肝门部胆管癌的诊治：附96例报告

目的:探讨肝门部胆管癌的治疗方法和效果。方法:回顾性分析12年余收治的96例肝门部胆管癌的临床资料，其中手术65例（R0 28例，R1 2例，R2 4例，胆道引流术31例），介入引流31例（PTCD 5例，胆道支架置放术26例），切除术后联合治疗33例（放射治疗18例，经肝动脉灌注化疗15例）。结果:术后生存的95例中获得随访88例，随访率为92.6%，平均随访时间26（2~99）个月。(1)根治性切除组、姑息性切除组、手术引流组、介入引流组的平均生存时间分别为25，15.5，11.5，11个月，根治性切除组优于姑息性切除组（t=8.70,P＜0.01），姑息性切除组优于手术引流组（t=4.31,P＜0.01），介入引流组与手术引流组相似（t=1.31，P＞0.05）。(2)R0 切除联合放化疗组平均生存期为27个月，1，3，5年生存率分别为75%，45%，15%；R0未联合放化疗组平均生存期为24个月，1，3，5年生存率为50%，12.5%，0,两组疗效有显著性差异（t=2.37，P＜0.05； χ=3.88，P=0.049）。(3)胆红素≥400 μmol/L的患者其并发症发生率明显高于胆红素＜400 μmol/L者（P＜0.05）。结论:根治性切除是治疗肝门部胆管癌最有效的方法。手术引流和介入引流治疗效果相似，但介入治疗创伤小，恢复快。当总胆红素≥400 μmol/L时，手术前应作减黄处理。手术切除联合放疗、介入化疗，可以提高疗效。     

姑息性手术与支架植入术治疗不可切除晚期胃癌疗效Meta分析

目的评价姑息性胃空肠吻合与支架植入术在不可切除晚期胃癌胃出口梗阻病人中的安全性、有效性和疗效。方法检索2017年8月前Pubmed、Elsevier、SPRINGER、Cochrane Library、中国期刊全文数据库、万方数据库、中国生物医学文献数据库数据库中对比姑息性胃空肠吻合和支架植入在晚期不可切除胃癌中应用的文献。按纳入标准筛选后进行质量评分,提取临床效应指标,采用Stata 12.0软件对所纳入的数据进行Meta分析。结果共有13篇文献纳入分析。与支架植入组相比,胃空肠吻合组临床成功率高(OR=2.271,95%CI=1.539~3.352,P0.001)、术后再梗阻发生率低(OR=0.351,95%CI=0.248~0.496,P0.001)、术后胃出口通畅时间(WMD=243.386,95%CI=152.309~388.925,P0.001)。而支架植入操作时间(WMD=112.548,95%CI=90.272~140.320,P0.001)、术后进食时间(WMD=6.121,95%CI=4.616~8.118)和术后住院时间(WMD=14.208,95%CI=9.578~21.077,P0.001)方面有优势。两组在操作相关死亡率及术后并发症发生率方面差异无统计学意义。结论胃空肠吻合和内镜下支架植入对于晚期不可切除胃癌引起的胃出口梗阻都是安全有效的,对于预期生存时间较长病人建议行姑息性胃空肠吻合术。     

老年人肝门部胆管癌的外科治疗(附91例临床回顾分析)

