Effect of preoperative biliary drainage on surgical results after pancreaticoduodenectomy in patients with distal common bile duct cancer:Focused on the rate of decrease in serum bilirubin

AIM: To examine if the rate of decrease in serum bilirubin after preoperative biliary drainagecan be used as a predicting factor for surgical complications and postoperative recovery after pancreaticoduodenectomy in patients with distal common bile duct cancer.METHODS: A retrospective study was performed in 49 consecutive patients who underwent pancrea-ticoduodenectomy for distal common bile duct cancer. Potential risk factors were compared between the complicated and uncomplicated groups. Also, the rates of decrease in serum bilirubin were compared pre- and postoperatively. RESULTS: Preoperative biliary drainage (PBD) was performed in 40 patients (81.6%). Postoperative morbidity and mortality rates were 46.9% (23/49) and 6.1% (3/49), respectively. The presence or absence of PBD was not different between the complicated and uncomplicated groups. In patients with PBD, neither the absolute level nor the rate of decrease in serum bilirubin was significantly different. Patients with rapid decrease preoperatively showed faster decrease during the first postoperative week (5.5 ± 4.4 μmol/L vs -1.7 ± 9.9 μmol/L, P = 0.004).CONCLUSION: PBD does not affect the surgical outcome of pancreaticoduodenectomy in patients with distal common bile duct cancer. There is a certain group of patients with a compromised hepatic excretory function, which is represented by the slow rate of decrease in serum bilirubin after PBD.

Prognostic factors in patients with middle and distal bile duct cancers

AIM: To identify the influence of the surgery type and prognostic factors in middle and distal bile duct cancers.

Robotic assisted Roux-en-Y hepaticojejunostomy in a post-cholecystectomy type E2 bile duct injury

Roux-en-Y hepaticojejunostomy anastomosis is the treatment of choice for common hepatic duct injury type E2.It has been performed laparoscopically with the advancement of laparoscopic skill.Recently,a telemanipulative robotic surgical system was introduced,providing laparoscopic instruments with wrist-arm technology and 3-dimensional visualization of theoperative field.We present a case of 36-year-old female patient who had undergone elective cholecystectomy2 mo ago for gall stones and had a common bile duct injury during surgery.As the stricture was old and complete it could not be tackled endoscopically.We did a laparoscopic assisted adhesiolysis followed by robotic Roux-en-Y hepaticojejunostomy.No intraoperative complications or technical problems were encountered.Postoperative period was uneventful and she was discharged on the 4th postoperative day.At followup,she is doing well without evidence of jaundice or cholangitis.This is the first reported case of robotic hepaticojejunostomy following common bile duct injury.The hybrid technique gives the patient benefit of laparoscopic adhesiolysis and robotic suturing.

Effectiveness of a new approach to minimally invasive surgery in palliative treatment of patients with distal malignant biliary obstruction

BACKGROUND Palliative endoscopic biliary drainage is the primary treatment option for the management of patients with jaundice which results from distal malignant biliary obstruction(DMBO).In this group of patients,decompression of the bile duct(BD)allows for pain reduction,symptom relief,chemotherapy administration,improved quality of life,and increased survival rate.To reduce the unfavorable effects of BD decompression,minimally invasive surgical techniques require continuous improvement.AIM To develop a technique for internal-external biliary-jejunal drainage(IEBJD)and assess its effectiveness in comparison to other minimally invasive procedures in the palliative treatment of patients with DMBO.METHODS A retrospective analysis of prospectively collected data was performed,which included 134 patients with DMBO who underwent palliative BD decompression.Biliary-jejunal drainage was developed to divert bile from the BD directly into the initial loops of the small intestine to prevent duodeno-biliary reflux.IEBJD was carried out using percutaneous transhepatic access.Percutaneous transhepatic biliary drainage(PTBD),endoscopic retrograde biliary stenting(ERBS),and internal-external transpapillary biliary drainage (IETBD) were used for the treatment of studypatients. Endpoints of the study were the clinical success of the procedure, the frequency andnature of complications, and the cumulative survival rate.RESULTSThere were no significant differences in the frequency of minor complications between the studygroups. Significant complications occurred in 5 (17.2%) patients in the IEBJD group, in 16 (64.0%)in the ERBS group, in 9 (47.4%) in the IETBD group, and in 12 (17.4%) in the PTBD group.Cholangitis was the most common severe complication. In the IEBJD group, the course ofcholangitis was characterized by a delayed onset and shorter duration as compared to other studygroups. The cumulative survival rate of patients who underwent IEBJD was 2.6 times higher incomparison to those of the PTBD and IETBD groups and 20% higher in comparison to that of theERBS group.CONCLUSIONIEBJD has advantages over other minimally invasive BD decompression techniques and can berecommended for the palliative treatment of patients with DMBO.

