Carcinoid tumor of the common bile duct in children: a case report

Carcinoid tumors of common bile duct (CBD) are rare, with fewer than 60 cases reported worldwide. Typically, jaundice is the most common presenting symptom. Preoperative diagnosis is difficult because methods for obtaining adequate specimens for histologic analysis are limited. Surgery is the primary treatment for CBD carcinoids to have disease-free survival. This is a case report concerning a 10-year-old boy with a carcinoid tumor of the CBD. An overview of the clinical presentation, diagnosis, radiologic workup, surgical treatment, histologic features, and prognosis of carcinoid tumor is provided.     

远端胆管癌切除患者术后生存的影响因素分析

目的 研究影响远端胆管癌手术预后的因素,为远端胆管癌手术方式的选择和治疗提供依据.方法 对北京世纪坛医院、北京大学人民医院和北京大学第一医院1995-2009年具有完整随访资料的103例远端胆管癌病例进行回顾性分析,应用Kaplan-Meier单因素分析法和Cox比例风险模型多因素分析法对10个可能对预后产生影响的因素进行分析.结果 1、3、5年总体生存率分别为72%、41%和25%,中位生存期为24.13个月;单因素方差分析结果表明手术方式、淋巴结转移、TNM分期和切缘情况与远端胆管癌术后生存有关;Cox比例风险模型多因素分析结果表明切缘情况、淋巴结转移和TNM分期是影响远端胆管癌切除术后预后的独立因素.结论 切缘情况、淋巴结转移和TNM分期为远端胆管癌切除术后有关生存影响的独立因素,胰十二指肠切除术为远端胆管癌首选的手术方式.     

应用胆道化学性栓塞进行化学性肝切除的实验研究

目的　探讨应用胆道化学性栓塞进行化学性肝切除的可行性、疗效和作用机理。方法应用苯酚或无水乙醇与氰基丙烯酸酯对大鼠行胆道化学性栓塞,通过组织学观察、Fas和TGF β1的检测初步探讨化学性肝切除的可行性和作用机理。结果　苯酚与氰基丙烯酸酯的组合能够更好的毁损、栓塞肝内胆道系统,并在栓塞肝叶的周边部取得了无肝细胞存在的化学性肝切除的效果。苯酚栓塞组和乙醇栓塞组的Fas(88 90±38 10 ,72 39±2 9 5 1)和TGF β1表达(185 2 2±70 39,16 3 5 6±5 1 75 ) ,均高于胆管结扎组(2 6 31±12 0 7,74 84±4 0 73) (q值分别为10 37、8 4 5、9 83和8 0 7,P <0 0 5 )。而苯酚栓塞组的羟脯氨酸含量(4 89±0 83mg/g 湿肝重)又高于乙醇栓塞组(3 5 4±0 87mg/g 湿肝重) (q=6 2 5 ,P <0 0 5 )。结论　胆道化学性栓塞有可能达到化学性肝切除的效果。     

Classification and management of bile duct injuries

To review the classification and general guidelines for treatment of bile duct injury patients and their long term results. In a 20-year period, 510 complex circumferential injuries have been referred to our team for repair at the Instituto Nacional de Ciencias Médicasy Nutrición "Salvador Zubirán" hospital in Mexico City and 198 elsewhere (private practice). The records at the third level Academic University Hospital were analyzed and divided into three periods of time: GⅠ-1990-99 (33 cases), G Ⅱ2000-2004 (139 cases) and GⅢ2004-2008 (140 cases). All patients were treated with a Roux en Y hepatojejunostomy. A decrease in using transanastomotic stents was observed (78% vs 2%, P = 0.0001). Partial segment Ⅳ and Ⅴ resection was more frequently carried out (45% vs 75%, P = 0.2) (to obtain a high bilioenteric anastomosis). Operative mortality (3% vs 0.7%, P = 0.09), postoperative cholangitis (54% vs 13%, P = 0.0001), anastomosis strictures (30% vs 5%, P = 0.0001), short and long term complications and need for reoperation (surgical or radiological) (45% vs 11%, P = 0.0001) were significantly less in the last period. The authors concluded that transition to a high volume center has improved long term results for bile duct injury repair. Even interested and tertiary care centers have a learning curve.     