目的报道老年肝门胆管癌病人的手术治疗结果。方法对1996年1月至2010年12月15年间收治老年肝门胆管癌病人91例(年龄65~83岁)的资料并进行分析。按照Bismuth分型:I型17例,Ⅱ型24例,Ⅲa型19例,Ⅲb型22例,Ⅳ型9例。其中外科手术治疗75例;胆道引流16例。根据治疗情况及手术类型分为三组:第1组:根治性切除术(R0切除组)44例;第2组:姑息切除(R1切除组)31例;第3组:胆道引流组(开腹经胆总管胆道内支架置入7例,行经皮肝穿刺引流9例)16例。围手术期死亡3例。死亡原因:肝衰竭2例,肺部感染1例。结果术后1年、2年、3年、5年生存率:R0切除组分别为68.18%、40.90%、31.81%、15.91%,中位生存期为(20±3)个月;R1切除组分别为64.52%、35.48%、22.58%、6.45%,中位生存期为(18±2)个月;胆道引流组分别为56.25%、6.25%、0%、0%,中位生存期为(13±1)个月。R0组与R1组术后生存率相仿(x~2=7.39,P=0.0582);R0组术后生存率优于胆道引流组(x~2=34.45,P=0.0016);R1组术后生存率也优于胆道引流组(x~2=26.18,P=0.0037)。结论认真、仔细、严格的术前准备,合理手术方式,积极处理合并症,老年肝门胆管癌病人可获得良好的手术疗效;手术治疗是老年肝门胆管癌病人的首选方法。本组R0切除组与R1切除组治疗效果明显优于胆道引流组。即便是R1切除,也能获得与R0切除相似的疗效。     

2280例肝门胆管癌的荟萃分析

目的 探讨我国肝门部胆管癌(hilar cholangiocarcinoma,HCC)的流行病学、临床特点、诊断方法、Bismuth-Corlette分型、病理类型、治疗方式、并发症及预后,以期指导临床.方法 以肝门胆管癌为检索词,在中国知网、重庆维普、中国学术期刊网全文数据库CNKI进行检索.将所得22篇文献,共2280例HCC的临床资料进行统计学分析.临床资料分析及数据提取分别由两人完成.结果 与姑息性切除组比较,根治性切除组术后1年生存率(84.0％与46.8％,OR=5.71,95％CI 3.99～8.17,P＜0.01)和术后3年生存率(31.5％与13.5％,OR=4.43,95％CI 2.07～9.47,P＜0.01)均较高.与姑息性切除组相比,内外引流组术后1年生存率(27.2％与38.7％,OR=0.47,95％CI0.31～0.72,P＜0.01)较高.经卡方检验,我们同时发现2002年后HCC手术切除率比2002年前有上升(X2 =35.9588,P＜0.01),但根治性切除率却没有明显变化(X2=2.1052,P=0.1468).结论 根治性切除组术后1、3年生存率高于姑息性切除组.内外引流组术后1年生存率高于姑息性切除组.根治性切除术仍是治疗HCC最理想的方法.如果无法达到根治性切除,姑息性引流术是较好的选择.姑息性切除术并不能提高生存率,因而不被提倡.     

联合血管切除在手术治疗肝门部胆管癌中作用的Meta分析

目的:系统评价联合血管切除(VR)在肝门部胆管癌(HCCA)手术治疗中的作用。方法:系统检索国内外多个文献数据库,收集手术联合VR对比未联合VR治疗HCCA的文献,评估联合VR的安全性及疗效,并根据联合切除血管的类型分亚组分析。结果:共纳入27篇文献,总计3 218例HCCA患者,其中联合VR治疗888例(联合VR组),未联合VR治疗2 330例(对照组)。Meta分析的总体结果显示,与对照组比较,联合VR组安全性方面降低(病死率:OR=2.83,95%CI=1.80~4.44;术后并发症:OR=2.48,95%CI=1.44~4.28)且疗效不佳(1、3、5年生存率:OR=0.60,95%CI=0.49~0.73、OR=0.57,95%CI=0.47~0.69、OR=0.61,95%CI=0.41~0.91)(均P0.05)。在门静脉切除亚组中,虽然术后并发症发生率较对照组高(P0.05),但在其他有效性及安全性指标方面与对照组之间无统计学差异(均P0.05);在肝动脉切除亚组中,所有的合并效应与总体的分析结果一致(均P0.05)。结论:对于仅有门静脉被侵犯的HCCA患者,手术联合VR是可行的,然而,一旦有肝动脉受累,则联合VR治疗需慎重施行。     

