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。     

Biliary cooling during radiofrequency ablation of liver tumours close to central biliary tree: A systematic review and pooled analysis

IntroductionBiliary cooling during radiofrequency ablation (RFA) of liver tumour has been proposed as a protective measure for RFA-related biliary complications in cases whereby the RFA site is close to central biliary tree. This systematic review aims to assess the effect of biliary cooling during RFA on: 1) the development of biliary complications and 2) tumour recurrence rates at ablation site.MethodologyA systematic literature search was performed using the PubMed/EMBASE databases using PRISMA methodology (2000-2019). The initial search yielded 75 reports which were potentially suitable for inclusion. Studies reporting at least one outcome of interest were considered to be suitable for inclusion. Conference abstracts, case reports and animal studies were excluded. Data was retrieved from each study on patient demographics, tumour characteristics, method of cooling, biliary complications, local tumour recurrence and duration of follow-up.ResultsThe final number of studies which met the inclusion criteria was 7, involving 100 patients. There were no randomized controlled trials identified after the literature search. The mean age of the patients included was 65 years. Biliary cooling was performed with the use of a nasobiliary tube in 4 out of 7 studies, via a choledochal incision in 2 out of 7 studies and through the cystic duct in a single study. The overall biliary stricture rate was 2% and the overall tumour recurrence rate at RFA treated site was 14.5%.ConclusionBiliary complications appear to be low after biliary cooling during RFA close to central biliary tree. More evidence is required to assess the tumour recurrence rates.     

经皮肝穿胆道内涵管置入治疗梗阻性黄疸

目的：探讨经皮肝穿胆道内涵管置入治疗梗阻性黄疸的疗效及并发症。方法对５５例梗阻性黄疸患者行经皮肤穿胆道内涵管置入术,其中４５例随访３０至３３２天,观察近中期疗效和并发症。结果：经皮肝穿胆道内涵管置入术技术成功率为１００％,置入后血总胆红素水平较置入前明显下降（Ｐ〈０．０５）。开通时间平均为１０８天,半年开通率为５６％。并发症发生率１６％,主民括胰腺炎和逆行胆道感染等。结论：经皮肝穿胆道内涵管置入术     

Biliary reconstruction when the liver hilum is inaccessible: The anterior approach

Objective

This paper focuses on a novel approach to biliary reconstruction after previous extensive liver surgery.

Summary background data

Bile leak and subsequent biliary strictures are not uncommon after extensive liver surgery. Biliary reconstruction is then required, but the liver hilum is usually inaccessible for further surgical intervention.

Methods

A novel surgical technique is described in two patients with biliary stenosis after previous extensive liver surgery. Access to the biliary tree was obtained using an anterior approach. A previously inserted PTC drain was used as guidance to the bile duct suitable for creating a biliary-digestive anastomosis.

Results

The described technique proved to cause complete biliary drainage in both patients. There was no treatment-related morbidity nor was further biliary intervention needed during follow-up.     

胆道恶性梗阻的光动力治疗疗效观察

目的 探讨光动力治疗对胆道恶性梗阻的疗效和安全性。方法 回顾性分析我中心接受经皮光动力治疗的胆管恶性梗阻患者临床资料，根据是否联合介入、靶向或免疫治疗分为光动力组和联合组。观察治疗后肝功能变化、胆道通畅时间及术后1月内并发症。结果 共入组19位患者，光动力治疗成功率达100%。术后1月未观察到肝功能下降。最长随访时间17.7月，术后1、3、6和12月胆道通畅率分别为100%、89.5%、72%和64%，平均胆道通畅时间约6.9±0.8月（95%CI:5.2～8.7月）。BismuthⅢ型胆道通畅时间7.5±1.1月，BismuthⅣ型胆道通畅时间6.1±1.3月。单纯光动力治疗组胆道通畅时间约3.3±0.7月，联合治疗组患者胆道通畅时间约7.9±0.9月，两组差异具有统计学意义（P=0.017）。结论 光动力治疗BismuthⅢ-Ⅳ型胆道恶性梗阻安全有效，联合全身治疗可使胆道通畅时间显著延长。     

