目的 探讨经皮经肝穿刺胆道引流术（PTCD）联合胆道支架置入术治疗恶性梗阻性黄疸的操作技巧及其临床应用价值。方法 2009年8月至2011年5月期间中国医科大学附属第四医院介入科对39例恶性梗阻性黄疸患者施行了PTCD联合胆道支架置入术，对其临床资料和效果进行回顾性分析。结果 39例患者全部穿刺成功，穿刺成功率为100％。穿刺左叶胆管11例，穿刺右叶胆管19例，左右胆管均行穿刺9例；单纯外引流22例，内外引流17例；引流管保留7～14d后均成功行胆道支架置入术。 33例患者自觉症状有缓解。患者术后14d时，其白蛋白、碱性磷酸酶、丙氨酸转氨酶、总胆红素、直接胆红素和间接胆红素水平均较术前降低（P＜0.05）。术后发生胆道感染3例（7.69％），发生急性胰腺炎4例（10.26％），发生支架脱落移位1例（2.56％），无胆汁性腹膜炎等并发症发生。本组32例患者获访，随访时间为8d～16.5个月，平均9.4个月。随访期间，27例患者死于肿瘤进展及多脏器功能衰竭；5例患者存活，无黄疸加重症状。结论 PTCD联合胆道支架置入术是一种姑息治疗恶性梗阻性黄疸的有效方法，具有简便、有效、安全、可重复性等优点，但需注意其适应证的选择和并发症的预防。
ObjectiveTo study the effectiveness of liver function, hepatic energy metabolism, regeneration, and apoptosis on the obstructive jaundice rat after partial hepatectomy (PH) combined with internal biliary drainage under the condition of conspicuous bilirubinemia. MethodsOne hundred and twenty male SD rats were used in research, six of whom were divided into sham operation (SO) group. Twenty rats underwent bridge operation between common bile duct and duodenum after 70% PH (70%PH group), and 6 rats out of the 94 rats who underwent common bile duct ligation (CBDL) for 5 d were randomly selected as CBDL group, and the residual rats were done the second operations after 5 d and were divided into three groups: bile duct obstruction combined with reperfusion of bile flow group （BDO-RBF group， n=20), 42% PH with BDO-RBF group (n=20), and 70%PH with BDO-RBF group (n=25). Levels of TB, ALT, ALB, and ALP in serum; HGF, bcl-2 mRNA and protein； ATP, ADP, and AMP; hepatocyte proliferation/apoptosis index in hepatic tissues were dynamically observed after operation (24 h, 72 h, and 7 d), respectively. The liver function and hepatocyte energy metabolism were only detected in the SO group. ResultsRats without obstructive jaundice would have an excellent liver regeneration after 70% PH, while the liver function and hepatocyte energy metabolism could recover rapidly. The liver function, hepatocyte energy metabolism, HGF and bcl-2 mRNA and protein of liver tissue and the hepatocyte proliferation/apoptosis index in partial (42% or 70%) hepatectomy combined with internal biliary drainage in obstructive jaundice group were significantly influenced while recovered rapidly (Plt;0.05). ConclusionsUnder the condition of conspicuous bilirubinemia, the influences of hepatectomy combined with internal biliary drainage on hepatocyte energy metabolism, liver function, hepatocyte regeneration and apoptosis are severer than that of normal rats who underwent 70% hepatectomy, while also make the rats recover rapidly in hyperbilirubinemia groups. The database suggest that it is not necessary to do preoperative external biliary drainage before performing liver resection.
ObjectiveTo compare and evaluate the effect and quality of T-tube drainage and bulit-in-tube drainage plus primary suture after laparoscopic cholecystectomy (LC). MethodsA clinical trial was taken in 79 cases with T-tube drainage (control group) and 62 cases with built-in-tube drainage (observation group). The treatment success rate, incidence of complications, bilirubin recovered time, length of stay, recuperation time, and treatment cost were measured and compared between the two groups. ResultsThere were no statistically significant differences between the two groups in treatment success rate, incidences of complications, and bilirubin recovered time of patients （Pgt;0.05）, while length of stay, recuperation time, and treatment cost of patients in observation group were significantly less than those in control group （Plt;0.05）. ConclusionsBuilt-in-tube drainage plus primary suture after LC and common bile duct exploration could achieve the same therapeutic effect as the traditional T-tube drainage with less length of stay, recuperation time, and treatment cost.