肝门部胆管癌的手术治疗

目的 总结肝门部胆管癌的手术治疗经验.方法 回顾性分析2007年1月至2011年12月哈尔滨医科大学附属第一医院同一医疗组手术治疗的88例肝门部胆管癌患者的临床资料.所有患者术前经影像学检查确诊,并根据黄疸程度及剩余肝脏体积进行术前辅助治疗,行PTCD 19例、门静脉栓塞4例.基本手术方式为肝门部胆管癌切除+肝十二指肠韧带骨骼化+胆管空肠Roux-en-Y吻合术,并常规放置支撑管引流6个月.计数资料采用x2检验,以Kaplan-Meier法计算生存率,生存分析采用Log-rank检验.结果 88例手术治疗的患者中,58例(含11例PTCD治疗者)行肝门部胆管癌切除术,其中43例(含4例术前门静脉栓塞者)为R0切除,15例为姑息性切除;30例行内和(或)外引流术.联合肝切除22例(包括左半肝切除9例、扩大左半肝切除2例、左半肝联合尾状叶切除7例、右半肝切除4例),联合胰头十二指肠切除7例,联合肝固有动脉切除3例(重建2例),联合门静脉管壁部分切除2例.按改良Bismuth-Corlette分型,88例患者中Ⅰ型17例、Ⅱ型19例、Ⅲa型21例、Ⅲb型20例、Ⅳ型11例.58例肝门部胆管癌切除术患者中,19例出现各种术后并发症,2例术后30 d内死亡.本组共73例患者获得随访,总体1、3、5年生存率分别为68.5％、28.8％、11.0％.37例R0切除患者、14例姑息性切除患者及22例引流患者1年生存率分别为94.6％、78.6％、18.2％;3年生存率分别为43.2％、35.7％、0;5年生存率分别为18.9％、7.1％、0.R0切除患者生存率高于姑息性切除患者(x2=4.77,P＜0.05);姑息性切除患者生存率高于内和(或)外引流患者(x2=13.26,P＜0.05).结论 手术治疗肝门部胆管癌,应力求R0切除,尽量避免单纯性胆汁引流;术前充分而高效的肝功能恢复与储备能确保手术的疗效.     

光动力治疗在胆管癌中应用研究进展

胆管癌的早期诊断十分困难,大部分病人在初次确诊时已失去手术机会。而未经干预的胆管癌病人,中位生存时间不超过3个月。对于无法接受根治性手术切除的胆管癌病人,合理的胆道引流策略是影响病人生存质量及预后的重要因素。经历过手术建立胆肠旁路引流、胆道支架内引流、经皮肝穿刺胆道外引流等干预措施后,国外已将目光聚集于光动力治疗在胆管癌姑息性治疗中的应用。由于光动力治疗具有治疗创伤性小、术后并发症轻、光敏药物毒副反应少、治疗可重复性强、病灶选择性高等优点,国外已将光动力治疗作为不可切除胆管癌的常用姑息性治疗手段。     

肝门部胆管癌手术疗效的临床研究

目的 探讨肝门部胆管癌不同手术方式的临床疗效.方法 对89例肝门部胆管癌病人的临床资料进行回顾性研究.按治疗方式分为3组:根治性切除组(n=23),姑息性切除组(n=44),外引流手术组(n=22).对3组病人术后并发症、生存率、生存质量进行比较.结果 根治组术后并发症高于引流组(P<0.05),其与姑息组比较无显著性差异(P>0.05),两组围手术期死亡率比较无显著性差异(P>0.05),1、2、3年生存率比较根治组显著高于其它两组(P<0.01),生存质量比较根治组显著性高于姑息组及引流组(P<0.01),姑息组生存质量又显著性高于引流组(P<0.01).结论 肝门部胆管癌根治性切除能提高远期生存率,同时能明显提高病人的生存质量,对不能根治切除的病人,应争取行姑息性切除,亦可延长生存时间,改善生存质量.     

