Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: A systematic review and meta-analysis

PurposeThe purpose of this study was to make a systematic review and meta-analysis to determine the stent diameter (8 mm vs. 10 mm) that conveys better safety and clinical efficacy for transjugular intrahepatic portosystemic shunt (TIPS).Materials and methodsFour databases were used to identify clinical trials published from inception until March 2020. Data were extracted to estimate and compare one-year and three-year overall survivals, hepatic encephalopathy, variceal rebleeding, and shunt dysfunction rates between patients with 8 mm covered stents and those with 10 mm covered stents.ResultsFive eligible studies were selected, which included 489 patients (316 men, 173 women). The 8 mm covered stent group had higher efficacy regarding one-year or three-year overall survival (odds ratio [OR], 2.88; P = 0.003) and (OR, 1.81; P = 0.04) and lower hepatic encephalopathy (OR, 0.69; P = 0.04) compared with 10 mm covered stent group. There were no significant differences in variceal rebleeding rate (OR 0.80; P = 0.67). However, shunt dysfunction was lower in 10 mm covered stent group (OR, 2.26; P = 0.003).ConclusionsOur results suggest that the use of 8 mm covered stents should be preferred to that of 10 mm covered stents for TIPS placement when portal pressure is frequently monitored.     

肝移植术后肝窦阻塞综合征的单中心诊疗经验

目的  总结肝移植术后肝窦阻塞综合征（HSOS）的发病情况和诊疗经验。方法  回顾性分析4例肝移植术后HSOS患者的临床资料。收集肝移植术后HSOS的发病情况、临床表现、影像学及病理学特点,分析HSOS患者的治疗方式及转归情况。结果  肝移植术后HSOS的发生率为0.8%（2/239）,中位发病时间为肝移植术后4.5（1.7,9.0）个月。HSOS的临床表现主要包括腹胀、腹腔积液、肝肿大、胆红素升高,部分伴有肾功能不全。4例HSOS患者的腹部增强CT均呈“花斑样”不均匀强化;肝组织病理学表现主要为肝窦扩张伴淤血。4例患者均给予调整免疫抑制剂,将他克莫司（Tac）转换为环孢素,并加用华法林抗凝治疗,其中1例患者接受经颈静脉肝内门体静脉分流术（TIPS）治疗。3例患者经治疗后症状完全缓解,1例患者治疗无效死亡,1例患者在治疗好转后因肺部感染和消化道出血死亡。结论  HSOS是肝移植术后少见但致命的并发症,及时的诊断和治疗可以避免移植物衰竭,改善患者预后。     

肝内胆管脓肿的CT特征探讨

目的 肝内胆管脓肿（intrahepatic bile duct abscess,IBDA）的CT表现特点及病理基础。方法 回顾性研究1989年10月至1999年2月经手术及临床抗炎治疗后复查证实的IBDA连续性病例31例的C T资料,病因包括多种原因所致的急性梗阻性化脓性胆管炎和胆道逆行感染。所有病例分别从肝脓肿征象、胆源性征象及反映两者间相关性的征象进行观察。结果 31例中均可见肝脓肿CT表现特征（31／31,100％）。胆源性CT表现包括各种梗阻病因的特征性 CT表现和其他胆道异常表现,包括胆管扩张（29／31,93.5％）、扩张的胆管与脓肿相通（5／31,16.1％）或相紧邻（8／31,25.8％）及胆道积气（10／31,32.2％）等。前两者间相关的CT表现,包括肝脓肿上与梗阻点及其近侧扩张胆管相一致（15／31,48.4％）,肝脓肿发生于无（7／31,22.6％）或有（４／３１,１２.９％）肝内胆管积气的肝叶、肝段等。结论 ＩＢＤＡ的ＣＴ表现包括肝脓肿征象、胆源性征象,并能反映两者间相关的具有一定特征的ＣＴ征象。     