Extensive hilar bile duct resection using a transhepatic approach for patients with hepatic hilar bile duct diseases

BACKGROUND: Extensive hilar bile duct resection beyond the second- or third-order intrahepatic biliary radicals is usually required for patients with hilar cholangiocarcinoma as well as those with benign inflammatory stricture. Most hilar cholangiocarcinoma is resected with combined major hepatectomy to obtain free surgical margins. The purpose of this study was to show the surgical procedure and the usefulness of extensive hilar bile duct resection using a transhepatic approach for patients with hilar bile duct diseases. METHODS: Five patients with hepatic hilar bile duct disease and who were unfit for major hepatectomy for several reasons underwent extensive hilar bile duct resection by way of a transhepatic approach. Four of the patients had hilar bile duct cancer, including 1 with mucous-producing bile duct cancer of low-grade malignancy and 1 with a postsurgical benign bile duct stricture. RESULTS: After extensive hilar bile duct resection, bile duct stumps ranged in number from 3 to 7 mm (mean 4.4). Surgical margins at bile duct stump were free of cancer in all 4 cancer patients. The long-term outcomes were as follows: 3 patients are alive at the time of publication, and 2 patients have died. CONCLUSIONS: A transhepatic approach may be useful when performing extensive hilar bile duct resection bile duct stricture of biliary disease at the hepatic hilus, especially in high-risk patients who are unfit for major hepatectomy as well as in those having benign bile duct stricture and low-grade malignancy.     

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目的 了解我国当前对医源性胆管损伤外科治疗概况及胆管损伤治疗效果。方法 通过检索解放军医学图书馆中文生物医学期刊数据库（CMCC）从1995年1月至2000年1月全国各级期刊关于胆管损伤的论文,统计来自165个医疗单位2742例医源性胆管损伤。结果 统计显示胆管损伤的94％来自与胆囊有关的手术,以胆管横断伤为多（47％）,损伤类型时要为胆总管（44％）和肝总管（36％）,有40％为术中及时发现处理,胆管损伤修复手术因狭窄再手术占总数的23％,术中发现和术后发现及胆管修复的方式有明显的差异。结论 胆管损伤后期的修复防止狭窄是较困难的,调查修复方式显示术中发现的作胆管修补＋T管支撑引流,术后发现手术作胆管空肠吻合＋长期支撑的手术方式效果较好。     

腹腔镜胆道探查术治疗胆道结石的体会

目的探讨腹腔镜胆道探查术(LCBDE)的应用及其相对于开腹胆道探查术(CBDE)的优越性。方法回顾分析我院2011年7月-2013年12月手术治疗的胆道结石患者共73例分为CBDE组39例和LCBDE组34例,比较两组患者在手术时间、术中出血、胃肠功能恢复时间、住院时间、镇痛药物使用率、残留结石率、并发症发生率等方面的差异。结果两组在手术时间、残留结石率、并发症发生率等方面的差异不具有统计学意义(P>0.05),LCBDE组在术中出血、胃肠功能恢复时间、住院时间、镇痛药物使用率等方面明显优于CBDE组,两组比较差异有统计学意义(P<0.05)。结论 LCBDE是一种安全、可行、微创、康复快的手术方式,适宜临床推广。     

肝外胆管癌的手术治疗效果分析

目的探讨肝外胆管癌的外科治疗。方法回顾分析我院外科手术收治的61例肝外胆管癌临床资料。结果其中胆管中段癌28例、胆管下段癌33例。胆管中段癌根治性切除率为64.29%,手术并发症14.28%,5年生存率38.89%;胆管下段癌根治性切除率为75.76%,手术并发症36%,5年生存率24%,两组间均无统计学差异。结论肝外胆管癌缺乏有效的早期诊断方法,手术仍是治疗肝外胆管癌的首选方法,胆管中段癌和胆管下段癌不需要区别讨论。     

原发性肝癌伴胆管癌栓的外科治疗

目的　探讨伴胆管癌栓的原发性肝癌 (HCC)外科治疗方式的选择及对预后的影响。方法　回顾性分析 1994～ 2 0 0 1年 15例HCC伴胆管癌栓的外科治疗情况。　结果　肝癌切除加胆管癌栓清除术 7例 ,肝癌切除加肝外胆管切除术 4例 ,单纯胆总管切开取栓术 3例 ,背驮式肝移植 1例。术后 1年生存率为 73 3%,3年生存率为 40 %,其中有 2例生存已超过 5年。门静脉侵犯者的生存率显著低于未侵犯者 (P <0 0 5 )。　结论　原发性肝癌伴胆管癌栓行外科治疗是一种积极有效的治疗方法。复发后选择适当病例再次手术 ,仍可取得较好疗效。肝移植作为一种崭新的手术方式值得探讨。     

肝切除在肝门胆管癌根治术中应用

目的 总结肝切除在肝门部胆管癌根治术中应用经验.方法 回顾分析1993年1月至2007年12月手术切除的肝门部胆管癌病人临床资料及随访结果.结果 全组共有69例肝门胆管癌,切除率66.4%(69/104).其中局部切除31例;合并肝叶部分切除38例;合并胰头十二指肠切除3例;合并门静脉壁部分切除2例.根治手术为44例.手术根治切除率由28.2%(2000年以前)提高到50.8%(2000年后),肝功能衰竭、感染等严重并发症以及围术期死亡率均控制较好.总体1,2,3年生存率为73.9%,38.4%和14.9%,根治手术1,2,3年生存率分别为87.1%,58.2%和23.6%,非根治切除1,2,3年生存率分别为44.0%,21.6%和11.4%.结论 根治性切除的生存率比非根治切除显著提高,联合肝部分切除能明显提高根治性手术的切除率,可考虑为首要的治疗选择.     

