记忆合金支架在肝门部胆管狭窄手术治疗中的应用

目的探讨镍钛记忆合金胆道支架在肝门部胆管狭窄手术治疗中的应用。方法回顾性分析2001年1月~2004年12月我院收治的肝门部胆管狭窄35例的临床资料。其中,恶性肿瘤32例,多数实施肿瘤姑息性切除术;良性病变3例,采用钛镍记忆合金辅助胆肠吻合。结果手术后1~5周黄疸消退31例。手术死亡1例。恶性肿瘤病人术后平均生存期为18.6个月,1年生存率为53.1%;胆管良性狭窄的2例,由于反复出现寒战、发热,术后1年取出支架。结论对肝门部胆管狭窄置入镍钛合金胆道支架,可明显减轻黄疸、改善肝脏功能,提高病人的生存质量和延长生存时间,是一种安全、有效的姑息性治疗方法。     

An approach to the hepatic hilus with marked fibrosis: A surgical technique for reconstruction of the bile duct with a benign stricture

It is very difficult to approach the hepatic hilus safely in patients with common and/or hepatic bile duct strictures in which normal tissue has been replaced by scarred tissue with firm fibrous adhesions. In this report, we describe how eight patients with benign strictures of the bile duct underwent an operation which involved dividing the superior mesenteric and portal veins from the lower margin of the pancreas in a dorsal direction using a finger in a tunneling technique. The common bile duct, which was buried in scar tissue, was then explored, while the common and/or proper hepatic arteries in the hepatoduodenal ligament were confirmed, after transsection at the superior margin of the pancreas. Biliary reconstruction was successfully performed after resection of the constricted bile duct in all the patients, none of whom have experienced recurrence from 6 months to 5 years after the operation.     

老年胆道梗阻的特点及治疗

目的：总结老年胆道梗阻性疾病的临床特点，治疗方法及效果。方法对１９８４年１月至１９９９年９月收治的６５岁以上胆道梗阻疾病１５８例进行回顾性分析，结果死亡率为９％（１３例），其中良性梗阻５例，恶性梗阻８例，均死于术后并发症及多器官功能有衰。结论：老年胆道梗阻病因复杂，病情进展快，强化围手术期治疗，预防胆道感染，及时有效的胆道引流，合理的术式选择，是提高治愈率，降低并发症及死亡率的关键，经皮经肝穿刺胆     

Common Bile Duct Obstruction by Free Floating Tumor

Tumors usually spread by local invasion or by vascular or lymphatic metastases. We report six patients in whom tumor cells were shed into the common bile duct with resulting obstruction. The three men and three women had jaundice and upper abdominal discomfort. Jaundice was intermittent in four patients. Preoperative total serum bilirubin ranged from 2.5 to 16.1 mg/dl; alkaline phosphatase ranged from 221 to 605 IU/1. Ultrsasound showed a dilated gallbladder [GB] in five patients with dilated intrahepatic ducts in three and stones in only one. ERCP showed a single filling defect in two of three patients and multiple defects in one. PTC showed multiple defects in one patient. At operation a thick gelatinous tissue fragment or clot was seen in the common bile duct of each patient. Frozen section identified tumor tissue in all. The source was GB carcinoma [2], GB adenomyoma [1], hepatic metastases of colon cancer [2] and common bile duct cancer [1]. Treatment consisted of pancreaticoduodenectomy [2], including one for GB cancer, left hepatic lobectomy [1], choledochoduodenostomy [1], common duct exploration with T-tube insertion and cholecystectomy [1]. One patient with metastatic colon cancer and another with gallbladder cancer died within one year of operation. The other four are alive from 2 to 4 years later. Conclusion: Benign or malignant tumors within the hepatobiliary tree can shed tissue into the common bile duct which can cause biliary obstruction. Any tissue fragment found in the common bile duct should be evaluated by frozen section. Recognition of this mode of tumor spread is needed for appropriate therapy of the underlying benign or malignant tumor.     