腺病毒介导的p16和p53的联合应用对胆管癌细胞QBC939的生长抑制作用

为研究p16和p53基因的联合应用对胆管癌细胞的作用,将重组体腺病毒p16、p53、p16联合p53转移到人胆管癌细胞QBC939,对p16、p53基因的表达,细胞的生长抑制及机制进行了分析。RT－PCR显示在胆管癌QBC939细胞系中p16呈低表达,p53不表达,重组体腺病毒能介导p16和p53等外源基因在胆管癌QBC939细胞系中高效表达,两者联合应用能明显抑制QBC939细胞的生长和集落形成。流式细胞计数证实其能诱导,QBC939细胞发生明显半调并导致其发生G1期阻滞,本研究显示p16及p53基因通过诱导肿瘤细胞凋亡及G1期阻滞在肿瘤的基因治疗方面发挥作用,两者联合应用具有协同作用。     

伴神经浸润的肝门部胆管癌的病理和临床分析

目的总结伴神经浸润的肝门部胆管癌的临床病理类型、手术方式,探讨伴神经浸润的肝门部胆管癌治疗方法及远期存活率。方法对1993年1月至2004年12月收治的311例肝门部胆管癌(神经浸润组89例、无神经浸润组222例)的临床病理及随访资料进行回顾性分析。结果神经浸润是肝门部胆管癌的一种重要转移方式。伴神经浸润组的89例肝门部胆管癌的1、3、5年存活率分别为65.59%、22.71%、14.83%,无神经浸润组的222例肝门部胆管癌的1、3、5年存活率分别为80.62%、35.14%、24.98%,无神经浸润组存活率明显高于神经浸润组(P=0.037)。结论肿瘤的分化程度、手术方式是影响预后的重要因素。根治性切除是目前较理想的治疗方式。伴神经浸润的肝门部胆管癌患者的预后较差,远期疗效仍无显著改善,根治性切除术可望改善其预后。     

Portal hypertension and ascites

Portal pressure is the product of portal blood flow and resistance; an increase in either leads to increased portal pressure. Cirrhosis is the underlying cause in most cases, but portal hypertension can develop due to pre-, intra- and post-hepatic obstruction to the flow, secondary to variety of causes. Diagnosis can be established by a combination of non-invasive imaging or portal vasculature and clinical or serological markers for the cause underlying cirrhosis. Development of gastro-oesophageal varices and ascites is the most important clinical manifestation of portal hypertension. Non-selective beta-blockers and endoscopic band ligation are effective in primary and secondary prevention of variceal bleeding. Active variceal haemorrhage is managed using a combination of vasoactive drug (for example terlipressin) and endoscopic band ligation. If these measures fail, transjugular intrahepatic portosystemic shunt (TIPS) insertion achieves haemostasis. Diuretic therapy with spironolactone and furosemide are the mainstays of management of ascites. If ascites becomes refractory, repeat large-volume paracentesis and TIPS in selected cases help to control symptoms. Development of ascites is an important landmark in the natural history of cirrhosis and liver transplantation should be considered definitive treatment.     

Intrahepatic cholangiojejunostomy for unresectable malignant biliary tumors with obstructive jaundice

We reviewed our experience with intrahepatic cholangiojejunostomy as a palliative therapy for patients with unresectable malignant diseases involving the ductal confluence or the common hepatic duct. Fifteen patients with malignant biliary obstruction were treated by cholangiojejunostomy at our hospital. Two patients had intrahepatic cholangiocarcinoma, 7 had gallbladder carcinoma, 5 had bile duct carcionoma, and 1 had pancreatic carcinoma. Segment III cholangiojejunostomies were performed in 14 patients and segment V cholangiojejunostomy in 1. Contraindications for surgical resection were locoregional invasion of tumors involving the proper and/or common hepatic artery and portal vein in 15 patients and the presence of hepatic metastases in 6 patients. Liver metastases were detected in 5 of the 7 patients with gallbladder carcinoma. Postoperative complications occurred in 2 patients (13%), but there was no leakage of the cholangioenteric anastomosis in our series. There was no operative mortality after cholangiojejunostomy. Of the 9 patients who survived for more than 6 months after surgery, 7 showed a significant improvement in performance status (PS) (82 ± 10%) 3 months after the surgery compared with the preoperative PS (70 ± 7%). Four of the 9 patients had recurrent cholangitis as a late complication, but 4 were completely free from jaundice. Median survival after cholangioenteric bypass was 9 months (range, 2–25 months). With respect to tumor location, the median survival time was 4 months (range, 2–25 months) in patients with gallbladder carcinoma and 15.5 months (range, 12–22 months) in those with bile duct carcinoma. While the median survival period after surgery was only 3 months (range, 2 to 8 months) in the 5 patients with hepatic metastases from gallbladder carcinoma, 2 patients without liver metastasis survived for 9 and 25 months after segment III cholangioenteric bypass. In conclusion, cholangiojejunostomy can provide useful palliation for malignant biliary obstruction when combined with careful patient selection. Received: September 5, 2000 / Accepted: November 8, 2000     