Comparison of mismatch repair and immune checkpoint protein profile with histopathological parameters in pancreatic,periampullary/ampullary,and choledochal adenocarcinomas

BACKGROUND Pancreatic,periampullary/ampullary,and choledochal adenocarcinomas are aggressive malignancies with a poor prognosis.Immune checkpoint blockade is a promising treatment option for several tumor types.H long terminal repeatassociating 2(HHLA2),which is analogous to programmed death-ligand 1(PDL1),is a recently discovered member of the B7/cluster of differentiation 28 family and is expressed in many malignancies.AIM To analyze the expression of HHLA2 and its association with the pathologic biomarkers that predict sensitivity to immunotherapy.METHODS Ninety-two adenocarcinoma cases located in the pancreas,ampulla,and distal common bile duct were identified.This study assessed 106 pancreaticoduodenectomy and distal/total pancreatectomy samples that were delivered to Ankara City Hospital between 2019 and 2021.Immunohistochemistry was conducted to examine the expression of DNA mismatch repair(MMR),PD-L1,and HHLA2 proteins.RESULTS Patients with high HHLA2 expression had a higher mean age than those with low expression.Low HHLA2 expression was associated with high perineural invasion.HHLA2 expression was low in pathological stage T3(pT)3 cases and high in pathological stage T1,T2,and T4 cases.There was no correlation between HHLA2 expression and the expression of MMR proteins and PD-L1.CONCLUSION Evaluation of HHLA2 expression in microsatellite stable and PD-L1-negative tumors may be useful for predicting the response of individuals to immunotherapy and may serve as a novel therapeutic target for immunotherapy in advanced-stage disease.

远端胆管癌外科治疗的效果分析

目的 探讨远端胆管癌外科治疗的并发症、术后生存率及其相关因素。方法 回顾性分析我科 12年间外科治疗的 2 3例远端胆管癌患者的临床资料。结果 出现手术并发症的患者其术前症状持续的时间 ( 0 .5 0± 0 .18)个月显著短于无手术并发症的患者 ( 1.2 9± 0 .2 3 )个月 (P <0 .0 5 )。总体术后中位时间生存 18( 1～ 70 )个月 ,17例 ( 73 .9% )生存 1年以上 ,5例 ( 2 1.7% )生存 3年以上 ,2例 ( 8.7% )生存 5年或 5年以上。是否行根治性切除、手术时是否出现远处转移与术后生存率显著相关 (P <0 .0 5 )。结论 首发症状持续时间可能和外科治疗后并发症发生率有关。胰十二指肠切除是治疗远端胆管癌的有效手段。手术时出现远处转移者预后较差。