精准肝切除治疗原发性肝癌近期疗效的Meta分析

目的:系统性评价精准肝切除治疗原发性肝癌的近期疗效。方法:检索国内外数据库,收集有关比较精准肝切除与常规肝切除治疗原发性肝癌疗效的随机对照试验(RCT)与临床对照试验(CCT)。按纳入标准筛选后进行质量评分,提取数据,采用Rev Man 5.3软件行Meta分析。结果:共纳入了6个RCT及9个CCT,其中患者1 367例,精准肝切除术685例(精准组),传统肝切除术682例(对照组)。Meta分析结果显示,与对照组比较,精准组术中出血量、围手术期输血量、住院时间减少,但手术时间延长(MD=-175.45,95%CI=-234.37~-116.53;MD=-311.04,95%CI=-444.53~-177.55;MD=-3.11,95%CI=-4.36~-1.87;MD=31.72,95%CI=12.00~51.44,均P0.05);肿瘤完整切除率提高(OR=0.18,95%CI=0.07~0.45,P=0.0003);肝功能恢复加快(ALT:M D=-81.75,95%C I=-109.50~-54.00;AST:M D=-67.27,95%C I=-94.36~-40.18;TBIL:M D=-4.54,95%CI=-7.33~-1.75;ALB:MD=3.75,95%CI=0.54~6.97,均P0.05);并发症发生率减少(OR=0.24,95%CI=0.17~0.35,P0.05);1年复发率降低、1年生存率提高(OR=0.56,95%CI=0.37~0.85;OR=1.61,95%CI=1.01~2.57,均P0.05)。结论:精准肝切除治疗原发性肝癌较常规肝切除创伤小、恢复快,且近期预后好。     

完整网膜囊切除在胃癌根治术中应用效果的Meta分析

目的:评价胃癌根治术中行完整网膜囊切除的效果。方法:检索2014年10月以前公开发表的比较行完整与不完整网膜囊切除在胃癌根治术中应用情况的文献。按纳入标准筛选后进行质量评分,提取临床效应指标,采用Rev Man 5.0软件对所纳入的数据进行Meta分析。结果:最终纳入7项研究,共1 224例患者,其中完整网膜囊切除组486例,非完整网膜囊切除组738例。Meta分析结果显示,与非完全网膜囊切除组比较,完整网膜囊创伤相关并发症发生率较高(OR=2.1,95%CI=1.05~4.21,P=0.04);术后总并发症情况、肠梗阻、吻合口相关并发症、肺部感染等并发症情况差异无统计学意义(均P>0.05);两组术后3、5年总生存率(OR=1.35,95%CI=0.82~2.21;OR=1.03,95%CI=0.82~1.63)及术后复发率(OR=0.90,95%CI=0.66~1.22)均无统计学差异(均P>0.05)。结论:D1、D2胃癌根治术中进行完整网膜囊切除可能增加创伤相关并发症的风险,在提高患者生存率和降低肿瘤复发率方面无明显优势。     

胆管癌的姑息治疗进展

胆管癌治愈的唯一选择依然是治愈性手术切除，但是大约80％的胆管癌由于转移或进展期只能行姑息治疗。姑息治疗的目的是提供胆汁引流，改善瘙痒、胆管炎、疼痛和黄疸。经内窥镜放置自行扩张的金属支架、经皮肝穿刺胆汁引流、胆肠吻合术均可提供胆汁引流。这些措施已取得令人鼓舞的效果，但是有一定的发病率和病死率的局限性。其他的治疗模式比如放射治疗、化疗治疗和光动力学治疗等正在进一步研究中。     

Resection and drainage of hilar cholangiocarcinoma: an 11-year experience of a single center in mainland China