LC术中胆道损伤的危险因素及预防分析

目的:探讨腹腔镜胆囊切除术(LC)胆管损伤的危险因素及患者的预后。方法:回顾分析4 532例腹腔镜胆囊切除术患者的临床资料,对出现胆管损伤患者相关影响因素进行单因素分析,并分析胆管损伤的独立危险因素。结果:4 532例腹腔镜胆囊切除术患者中发生术后并发胆管损伤者19例,发生率为0.42%,单因素分析结果显示观察组患者处于急性期、胆囊壁增厚、解剖变异和术者经验少的比例均明显高于对照组(P<0.05)。经回归分析,解剖变异和术者经验是发生胆管损伤的独立危险因素(P<0.05)。结论:胆管损伤是严重的LC后并发症,解剖变异和术者经验少是影响其发生的独立危险因素。     

Right hemihepatectomy for bile duct injury following laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic cholecystolithiasis. But with the introduction of this technique, the incidence of bile duct injuries has increased. We report the case of a 33-year-old man who was transferred from an affiliated hospital to our department for the treatment of a bile duct injury 2 weeks after LC. Prior to transfer, a laparotomy had been performed, with insertion of a T-tube and a Robinson drain on day 5 after LC. Endoscopic retrograde cholangiography (ERC) on admission day revealed an extensive defect of the right biliary system, which could not be treated endoscopically. An emergency laparotomy had to be performed at night for acute bleeding from the portal vein. Due to massive inflammation in the porta hepatis and intraparenchymal destruction of the right bile duct, liver resection was performed 2 days later, after the patient had stabilized in the intensive care unit (ICU). The patient had a prolonged postoperative course, but he finally recovered well from these operations. In conclusion, the management of bile duct injuries should include ultrasound to detect and drain fluid collections and ERC to classify the injury. Emergency laparotomy should never be performed without these examinations, since the majority of bile duct injuries can be treated endoscopically. Surgery for this serious complication should always be performed at specialized centers for hepatobiliary surgery.     

胆道损伤的处理

目的 探讨胆道损伤的分类和临床特点。方法 回顾性分析临床资料，72例胆道损伤中，医源性49例，外伤性23例(胆总管下段损伤5例，胆总管上段／肝总管损伤50例，肝内胆管损伤17例)，经局部缝合、组织修补、胆肠吻合等方式治疗。结果 全组发生胆漏2例，死于胆道感染、出血2例；随访66例，发现胆道狭窄4例，结石复发3例。结论 应努力避免和及时发现胆道损伤，根据损伤部位、类型、程度、特点分类，采取不同方式修复胆道损伤，并保证修复后胆道血供良好。     

肝管空肠吻合术治疗医源性胆管损伤伴狭窄

医源性胆管损伤是胆囊切除术严重的并发症之一.在LC迅速发展的今天,LC导致医源性胆管损伤的发生率较开腹胆囊切除术更高.2006年10月至2011年8月我中心采用肝管空肠吻合术治疗14例医源性胆管损伤患者,取得了良好的疗效,现报道如下. 1 资料与方法 1.1 一般资料 本组医源性胆管损伤患者14例,男6例,女8例;年龄28～62岁,平均年龄46岁.5例胆管损伤发生于开腹胆囊切除术,9例发生于LC.14例患者中,修复手术距胆囊切除术时间4个月至6年.4例患者带有T管.所有患者有急、慢性胆管炎表现,包括腹痛,伴或不伴发热,症状发作时均伴有黄疸.     

腹腔镜再次胆道探查术治疗胆管结石

目的：探讨腹腔镜再次胆道探查术治疗胆管结石的方法和临床应用价值。方法：回顾分析为31例复发性胆管结石患者施行腹腔镜胆道探查取石术的临床资料。结果：31例中2例因腹腔粘连致密,胆道周围组织充血水肿严重而中转开腹。29例完成腹腔镜手术,其中1例因胆总管结石大,1例胆总管下端结石嵌顿,1例肝内胆管结石较多,胆道镜和取石钳取石困难,剑突下切口延长至3~4 cm,直视下用取石钳联合胆道镜取石。行胆总管一期缝合5例,24例行胆总管T管引流术。手术时间平均170 min。术后均无腹腔出血和肠漏等并发症发生。3例出现少量胆漏,未出现腹膜炎和腹内感染征象,腹腔引流管分别于术后第6,9,10天拔除。2例剑突下切口感染均是切口延长者,通过局部换药愈合。胆总管一期缝合5例,术后5~7 d出院。24例行胆总管T管引流的患者中,10例于术后7 d带T管出院,14例于术后14 d夹闭T管后带管出院。术中19例结石取净,10例胆道残余结石患者于术后2个月经胆道镜取出。结论：腹腔镜再次胆道探查术安全,患者创伤小,康复快。胆管炎症严重及肝内外结石较多、胆总管下端结石嵌顿者需慎重选择腹腔镜手术。     

