Hilar cholangiocarcinomas are common tumors of the bile duct that are often unresectable at presentation. Palliation, therefore, remains the goal in the majority of these patients. Palliative treatment is particularly...Hilar cholangiocarcinomas are common tumors of the bile duct that are often unresectable at presentation. Palliation, therefore, remains the goal in the majority of these patients. Palliative treatment is particularly indicated in the presence of cholangitis and pruritus but is often also offered for high-grade jaundice and abdominal pain. Endoscopic drainage by placing stents at endoscopic retrograde cholangio-pancreatography(ERCP) is usually the preferred modality of palliation. However, for advanced disease, percutaneous stenting has been shown to be superior to endoscopic stenting. Endosonography-guided biliary drainage is emerging as an alternative technique, particularly when ERCP is not possible or fails. Metal stents are usually preferred over plastic stents, both for ERCP and for percutaneous bili-ary drainage. There is no consensus as to whether it is necessary to place multiple stents within advanced hi-lar blocks or whether unilateral stenting would suffice. However, recent data have suggested that, contrary to previous belief, it is useful to drain more than 50% of the liver volume for favorable long-term results. In the presence of cholangitis, it is beneficial to drain all of the obstructed biliary segments. Surgical bypass plays a limited role in palliation and is offered primarily as asegment Ⅲ bypass if, during a laparotomy for resec-tion, the tumor is found to be unresectable. Photody-namic therapy and, more recently, radiofrequency abla-tion have been used as adjuvant therapies to improve the results of biliary stenting. The exact technique to be used for palliation is guided by the extent of the bili-ary involvement(Bismuth class) and the availability of local expertise.展开更多
目的比较经皮肝穿刺胆道腔内射频消融联合支架植入术和单纯经皮肝穿刺胆道支架植入术治疗恶性梗阻性黄疸的疗效。方法回顾性地分析2011年4月至2014年9月军事医学科学院附属医院和解放军309医院收治的恶性梗阻性黄疸且不能手术切除患者56...目的比较经皮肝穿刺胆道腔内射频消融联合支架植入术和单纯经皮肝穿刺胆道支架植入术治疗恶性梗阻性黄疸的疗效。方法回顾性地分析2011年4月至2014年9月军事医学科学院附属医院和解放军309医院收治的恶性梗阻性黄疸且不能手术切除患者56例,其中25例行经皮肝穿刺胆道腔内射频消融联合支架植入术（射频组）,31例行单纯经皮肝穿刺胆道支架植入术（支架组）。观察治疗前后7~14 d血清总胆红素（TB）,直接胆红素（DB）的变化,并对全体患者的手术并发症、支架中位通畅期及患者中位生存期进行比较,通过电话随访或从患者复查记录中获取随访数据。结果手术成功率均为100%,术后均未出现腹膜炎、穿孔等致死性并发症。射频组3例患者及支架组3例患者出现胆管炎,经积极内科保守治疗后缓解。射频组治疗前、治疗后7~14 d TB和DB的变化有显著性意义（P〈0.01）,支架组治疗前、治疗后7~14 d TB和DB的变化有显著性意义（P〈0.01）,但7~14 d后射频组TB下降了（149.05±110.71）μmol/L,DB下降了（96.93±69.12）μmol/L;支架组两者分别下降了（151.40±94.47）和（94.21±67.36）μmol/L,两组间TB和DB下降无显著性意义。两组的支架中位通畅期分别为122（9~550）和157（16~510）d,中位生存期分别为125（9~550）和163（16~520）d,两组比较差异无显著性意义。结论腔内射频消融联合支架植入与单纯支架植入均是治疗不能手术切除的恶性梗阻性黄疸有效而安全的方法,两者的近期及远期疗效差异均无明显统计学意义。展开更多
AIM To evaluate the best management of plastic stents in patients with choledocholithiasis who were unfit for endoscopic stone removal or surgery. METHODS Between April 2007 and September 2017, 87 patients(median age ...AIM To evaluate the best management of plastic stents in patients with choledocholithiasis who were unfit for endoscopic stone removal or surgery. METHODS Between April 2007 and September 2017, 87 patients(median age 83.7 years) with symptomatic choledocholithiasis were treated with insertion of 7-Fr plastic stents because complete endoscopic stone retrieval was difficult, and their general condition was not suitable for surgery. Seventy of these patients agreed to regular stent management and stent exchange was carried out at every 6 mo(Group A, n = 35) or every 12 mo(Group B, n = 35). The remaining 17 patients did not accept regular stent exchange, and stents were replaced when clinical symptoms appeared(Group C). We evaluated the frequency of biliary complication and stent patency rate during follow-up periods. RESULTS The patency rate of biliary plastic stents was 91.4% at 6 mo(Group A) and 88.6% at 12 mo(Group B), respectively. Acute cholangitis occurred in 2.9% of Group A patients and in 8.6% of Group B patients. In Group C, median stent patency was 16.3 mo, and stent exchange was carried out in 70.6% of cases because of acute cholangitis or obstructive jaundice. Although a high incidence of acute cholangitis occurred, there was no biliary-related mortality. CONCLUSION Plastic stent exchange at 12-mo intervals is considered a safe procedure for patients with choledocholithiasis. Long-term biliary stenting increases biliary complications, but it can be an acceptable option for select patients who are medically unfit for further invasive procedures.