. This also needs to be clarified by randomized controlled trials. Aside from preoperative biliary drainage, the utilization of biliary drainage or stenting has been fully recognized as important for removing intrahepatic stones or choledochal stones, as well as for emergency drainage for acute cholangitis and for the treatment of unresectable malignant biliary stenosis. Additionally, percutaneous transhepatic cholangioscopy (PTCS), using the PTCD, or percutaneous transhepatic biliary drainage (PTBD) route, plays a major role not only in the removal of biliary stones but also in the diagnosis of cases in which it is difficult to differentiate between benign and malignant lesions. Received: August 2, 2000 / Accepted: September 22, 2000     

Bile duct stricture in an infant with gastroschisis treated by percutaneous transhepatic drainage, biliary stenting, and balloon dilation

A newborn twin with an antenatal diagnosis of gastroschisis underwent staged repair of the abdominal wall defect. She developed multiple fistulae due to ischemic bowel and then abdominal wall dehiscence requiring additional surgical interventions. Obstructive jaundice, first evident at 3 weeks of age, became progressively severe. A stricture of the common bile duct was diagnosed by percutaneous transhepatic cholangiography. The stricture was treated by percutaneous biliary drainage, biliary stenting, and balloon dilation of the common bile duct. These procedures, commonly used in adults for biliary decompression, may be useful alternatives to surgical intervention in infants and children with obstructive jaundice due to bile duct stricture.     

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??A one-stage percutaneous tract dilation technique in percutaneous transhepatic cholangioscopy (PTCS) for patients with bile duct stones: A report of 35 cases LOU Jian-ying, CHEN Wei, WANG Ji, et al. Department of Hepato-Pancreato-Biliary Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
Corresponding author: LIANG Ting-bo, E-mail: liangtingbo@zju.edu.cn
Abstract Objective To evaluate the safety, efficiency, indications and procedure of percutaneous transhepatic cholangioscopy (PTCS), using a one-stage percutaneous tract dilation technique, in patients with intrahepatic and/or common bile duct stones. Methods The medical records of 35 cases of intrahepatic and/or common bile duct stones treated by PTCS, using a one-stage tract dilation technique, from January, 2015 to April, 2017 in the Second Affiliated Hospital of Zhejiang University School of Medicine were studied retrospectively. All the patients were treated with lithotripsy and basket stone removal through PTCS using one-stage percutaneous tract dilation technique after percutaneous transhepatic cholangial drainage (PTCD). The perioperative morbitity, stone clearance rate, and stone recurrence rate were analyzed. Results The intrahepatic biliary duct and common bile duct were successfully accessed in all 35 cases using ultrasound-guided one-stage percutaneous tract dilation PTCS technique. The stones were completely removed (level A) in 65.7% (23/35) of the cases including 18 cases of intrahepatic stones and 5 cases of common bile duct stones. The stones were almost cleared (level B) in 22.9% (8/35) of intrahepatic stones cases. Stone clearance was achieved in 31 (88.6%) cases (level A and B). One case suffered PTCD site bleeding and one case had percutaneous transhepatic tract rupture during the secondary stone removal procedure. There were no other serious procedure-related complications such as life-threatened bleeding, bile leak and conversion to laparotomy. With follow-up of 1-28 months, 6 (26.1%) of 23 cases of level-A stones clearance had recurrent intrahepatic stones and cholangitis. Conclusion PTCS using one-stage dilation of the tract, is an effective, safe and alternative minimal invasive method forintrahepatic and/or common bile duct stones when surgery or peroral approach is not indicated.     

经皮经肝胆道镜治疗医源性胆管损伤后再狭窄

目的探讨医源性胆管损伤后肝外胆管再狭窄的原因和治疗方法。方法对我院1998年1月～2005年1月12例（开腹胆囊切除术5例，腹腔镜胆囊切除术7例）医源性胆管损伤后肝外胆管再狭窄，建立经皮经肝通道，采用胆道镜取石、球囊扩张、支架管置入支撑扩张狭窄段胆管。结果8例用F20 Gruntzig型球囊导管扩张狭窄段胆管，2次即可放入6～8mm塑料支架引流管；4例球囊扩张3次后置入。塑料支架引流管置管6～12个月。12例随访2～3年，平均2．6年，无腹痛、发热、黄疸再次发作，B超、MRCP检查胆管无狭窄及再发结石。结论胆道镜取石、球囊扩张支架管置入治疗医源性胆管损伤后肝外胆管再狭窄创伤小，安全可行，效果良好。     

Extrahepatic biliary obstruction secondary to metastatic cancer

Thirty patients with extrahepatic biliary obstruction secondary to metastatic cancer were reviewed to determine the sites of the primary tumor, diagnostic methods, therapy and success of palliation. Colon carcinoma was the most common primary tumor, and the common bile duct was most often obstructed. Both percutaneous transhepatic and surgical decompression of the biliary tract were employed. Twenty-seven (90 percent) of the patients obtained successful palliation. The length of survival averaged 270 ± 49 days in patients treated surgically compared with 60 ± 11 days in patients who under-went decompression by radiologic techniques. Mortality was not increased in patients undergoing operative biliary drainage. Surgical decompression may be the best method for managing patients with biliary obstruction secondary to metastatic cancer.     