肝胆管结石合并高位胆管狭窄的外科治疗

目的 探讨如何提高肝胆管结石合并高位胆管狭窄的疗效。方法 对我院1993年1月至2002年l0月经手术治疗的216例肝胆管结石合并高位胆管狭窄病例进行回顾性分析。结果 216例中183例行择期手术；33例因急性梗阻性化脓性胆管炎行单纯胆道探查引流术，其中30例行再手术治疗。手术方式：肝切除术，胆管狭窄切开、胆管原位整形，肝Ⅱ、Ⅲ级胆管切开盆式整形及自体组织补片修复胆管或胆肠吻合术。治愈206例(95．4％)，好转8例(3．7％)，死亡2例(O．9％)。结论 肝叶切除术在治疗肝胆管结石病中效果最好。肝Ⅱ、Ⅲ级胆管切开对解除肝胆管狭窄、清除结石及通畅引流提供了一条满意的途径。对肝外胆管和Oddi’s括约肌功能正常者，尽可能应用自体组织补片修复胆管，以保持胆道正常的生理状态和功能。术中胆道镜的应用对降低残石率有重要作用。     

A case of benign bile duct stricture causing difficulty in differential diagnosis from bile duct carcinoma

We report a patient with benign bile duct stricture causing difficulty in differential diagnosis from bile duct carcinoma. A 66-year-old woman consulted a local physician because of general fatigue. Blood biochemical tests showed increased levels of biliary tract enzymes. Abdominal ultrasonography (US) revealed tapering and blockage of the midportion of the bile duct and dilation of the intrahepatic bile ducts. Magnetic resonance cholangiopancreatography (MRCP) demonstrated obstruction of the midportion of the bile duct. Later, because a marked increase in biliary tract enzymes and jaundice appeared, percutaneous transhepatic biliary drainage (PTBD) was performed. Post-PTBD cytological examination of bile was negative for cancer. A third biopsy showed slight hyperplasia with no malignant findings. Recholangiography, performed through PTBD, suggested gradual improvement of bile duct stricture, but could not completely exclude the possibility of malignancy; thus, resection of the bile duct including the stricture site was performed, and the resected specimen was submitted for intraoperative frozen section examination. Histopathological diagnosis did not reveal malignant findings. After cholecystectomy and bile duct resection, hepaticojejunostomy (Roux-en-Y) was performed. Because only erosion and desquamation of the mucosal epithelium and mild submucosal inflammatory cell infiltration and fibrosis were observed, chronic cholangitis was diagnosed histopathologically. Surgical resection of the bile duct should be considered for potentially malignant stricture of the bile duct.     

Mucin-producing Bile Duct Tumor of the Caudate Lobe Protruding into the Common Hepatic Duct

Mucin-producing tumor in the bile duct is referred to clinically as mucin-producing bile duct tumor (MPBT). Intraductal papillary neoplasm of the biliary tract that resembles an intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a rare category of MPBT and is not well characterized. We, herein, report a case of MPBT of the caudate lobe of the liver that showed papillary growth and communicated with the bile duct of the caudate lobe and protruded into the common hepatic duct. Histologically, MPBT cells showed papillary overgrowth with abundant mucinous secretions, resembling an IPMN of the pancreas. The MPBT cells showed the same immunostaining pattern as that of cells from IPMN of the pancreas.     

胆道再次手术235例分析

目的总结胆道再次手术的经验，探讨胆道再次手术的原因、临床特点及处理方法。方法对1996年7月至2005年6月收治的235例胆道再次手术的临床资料进行回顾性分析。结果胆道再次手术的主要原因是肝胆管结石残留或复发，占全组病例的82．2％；其次为胆肠吻合术后狭窄，胆管囊肿，胆管狭窄及胆管肿瘤。再次手术治疗方式以肝叶切除（占66％）合并胆肠吻合或T管引流为主。胆道再次手术后并发症发生率为25％。结论胆道再次手术既有胆道疾病本身因素，亦有医源性因素；充分的术前准备，术中仔细探查，选择合理手术方式及合适的术后辅助治疗是减少胆道再次手术的关键。     

Extensive hilar bile duct resection using a transhepatic approach for patients with hepatic hilar bile duct diseases

BACKGROUND: Extensive hilar bile duct resection beyond the second- or third-order intrahepatic biliary radicals is usually required for patients with hilar cholangiocarcinoma as well as those with benign inflammatory stricture. Most hilar cholangiocarcinoma is resected with combined major hepatectomy to obtain free surgical margins. The purpose of this study was to show the surgical procedure and the usefulness of extensive hilar bile duct resection using a transhepatic approach for patients with hilar bile duct diseases. METHODS: Five patients with hepatic hilar bile duct disease and who were unfit for major hepatectomy for several reasons underwent extensive hilar bile duct resection by way of a transhepatic approach. Four of the patients had hilar bile duct cancer, including 1 with mucous-producing bile duct cancer of low-grade malignancy and 1 with a postsurgical benign bile duct stricture. RESULTS: After extensive hilar bile duct resection, bile duct stumps ranged in number from 3 to 7 mm (mean 4.4). Surgical margins at bile duct stump were free of cancer in all 4 cancer patients. The long-term outcomes were as follows: 3 patients are alive at the time of publication, and 2 patients have died. CONCLUSIONS: A transhepatic approach may be useful when performing extensive hilar bile duct resection bile duct stricture of biliary disease at the hepatic hilus, especially in high-risk patients who are unfit for major hepatectomy as well as in those having benign bile duct stricture and low-grade malignancy.     