经皮经肝胆道引流与胆道金属支架置入治疗肝门部胆管癌的疗效分析

目的 对比分析经皮经肝胆道金属支架内引流和导管外引流治疗肝门部胆管癌的疗效和安全性.方法选择肝门部胆管癌患者46 例.按照不同引流方法分为金属支架内引流组27 例和导管外引流组19 例.术后7 天复查两组患者肝功能,记录患者术前术后并发症的发生情况.观察两组患者术后生存情况.结果 两组患者治疗后血清ALT?AST?GGT?ALP?TBiL和DBiL 水平均较术前显著下降,差异有统计学意义(P <0.05);相比于导管外引流组,金属支架内引流组患者ALT?AST?GGT?ALP?TBiL 和DBiL 各指标水平下降更显著,差异有统计学意义(P <0.05).金属支架内引流组患者中位生存时间为12.5 个月,略高于导管外引流组患者的(10.6 个月),但是差异无统计学意义(χ2 =2.531,P =0.112).导管外引流组并发症发生率为31.6%,显著高于金属支架内引流组的11.1%,差异有统计学意义(P<0.05).结论 经皮经肝胆道引流途径金属支架置入姑息性治疗肝门胆管癌的疗效确切,安全性高,优于于经皮经肝胆道导管外引流方法.     

28例不能手术的肝外胆道系统肿瘤放化疗疗效分析

目的 评价放疗晚期肝外胆道系统肿瘤的疗效。方法 对28例手术不可切除的肝外胆道系统肿瘤采用放化疗，其中胆囊癌13例，肝外胆管癌15例。15例采用常规放疗，中位照射剂量45Gy（30～60Gy），13例采用三维适形放疗（3DcRT）多野（3～5个野）照射或加量，中位照射剂量55Gy（50～70Gy）。12例单纯放疗，16例放化结合。化疗方案为氟尿嘧啶500mg，2次／周，或氟尿嘧啶500mg＋顺铂30mg，1次／周，疗程3～6个周期。结果 全部患者近期有效率14％。全组中位生存期9．4个月（2～28个月）。1、2年生存率分别为38％、15％；其中1年生存率胆囊癌为46％，肝外胆管癌为27％，3DCRT为42％，常规放疗为33％，单纯放疗为37％，放疗＋化疗为31％；〈50Gy的为29％，≥50Gy的为45％。只有照射剂量（≥50Gy）对1年生存率有影响（X^2=5．31，P=0．023）。急性消化道反应1～2级为57％，3级为18％，仅有25％的出现1～2级血液毒性反应。结论 对晚期肝外胆道系统肿瘤采用放化疗可取得一定疗效，且副作用可耐受。     

经胆囊床右肝管置管胆囊空肠吻合术治疗肝门部癌

自1983年～1995年，我院对18例肝门部占位梗阻性黄疸，采用经胆囊床右肝管置管胆囊空肠Roux—y吻合内外引流术，术前诊断依靠B超、CT、PTC检查。18例中原发性高性胆管癌8例,胆总管癌侵入肝门4例,转移癌5例，原因不明1例.术后效果满意，生存年限：2年2例，1年12例，6个月2例，4个月1例，另1例术后1年复查一切正常至今。认为本法作为一种胆汁内外引流相结合的手术方法，克服了单纯外引流的胆汁回输困难处境，又克服了单纯内引流的一些手术难度和并发症，具有两种引流的优越性。     

胆道肿瘤的免疫治疗

胆道肿瘤（BTC）侵袭性强,早期诊断率仅为10％。研究显示,吉西他滨联合顺铂方案现已成为晚期 BTC 的标准一线化疗方案,但疗效仍不满意。免疫细胞的浸润以及免疫相关的微环境可以抑制多种不同类型的肿瘤。研究发现,肿瘤浸润性 CD8＋细胞毒 T 细胞和 CD4＋T 细胞数量与 BTC 的预后密切相关,提示 BTC 的免疫治疗可能是一种新的手段。     

