经皮经肝胆道引流治疗转移性胃癌并发阻塞性黄疸的疗效与并发症

Objective  

The aim of our study was to evaluate the efficacy and incidence of complications of percutaneous transhepatic biliary drainage (PTBD) as palliative treatment of obstructive jaundice caused by metastatic gastric cancer.     

超声引导经皮经肝胆管置管引流术在胆道梗阻疾病中的应用

目的评价超声引导经皮经肝胆管置管引流术在无手术适应证胆道梗阻疾病中的应用价值及疗效判断。方法本组39例,男22例,女17例。平均年龄51.2岁。使用自制穿刺辅助装置,日本八光S型引流套管（8F）。选择内径≥10 mm、走行较平坦、无扭曲的胆管为穿刺点,胆管周围加以彩色血流成像并注意避开血管。成功置管的38例中33例行左胆管置管,5例右胆管置管。结果39例除1例因术中出血未成功外,38例均成功置管,随访未发现胆漏、出血、感染等并发症。引流胆汁后患者症状明显改善,血清胆红素逐渐下降,其中6例降至正常。本组胆汁日引流量380～1400 ml。38例中术后生存2～5个月8例、〉6个月15例、〉9个月11例、〉1年4例,最长生存期17个月。结论超声引导肝胆管置管引流,操作简便、痛苦小、成功率高,使患者得到了持续性胆汁引流的机会,对改善梗阻导致的黄疸,减轻由其产生的损害和症状,延长患者生存期及提高晚期生存质量将起到重要的积极作用。     

恶性高位梗阻性黄疸的介入治疗

背景与目的:侵犯或压迫肝门部胆管的恶性肿瘤造成的胆道高位梗阻,因梗阻部位多位于胆总管上段、肝总管,左右叶肝管甚至互不相通,单侧PTBD引流只能局限于引流管头端所放置的单一分支肝管,部分病例PTBD术后黄疸没有明显减退,甚至短期内加重,导致病情进一步恶化。本研究探讨左右叶双侧PTBD结合内支架术治疗恶性高位梗阻性黄疸的疗效。方法:17例高位恶性梗阻性黄疸的患者(男性11例,女性6例,平均年龄63.4岁),行左、右叶双侧PTBD结合内支架治疗。置入2枚支架的15例;2例为一侧肝管至胆总管置入支架,另一侧留置引流管。15例PTBD术后行TAI/TACE或放疗。结果:全部患者PTBD手术成功。治疗后总胆红素明显下降,由(357.7±142.5)μmol/L降至(174.7±87.6)μmol/L。引流通畅中位时间8.9个月,全组生存中位时间11.2个月。结论:左右叶双侧PTBD结合内支架治疗高位恶性梗阻性黄疸近期疗效肯定,早期引流与多支引流同样重要。     

恶性高位胆道梗阻经皮经肝胆道引流方式的疗效分析

目的:探讨恶性高位胆道梗阻患者经皮经肝胆道引流方式对术后近远期疗效影响,为临床选择适当的治疗方式提供依据.方法:回顾性分析我院108例恶性高位胆道梗阻患者,比较单侧引流(68例)和双侧引流(40例),左右肝管是否相通,引流材料对近期胆红素下降值和生存情况的影响.结果:三组术后3-5天胆红素的下降值明显,但无统计学差异(P＞0.05).随访1-36个月,单侧组和双侧组、单枚引流管与单枚支架生存率没有显著差异(P＞0.05).结论:恶性高位胆道梗阻以右侧入路单侧引流为主,生存期预计大于3个月,放置胆道支架,否则置入胆道引流管.     