肝门部胆管癌外科治疗20年经验回顾

目的 总结 2 0年肝门部胆管癌外科治疗的经验 ,探讨提高切除率 ,减少并发症的有效措施。方法 回顾总结 1978年 1月～ 1997年 12月西南医院外科治疗 2 0 1例肝门部胆管癌的临床资料 ,以 1991年为界限前后分为两个阶段以对照手术切除率、并发症及死亡率等。结果 2 0 1例中手术切除 97例 ,非切除行胆道内、外引流者 84例 ,单纯剖腹探查 2 0例。切除组中根治切除 5 1例 ,姑息切除 46例。随访 75例中 ,根治切除者 1,3,5年生存率分别为95 45 %,40 91%,13 6 4%;姑息切除者 1,3年生存率为 5 5 %,10 %,无 5年生存者 ;非切除性胆道内、外引流者 1年生存率为 36 %,无 3年生存者 ;单纯剖腹探查者均于 3个月内死亡。两个阶段对照显示 :手术切除率由 1990年 12月以前的 34 95 %提高到以后的6 2 2 4%,其中根治切除率由 15 5 3%提高到 35 71%;手术并发症及死亡率分别由 39 8%和 17 84%降低到 18 37%和 6 12 %。结论 根治切除是提高肝门部胆管癌远期存活率的关键 ,合理的围手术期处理可降低手术并发症发生率及死亡率。

肝胆管结石再手术原因及处理:附81例报告

目的 探讨肝胆管结石再手术的原因及手术处理方法。方法 回顾性分析 81例肝胆管结石患者的临床资料。再手术的方法主要包括肝叶切除、肝肠Roux en Y盆式内引流、肝叶切除加肝胆管Roux en Y盆式内引流。结果 肝胆管结石再手术的主要原因包括胆管狭窄和结石残留、胆管变异、合并胆管细胞癌等 ,再次手术后经胆道造影证实残留率为 6.2 % ,随访术后病人优良率为93 .8%。结论 清除结石、解除狭窄、矫正崎形、切除病肝、通畅引流系肝胆管结石的治疗原则。

腹腔镜胆总管探查胆管一期缝合术(附35例报告)

目的 探讨腹腔镜胆囊切除术 (LC)及胆总管探查、一期缝合胆总管的方法和效果。方法 LC后立即探查 3 5例有病变的胆总管 ,并进行胆道镜检查和取石 ,在取尽结石、确定胆总管下端无狭窄情况下 ,用可吸收线一期缝合胆总管。结果 3 2例胆总管结石取尽 ,3例探查阴性 ,3 5例全部行一期缝合胆总管 ,术后出现胆漏 2例 ,经保守治疗治愈。随访 2 9例 ,时间 3～ 2 4个月 ,无结石残留和胆管狭窄发生。结论 如病例选择恰当 ,腹腔镜下胆总管一期缝合是安全和有效的。

联合肝叶和肝门血管切除治疗肝门胆管癌

目的 探讨治疗肝门胆管癌理想的肝叶切除术式 ,以期提高其疗效、降低并发症和病死率。方法 对 16例侵犯肝门血管的肝门胆管癌 ,采用肝I ,IV段连同肝门胆管肿瘤与受侵血管整块切除及肝十二指肠韧带骨骼化淋巴清扫。结果 15例获手术切除 ,切除率为 93 .8% ,12例获R0 切除。无手术死亡和住院死亡。发生暂时性胆漏 1例 ,腹腔感染 1例 ,并发症发生率为 13 .3 % ,均行非手术治愈。随访病例中位生存期为 2 2个月 ,7例尚存活。结论 合并肝叶、肝门血管切除可提高肝门胆管癌的切除率和生存率 ;肝中叶和肝尾叶是肝门胆管癌手术联合切除的主要部位。肝门受侵血管的切除对提高该病切除率和根治率是有意义的 ,应酌情重建或不重建肝门血管。

多发性肝胆管结石及狭窄的外科治疗

目的 探讨肝段切除与胆管切开取石术治疗肝胆管结石的临床效果。方法 回顾性分析3 16例肝内胆管结石及狭窄的外科治疗情况。其中采用肝段切除为主治疗 172例 ,采用胆管切开为主14 4例。结果 肝段切除组其残石率、再手术率明显低于胆管切开组 (P <0 .0 5 ) ,其优良率肝段切除组明显高于胆管切开组 (P <0 .0 5 )。结论 重视术前诊断和准备 ,采取以肝段切除为主 ,合理选择胆肠吻合术是治疗肝胆管结石的最佳方式。