展开更多
AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy. METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic ...AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy. METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared. RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed beforecomplete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions). CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.展开更多
目的探讨经内镜逆行胰胆管造影技术(ERCP)在原发性肝细胞癌并梗阻性黄疸治疗中的作用。方法回顾分析2002年1月至2004年6月间48例肝细胞癌并梗阻性黄疸的ERCP处理情况。结果32例(66.7%)经内镜引流术后减黄显著(103.5μmol/L vs 236.5μmo...目的探讨经内镜逆行胰胆管造影技术(ERCP)在原发性肝细胞癌并梗阻性黄疸治疗中的作用。方法回顾分析2002年1月至2004年6月间48例肝细胞癌并梗阻性黄疸的ERCP处理情况。结果32例(66.7%)经内镜引流术后减黄显著(103.5μmol/L vs 236.5μmol/L,P<0.01),其中6例(12.5%)行手术切除,11例(22.9%)行肝动脉栓塞化疗,1例行伽玛刀治疗,获得较长生存期(1年生存期56.3%)及较好生存质量,全组无严重ERCP操作相关并发症。结论ERCP技术对肝细胞癌并梗阻性黄疸病人是较好的检查及治疗手段,其侵袭性小,并发症可接受,内镜胆道引流术操作相对简单、有效,不仅可改善病人生存质量,而且可为部分病人进一步手术及介入治疗创造条件。展开更多
目的：比较单纯经皮肝穿刺胆道支架植入术和腔内射频消融联合支架植入术治疗恶性梗阻性黄疸的疗效。方法回顾性分析2012年1月至2014年12月我院收治的恶性梗阻性黄疸且不能手术切除患者21例，其中10例行经皮肝穿刺单纯胆道支架植入术（...目的：比较单纯经皮肝穿刺胆道支架植入术和腔内射频消融联合支架植入术治疗恶性梗阻性黄疸的疗效。方法回顾性分析2012年1月至2014年12月我院收治的恶性梗阻性黄疸且不能手术切除患者21例，其中10例行经皮肝穿刺单纯胆道支架植入术（支架组），11例行胆道腔内射频消融联合支架植入术（射频组）。观察治疗前、治疗后7 d 的 AST、ALB、血清总胆红素（TB）和直接胆红素（DB）的变化，并对患者的手术并发症、支架通畅期及生存期进行比较。结果手术成功率为100%，术后未出现严重并发症。支架组和射频组治疗前、治疗后7 d 的 AST、ALB、TB 和 DB 的变化有统计学意义（P ﹤0.01），治疗后两组之间 AST、ALB、TB 和 DB 差异无统计学意义（P ﹥0.05）。两组的支架通畅期分别为（102±69）d 和（213±130）d，生存期分别为（129±94）d 和（245±142）d，两组比较差异有统计学意义（P ﹤0.05）。结论单纯支架植入和胆道腔内射频消融联合支架植入，均是治疗不能手术切除的恶性梗阻性黄疸有效而安全的方法，两者的近期疗效差异无统计学意义，射频组的支架通畅期和生存期优于支架组。展开更多
AIM:To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma.METHODS:In total,118 patients with hilar cholangiocarcinoma underwent endoscopic management[endoscopi...AIM:To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma.METHODS:In total,118 patients with hilar cholangiocarcinoma underwent endoscopic management[endoscopic nasobiliary drainage(ENBD)or endoscopic biliary stenting]as a temporary drainage in our institution between 2009 and 2014.We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment.The risk factors for biliary reintervention,post-endoscopic retrograde cholangiopancreatography(post-ERCP)pancreatitis,and percutaneous transhepatic biliary drainage(PTBD)were also analyzed using patient-and procedure-related characteristics.The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage.RESULTS:In total,137 complications were observed in92(78%)patients.Biliary reintervention was required in 83(70%)patients.ENBD was significantly associated with a low risk of biliary reintervention[odds ratio(OR)=0.26,95%CI:0.08-0.76,P=0.012].Post-ERCP pancreatitis was observed in 19(16%)patients.An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis(OR=3.46,95%CI:1.19-10.87,P=0.023).PTBD was required in 16(14%)patients,and Bismuth type III or IV cholangiocarcinoma was a significant risk factor(OR=7.88,95%CI:1.33-155.0,P=0.010).Of 102 patients with initial unilateral drainage,49(48%)required bilateral drainage.Endoscopic sphincterotomy(OR=3.24,95%CI:1.27-8.78,P=0.004)and Bismuth II,III,or IV cholangiocarcinoma(OR=34.69,95%CI:4.88-736.7,P<0.001)were significant risk factors for bilateral drainage.CONCLUSION:The endoscopic management of hilar cholangiocarcinoma is challenging.ENBD should be selected as a temporary drainage method because of its low risk of complications.展开更多
