胆囊切除术中经胆囊管造影1569例临床分析

目的探讨经胆囊管造影在单纯性胆囊切除术中的价值。方法回顾分析本院在1991年1月-2004年12月间1569例单纯性胆囊切除术中常规经胆囊管造影胆管结石的发生率。结果1023例无胆总管探查指征，经术中胆囊管造影51例，阳性49例，经探查证实有结石，546例有胆总管相对探查指征，经胆囊管造影158例阳性，151例探查证实。结论单纯性胆囊切除术中常规经胆囊管造影可发现隐匿性胆总管结石，能有效减少胆管残余结石，减少胆道损伤。     

阻塞性黄疸:PTC下胆管钳夹活检的技术方法学研究

目的探索切实可行的胆管病理学检查新途径.资料与方法连续92例阻塞性黄疸患者接受经皮肝穿刺胆管造影(PTC)和经皮肝穿胆管引流(PTCD)治疗.PTCD过程中,影像监测下经皮经肝胆管穿刺,向胆管内引入活检钳对梗阻段钳夹活检,行组织病理学检查.统计学分析用χ2检验或Fisher确切概率计算法,以α=0.05作为检验水准.结果 92例钳夹活检患者90例成功获得组织块,技术成功率97.83%(90/92).钳夹活检敏感性为88.04%,63例胆管癌性恶性肿瘤钳夹活检敏感性较25例非胆管癌性恶性肿瘤高(93.65%比72.00%,P＜0.05).结论PTC下胆管钳夹活检操作简单,创伤小,敏感性高,是一种值得推广的胆管病理学诊断新途径.     

Intravenous cholangiography,ERCP, and selective operative cholangiography in the performance of laparoscopic cholecystectomy

Between March 1990 and March 1993 some 822 consecutive patients underwent an attempt at laparoscopic cholecystectomy. Intravenous cholangiography (IVC), ERCP, and selective intraoperative cholangiography (IOC) were used in the evaluation of common bile duct (CBD) stones. Two hundred thirteen patients (26%) were identified preoperatively with either abnormal liver functions or a dilated common bile duct suggestive of CBD stones. IVC was performed in 143 patients (67%). Choledocholithiasis was identified in 14 patients (10%). Preoperative therapeutic ERCP was successful in all 14 patients (100%). Diagnostic ERCP was attempted in 61 patients and successful in 59 (97%). Choledocholithiasis was identified in 25 patients (41%). Successful extraction was accomplished in 23 patients (92%). Transcystic common bile duct exploration was used effectively in the patients with an unsuccessful ERCP. IOC was attempted in 50 patients and successful in 48 (96%). Choledocholithiasis was identified in three (6%). A retained CBD stone was present in eight patients (1%). There was one level I CBD injury (0.122%). The use of IVC, selective ERCP, and selective IOC is a reasonable approach in the performance of laparoscopic cholecystectomy.     

PERCUTANEOUS LAPAROSCOPIC CHOLECYSTECTOMY: INDICATIONS,CONTRAINDICATIONS AND COMPLICATIONS

The indications, contraindications and complications of percutaneous laparoscopic cholecystectomy (PLC) were established from a group of 308 patients referred for cholecystectomy. Of the 308 patients 86% underwent PLC, 5% were commenced laparoscopically, but converted to open cholecystectomy and 9% were performed as open cholecystectomy from the outset. Complications included two bile leaks from the gall-bladder bed, one cystic duct stump leak and three retained stones. Pre-operative rather than intra-operative duct imaging was used so that common duct stones could be removed before operation. PLC is a safe procedure that has now become the standard technique for cholecystectomy.     

Symptoms, diagnosis and endoscopic management of common bile duct stones

Symptomatic BDS commonly cause significant morbidity and attempt at stone removal should be attempted if possible. Complications of CBDS include biliary colic, jaundice, cholangitis and pancreatitis. Investigations aimed to predict the presence of stones within the bile duct include serum bilirubin, AST, ALP, common bile duct diameter and age as independent predictors of choledocholithiasis. TUS is a sensitive test in detecting bile duct dilatation but the sensitivity is reduced in its ability to detect choledocholithiasis. A NIH consensus statement found that ERC, MRC and EUS were comparable in their sensitivities, specificities and accuracy rates for detection of choledocholithiasis. ERC and stone removal using a balloon or basket is often performed following EST. EBD may be performed if patients have uncorrected coagulopathies but the risk of pancreatitis is higher than for EST (although the risk of bleeding complications is lower for EBD). ML is often required in difficult to remove CBDS and using this device, CBDS can be removed in 90–95% of cases. Other forms of lithotripsy including laser lithotripsy and EHL are confined to specialised centres and the evidence for their use is based on small studies. ESWL may clear stones from the bile duct in up to 93% of patients but frequently ERC and stone fragment removal is required post ESWL. The role of medical therapy in difficult to remove CBDS (or in CBDS in patients with severe co-morbid illness preventing ERC + stone removal) is still currently uncertain due to a lack of large randomised control trials.     