Adenomyomatous Hyperplasia of the Common Bile Duct: Report of a Case

Adenomyomatous hyperplasia is most commonly found in the stomach, gallbladder, duodenum, and jejunum, while it is rarely found in the extrahepatic bile duct. A 62-year-old woman was referred to our institution with a diagnosis of common bile duct (CBD) stenosis which had been detected by endoscopic retrograde cholangiopancreatography (ERCP). Abdominal computed tomography with contrast medium revealed a thickening of the wall of the lower CBD, and this lesion was weakly enhanced by contrast medium in the arterial phase. ERCP revealed a 15-mm-long stenosis of the lower CBD, but no malignant cells were detected by either bile cytology or brush cytology. Because CBD cancer could not be ruled out, pylorus-preserving pancreatoduodenectomy was performed. Histopathologically, multiple hyperplastic glands without cellular atypia were present in the lower CBD wall. An immunohistochemical study showed fibroblasts with positive staining for α-smooth muscle actin surrounding the glands. The lesion was diagnosed to be adenomyomatous hyperplasia of the CBD. When a diagnosis of adenomyomatous hyperplasia of the CBD is difficult to make both preoperatively and intraoperatively, then a radical surgical procedure, such as a pancreatoduodenectomy, may be an effective treatment alternative.     

Role of Hepatectomy in the Treatment of Hilar Bile Duct Carcinoma

Purpose. To clarify the role of hepatic resection in the surgical treatment of hilar bile duct carcinoma.Methods. Between 1980 and 1997, 68 patients underwent surgery for hilar bile duct carcinoma. The patients were divided into a hepatectomy group (n = 40) and a nonhepatectomized group (n = 28) depending on whether they underwent resection of the bile duct confluence in combination with hepatectomy, or alone, respectively. Background data, operative morbidity and mortality, and survival were retrospectively compared between the two groups.Results. There were no significant differences in morbidity and mortality, or in postoperative survival between the two groups (the 5-year survival rates being 20.6% in the hepatectomized group and 7.1% in the nonhepatectomized group; P = 0.0806). However, patients who underwent curative resection had significantly better postoperative survival than those who underwent noncurative resection (P = 0.048). Hepatectomy provided a significantly better cancer-free margin than bile duct resection alone (P = 0.0296).Conclusions. Although a countermeasure must be taken to decrease mortality, the introduction of hepatectomy with bile duct resection would provide a better cancer-free surgical margin than bile duct resection alone for hilar bile duct carcinoma. Curative resection contributed to long-term survival in this series.     

肝门胆管良性狭窄的原因和处理

目的：探讨单纯肝门胆管良性狭窄的原因和治疗。方法：回顾性总结分析单纯肝门胆管良性狭窄73例的病因,治疗方法和效果。结果：病因依次为肝胆管结石（48例）,高位胆管损伤（19例）,胆囊结石Mirizzi征（4例）,单纯良性瘢痕性狭窄（2例）,分别施行了肝门胆管空肠吻合,肝门胆管整形,肝门胆管切除等手术87例次,随访1－19年61例次的远期效果,优良77％,好转6．6％,差16．4％,其中,以肝门胆管空肠吻合效果最好,优良达90．7％,结论：肝门胆管良性狭窄的主要原因是肝胆管结石和高位胆管损伤,治疗以肝门胆管空肠大口吻合效果最好。     

腹腔镜胆囊切除术中胆管损伤的术中镜下修复

目的总结腹腔镜胆囊切除术（1aparoscopic cholecystectomy,LC）中胆管损伤的原因及术中镜下修复经验,探讨术中腹腔镜下修复胆道损伤的可行性。方法我院2001年7月～2012年9月共完成7例Lc术中胆管损伤的镜下修复,其中1例肝总管完全横断伤、1例胆总管完全横断伤及1例左肝管不完全横断伤、1例右肝管不完全横断伤、1例肝总管不完全横断伤采用胆管对端吻合T管引流术;1例左、右肝管汇合下方肝总管前壁直径10Inln缺损,采用转移胆囊管壁瓣修复肝管缺损T管引流术;1例肝总管不完全横断伤采用对端吻合,未留置T管。结果所有手术均获成功,无中转开腹。1例胆总管对端吻合病例术后胆漏,腹腔引流管引流20d愈合。余无并发症出现。6例放置T管引流者术后1年拔除T管。7例术后随访0．5～10年,平均3．2年,无腹痛、黄疸、发热,肝功能正常,B超未见胆管扩张。结论LC胆管损伤的术中修复可以在腹腔镜下顺利完成．     