文摘Hilar cholangiocarcinomas are common tumors of the bile duct that are often unresectable at presentation. Palliation, therefore, remains the goal in the majority of these patients. Palliative treatment is particularly indicated in the presence of cholangitis and pruritus but is often also offered for high-grade jaundice and abdominal pain. Endoscopic drainage by placing stents at endoscopic retrograde cholangio-pancreatography(ERCP) is usually the preferred modality of palliation. However, for advanced disease, percutaneous stenting has been shown to be superior to endoscopic stenting. Endosonography-guided biliary drainage is emerging as an alternative technique, particularly when ERCP is not possible or fails. Metal stents are usually preferred over plastic stents, both for ERCP and for percutaneous bili-ary drainage. There is no consensus as to whether it is necessary to place multiple stents within advanced hi-lar blocks or whether unilateral stenting would suffice. However, recent data have suggested that, contrary to previous belief, it is useful to drain more than 50% of the liver volume for favorable long-term results. In the presence of cholangitis, it is beneficial to drain all of the obstructed biliary segments. Surgical bypass plays a limited role in palliation and is offered primarily as asegment Ⅲ bypass if, during a laparotomy for resec-tion, the tumor is found to be unresectable. Photody-namic therapy and, more recently, radiofrequency abla-tion have been used as adjuvant therapies to improve the results of biliary stenting. The exact technique to be used for palliation is guided by the extent of the bili-ary involvement(Bismuth class) and the availability of local expertise.
文摘目的比较经皮肝穿刺胆道腔内射频消融联合支架植入术和单纯经皮肝穿刺胆道支架植入术治疗恶性梗阻性黄疸的疗效。方法回顾性地分析2011年4月至2014年9月军事医学科学院附属医院和解放军309医院收治的恶性梗阻性黄疸且不能手术切除患者56例,其中25例行经皮肝穿刺胆道腔内射频消融联合支架植入术（射频组）,31例行单纯经皮肝穿刺胆道支架植入术（支架组）。观察治疗前后7~14 d血清总胆红素（TB）,直接胆红素（DB）的变化,并对全体患者的手术并发症、支架中位通畅期及患者中位生存期进行比较,通过电话随访或从患者复查记录中获取随访数据。结果手术成功率均为100%,术后均未出现腹膜炎、穿孔等致死性并发症。射频组3例患者及支架组3例患者出现胆管炎,经积极内科保守治疗后缓解。射频组治疗前、治疗后7~14 d TB和DB的变化有显著性意义（P〈0.01）,支架组治疗前、治疗后7~14 d TB和DB的变化有显著性意义（P〈0.01）,但7~14 d后射频组TB下降了（149.05±110.71）μmol/L,DB下降了（96.93±69.12）μmol/L;支架组两者分别下降了（151.40±94.47）和（94.21±67.36）μmol/L,两组间TB和DB下降无显著性意义。两组的支架中位通畅期分别为122（9~550）和157（16~510）d,中位生存期分别为125（9~550）和163（16~520）d,两组比较差异无显著性意义。结论腔内射频消融联合支架植入与单纯支架植入均是治疗不能手术切除的恶性梗阻性黄疸有效而安全的方法,两者的近期及远期疗效差异均无明显统计学意义。
文摘AIM To evaluate the best management of plastic stents in patients with choledocholithiasis who were unfit for endoscopic stone removal or surgery. METHODS Between April 2007 and September 2017, 87 patients(median age 83.7 years) with symptomatic choledocholithiasis were treated with insertion of 7-Fr plastic stents because complete endoscopic stone retrieval was difficult, and their general condition was not suitable for surgery. Seventy of these patients agreed to regular stent management and stent exchange was carried out at every 6 mo(Group A, n = 35) or every 12 mo(Group B, n = 35). The remaining 17 patients did not accept regular stent exchange, and stents were replaced when clinical symptoms appeared(Group C). We evaluated the frequency of biliary complication and stent patency rate during follow-up periods. RESULTS The patency rate of biliary plastic stents was 91.4% at 6 mo(Group A) and 88.6% at 12 mo(Group B), respectively. Acute cholangitis occurred in 2.9% of Group A patients and in 8.6% of Group B patients. In Group C, median stent patency was 16.3 mo, and stent exchange was carried out in 70.6% of cases because of acute cholangitis or obstructive jaundice. Although a high incidence of acute cholangitis occurred, there was no biliary-related mortality. CONCLUSION Plastic stent exchange at 12-mo intervals is considered a safe procedure for patients with choledocholithiasis. Long-term biliary stenting increases biliary complications, but it can be an acceptable option for select patients who are medically unfit for further invasive procedures.
