经皮经肝胆道内置引流术治疗恶性梗阻性黄疸60例回顾性分析

目的探讨经皮经肝胆道穿刺引流（PTCD）后植入胆道金属支架姑息性治疗恶性梗阻性黄疸的临床应用价值。方法对60例失去根治性手术机会的恶性梗阻性黄疸患者先行超声引导下经皮经肝胆道穿刺引流术（PTCD）,再在DSA下经PTCD窦道植入胆道金属支架,将外引流转变为内引流。结果 60例术前血清总胆红素（449.6±189.1）μmol/L,术后1 w与1个月时,血清总胆红素分别下降到（213.6±43.7）μmol/L与（174.2±51.5）μmol/L（P〈0.05）,碱性磷酸酶与丙氨酸转氨酶也下降明显（P〈0.05）。出现并发症27例（45.0%）。结论经皮经肝胆道内置引流术是一种治疗恶性梗阻性黄疸的有效方法,具有安全、简便、可重复等优点。     

使用微泡对比剂进行超声引导下经皮胆道造影术评价胆道扩张程度:初步经验

目的评估使用微泡对比剂进行超声引导下经皮胆道造影术(PUSC)评定胆道阻塞性疾病的可行性。方法共58例梗阻性黄疸病人超声引导下经皮经肝胆道引流术(PTCD)后分别进行了PUSC和经皮肝穿刺胆道造影术     

胆管癌性阻塞姑息性胆肠吻合术后再发梗阻的介入治疗

目的　探讨胆管癌性阻塞姑息性胆肠吻合术后再发梗阻的介入治疗方法。方法　 10例胆管癌性阻塞姑息性胆肠吻合术后再发梗阻患者 ,9例采用经皮肝穿刺胆道引流术 (PTCD)加金属内支架置入术 ,共使用 9枚金属内支架 ,1例置入内外引流管 ,并比较介入手术前后总胆红素、谷丙转氨酶、谷氨酰转肽酶、碱性磷酸酶的变化。结果　 10例采用经皮经肝穿刺置入金属胆道内支架或内外引流管均获得成功 ,均一次性置入支架。术后总胆红素、谷丙转氨酶、谷氨酰转肽酶、碱性磷酸酶均有明显下降 ,与术前比较差异有显著性。术后黄疸消退满意。结论　经皮经肝穿刺胆管内金属支架再置入术治疗胆管癌性阻塞姑息性胆肠吻合术后再发梗阻 ,疗效满意 ,操作简单 ,并发症少     

恶性梗阻性黄疸微创引流及并发症的处理

目的 探索经皮肝穿刺胆道微创引流术(PTBD)治疗恶性梗阻性黄疸有效方法及常见并发症的处理.方法 对126例恶性胆道梗阻患者分别行经皮肝穿刺胆道引流术,所有病人均依据CT、MR及B超等影像资料和血液生化检查及临床体征确诊为恶性梗阻性黄疸.结果 本组经皮肝穿刺胆道成功率为98.4%(124/126),其中46例行外引流,34例行内外引流,内支架置入35例(2例双支架),3例行联合右支内外引流及左支外引流,8例因穿刺失败或肝内胆管置管困难未能行引流术.置入引流管或内支架后血清总胆红素、游离胆红素、结合胆红素、白蛋白、天门冬氨酸转移酶、丙氨酸氨基转移酶、碱性磷酸酶及γ-谷氨酰基转移酶较术前明显下降(P<0.05),患者全身状况改善.本组并发症发生率为20.2%(25/124),包括胆道感染9例,胆道出血8例,胆心反射5例,术中胆漏2例,术后胆汁腹膜炎1例.多数经保守治疗后症状消失,1例胆汁腹膜炎患者经开腹手术留置T管治疗,其中3例胆道出血患者因肝功能衰竭死亡.结论 经皮肝穿刺胆道引流术疗效可靠,单纯外引流和内外引流术具有同样减黄效果,临床工作中应根据梗阻部位和梗阻程度选择引流方法.     