Histologic bile duct invasion by a mass-forming intrahepatic cholangiocarcinoma

Abstract. Background/Purpose: Although curative surgical resection provides the best chance of long-term survival for patients with intrahepatic cholangiocarcinoma, the presence of bile duct invasion decreases postoperative survival rates in patients with mass-forming intrahepatic cholangiocarcinoma. We carried out this study to determine a surgical strategy for patients with bile duct invasion of these tumors. Methods: Forty-one patients with mass-forming intrahepatic cholangiocarcinoma were classified as either having bile duct invasion (n= 26) or not having bile duct invasion (n= 15). Clinicopathologic findings, including postoperative outcomes, were compared between these two groups. Results: Perineural invasion, lymphatic invasion, and a positive resection margin were more frequent in patients with ductal invasion. Patients with ductal invasion had lower survival rates than those without ductal invasion. Conclusions: Intraoperative frozen section examination of the bile duct stump to confirm a clear resection margin is required in patients with mass-forming tumors. Resection of the extrahepatic bile duct should be considered when tumor cells are identified at the surgical margin of the resected bile duct. Received: October 30, 2001 / accepted: November 16, 2001     

Hilar bile duct resection for bile duct carcinoma at the hilus of the liver

Hilar bile duct resection, by which only the bile duct is resected, was carried out in 31 patients with bile duct carcinoma at the hepatic hilus. However, curative resection was possible in only 4 patients (12.9%). The postoperative 1-, 3-, and 5-year survival rates were 58.1%, 19.4%, and 7.7%, respectively. These results indicate that treatment of this hilar bile duct carcinoma by hilar bile duct resection is of limited value. We believe that this operative procedure should be used only for papillary or nodular carcinoma at the hepatic confluence at relatively early stages of Bismuth's type I or II.     

医源性胆道损伤的诊治与预防

本文医源性胆道损伤48例，对其损伤的部位、类型、损伤后的症状、诊断方法、胆道重建和修复的方法，胆肠吻合术的原则，随访结果进行了分析。作者认为引起胆道损伤的原因除解剖变异、病理改变外，主要是术者责任心不强造成的，并提出了预防措施。     

Role of Hepatectomy in the Treatment of Hilar Bile Duct Carcinoma

Purpose. To clarify the role of hepatic resection in the surgical treatment of hilar bile duct carcinoma.Methods. Between 1980 and 1997, 68 patients underwent surgery for hilar bile duct carcinoma. The patients were divided into a hepatectomy group (n = 40) and a nonhepatectomized group (n = 28) depending on whether they underwent resection of the bile duct confluence in combination with hepatectomy, or alone, respectively. Background data, operative morbidity and mortality, and survival were retrospectively compared between the two groups.Results. There were no significant differences in morbidity and mortality, or in postoperative survival between the two groups (the 5-year survival rates being 20.6% in the hepatectomized group and 7.1% in the nonhepatectomized group; P = 0.0806). However, patients who underwent curative resection had significantly better postoperative survival than those who underwent noncurative resection (P = 0.048). Hepatectomy provided a significantly better cancer-free margin than bile duct resection alone (P = 0.0296).Conclusions. Although a countermeasure must be taken to decrease mortality, the introduction of hepatectomy with bile duct resection would provide a better cancer-free surgical margin than bile duct resection alone for hilar bile duct carcinoma. Curative resection contributed to long-term survival in this series.     

胆管壁坏死的手术处理

目的 探讨胆管壁坏死外科手术处理.方法 回顾性分析了1990年5月至2008年12月收治的94例胆管壁坏死病人的临床资料.结果 无手术病死、无胆瘘、大出血等严重并发症.结论 根据胆管壁坏死的特点采用相应的手术方式.

Abstract：

Objective To explore the surgical treatment of bile duct necrosis.Methods Clinical data of 94 cases of bile duct necrosis treated in this hospital from May1990 to December 2008 were retrospectively analyzed.Results There were no death or severe complications such as biliary fistula and massive hemorrhage in these patients.Conclusion Bile duct necrosis should be treated with a proper surgical approach based on its features.