良性胆管狭窄行胆肠Roux-en-Y吻合术后再手术临床分析

目的 探讨良性胆管狭窄行胆肠Roux-en-Y吻合术后再手术的原因和再手术的方法.方法 回顾性分析良性胆管狭窄行胆肠Roux-en-Y吻合术后28例再次手术患者的临床资料.文中数据统计分析计量资料采用t检验,多因素分析采用Stepwise logistic回归分析.结果 再次手术原因为残余结石合并胆管狭窄10例,单纯吻合口狭窄11例,胆管狭窄6例,吻合口漏和十二指肠漏1例.再手术方式为:肝叶或肝段切除+胆肠Roux-en-Y吻合术18例,肝正中裂劈开+胆肠Roux-en.Y吻合术5例,右半肝切除术1例,吻合口狭窄段切除+胆肠Roux-en-Y吻合术1例,腹腔引流+十二指肠造瘘+空肠造瘘术1例,胆管切开取石+T管引流术2例,术后发生并发症13例.结论 胆道再手术病情复杂,手术难度高,详细了解病情和正确的手术方式是良性胆管狭窄再手术成功的关键.     

腹腔镜在胆道损伤修复手术中的临床应用（附9例报告）

目的探讨应用腹腔镜技术修复肝外胆管不同部位、不同程度损伤的可行性。方法 2001年7月~2010年4月,采用如下三种腹腔镜下胆管修复方法治疗肝外胆管损伤9例：①1例左肝管不完全横断伤、1例右肝管不完全横断伤、2例肝总管横断伤、1例胆总管损伤修复后狭窄,采用对端结节外翻缝合左肝管、右肝管、肝总管或胆总管,T管引流术;②3例高位肝管损伤采用Roux-en-Y胆肠吻合,经左或右肝管或肠管放置T管支撑胆肠吻合口;③1例左、右肝管汇合下方肝管前壁10mm直径缺损,采用转移胆囊管壁瓣修复肝管缺损,T管引流术。结果 9例均获治愈,1例肝管对端吻合病例出现胆漏,腹腔引流管引流20 d后愈合。2例高位肝管损伤者行Roux-en-Y胆肠吻合术后出现应激性溃疡和术后腹腔渗血。全组术后随访1~9年,平均4年,无吻合口狭窄。结论腹腔镜在肝胆管修复中有利于视野观察,并且放大较细的肝管,利于精准的缝合操作,从而可以达到最佳的吻合效果。再加上T管对吻合口的支撑作用,最大限度地避免吻合口狭窄的发生,为肝胆管损伤提供了一种精准的吻合方法。     

Resection of the intrapancreatic bile duct preserving the pancreas

Benign neoplasms of the distal bile duct are rare, but pose a therapeutic challenge. Usually, these lesions are resected by means of ampullectomy if located in close proximity to the ampulla of Vateri or by partial pancreaticoduodenectomy if located intrapancreatic and distant from the ampulla. Here, we present a case of an intrapancreatic benign neuroendocrine tumor that was resected by performing a pancreas-preserving distal bile duct resection. First, a duodenotomy was carried out and a probe was inserted into the pancreatic duct to avoid inadvertent injury. Subsequently, the bile duct was divided proximal the lesion and dissected towards the ampulla. Pancreatic parenchyma was dissected dorsally and closed using absorbable interrupted sutures. The duodenal incision was closed, and reconstruction was performed by an end-to-side hepaticojejunostomy and a Roux-Y jejunojejunostomy. The postoperative course of the patient was uneventful. In conclusion, pancreas-preserving distal bile duct resection might be an option for intrapancreatic benign lesions of the distal bile duct that would otherwise require a partial pancreaticoduodenectomy.     