文摘AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy. METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared. RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed beforecomplete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions). CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.
文摘目的探讨经内镜逆行胰胆管造影技术(ERCP)在原发性肝细胞癌并梗阻性黄疸治疗中的作用。方法回顾分析2002年1月至2004年6月间48例肝细胞癌并梗阻性黄疸的ERCP处理情况。结果32例(66.7%)经内镜引流术后减黄显著(103.5μmol/L vs 236.5μmol/L,P<0.01),其中6例(12.5%)行手术切除,11例(22.9%)行肝动脉栓塞化疗,1例行伽玛刀治疗,获得较长生存期(1年生存期56.3%)及较好生存质量,全组无严重ERCP操作相关并发症。结论ERCP技术对肝细胞癌并梗阻性黄疸病人是较好的检查及治疗手段,其侵袭性小,并发症可接受,内镜胆道引流术操作相对简单、有效,不仅可改善病人生存质量,而且可为部分病人进一步手术及介入治疗创造条件。
文摘目的：比较单纯经皮肝穿刺胆道支架植入术和腔内射频消融联合支架植入术治疗恶性梗阻性黄疸的疗效。方法回顾性分析2012年1月至2014年12月我院收治的恶性梗阻性黄疸且不能手术切除患者21例，其中10例行经皮肝穿刺单纯胆道支架植入术（支架组），11例行胆道腔内射频消融联合支架植入术（射频组）。观察治疗前、治疗后7 d 的 AST、ALB、血清总胆红素（TB）和直接胆红素（DB）的变化，并对患者的手术并发症、支架通畅期及生存期进行比较。结果手术成功率为100%，术后未出现严重并发症。支架组和射频组治疗前、治疗后7 d 的 AST、ALB、TB 和 DB 的变化有统计学意义（P ﹤0.01），治疗后两组之间 AST、ALB、TB 和 DB 差异无统计学意义（P ﹥0.05）。两组的支架通畅期分别为（102±69）d 和（213±130）d，生存期分别为（129±94）d 和（245±142）d，两组比较差异有统计学意义（P ﹤0.05）。结论单纯支架植入和胆道腔内射频消融联合支架植入，均是治疗不能手术切除的恶性梗阻性黄疸有效而安全的方法，两者的近期疗效差异无统计学意义，射频组的支架通畅期和生存期优于支架组。
文摘AIM:To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma.METHODS:In total,118 patients with hilar cholangiocarcinoma underwent endoscopic management[endoscopic nasobiliary drainage(ENBD)or endoscopic biliary stenting]as a temporary drainage in our institution between 2009 and 2014.We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment.The risk factors for biliary reintervention,post-endoscopic retrograde cholangiopancreatography(post-ERCP)pancreatitis,and percutaneous transhepatic biliary drainage(PTBD)were also analyzed using patient-and procedure-related characteristics.The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage.RESULTS:In total,137 complications were observed in92(78%)patients.Biliary reintervention was required in 83(70%)patients.ENBD was significantly associated with a low risk of biliary reintervention[odds ratio(OR)=0.26,95%CI:0.08-0.76,P=0.012].Post-ERCP pancreatitis was observed in 19(16%)patients.An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis(OR=3.46,95%CI:1.19-10.87,P=0.023).PTBD was required in 16(14%)patients,and Bismuth type III or IV cholangiocarcinoma was a significant risk factor(OR=7.88,95%CI:1.33-155.0,P=0.010).Of 102 patients with initial unilateral drainage,49(48%)required bilateral drainage.Endoscopic sphincterotomy(OR=3.24,95%CI:1.27-8.78,P=0.004)and Bismuth II,III,or IV cholangiocarcinoma(OR=34.69,95%CI:4.88-736.7,P<0.001)were significant risk factors for bilateral drainage.CONCLUSION:The endoscopic management of hilar cholangiocarcinoma is challenging.ENBD should be selected as a temporary drainage method because of its low risk of complications.