Development of bile duct cancer in a 26-year-old man after resection of infantile choledochal cyst

Anomalous arrangement of the pancreaticobiliary duct is considered to be a high-risk factor for biliary tract malignancy. We report a case of intrahepatic cholangiocarcinoma in a 26-year-old man after total resection of choledochal cyst with anomalous arrangement of the pancreaticobiliary duct at the age of 5 months. He had been doing well after total resection of the choledochal cyst; however, he suddenly presented with a spiky fever and abdominal pain in the right upper quadrant at the age of 26 years. Computed tomographic scan and percutaneous transhepatic cholangioscope revealed multiple stones and stenosis of the hepatic duct and the left intrahepatic bile duct. Histologic examination of a biopsy specimen obtained from the stenotic site showed adenocarcinoma of the intrahepatic bile duct. Left lobectomy with re-reconstruction by right hepaticojejunostomy was performed, and his postoperative course was uneventful. One year after the operation, however, he died of carcinomatous peritonitis with recurrence of cholangiocarcinoma. This report warns us that bile stasis owing to stenosis of the intrahepatic bile duct and repeated cholangitis with multiple stones are high-risk factors for carcinogenesis of the intrahepatic bile duct even after total resection of the infantile choledochal cyst.     

经皮经肝胆管引流术治疗肝移植相关性胆瘘

目的 探讨经皮经肝胆管引流术(PTBD)治疗肝移植(OLT)相关性胆瘘的方法 及疗效.方法 回顾性分析经PTBD治疗的7例OLT相关性胆瘘,OLT术后受体胆瘘6例,活体肝移植(LDLT)供体胆瘘1例.吻合口瘘6例(1例合并吻合口狭窄),其中2例合并肝动脉狭窄;肝切缘小胆管残端瘘1例.引流方式采用外引流,引流管前端跨过瘘口部位,成畔固定于胆总管内.瘘口闭合、腹腔引流管无胆汁引出为治愈.结果 7例胆瘘病人PTBD引流量180～450 ml/d,经引流21～87 d(中位时间62 d)后,复查造影瘘口闭合,胆瘘治愈率为7/7.随访时间93～675 d(中位时间124 d),4例无症状生存,2例因多器官功能不全放弃治疗,1例肝癌复发病死.1例在引流期间出现胆道感染.结论 PTBD是治疗0LT相关性胆瘘的一种安全、简便、有效的方法 .     

Right hepatic lobectomy and subsegmental resection of the left caudate lobe for gallbladder carcinoma involving the hepatic hilus: Preservation of the ventral portion of the left caudate lobe

A case of gallbladder carcinoma in a 75-year-old woman with familial hyperbilirubinemia and preoperative hepatic dysfunction is presented. Tube cholangiography through a percutaneous transhepatic biliary drainage (PTBD) catheter demonstrated a stricture and the hepatic confluence without filling of the gallbladder and showed two bile duct branches arising from the left caudate lobe. Cholangiography also disclosed that the left dorsal branch, which joined the right hepatic bile duct, was involved with tumor, while the left ventral branch, which joined the left hepatic duct, was not. Extended right hepatic lobectomy with resection of the dorsal portion of the left caudate lobe, preserving the ventral portion of the left caudate lobe, was performed. Postoperative cholangiography showed that the ventral branch of the left caudate lobe bile duct was preserved. Precise preoperative anatomic diagnosis of the biliary system in patients with hepatobiliary cancer allows successful subsegmental resection of the caudate lobe. Received for publication on July 23, 1997; accepted on Oct. 6, 1997     

Villous tumor of the papilla of Vater presenting with hypopotassemia

We report a case of villous tumor of the papilla of Vater associated with hypopotassemia. The patient was a 73-year-old woman who presented with jaundice and fever. She had a history of diabetes mellitus and liver dysfunction. Laboratory studies revealed that levels of total bilirubin, alkaline phosphatase, and C-reactive protein, and the white blood cell count were elevated (suggestive of cholangitis) and that the serum potassium level was markedly reduced, to 1.9 mEq/l (normal value 3.5–5.0 mEq/l). Duodenoscopy showed a villous tumor arising in the papilla of Vater. Percutaneous transhepatic biliary drainage was performed. Approximately 700–1500 ml of bile with viscous mucoid fluid was drained daily. Percutaneous transhepatic cholangioscopy showed a papillary lesion in the distal common bile duct. Biopsied specimens from both percutaneous transhepatic cholangioscopy and duodenoscopy disclosed tubulovillous adenoma. Endoscopic ultrasonography showed that the tumor had spread to the main pancreatic duct as well as to the common bile duct. The patient underwent pylorus-preserving pancreaticoduodenectomy. Pathology examination disclosed well differentiated adenocarcinoma, carcinoma in situ, in tubulovillous adenoma. The cancer cells were observed at the bottom of the tumor spreading in the common bile duct. This is a rare case of a patient presenting with hypopotassemia associated with a tubulovillous tumor of the papilla of Vater that secreted mucoid material.