Objective To discuss the relationship between the efficiency of bile duct drainage and the postoperative liver functional recovery and the prognosis of hilar cholangiocarcinoma. Methods We studied retrospectively 58 cases of hilar cholangiocarcinoma which entered our department between June 1987 and October 1998. The postoperative liver functional recovery and mortality and morbidity between unilateral (n＝27) and bilateral (n＝31) bile duct drainage groups were compared. Results The liver function in bilateral drainage group was nearly normal within 6 weeks after operation. The ALb level of unilateral drainaged patients recovered gradually to normal after operation, and the TBIL and ALT decrease nearly to the normal range within 6 weeks after operation. The AKP decreased within 2 postoperative weeks, then steadily increased. The differences of perioperative complication rate and mortality of the two groups showed no significance. Conclusion The data showed that the liver function can recover to some extent by unilateral bile duct drainage, and unilateral drainage operations are the choice for hilar cholangiocarcinoma that can not be excised now.
ObjectiveTo analyze effect of percutaneous transhepatic choledochus drainage (PTCD) for hilar cholangiocarcinoma. MethodsClinical data of 67 cases of hilar cholangiocarcinoma who treated in our hospital from Jan. 2005 to Dec. 2010 were retrospectively analyzed. ResultsOf the 67 cases, 30 cases were performed PTCD, 20 cases were performed radical surgery after PTCD, and 17 cases were performed palliative surgery after PTCD. There were 59 cases who were followed-up for 3-30 months, and the median time was 9.3 months. The median survival time of patients who underwent PTCD, radical surgery, and palliative surgery were 10.2, 21.4, and 8.9 months respectively. The survival of patients who underwent radical surgery was better than those of underwent PTCD (χ2=13.6, P=0.000 4) and palliative surgery (χ2=15.2, P=0.003 8), and survival of patients who underwent PTCD was better than patients underwent palliative surgery (χ2=5.3, P=0.040 1). ConclusionsPTCD is contribute to preoperative diagnosis and evaluation, in addition, it can reduce unnecessary surgical exploration, guarantee the safety of the radical surgery, and provide follow-up care for palliative operation channel which is favorable for local internal radiation therapy.
ObjectiveTo explore the treatment and prognostic factors of typeⅢhilar cholangiocarcinoma. MethodsThe data of 170 cases of typeⅢhilar cholangiocarcinoma treated in our hospital from Jan. 2002 to Dec. 2011 were retrospectively analyzed. ResultsAmong these 170 patients of typeⅢhilar cholangiocarcinoma, 109 patients underwent surgical exploration in which 60 patients underwent resection and the remaining 49 patients were found unresectable and underwent U-tube or metallic stent drainage. Sixty one patients were preoperatively assessed as unresectable in which 14 patients underwent percutaneous transhepatic cholangial drainage and the remaining 47 patients refused any surgical intervention. Results of Cox proportional hazard model showed that residual tumor status (HR=4.621, 95% CI:1.907-11.199, P=0.001), lymph node metastasis (HR=2.792, 95% CI:1.393-5.598, P=0.004), and hepatectomy (HR=3.003, 95% CI:1.373-6.569, P=0.006) were independent prognostic factors which associated with patients in resection group. Besides, treatmentR0 resection (HR=0.177, 95% CI:0.081-0.035, P < 0.001), no treatment (HR=5.568, 95% CI:2.733-11.342, P < 0.001)] and vascular invasion (HR=1.667, 95% CI:1.152-2.412, P=0.007) were prognostic factors associated with all patients. ConclusionsTreatment and vascular invasion are the most important predictors of prolonging survival associated with typeⅢhilar cholangiocarcinoma. Besides, R0 resection including hepatectomy without lymph nodes metastasis is feasible in the majority of patients with resectable hilar cholangiocarcinoma.