CK7和CK20在肝内胆管癌及肝内胆管结石旁胆管组织中的表达

目的：探讨细胞角蛋白7（CK7）、细胞角蛋白20（CK20）在肝内胆管癌及肝内胆管结石旁胆管组织中的表达及临床意义。方法：免疫组织化学方法检测30例肝内胆管癌、例肝内胆管结石旁胆管组30织及15例正常肝内胆管组织中的CK7、CK20表达。结果：CK7在肝内胆管癌、正常肝内胆管组织中的阳性表达率分别为96.7%（29/30）、13.3%（2/15）,差异有统计学意义（P〈0.01）;CK20在肝内胆管癌组织、正常肝内胆管组织中阳性表达率分别为43.3%（13/30）、（1/15）,差异有统计学意义（P〈0.01）。CK76.7%在肝内胆管结石旁胆管组织阳性表达率为76.6%（23/30）,与正常肝内胆管组织阳性表达率13.3%（2/15）比较,差异有统计学意义（P〈0.05）。CK20在肝内胆管结石旁胆管组织阳性表达率为6.7%（2/30）,与正常肝内胆管组织阳性表达率6.7%（1/15）比较,差异无统计学意义（P〉0.05）。结论：CK7和CK20可能成为肝内胆管癌特异性肿瘤标志物。     

Da Vinci机器人辅助下肝门部胆管癌手术治疗术式选择与改进

目的总结daVinci机器人手术系统在肝门部胆管癌切除手术中的早期应用经验。方法复习第二炮兵总医院2009年1~6月57例机器人辅助的肝胆胰手术病例临床资料,介绍其中6例肝门部胆管癌切除术的临床效果。结果6例中,男5例,女1例;年龄(60±8)岁。Bismuth分型I型1例,Ⅲb型2例,Ⅳ型3例(1例术前行PTCD1个月)。BismuthI型病人实施机器人辅助下根治性胆管癌切除、胆肠吻合术;Ⅲb型病人1例实施左半肝切除术,1例实施肝门部胆管癌切除、胆管外引流术;BismuthⅣ型病人均实施机器人辅助下胆管癌切除、间置胆囊胆道重建术。术后1例进食后发生不全性肠梗阻,禁食1d后缓解;未发生胆漏、腹膜炎等其他并发症。中位随访时间3个月,未见明确肿瘤复发征象。结论daVinci机器人手术系统实施肝门部胆管癌切除术完全可行,具有手术视觉更扩大清晰,深度操作更确切容易,解剖性探查精细灵巧,手术方案可进可退,创伤小恢复快等优点。机器人辅助下肝门部胆管癌手术对病人的远期生存的影响,仍须进一步观察。     

MRCP在肝内胆管黏液性肿瘤诊断与可切除性评估中的应用

由于肝内胆管黏液性肿瘤（MPIBT）的胆管内存在大量胶冻样黏液,影像学检查如超声、腹部CT、经皮肝胆管穿刺等难以在术前明确诊断,MRCP检查较少用于MPIBT评估肿瘤可切除J生。回顾J生分析2004年1月至2012年12月福建省立医院收治的10例行手术治疗并经病理检查证实的MPIBT患者的临床资料,探讨MRCP检查在术前明确MPIBT诊断及评估肿瘤可切除性中的作用。肝内胆管不对称性扩张和远离肿瘤的肝内外胆管扩张而无肝外胆管的突然截断是MPIBT的MRCP检查最主要特征。MRCP检查示病灶侧扩张胆管与相对正常胆管的交界线为肿瘤与正常胆管黏膜的移行处,从而术前判断MPIBT能否被切除以及采取适当的手术方式。根据术前手术规划,5例患者接受根治性的手术切除,5例行姑息性胆道引流。MRCP检查作为一种非侵袭性技术,是术前明确MPIBT的诊断与评估肿瘤可切除性的有效手段。