经皮肝穿刺胆道支架置入及引流术治疗梗阻性黄疸

目的 探讨梗阻性黄疸经皮肝穿刺胆道支架置入及引流术的治疗方法与疗效.方法 对44例胆道梗阻患者先行经皮肝穿刺胆道造影(PTC),如导丝不能越过阻塞段,则直接行外引流;如能越过阻塞段,则行支架置入或内外引流术.结果 44例患者中6例单纯外引流;7例单纯内外引流;2例仅行PTC胆道造影而未行胆道引流;29例置入支架32枚,其中19例行支架置入 外引流,10例单纯支架置入.在有完整随访资料的16例中,术后1周血清总胆红素从术前(351±142.4)μmol/L降至(143.5±97.6)μmol/L,13例血清总胆红素1个月降到正常或接近正常水平,3例血清总胆红素1个月无明显下降(＜50%).死亡9例,生存时间3～21个月,中位生存期6.8个月.结论 经皮肝穿刺胆道支架置入及引流术是治疗梗阻性黄疸的一种安全、有效的姑息性方法.     

经皮胆道引流术治疗恶性梗阻性黄疸

目的　回顾性分析恶性梗阻性黄疸的介入性经皮胆道引流治疗方法及其疗效。方法　对4 7例患者采用经皮肝穿刺胆道引流术治疗恶性梗阻性黄疸。先行PTC后探查通过阻塞段 ,如不能越过阻塞段 ,则直接进行外引流 ;如能越过阻塞段 ,则置入内外引流管作内外引流或置入金属支架或塑料内涵管作内引流。结果　内引流组 18例 ,15例置入金属支架 ,共 18枚 ,3例置入塑料内涵管 ,共 4根 ;内外引流组 15例 ,置入 18根内外引流管 ;外引流组 14例 ,置入 17根外引流管。术后 1周总胆红素从术前的 (5 14 .1± 2 0 4 .3) μmol/L降至 (2 38.4± 14 2 .8) μmol/L(P <0 .0 0 1) ,碱性磷酸酶与丙氨酸转氨酶均下降明显 (P均 <0 .0 0 1)。 4例于术后 1个月内死亡。跟踪随访 37例 ,平均随访 5 .3个月 ,8例仍存活。随访期内 18例 (48.6 % )总胆红素降至正常范围。结论　经皮肝穿刺胆道引流术是对恶性梗阻性黄疸的一种安全、有效的姑息性治疗方法 ,可明显缓解黄疸、减轻痛苦、提高生存质量 ,并可改善肝脏功能 ,有限地延长生存时间。     

经皮国产胆道金属内支架置入术治疗恶性梗阻性黄疸

目的:探讨国产胆道金属内支架的经皮经肝穿刺置入技术及其临床应用价值.方法:1996年7月～2006年10月经皮经肝穿刺胆道金属内支架置入术治疗恶性梗阻性黄疸患者167例.其中67例患者置人国产胆道金属内支架,男42例.女25例,年龄28～88岁.首先经皮经肝穿刺胆道造影,再选择性穿刺理想肝内胆管分支,送入导丝导管通过胆道梗阻段后导入硬交换导丝,沿该导丝送入球囊预扩张病变节段后置入胆道金属内支架,最后送入内-外引流管引流观察5天左右后撤出.结果:67例患者置入国产胆道金属内支架96枚,术中均未出现严重并发症,术后住院治疗5～10天.术后1个月复查血清总胆红素,均降至术前的1/2以下,44例降至正常范围.谷丙转氨酶、谷氨酸转肽酶均较术前显著下降.6个月生存48例,12个月生存14例,2例生存2年.结论:国产胆道金属内支架置入术治疗恶性梗阻性黄疸安全有效,价格低,治疗效果与进口胆道支架无明显差异.可明显缓解黄疸,减轻痛苦,提高生存质量,改善肝脏功能,延长生存时间.     