磁共振胰胆管成像技术的临床应用

目的　探讨磁共振胰胆管成像（Ｍａｇｎｅｔｉｃ　ｒｅｓｏｎａｎｃｅ　ｃｈｏｌａｎｇｉｏｐａｎｃｒｅａｔｏｇｒａｐｈｙ,ＭＲＣＰ）技术的优势及临床意义。方 法３４例疑有胆道梗阻的患者,在常规ＭＲＩ扫描后,再以ＭＲＣＰ术行快速自旋回波重Ｔ２ＷＩ序列扫描,图像采用最大 强度投影法（ＭＩＰ）重建。结果２９例阳性患者清晰地显示了梗阻的部位、形态及肝内胆管扩张情况。结论　采用ＭＲＣＰ 技术,可以在不注入造影剂的情况下,取得类似内窥镜逆行胰胆管造影（ＥＲＣＰ）和经皮肝穿胆道造影的造影效果。它对 胆道梗阻有很高的敏感性和特异性。最大优势是无创伤性、无并发症。对年高、体弱及胆肠吻合术后ＥＲＣＰ插管困难者 尤为适宜,有望取代部分创伤性胆道造影技术。     

术中经胆囊管胆道造影的应用价值

目的：探讨胆囊切除术时经胆囊管作胆道造对胆道结石病人的应用价值。方法回顾分析442例患有胆囊胆道结石的病人经胆囊管胆道造影的情况。结果442例病人中,假阳性3例,假阴性1例,诊断准确率达99．1％,结论对胆囊胆道结石病人,特别具有胆总管相对探查指征的病人,常规作术中经胆囊管胆道造影可降低胆道残余结石发生率,减少胆道损务,避免不必要的胆总管探查。     

磁共振胰胆管成像的临床应用与进展

本文综述了磁共振胰胆管成像 (MRCP)的原理、技术及临床应用 ,讨论其与直接胆道造影比较的优、缺点 ,认为MRCP在很多情况下已可取代传统的诊断性内窥镜逆行胰胆管造影术 (ERCP)或经皮肝胆管造影术(PTC)的作用 ,并推测未来MRCP还将应用于胰胆管病变的介入治疗。     

Extrahepatic bile duct angulation by T-tube: The elbow sign

The normal shape of the extrahepatic bile ducts approximates a straight line. The cholangiograms of 50 patients with indwelling T-tube catheters were retrospectively reviewed between 4 and 14 weeks postcholecystectomy. We observed a lateral distortion in the shape of the bile ducts in 35 patients (70%) such that an angle measured between the proximal and distal parts of the duct, centered at the site of T-tube insertion, decreased to between 60° and 158°. We have called this observation the elbow sign, which to our knowledge has not been previously described and appears to be of no clinical consequence.     

Role of radiology in the treatment of malignant hilar biliary strictures 2: 10 years of single‐institution experience with percutaneous treatment

We reviewed the results of percutaneous intervention of hilar biliary malignancy over a 10‐year period at a single institution: the Royal Melbourne Hospital. Ninety‐nine patients (100 treated in total) were included. Information was retrieved by retrospective examination of patient notes and radiology, combined with interviews with family and relevant physicians. Sixty‐nine patients were treated with insertion of semipermanent stents, 19 had external drain tubes, and 25 received percutaneous access for Iridium brachytherapy. Adequate drainage was achieved in 87% of the patients stented, and percutaneous access was successful in 96% of patients planned for brachytherapy. Of those patients undergoing endoprosthesis insertion, early complications occurred in 39% and late complications in 23%. Average survival for the entire patient population was 227.3 days, with a median of 167 days. Longer survival times (213 vs 142 days) and lower complication rates (44 vs 64%) are observed with metal stents in comparison with plastic stents. Percutaneous intervention is an important treatment option in hilar biliary malignancy, particularly in patients unfit for surgery. Reasonable survival with good palliation is the most common outcome, and most patients do not require further intervention.