肝门部胆管癌的手术治疗:附102例报告

目的探讨肝门部胆管癌的手术治疗方式。方法回顾性分析1 9 9 0年8月—2 0 0 3年8月我院收治的1 0 2例肝门部胆管癌的临床资料。结果1 0 2例肝门部胆管癌中,5 8例(5 6.9%)行手术切除,其中2 7例(2 6.5%)行根治性切除,3 1例(3 0.4%)行姑息性切除;4 4例(4 3.1%)行胆管引流术,其中行胆肠吻合内引流术2 0例,胆管外引流术2 4例。根治性切除术组1,2,3,5年生存率分别为8 8.8 9%,5 1.8 5%,3 7.0 3%,2 2.2 2%;姑息性切除术组1,2,3,5年生存率分别为51.61%,6.4 5%,3.2 2%,0%;胆肠吻合内引流术组和胆管外引流术组的1年生存率分别是29.41%和2 3.8 0%,无生存2年者。结论手术切除,特别是根治性切除治疗肝门部胆管癌可取得较好的疗效。

胆源性急性胰腺炎的临床分型与手术时机的选择

目的 探讨胆源性急性胰腺炎 (GAP )的临床分型与手术时机的选择。 方法 对 10 9例GAP患者的临床资料进行回顾性分析。 结果及结论 按壶腹部有无梗阻及胰腺炎的严重程度 ,将GAP分为 4型并用不同方法处理 :( 1)轻症非梗阻型 ,以非手术治疗为主 ;( 2 )轻症梗阻型 ,自发病起观察约 36h ,如梗阻仍未解除需早期手术 ,如梗阻解除则继续非手术治疗 ;( 3)重症非梗阻型 ,以非手术治疗为主 ,并按胰腺坏死是否并发感染决定其是否手术 ;( 4 )重症梗阻型 ,宜行EST及时解除梗阻 ,如无此条件 ,应在短期支持治疗后早期手术。注意 :非手术治疗中如出现胆囊或胆道化脓性炎症宜早期手术 ;经非手术治疗度过急性期的患者 ,应限期手术解决胆石病。

肝胆管结石的手术治疗:附178例报告

目的探讨肝胆管结石的有效治疗方法。方法回顾性分析178例肝胆管结石的手术治疗患者的临床资料。178例中:T管引流术107例(其中并肝左叶或肝方叶切除7例);胆肠吻合手术71例(其中并肝左外叶或肝方叶切除11例)。结果术后胆管炎复发率分别为49.5%和24%,再手术率分别为28.7%和8%。结论解除胆道狭窄,去除病灶,通畅引流是预防胆管炎复发,减少再手术率的关键。

肝内胆管结石合并肝胆管癌:附24例报告

目的探讨肝内胆管结石与肝胆管癌发生的关系及提高早期诊断的措施。方法回顾性分析近2 0年收治的2 4例肝内胆管结石并发肝胆管癌患者的临床资料。结果肝内胆管结石并肝内胆管肿瘤在所有肝内胆管结石的病例中占2.8%(2 4/8 6 0),癌肿均发生于含结石胆管处,部分切片中可见癌与不同程度的胆管上皮不典型增生同时存在。术前B超、CT和MR I/MPCP对肝内胆管结石并发肝占位病变诊断率分别为4 0.9%(9/2 2),5 3.8%(7/1 3)和6 6.7%(4/6);手术切除率70.8%(1 7/2 4),根治性切除率为3 3.3%(8/2 4)例,姑息切除率为3 7.5%(9/2 4)。术后1,3年生存率:根治组为6 2.5%,2 5.0%,姑息性组为3 3.3%,1 1.1%,活检组为0%。结论长期肝内胆管结石反复发作是引起胆管癌发生的重要原因;结石型肝内胆管癌的延误诊断率高、根治性切除率低、预后差。重视结石型肝胆管癌临床延误诊断的原因并采取相应的避免措施有助于早期诊断。