The purpose of this study is to provide appropriate approaches for resection and drainage of hilar cholangiocarcinomas. Surgical approaches and postoperative survival rates of the patients were analyzed retrospectively. The 1-, 3-, and 5-year cumulative survival rates for patients who underwent resection were 76.6, 36.2, and 10.6 per cent, which was higher than those of 60, 14.3, and 0 per cent, respectively, in palliative operation. Moreover, the 1-, 3-, and 5-year cumulative survival rates for patients who underwent R0 were 88.9, 44.4, and 13.9 per cent, which was improved compared with those of 36.4, 9.1, and 0 per cent, respectively, in nonR0 resection. In addition, the overall survival time of patients who underwent R0 resection combined with hemihepatectomy and caudate lobe resection was longer than of those who underwent R0 without this extra operation, especially within 3 years after operation. After endoscopic metal biliary endoprothesis for patients who were intolerant of resection, liver function was improved at 2 weeks postoperation and the 1-, 3-, and 5-year cumulative survival rates for these patients were 72.7, 18.2, and 0 per cent, respectively. Treatment should be personalized. Resection is the most efficacious therapy, and negative histologic margins should be achieved in radical operation and "skeletonized" surgical operation is the basic requirement of radical treatment of hilar cholangiocarcinoma. Portal vein resection is beneficial to long-term survival and R0 resection combined with caudate lobe resection and hemihepatectomy is more efficacious for patients with Bismuth-Corlette type III hilar cholangiocarcinoma. The preferred approach of drainage in palliative operation is endoscopic metal biliary endoprothesis, which is more appropriate than tumor resection for the patients who suffer from serious comorbidities.     

胆管癌姑息性减黄治疗方式的选择

目的 比较开腹胆道旁路手术与两种胆道支架置入术针对胆管癌的姑息性减黄治疗的效果及适应证.方法 收集2008年3月-2013年3月广州医科大学第三附属医院接受姑息性减黄治疗的69例胆管癌患者临床资料,其中行开腹旁路手术者17例;接受介入治疗者共52例（接受经皮肝穿刺胆道支架置入术者25例,经内镜胆道支架置入术治疗者27例）.比较经不同引流方式后胆管癌患者近期减黄率、平均住院时间、病死率、相关并发症发病率等.结果 不同引流方式均有较好的减黄效果,减黄率差异无统计学意义（P＞0.05）;在住院时间和术后生存期上,介入治疗较开腹旁路手术者有明显优势（P＜0.05）.在不同介入方式之间,内镜组胰腺炎的发病率明显高出经皮组（P＜0.05）;胆道感染及出血的发病率则差异无统计学意义（P＞0.05）;各型肝外胆管癌患者接受不同介入支架置入术的成功率之间差异无统计学意义（P＞0.05）.结论在胆管癌的姑息性减黄治疗手段当中,介入支架置入内引流术在住院时间和术后生存期上要优于开腹胆道旁路手术.在不同介入方式当中,首选经内镜胆道支架置入术.     

170例Ⅲ型肝门胆管癌的治疗及预后分析

目的探讨Ⅲ型肝门胆管癌的治疗及其预后的影响因素。方法回顾性分析2002年1月至2011年12月期间笔者所在医院收治的170例Ⅲ型肝门胆管癌患者的临床资料。结果170例患者中,行手术切除60例,行姑息性支架或u管支撑引流49例,行经皮经肝胆管外引流14例,未治疗47例。60例手术切除患者中,R0切除50例,R1切除10例。手术切除患者预后影响因素的Cox比例风险模型结果显示,手术切缘（HR=4．621,95％ CI：1．907-11．199,P=0．001）、肝叶切除（HR=3．003,95％ CI：1．373-6．569,P=0．006）及淋巴结转移（HR=2．792,95％ CI：1．393-5．598,P=0．004）与预后均相关。所有患者预后影响因素的Cox比例风险模型结果显示,治疗方法【R0切除（HR=0．177,95％ CI：0．081-0．035,P〈0．001）,未治疗（舰=5．568,95％ CI：2．733-11．342,P〈0．001）]及血管侵犯（HR=I．667,95％ CI：1．152-2．412,P=-0．007）与预后均相关。结论治疗方式与血管是否受侵犯与Ⅲ型肝门胆管癌的预后相关;可行手术切除患者中联合肝叶切除、R0切除及无淋巴结转移者的预后相对较好。     