胆道支架置入术治疗胆道恶性梗阻

目的:评价胆道支架置入术治疗胆道恶性梗阻的价值.方法:135例胆道恶性梗阻患者,应用经皮肝穿胆道造影及支架置入技术,其中87例合并动脉内化疗或化疗栓塞术,48例单纯应用支架置入术.结果:单支置入128例,双支置入7例.支架置入术成功率为99.3%(成功植入142支/首次预计植入143支).黄疸完全缓解率86.7%(117/135),总有效率97.8%(132/135).6个月、12个月及24个月生存率分别为71.1%(96/135)、43.7%(59/135)及11.9%(16/135),联合抗肿瘤治疗与单纯支架治疗12个月生存率分别为:54.0%(47/87)及25.0%(12/48),统计学处理有显著性差异(X2=10.59,P＜0.001).支架再狭窄或阻塞21例,经皮穿刺外引流或支架内再置入支架治疗,黄疸再次消失.结论:胆道支架置入术减黄疗效肯定,与抗肿瘤治疗联合应用可提高患者生存率.     

肝内肝管空肠吻合治疗恶性肝门部胆管梗阻(附14例报告)

目的：观察与评价肝内肝管空肠吻合术治疗恶性肝门部胆管梗阻的减黄效果。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。结果：有效减黄率,95．0％,肝内胆管回缩率81．4％,早期合并发生例数,1／10例,黄疸再发率,0,平均生存期246天。结论：肝内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。     

血脂水平与胆道癌和胆石症关系的病例对照研究

目的：探讨血脂水平与胆道癌、胆石症的关系。方法：采用全人群病例对照研究方法，对上海市区462例胆道癌、982例胆石症和808例人群对照进行六项血脂指标的检测，采用多样本比较的秩和检验方法分析血脂水平与胆道癌和胆石症的关系。结果：男性胆石症层中，胆道癌患者TG的含量高于胆石症患者和人群对照；且各部位胆石症和胆道癌患者HDL的含量均低于人群对照。男性非胆石症层中，胆道癌患者TG和ApoB的含量显著高于人群对照，而TC、HDL、LDL和ApoA的水平则低于人群对照。在女性胆石症层中。胆道癌、胆石症患者和人群对照HDL、ApoA的平均含量由高到低分别为人群对照、胆石症和胆道癌患者。女性非胆石症层中，胆道癌患者HDL和ApoA的平均含量均显著低于人群对照。结论：男女性胆道癌和胆石症患者都存在脂质代谢异常，胆道癌患者TG水平高于对照和胆石症患者．而HDL水平则低于对照和胆石症患者。     

不同胆道引流方式对高位恶性胆道梗阻疗效的影响

 目的 探讨不同胆道引流方式对高位恶性胆道梗阻（malignant high biliary obstruction, MHBO）疗效的影响,为临床治疗方式的选择提供参考。方法 随访MHBO患者164例,其中行胆道完全外引流18例（A组）、胆道单支架植入并对侧外引流48例（B组）、胆道优势侧引流34例（C组）、胆道双支架植入64例（D组）,观察术后近、远期疗效。结果 4组患者术前ALT、AST、TBIL、DBIL与术后第3、7、14天比较,差异均有统计学意义（均P<0.05）;4组患者术后第7天的组间比较,A、B、D三组下降程度高于C组,差异均有统计学意义（均P<0.05）;4组患者术后第14天的组间比较,D组下降程度明显高于A、B、C三组,B组高于A、C两组,A组高于C组,差异均有统计学意义（均P<0.05）。4组患者术后第21天TBIL均值与术前比较,D组下降程度明显高于A、B、C三组,B组高于A、C两组,A组高于C组,差异均有统计学意义（均P<0.05）。4组患者术后生存期比较,D组中位生存期为（355.00±22.21）天,远高于A、B、C三组,差异均有统计学意义（均P<0.05）。结论 胆道双支架植入实现了胆汁的充分内引流,对迅速消除黄疸具有明显的优越性,明显的提高了患者的生存质量及延长了生存期。     

Interventional radiology in the management of malignant biliary obstruction

Malignant biliary obstruction is commonly due to pancreatic carcinoma, cholangiocarcinoma and metastatic disease which are often inoperable at presentation and carry a poor prognosis. Percutaneous biliary drainage and stenting provides a safe and effective method of palliation in such patients, thereby improving their quality of life. It may also be an adjunct to surgical management by improving hepatic and, indirectly, renal function before resection of the tumor.     