经皮肝穿胆汁引流术后胆道出血的临床分析

目的回顾经皮肝穿胆道引流术后胆道出血发生与处理措施。方法无法或不能耐受手术的梗阻性黄疸患者139例,经常规经皮肝穿胆管造影后,一步法或二步法穿刺扩张胆道,放置外引流管或内外引流管及金属内支架留置,临床观察治疗前后总胆红素指标改变及手术相关并发症,处理胆道出血。结果全部患者经皮经肝穿刺胆道引流手术成功,治疗后总胆红素明显下降,由360μmol/L降至158.2μmol/L,使用止血药物43例,11例轻微胆道出血,调整引流管及应用止血药后停止,5例严重胆道出血,4例肝动脉损伤,其中3例肝动脉栓塞治疗成功,1例失败。结论经皮经肝穿刺胆汁引流可并发胆道出血,能及时有效控制,术者应不断提高穿刺水平,减少胆道出血并发症发生。     

经皮经肝胆管引流术与ERCP对接胆道支架植入术治疗梗阻性黄疸

目的探讨经皮经肝胆管引流术（PTBD）与内镜下逆行胰胆管造影术（ERCP）对接胆道支架植入术治疗梗阻性黄疸的技术方法与临床应用价值。方法总结24例梗阻性黄疸患者ERCP治疗失败后，实施PTBD与ERCP对接胆道支架植入术的治疗方法与临床效果。结果24例PTBD与ERCP对接胆道支架植入术治疗梗阻性黄疸均获得成功。其中采取右侧肝管穿刺10例，左侧肝管穿刺14例；一次性对接成功16例，分次进行8例。术后4天血清总胆红素水平下降47．1％，血清直接胆红素水平下降45．4％。主要并发症为胆道感染。结论PTBD与ERCP对接胆道支架植入术是ERCP失败梗阻性黄疸治疗的另一途径，具有一定的临床应用价值。     

金属内支架在治疗恶性胆道梗阻中的应用

目的 :探讨经皮肝穿刺胆道金属内支架置入治疗恶性胆道梗阻临床应用价值。方法 :对 2 7例恶性梗阻性黄疸患者行经皮肝穿胆道金属内支架置入术。男 18例 ,女 9例 ,其中肝癌 6例 ,胆管癌 7例 ,胰腺癌 5例 ,转移癌 9例。梗阻部位在胆总管 12例 ,肝总管肝门区 15例。结果 :经皮肝胆道内支架置入术技术成功率为 10 0 %。 2 7例共置入金属内支架31枚 ,术后 1周复查肝功能血清学指标 ,总胆红素、碱性磷酸酶和谷丙转氨酶较术前明显下降 ,P <0 .0 0 1。随访开通时间平均为 14 1天 ,半年开通率 5 5 .6 % ,并发症发生率为 2 5 .9% ,主要为胆道感染 ,胆道出血等。结论 :金属内支架置入术是治疗胆道梗阻性黄疽的安全、有效的姑息治疗手段     

Silicone biliary stents for percutaneous management of biliary obstruction

Silicone tubes in 2-F increments from 12 to 20 F were developed for long term external-internal drainage of benign and malignant biliary obstructions. Passed coaxially over Teflon catheters and a guidewire, the silicone stents were softer and had larger sideholes than conventional drainage tubes. Once the acute track had matured (two weeks or longer), a silicone stent, 2 F larger than the preceding one, could be placed at each succeeding tube change. We have placed these tubes in 50 patients, 24 of whom had initially placed percutaneous catheters and 26 of whom had surgically placed stents. These tubes remain patent at least as long as conventional catheters and all patients have reported increased comfort using these catheters compared with standard ones.     

Malignant biliary obstruction: complications of percutaneous biliary drainage

The medical records of 161 patients who underwent percutaneous biliary drainage (PBD) for malignant biliary obstruction were reviewed with attention to the complications resulting from this mode of drainage. Observed was a higher incidence of complications--particularly of cholangitis--than that generally reported in the literature. Although PBD is an effective method of biliary drainage, it carries a high risk of cholangitis in patients with cancer, who frequently receive myelosuppressive agents that predispose them to infections.     

Percutaneous management of biliary leaks: biliary embosclerosis and ablation

Biliary leaks after hepatobiliary surgery are not uncommon. In certain situations minimal invasive percutaneous techniques may result in avoidance or reduction of the extent of surgery. Minimal invasive percutaneous techniques include (1) percutaneous bile collection (biloma) drainage, (2) percutaneous transhepatic biliary drainage, (3) biliary leak site embolization/sclerosis, and (4) leaking biliary segment ablation. There are two clinical applications for biliary ablation. The first is actual bile leak site ablation or embosclerosis to reduce an aperture or ablate a fistula (block a hole). The second is ablating an entire biliary segment to cease bile production and induce hepatic segmental atrophy (cease bile production). This article discusses the techniques used for biliary leak site embosclerosis/ablation (including biliary-cutaneous tract ablation) and biliary segmental ablation.     