恶性梗阻性黄疸术前减黄利弊的系统评价

目的系统评价恶性梗阻性黄疸患者术前行胆道引流（preoperative biliary drainage,PBD）的利弊。方法计算机检索CochraneLibrary、PubMed、EMBASE、中国生物医学文献数据库等数据库,并辅以手工检索,截止到2010年6月。对纳入的随机对照试验用RevMan5.0软件进行Meta分析。结果纳入7个随机对照试验,Meta分析结果显示：与对照组比较,PBD组术后死亡率（P=0.88）和总并发症发生率（P=0.66）的差异无统计学意义;采用经皮肝穿胆道引流（PTBD）（OR=0.49,95%CI=0.31～0.79,P=0.003）、引流前血清总胆红素〉200μmol/L（OR=0.56,95%CI=0.37～0.84,P=0.006）、引流时间小于4周（OR=0.60,95%CI=0.39～0.93,P=0.020）的患者术后并发症发生率降低。结论选择合适的病例,采取合适的引流方式,控制合适的引流时间,术前减黄可降低恶性梗阻性黄疸患者术后并发症发生率,但不能降低术后死亡率和总并发症发生率。     

Multivariate analysis of the factors affecting the prognosis of walled-off pancreatic necrosis after endoscopic ultrasound-guided drainage

Endoscopic ultrasound (EUS)-guided drainage has become the treatment of choice for walled-off pancreatic necrosis (WOPN). However, no consensus exists on the most significant patient- and procedure-related factors that affect prognosis. The aim of the study is to investigate the correlation between patient- and procedure-related factors and post-procedure complications after EUS-guided drainage. A retrospective analysis of the clinical characteristics of patients with WOPN who underwent EUS-guided drainage at our endoscopy center between November 2011 and August 2017 was performed. Chi-square analysis and binary logistic regression statistical methods were used to analyze the correlation between influencing factors and prognosis. A total of 85 patients (male/female, 50/35) with WOPN were included in the study. The average age was 44.95 years. The cyst diameter was 10.58 ± 4.78 cm. Multivariate analysis showed that WOPN with higher solid content (> 30%) increased the probability of endoscopic necrosectomy (OR 6.798; 95% CI 1.423, 32.470; p = 0.016). The use of a metal stent increased the probability of endoscopic necrosectomy (OR 3.503; 95% CI 1.251, 9.810; p = 0.017) and the length of hospitalization (OR 3.315; 95% CI 1.192, 9.215; p = 0.022). Female patients had a higher probability of requiring endoscopic necrosectomy (OR 2.683; 95% CI 1.027, 7.007; p = 0.044) and prolonged hospitalization (OR 2.675; 95% CI 1.065, 6.721; p = 0.036). The solid content of WOPN, type of stent, and sex of patients were associated with increased probability of endoscopic necrosectomy.     

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.     

Relationship between stent characteristics and treatment outcomes in endoscopic transmural drainage of uncomplicated pancreatic pseudocysts

Background

Transmural stents are placed at endoscopy to drain pancreatic fluid collections. This study evaluated the relationship between stent placement and treatment outcomes in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

Methods

This is a retrospective study of all patients who underwent endoscopic drainage of uncomplicated pancreatic pseudocysts over a 10-year period. After dilating the transmural tracts in the range of 8–15 mm, single or multiple, 7 or 10Fr double-pigtail plastic stents were deployed. The main outcome measure was to evaluate the relationship between stent characteristics and the number of endoscopic interventions required to achieve resolution of the pancreatic pseudocyst (treatment success).