经皮肝穿刺内支架植入治疗恶性胆道梗阻52例报告

目的总结经皮肝穿刺胆道金属内支架植入治疗恶性胆道梗阻性黄疸的临床疗效及其经验。方法在DSA下对52例恶性胆道梗阻性黄疸患者,经皮肝穿刺胆道内置入金属内支架治疗。根据胆道梗阻狭窄的不同部位和狭窄的程度采用相应的放置方式。结果52例患者中,45例植入单支支架于肝总管和(或)胆总管,7例植入2支以上支架于总管和分支胆管,其中2例为肝内胆管支架再狭窄后的重新植入。52例患者术前血清胆红素(236.25±112.27)μmol/L,术后2周复查血清胆红素下降到(120.40±51.20)μmol/L(P<0.01),并发症5例(9.62%)。结论经皮肝穿刺胆道内支架植入术是治疗恶性胆道梗阻性黄疸的有效的治疗方法。     

Biliary papillomatosis in three Caucasian patients in a Western centre

Introduction

Biliary papillomatosis (BP) is a rare condition with a strong potential for malignant transformation and cases from Western centres are sparse.¹ We discuss the presentation, investigation and management of this condition in three Caucasian patients and present a review of the existing literature on BP.

Patients and methods

The case notes of three Caucasian patients with BP who presented to our tertiary referral centre were reviewed. Their case histories, investigations and managements are presented.A search of MEDLINE, PubMed and Cochrane databases was performed to review relevant literature around BP.

Discussion

BP is a rare condition characterised by multiple papillary adenomas involving the biliary tree which lead to recurrent attacks of cholangitis. It is a low-grade neoplasm with high malignant potential and should be regarded as a pre-malignant lesion.     

胆道系统癌药物治疗进展

胆道癌唯一可治愈的方法是完全的手术切除,然而仅有10%的患者才适合手术,在这些患者中,肿瘤复发率又很高,所以,对于大部分胆道系统癌患者来说,全身化疗就成为一种主要的治疗方法.虽然Ⅲ期临床随机研究很少,但是一致性的一线化疗方案正在出现,包括经典的细胞毒药物化疗和很有发展前景的靶向治疗.     

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。     

Percutaneous Transhepatic Biliary Drainage for the Treatment of Obstructive Jaundice Caused by Metastases from Nonbiliary and Nonpancreatic Cancers

The usefulness of percutaneous transhepatic biliary drainage(PTBD) in the treatment of obstructive jaundice caused by metastasesfrom nonbiliary and nonpancreatic cancers was evaluated. Eighteenpatients underwent PTBD during a 3-year period. The primarycancers were located in the stomach (nine cases), colon (four),lung (three), uterus (one), and breast (one). The causes ofobstructive jaundice and bile duct strictures were investigatedusing both abdominal computed tomography and abdominal ultrasonography.The causes of obstructive jaundice, the usefulness of PTBD interms of the relief of symptoms and laboratory data, survivalafter PTBD, and the relationship between patient characteristicsand survival were evaluated. Obstructive jaundice was most oftenattributable to metastases to the lymph nodes (17 of 18 cases).One case was attributed to metastasis to the liver. PTBD decreasedthe jaundice and relieved the symptoms caused by biliary tractobstruction. Median survival after PTBD was 59 days. Patientswhose performance status was 2 or less survived longer thanthose with a performance status of 3 or more (P = 0.018). Furthermore,patients aged less than 60 years tended to survive longer thanthose aged 60 or over (P = 0.057). Our results suggest thatPTBD is useful for relief of symptoms caused by obstructivejaundice in patients with nonbiliary and nonpancreatic cancers.