Objective To investigate the clinical value of " O”continuous biliary-enteric anastomosis combined with percutaneous transhepatic cholangial drainage (PTCD) in pancreaticoduodenectomy (PD). Methods The clinical data of 35 patients with PD who were admitted to Xinyang Central Hospital from June 2015 to June 2017 were retrospectively analyzed. Results All patients completed the " O” continuous biliary-enteric anastomosis combined with PTCD without perioperative death. ① The preoperative indwelling time of PTCD tube was (13.24±3.39) d, total bilirubin (TBIL) was (363.67±12.26) μmol/L on admission and (155.59±17.63) μmol/L on preoperative after PTCD, respectively. ② The operative time was (231.46±18.69) min, the intraoperative blood loss was (158.30±31.33) mL, the diameter of the hepatic ductal segment was (1.3±0.2) cm, and the duration of the " O” continuous biliary-enteric anastomosis was (7.31±1.52) min. ③ After surgery, the indwelling time of PTCD tube was (8.13±1.49) d, the hospitalization time was (27.31±5.49) d. Biliary leakage occurred in 1 case, pancreatic fistula occurred in 5 cases (3 cases of biochemical sputum and 2 cases of B-stage pancreatic fistula), abdominal infection occurred in 2 cases, pneumonia occurred in 3 cases, wound infection occurred in 2 cases. No postoperative biliary-enteric anastomosis stenosis, biliary tract infection, and intra-abdominal hemorrhage occurred. There was no laparotomy patients in this group and all patients were discharged. ④ All patients were followed-up for 180 days after surgery. No death, bile leakage, biliary-enteric anastomotic stenosis, biliary tract infection, pancreatic fistula, gastro-intestinal leakage, and abdominal infection occurred. One case of delayed gastric emptying and 2 cases of alkaline reflux gastritis were cured after outpatient treatment. Conclusions The preoperative PTCD can improve the preoperative liver function and increase the security of PD. " O” continuous biliary-enteric anastomosis is simple, safe, feasible, and has the function of preventing biliary-enteric anastomosis stenosis. For severe jaundice patients with blood TBIL >170 μmol/L, the " O” continuous biliary-enteric anastomosis combined with PTCD is an alternative surgical procedure for PD.
ObjectiveTo systematically review efficacy of endoscopic ultrasonography guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) on patients with malignant obstructive jaundice.MethodsThe PubMed, EMbase, The Cochrane Library, CBM, WanFang Data, and CNKI were searched online to collect the randomized controlled trials or cohort studies of EUS-BD versus PTBD on the patients with malignant obstructive jaundice from inception to November 30, 2018. Two reviewers independently screened the literatures, extracted the data and assessed the risk of bias of included the studies, then the meta-analysis was performed by using the RevMan 5.3 software.ResultsThree randomized controlled trials and 6 cohort studies involving 496 patients were included. The results of meta-analysis showed that: compared with the PTBD, the EUS-BD had the lower occurrence of complications [OR=0.30, 95% CI (0.20, 0.47), P<0.000 01], lower rate of reintervention [OR=0.11, 95% CI (0.06, 0.22), P<0.000 01], shorter hospital stay [MD=–3.42, 95% CI (–6.72, –0.13), P=0.04], and less hospital costs [SMD=–0.83, 95% CI (–1.16, –0.49), P<0.000 01]. There were no significant differences in the technical success rate [OR=0.88, 95% CI (0.20, 3.85), P=0.86] and clinical effective rate [OR=1.73, 95% CI (0.97, 3.11), P=0.06] between the two groups.ConclusionsCurrent evidence shows that EUS-BD has some advantages of lower occurrence of complications, lower rate of reintervention, shorter hospital stay, and less hospital costs in treatment of patients with malignant obstructive jaundice as compared with PTBD. There are no significant differences between two groups in technical success rate and clinical effective rate. Due to limited quality and quantity of included studies, more high quality studies required to be verified above conclusions.