Results

Of 122 patients, 45 (36.9 %) had 10Fr stents of which 30 patients (66.7 %) had more than one stent; the remaining 77 (63.1 %) patients had 7Fr stents of which 56 (72.7 %) had more than one stent. The overall treatment success was 94.3 %. Treatment was successful in 102 patients (83.6 %) with one intervention; 13 patients (10.7 %) required re-intervention for successful drainage and 7 patients (5.7 %) failed endoscopic treatment. There was no significant difference in the number of interventions required for treatment success between patients with 7 or 10Fr stents (one intervention required in 87.7 vs. 90.5 %, respectively; p = 0.766) and between patients with 1 or >1 stent (one intervention required in 88.9 vs. 88.6 %, respectively; p = 0.999). On multiple logistic regression analysis, the stent size (OR 1.54; 95 % CI 0.23–10.4) and number (OR 1.15; 95 % CI 0.25–5.25) were not associated with the number of interventions required for treatment success when adjusted for pseudocyst size, location, drainage modality, the presence or absence of pancreatic duct stent and luminal compression.

Conclusions

There appears to be no relationship between the number of interventions required for treatment success and stent characteristics in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.     

内镜支架减压对比肠造口减压对梗阻性结直肠癌择期手术近远期疗效影响的Meta分析

目的比较急诊造口减压和内镜支架减压后择期手术切除治疗梗阻性结直肠癌的近远期效果。 方法检索PubMed、Embase、Cochrane Library、中国知网、万方数据库已公开发表的有关造口减压对比内镜支架减压后序贯择期手术切除的梗阻性结直肠癌近远期效果的文献,提取的数据采用RevMan 5.3软件进行Meta分析。 结果共10篇回顾性病例对照研究纳入汇总分析,Newcastle-Ottawa Scale评分范围为6~8分,其中高质量文献6篇。总样本量为1 807例,包括造口组939例,支架组868例。汇总分析结果提示,支架组两次手术间隔时间短于造口组（WMD=13.37,95% CI：7.88~18.86,P<0.000 01）,但造口组择期手术一期吻合率高于支架组（OR=1.58,95% CI：1.10~2.26,P=0.01）,3年总生存率也高于支架组（HR=0.77,95% CI：0.61~0.97,P=0.02）。两组在择期手术入路方式、永久性造口率、总体并发症和围手术期死亡率方面比较,差异均无统计学意义。 结论肠造口减压和内镜支架减压对梗阻性结直肠癌患者后续择期行结直肠癌根治术的安全性相近,但是肠造口减压患者的总生存率更高,远期疗效方面更胜一筹。     

Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery

BACKGROUND: Although previously examined, the potential relationship between preoperative biliary drainage (PBD), intraoperative bile culture (IBC), and postoperative morbidity and mortality rate for pancreatic surgery remains unclear. METHODS: Two hundred twenty patients underwent operation for either benign pancreatic disease or malignant periampullary and pancreatic neoplasms, consisting of pylorus-preserving proximal pancreatoduodenectomy (n = 180), biliary bypass (n = 31), and total pancreatectomy (n = 9). An intraoperative bile specimen was prospectively collected immediately after division of the bile duct and sent for bacteriologic evaluation for both aerobic and anaerobic microorganisms. Morbidity and mortality rates were evaluated. RESULTS: Of 220 patients evaluated, 113 patients (51.4%) had a positive IBC. Factors associated with a positive IBC were age >70 years (odds ratio [OR], 5.9;95% confidence interval, [CI]: 1.6-22.1; P = .007), history of coronary artery disease (OR, 0.08; 95% CI, 0.01-0.5; P = .007), diagnosis of neoplasia (OR, 0.3; 95% CI, 0.1-0.9; P =. 03), and PBD (OR, 0.1; 95% CI, 0.06-0.2; P = .0001). Infectious complications (OR, 1.8; 95% CI, 1-3; P = .03), and wound infection (OR, 2.8; 95% CI,1.4-5.3; P = .002) were greater in patients with positive IBC. CONCLUSIONS: PBD predisposes to a positive IBC. Patients with a positive IBC have a clinically important increased risk of developing both infectious complications and wound infection after pancreatic surgery.