恶性高位胆道梗阻经皮经肝胆道引流方式的疗效分析

目的：探讨恶性高位胆道梗阻患者经皮经肝胆道引流方式对术后近远期疗效影响,为临床选择适当的治疗方式提供依据。方法-回顾性分析我院108例恶性高位胆道梗阻患者,比较单侧引流（68例）和双侧引流（40例）,左右肝管是否相通,引流材料对近期胆红素下降值和生存情况的影响。结果：三组术后3—5天胆红素的下降值明显,但无统计学差异（P〉0．05）。随访1—36个月,单侧组和双侧组、单枚引流管与单枚支架生存率没有显著差异（P〉0．05）。结论：恶性高位胆道梗阻以右侧入路单侧引流为主,生存期预计大于3个月,放置胆道支架,否则置入胆道引流管。     

Internal-external percutaneous transhepatic biliary drainage for malignant biliary obstruction: a retrospective analysis

When percutaneous transhepatic biliary drainage (PTBD) is required for the management of malignant biliary obstruction, the local policy favours the use of internal–external drains. Regular planned drain exchanges are scheduled, and patients have open access back into the system to minimise complications. The aim of this study was to evaluate the success and complication rate of this method for the palliation of malignant biliary obstruction. The hospital records of 43 consecutive patients who underwent PTBD for malignant biliary obstruction at a single institution between 1 February 2004 and 31 January 2006 were reviewed. Outcomes were examined until January 2008. Biliary decompression was achieved in all 43 patients. The level of obstruction was defined as distal in 24 patients and perihilar in 19 patients. There was one procedure-related death. There were 91 routine outpatient drain exchanges performed at a median interval of 45 (range 21–64) days. Overall, 24/43 patients encountered 80 discrete complications related to biliary drainage. Fifty-two non-scheduled drain exchanges (accounting for 65% of all complications) were performed on an outpatient basis. Fourteen patients were readmitted on a median of one (range 1–3) occasion for a median duration of 3 (range 1–12) days. Median survival was 71 (range 7–850) days. PTBD can be performed with low mortality, but long-term morbidity remains high despite an aggressive approach to maintaining biliary patency. Providing patients with an open-access service means the majority of complications can be dealt with on an outpatient basis.     

经皮胆道内支架置入术姑息性治疗恶性梗阻性黄疸临床观察

目的研究经皮胆道内支架置入术姑息性治疗恶性梗阻性黄疸的临床价值。方法28例恶性梗阻性黄疸接受经皮经肝胆道内支架置入术,男18例,女10例。胆管癌13例,胰头癌4例,胆囊癌3例,肝门区转移癌8例。共置入胆道内28枚金属内支架。结果28例采用经皮经肝穿刺置入胆道内支架均获得成功。结论经皮胆道内支架置入术是姑息治疗手术不能切除的恶性梗阻性黄疸的有效方法,配合动脉内灌注化疗可提高恶性阻塞患者的生存率。     

经皮肝穿刺胆管引流和经皮肝穿刺胆管支架置入治疗老年人恶性胆管梗阻

目的:探讨经皮肝穿刺胆管引流(percutaneous transhepatic cholangial drainage,PTCD)和经皮肝穿刺胆管支架(percutaneous transhepatic cholangial sent,PTCS)置入对老年人恶性胆管梗阻的临床应用价值.方法:53例60岁以上老年人恶性胆管梗阻患者, 35例施行PTCS置入,11例施行PTCD,7例施行单纯外引流,术后1周进行肝胆管造影复查,手术前及手术后1周检测血清总胆红素(total bilirubin,TBIL)及丙氨酸氨基转移酶(alanine aminotransferase,ALT)等指标.结果:32例患者支架一次性置入成功,3例患者行肝胆管外引流5～7 d后成功置入支架.手术后1周TBIL及ALT较手术前明显下降(P<0.05).胆管内支架置入患者的平均生存期为11.5个月,行胆管内外引流患者的平均生存期为5.5个月.结论: PTCD和PTCS置入治疗老年人恶性胆管梗阻操作简便、有效.     

Management of malignant obstructive jaundice

This study compares the efficacy of percutaneous transhepatic drainage (PTD) versus operative biliary decompression for patients with malignant obstructive jaundice. The utilization of preoperative PTD as a surgical adjuvant is also examined. The records of 90 patients with obstructed jaundice from two large community hospitals were reviewed. In the group of patients undergoing curative resections, no advantage was noted for the patients who received preoperative PTD. The patients receiving only surgery left the hospital 8 days sooner. For the patients undergoing palliative treatment, the group receiving only the surgery had the lowest morbidity and mortality and the longest survival rates. The patients receiving only PTD had the shortest hospital stay, but also had many complications, the highest mortality rate, and the shortest survival rate. The group receiving preoperative PTD followed by surgical decompression had more complications and stayed in the hospital longer, with no change in postoperative mortality.     