Unusual causes of benign biliary strictures with cholangiographic features of cholangiocarcinoma

Focal strictures occurring at the hepatic duct confluence, or within the common hepatic duct or common bile duct in patients without a history of prior surgery in that region or stone disease, are usually thought to represent cholangiocarcinoma until proved otherwise. However, not uncommonly, patients undergo surgical exploration for a preoperative diagnosis of cholangiocarcinoma, based on the cholangiographic appearance of the lesion, only to find histologically that the stricture was benign in nature. Despite sophisticated radiographic, endoscopic, and histologic studies, it is often impossible before laparotomy to distinguish malignant from benign strictures when they have the characteristic radiographic appearance of cholangiocarcinoma. Even at the risk of overtreating some benign cases, most agree that aggressive surgical resection is the treatment of choice, given the serious consequences resulting from a failure to diagnose and adequately treat cholangiocarcinoma. Four patients who presented to our institution between February 1991 and June 2000 underwent laparotomy for a preoperative diagnosis of biliary tract malignancy based on clinical presentation and cholangiographic findings. The final pathology report in all patients showed marked fibrosis and inflammation of the biliary duct without evidence of malignancy. A review of the patient data and the relevant literature identified benign causes of focal extrahepatic biliary strictures associated with concomitant disease processes in two of the four patients. We present these cases and discuss the benign etiologies with emphasis on the role of surgery in both diagnosis and treatment.     

胆囊切除术中胆（肝）总管横断伤的处理（附5例报告）

目的探讨胆囊切除术中胆（肝）总管横断伤的处理对策。方法回顾性分析我院1993年1月-2008年3月3362例胆囊切除术中5例胆（肝）总管横断伤的临床特征、处理方法及效果。结果2例为肝总管横断,3例为胆总管横断伤。1例行胆肠内引流,4例行胆总管对端吻合术。术后均无胆漏并发症。1例用丝线对端吻合术后支撑管脱出,出现胆管狭窄、胆管炎2个月后改行胆肠内引流,随访15年,无腹痛、发热、黄疸发生;1例行胆肠内引流者拔除胆肠支架引流管后2个月内3次发生胆管炎,保守治疗,随访5年无腹痛、发热、黄疸发生;3例对端吻合者分别随访1、2、4年,无并发症发生。结论根据损伤胆管的类型及术者的经验,选择对端吻合或胆肠内引流处理胆（肝）总管横断伤可获得理想结果。     

Benign hilar biliary strictures stented with metallic stents can be resected by using an oncologic approach

BACKGROUND: Biliary metallic stents (MS) are being used increasingly to treat patients with malignant bile duct strictures. In patients with benign strictures, MS are contraindicated because these stents are considered unremovable. The aim of this study was to report the operative treatment of patients with benign biliary strictures at the hepatic confluence stented with MS. METHODS: Five patients with a benign hilar stenosis stented with MS underwent liver resection with biliodigestive anastomoses. The operations were designed to remove all MS by a combined biliary and hepatic resection. RESULTS: After preoperative portal vein embolization in 2 patients and percutaneous biliary drainage in 2 others, all underwent a major hepatectomy with resection of the biliary confluence and a biliodigestive anastomosis. One patient also underwent resection of the portal vein bifurcation that could not be freed from the bile duct wall. Four patients experienced postoperative complications. With a mean follow-up of 37 months (range, 31-47 months), all patients have remained symptom-free. CONCLUSIONS: Operative treatment of benign hilar strictures in patients with MS is possible if they are managed similarly as patients with hilar malignancies. This demanding procedure should be considered an alternative to liver transplantation for benign strictures treated with MS, but the procedure requires expertise in advanced hepatic resections.     

亚甲蓝示踪腹腔镜胆囊管分型的临床价值

目的:评价术中亚甲蓝示踪技术用于腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)预防胆管损伤的价值。方法:LC术中解剖分离胆囊三角、胆囊管前,将0.9%氯化钠注射液稀释的50%医用亚甲蓝注射液注入胆囊内,使胆囊、胆囊管、肝总管、胆总管染色,术野中胆囊管、肝总管、胆总管三者的解剖关系清晰可见,可预防LC手术过程中损伤胆管。结果:100例慢性结石性胆囊炎患者在LC时应用了亚甲蓝示踪技术,其中82例胆囊、胆囊管、肝总管、胆总管染色清晰可见;15例胆囊、胆囊壶腹部、胆囊管染色,3例仅胆囊、胆囊壶腹部染色。无一例发生胆管损伤。结论:非急性、结石嵌顿性胆囊良性疾病用此法可避免由于胆囊管、肝总管、胆总管三者关系的错误辨别所致胆管损伤的发生。