经皮肝穿刺胆道引流术及胆管内支架植入术在恶性梗阻性黄疸治疗中的应用

目的 评价经皮肝穿刺胆道引流(FTBD)及胆管内支架植入术(PTIBS)治疗恶性梗阻性黄疸的疗效.方法 对56例恶性梗阻性黄疸患者采取PTBD或PTIBS,所有患者均经B超、CT或MRI明确诊断,并确定梗阻部位,其中高位梗阻19例,低位梗阻37例.梗阻原因包括肝癌14例,胆管癌11例,胆囊癌5例,胃癌伴淋巴结转移14例,壶腹部占位1例,胰头癌11例.术中根据造影结果选择合适方案.结果 所有56例均成功完成手术.其中行PTBD 11例,PTIBS 40例,PTBD并PTIBS 5例.TBIL由术前(295.65 ±152.86)μmol/L降至术后(151.05 ± 107.36)μmol/L(P<0.01).术后感染对黄疸消退有影响(P<0.01).梗阻部位与黄疸消退情况比较差异无统计学意义(P=0.063).结论 经皮肝穿刺胆道引流及支架植入术治疗恶性梗阻性黄疸安全有效,可明显减轻黄疸,改善患者生活质量,延长生存期.     

Acute cholecystitis, biliary obstruction, and biliary leakage

The use of cholescintigraphy to diagnose acute cholecystitis, biliary obstruction, and biliary leakage dates back to the late 1970s. Today, despite the many advances in imaging instrumentation, radiopharmaceuticals, and methodology over these years, cholescintigraphy still plays an important role in confirming or excluding these diagnoses in acutely ill patients. Acute calculous and acalculous cholecystitis, gallbladder perforation, biliary obstruction, and biliary leakage often present as acute abdominal pain, and must be differentiated from other surgical and nonsurgical etiologies with similar symptoms and presentation. Understanding the pathophysiology of acute hepatobiliary diseases is vital for deciding on the most advantageous imaging work-up and for interpretation of the studies. To optimize the value of cholescintigraphy, up-to-date methology, proper use of appropriate pharmacologic interventions, and recognition of characteristic image findings are critical.     

Strategy for the use of biliary scintigraphy in non-iatrogenic biliary trauma

Biliary scintigraphy was used to examine 21 patients who had suspected non-iatrogenic biliary trauma. Seven patients (33%) had scintigraphic evidence of biliary leakage. Ultimately, surgical biliary repair was required for only three of these patients. Visualization of the gallbladder did not occur in eight trauma patients, but only one patient was shown to have cholecystitis. In this series, 16 patients had Tc-99m sulfur colloid scans that offered no significant advantage over cholescintigraphy in the detection of hepatic parenchymal defects. Biliary scintigraphy provides clinically useful information in cases both of blunt and penetrating trauma.     

内镜下置入胆管支架治疗恶性胆道梗阻的临床应用

 目的 探讨内镜下胆管支架置入术治疗恶性胆道梗阻的疗效及应用价值.方法 全部病例经内镜逆行胰胆管造影术(ERCP)确定胆管狭窄部位及程度,选择合适的支架,在透视引导下置入支架.塑料支架组16例,金属支架组12例.观察其操作成功率、黄疸消退效果、并发症发生情况及6~12个月生存率.结果 首次置管成功率83.3%,总置管成功率93.3%,置管成功28例均达到降黄疸目的,临床症状缓解.早期并发症主要为ERCP术后胰腺炎及胆管炎,其中胰腺炎2例,发生率7.1%;胆管炎3例,发生率10.7%;晚期并发症主要为支架堵塞.6个月、12个月生存率分别达78.6 %及39.3 %.结论 内镜下胆管支架置入术治疗恶性胆道梗阻是安全有效的方法.