超声检查在胆道下段阻塞性黄疸恶性病变中的应用价值

目的：探讨二维、彩色多普勒及超声造影技术在胆道下段阻塞性黄疸恶性病变中的声像图特征。方法：应用二维、彩色多普勒及超声造影技术对经病理证实的88例胆道下段阻塞性黄疸恶性病变即胰腺癌、胆管癌、壶腹癌患者观察其胆总管梗阻的程度、胰管增宽情况及肿瘤位置、大小形态、包膜边界、内部结构、血流状况等图像特征。胰腺癌中6例胰头癌患者进行超声造影。结果：88例恶性肿瘤患者中胰腺癌39例,胆管癌18例,壶腹癌31例。声像图特征：胆道下段阻塞性黄疸恶性病变均有肝内外胆管扩张、胆囊正常或增大、胰管扩张。胰腺癌包括胰头癌35例、胰体癌2例及胰尾癌2例,可有大小不等肿瘤,周围血流包绕。超声造影胰腺癌肿瘤本身与周围胰腺组织相比,表现出略低于正常胰腺的增强强度模式,时相呈典型低增强,造影剂充填分布不均,廓清时间早于正常胰腺组织,肿瘤病灶的大小和边界以及与胰腺周围动静脉的关系显示更清晰。胆管癌18例中,截断型2例,肿块型5例,漏斗型11例。壶腹癌31例。误诊8例：胰腺癌4例漏诊,胆管癌2例误诊,壶腹癌2例漏诊,诊断符合率为90．9％（80／88）。全部经病理证实。结论：引起胆道下段阻塞性黄疸之恶性肿瘤二维及彩色多普勒声像图根据其特征可作出诊断,对不典型图像还可采用超声造影技术进行确诊,有利于临床治疗方案的制定和术后疗效的评估。     

金属胆道支架植入联合介入化疗治疗恶性梗阻性黄疸的疗效

目的评价金属胆道支架植入联合介入化疗治疗恶性梗阻性黄疸的疗效。方法对20例接受金属胆道支架植入联合介入化疗治疗的恶性梗阻性黄疸患者,回顾性分析血清总胆红素和谷丙转氨酶的变化,以及联合介入化疗后的生存时间和生存率。结果术后两周,血清总胆红素和谷丙转氨酶较术前明显下降,术后四周,9例患者的血清总胆红素和谷丙转氨酶恢复正常。本组病例的中位生存时间为6个月,半年及一年生存率分别为60%及35%。结论对于无法外科手术治疗的恶性梗阻性黄疸患者,金属胆道支架植入联合介入化疗能明显提高其生活质量及生存率。     

恶性梗阻性黄疸患者的双介入治疗

目的 :探讨恶性梗阻性黄疸患者介入治疗的近期疗效。方法 :采用金属支架植入并与动脉灌注或栓塞化疗相结合的双介入治疗方法。结果 :12例均成功植入胆道支架 ,行动脉灌注化疗 49次 ,栓塞化疗 13次。肿瘤缩小 1/ 2者 2例 ,1/ 3者 3例。胆红素下降接近正常者 6例。平均存活 9 3个月。结论 :金属内支架植入并结合肝动脉超选药物灌注或栓塞治疗梗阻性黄疸减黄可靠 ,能明显提高生活质量 ,延长患者的生存期。     

术前减黄对恶性低位胆道梗阻患者行胰十二指肠切除术前后肝功能变化的影响

背景与目的:胰十二指肠切除术后的合并症发生率仍然较高。术前胆道引流可以改善肝功能,但对于恶性低位胆道梗阻患者行胰十二指肠切除术术前肝功能的具体影响,以及肝功能指标在手术前后的变化情况,目前仍未见报道。本研究分析术前胆道引流对恶性低位胆道梗阻行胰十二指肠切除术患者术前肝功能的影响,以及肝功能指标在手术前后的变化及分析其预后。方法:收集98例行胰十二指肠切除术恶性低位胆道梗阻患者[总胆红素(totalbilirubin,TB)>85μmol/L]的临床资料,分析肝功能指标和胆红素之间的相关性、手术前后肝功能的变化、以及分析预后;按照术前是否胆道引流分为减黄组、未减黄组,分析术前胆道引流对肝功能指标的影响,按照术后是否发生并发症分为有、无并发症组,分析并发症对术后肝功能变化的影响。结果:γ-谷氨酰转移酶(γ-glutamyltransferase,GGT)与TB呈正相关关系(r=0.368,P<0.001),而碱性磷酸酶(alkaline phosphatase,ALP)与TB无相关性。减黄组术前胆道引流后,TB、直接胆红素(direct bilirubin,DB)、丙氨酸转氨酶(alanine aminotransferase,ALT)、ALP、GGT分别由术前的(266±119)μmol/L,(160±75)μmol/L,(161±88)U/L,(508±276)U/L,(537±417)U/L减至术后的(184±115)μmol/L,(112±67)μmol/L,(99±90)U/L,(319±145)U/L,(203±176)U/L,差异有统计学意义(P<0.05),但减黄前后天冬氨酸转氨酶(aspartate aminotransferase,AST)的变化不显著。全组患者ALT、AST、GGT、ALP术后第7天达最低值,第14天轻度上升;术后7d时,TB、DB在有并发症组为(152±68)μmol/L,(80±57)μmol/L,较无并发症组的(101±77)μmol/L,(58±45)μmol/L升高,两组差异有统计学意义(P<0.05),白蛋白(albumin,ALB)在有、无并发症组分别为(36.2±4.7)g/L,(38.6±5.2)g/L,两组差异有统计学意义(P<0.05)。减黄组中位生存期19.2个月,未减黄组中位生存期16.4个月,两组相比差异无统计学意义(P=0.458)。结论:GGT更能反映恶性低位胆道梗阻的程度。术前胆道引流可以有效的改善肝功能,并发症的出现影响恶性低位胆道梗阻行胰十二指肠切除术患者术后短期内的黄疸以及肝功能的改善。术前减黄对远期预后无影响。     

Percutaneous management of malignant biliary disease

Percutaneous biliary interventions have established their role in the management of benign and malignant biliary disease. There are limited data comparing procedures performed by gastroenterologists and interventional radiologists in managing malignant biliary obstruction. Endoscopic procedures performed by gastroenterologists are not completely benign with reported complications ranging from 2% to 15%. It is important that gastroenterologists and interventional radiologists collaborate to form algorithms for management of malignant biliary obstruction which provide safe and efficacious care to these patients.     

表阿霉素在恶性梗阻性黄疸治疗中的应用

目的 探讨表阿霉素治疗恶性梗阻性黄疸（MOJ）的安全性和可行性。方法39例MOJ患者接受胆道支架置放术或经皮穿肝胆道引流术（PTBD）后,血清胆红素未降至正常水平即接受动脉化疗栓塞术（TACE）。TACE方案：法玛新30mg／m^2和超液化碘油混合成乳剂。参照WHO抗癌药物毒性分级标准观察毒性反应,Child-Putgh分级观察肝脏损害。随访患者黄疸复发时间和生存期。结果39例MOJ患者TACE术前血清总胆红素浓度为52．1-91．4μmol／L,中位值72．7μmol／L。表阿霉素总量40-60mg,中位值55．0mg,超液化碘油2～25ml。白细胞计数下降：Ⅰ度41．0％,Ⅱ度35．9％,Ⅲ-Ⅳ度15．4％;恶心呕吐：Ⅲ～Ⅳ度100％。肝脏Child-Pugh分级：8例由A级升至B级,1例由A级升至C级,3例由B级升至C级。全部患者未出现心脏毒性。39例患者的生存期为2～72个月,中位值6．0个月。19例黄疸复发,复发率48．7％,黄疸复发时间2～20个月,中位值9．0个月。结论MOJ患者行有效引流后,即使胆红素未降至正常水平,用30mg／m^2表阿霉素和超液化碘油乳剂进行单纯化疗栓塞治疗原发病灶是安全和有效的。     

恶性梗阻性黄疸患者短期肠外营养支持的临床观察

目的:探讨低氮低热量短期肠外营养支持对恶性梗阻性黄疸患者减黄术后机体代谢功能和免疫功能的影响.方法:回顾性将90例恶性梗阻性黄疸患者,分为单纯肠外营养(A组30例)、肠外营养+复合性药物(B组30例)和对照组(C组30例).采用不同方法解除胆道梗阻后,A组和B组给予低氮低热量肠外营养代谢支持,C组采用普通支持治疗.结果:全部患者均能耐受肠外营养支持,转氨酶、胆红素和胆汁酸指标下降,营养指标好转,血脂代谢改善,体液免疫和细胞免疫指标提高,P<0.05,B组较为明显.结论:胆道梗阻解除后,短期低氮低热量肠外营养是一种安全的临床营养支持过渡方法,对代谢功能和免疫功能具有明显的正相相关性,适当的复合性药物具有良好的代谢调理作用和免疫增强作用.     

Tuberculous biliary strictures: Uncommon cause of obstructive jaundice

Tuberculous biliary stricture is a very rare cause of obstructive jaundice. A case of a man who had had pulmonary tuberculosis 20 years ago is reported. He now presented with obstructive jaundice due to multiple strictures just below the confluence of the hepatic ducts and in the right hepatic duct. At surgery these turned out to be tuberculous in origin. There was also tuberculous involvement of the gall bladder and cystic duct. The commonest differential diagnosis in such cases is cholangiocarcinoma (as in the present case). Imaging helps in defining the extent of bile duct obstruction. Suspicion of the disease and establishing a tissue diagnosis is very important in treating this potentially curable condition, especially with the worldwide resurgence of tuberculosis.     

老年恶性梗阻性黄疸的围手术期处理

目的　探讨老年恶性梗阻性黄疸围手术期处理对术后并发症的影响。方法　对 1992～ 2 0 0 1年 78例老年恶性梗阻性黄疸患者进行回顾分析 ,并对术后并发症发生原因和采取治疗方法进行总结。结果　①梗阻性黄疸患者的高胆红素血症 ,内毒素血症及肝功能受损有密切关系 ;②术前行减黄手术与并发症发生率无关 (p>0 0 5 ) ;③外引流术作为姑息手术并不理想 ,内引流术可作为减黄的有效方法 ;④完全性胆道引流手术和部分胆道引流手术对并发症的发生率有明显影响 (p<0 0 5 )。结论　加强围手术期处理可提高老年恶性梗阻性黄疸患者的手术耐受性 ,降低术后并发症     

Percutaneous transhepatic cholangial drainage: direct approach under fluoroscopic control.

We devised a direct percutaneous transhepatic cholangial drainage under fluoroscopic control. The principle is as follows. After percutaneous transhepatic cholangiography, the three dimensional structure of intrahepatic bile ducts is projected to a two dimensional plane under fluoroscopy; the needle can then be introduced into the selected bile duct with accuracy. The technique can be used as a preoperative management of operations of patients with jaundice and also as a palliative management of advanced cancer without much complication.     

三级肝管与空肠吻合治疗肝门部胆管梗阻与非外科胆管引流疗效的对比研究

目的　观察与评价肝内三级肝管空肠吻合术治疗恶性肝门部胆管梗阻的减黄效果 ,合并症及对生存期的影响。方法　切除部分肝左外侧叶 ,解剖出左外下段支肝管或切除右前叶下段部分肝组织 ,解剖出右前下段支肝管与空肠行Roux y吻合 ,在有效减黄率 ,合并症 ,黄疸再发率及生存期等方面与三组非外科胆管引流方法PTBD、ERBD、EMBE进行对照比较。结果　手术组与经皮经肝胆管引流术 (PTBD)、经内镜逆行性胆管引流术 (ERBD)、经皮经肝自膨式金属支架术 (EMBE)。有效减黄率 :分别是 95 %、89.8%、73 %、93 % ;早期合并症发生例数 :1例 /10例 ,8例 /3 5例 ,12例 /2 1例 ,1例 /10例 ;黄疸再发率 :0 % ,5 0 % ,40 % ,0 % ;平均生存期 (天 ) :2 46 ,117.3 ,198.40 ,2 0 3 .6 ,均P <0 .0 5。结论　肝内三级肝管空肠吻合术对于不能切除的恶性肝门部胆管梗阻是确实可行的治疗方法 ,其减黄效果优于PTBD、ERBD和EMBE。