肝门部胆管癌手术治疗:附64例报告

目的探讨肝门部胆管癌手术方式。方法回顾性分析15年间我院收治的64例肝门部胆管癌的临床资料,包括临床表现、临床分型、手术方式及治疗效果。其中35例行手术切除,包括根治性切除16例,姑息性切除19例;29例行胆管引流术,包括胆肠内引流术16例,胆管外引流术13例。结果根治性切除组1,2,3年生存率分别是80.0%,53.3%及26.7%;姑息切除组1,2,3年生存率分别为50.0%,16.7%,0%;胆肠内引流组1,2年生存率分别是45.5%和18.2%;外引流组则为25.0%和0。结论手术切除特别是根治性切除治疗是提高肝门部胆管癌疗效和提高远期生存率可选择的方法。

腹腔镜胆道探查取石T管引流术术式的研究

目的 探讨腹腔镜胆总管探查取石的最佳手术方法及手术适应证。方法 对我中心实施12 4例腹腔镜胆囊切除与胆总管切开探查取石、T管引流术的临床资料进行分析。结果 82例改进术式 ,中转开腹 4例 (4 .9% ) ,平均手术时间 (80± 3 0 )min。常规术式 42例 ,中转开腹 6例 (14 .3 % ) ,平均手术时间 (170± 40 )min。改进术式在手术时间上明显缩短于常规术式 (P <0 .0 1) ;中转开腹率显著低于常规术式 (P <0 .0 5 )。疗效和住院日两者无明显差异。结论 改进后的胆总管切开探查取石、T管引流术是治疗胆总管结石更为安全有效的措施。

合金胆道支架治疗不能切除的恶性肿瘤所致的梗阻性黄疸

目的 探讨镍钛记忆合金胆道支架治疗不能切除的恶性梗阻性黄疸的价值和适应证。方法 回顾性分析笔者治疗的 15例恶性梗阻性黄疸的临床资料 ,其中胆管癌 8例 ,胆囊癌 3例 ,胰腺癌 2例 ,胃癌根治术后肝门转移癌 2例 ,均置入合金胆道支架。结果 放置支架后 11～ 3 8d黄疸消退 ;1例放射介入方法置入支架第 3天出现胆道出血 ,经非手术方法治愈。无手术死亡。全部病例定期随访。术后生存 3 0～ 3 84(平均 180 .5 )d。结论 对不能切除的恶性梗阻性黄疸置入镍钛合金胆道支架 ,操作较简单 ,痛苦较少 ,并发症较少 ,减黄效果满意 ,是一种较为理想的姑息性疗法。

输尿管导管胆道引流用于胆总管探查及胆管一期缝合手术218例临床观察

目的 评价经胆囊管残端输尿管导管胆道引流在胆总管探查、胆管一期缝合术中的应用价值。方法 回顾分析经胆囊管残端输尿管导管胆道引流应用于完成开腹胆总管探查、胆管一期缝合术 2 18例。结果 2 18例手术均成功 ,术后无胆漏、胆管狭窄等并发症。术后 5～ 7d拔管 2 15例 ,术后 10d拔管 3例 ,无拔管并发症。术中结石取净率 99.7% ( 2 17/2 18)。术后住院时间为 ( 6.5± 3 .0 )d。随访 2 18例 ,时间 1～ 5年。B超检查无胆管狭窄。结论 经胆囊管残端输尿管导管胆道引流用于开腹胆总管探查、胆道一期缝合手术 ,对预防术后胆漏、胆总管狭窄以及对术后遗留病变的诊断和治疗具有广泛的应用价值 ;该方法安全、可靠、有效。

腹腔镜胆囊切除联合手术

目的 探讨腹腔镜胆囊切除联合其他手术的临床应用价值。方法 回顾分析 2 0 6例腹腔镜胆囊切除 (LC)联合手术的临床资料。结果 2 0 6例腹腔镜胆囊切除联合手术中 ,LC联合总胆管探查 64例 ,联合阑尾切除术 2 9例 ,联合肝囊肿开窗术 3 8例 ,联合其他肝脏手术 13例 ,联合肾囊肿去顶术 15例 ,联合腹腔粘连松解 3 1例 ,联合其他手术 16例。 2 0 4例获成功 ,2例中转开腹手术。术后发生胆漏 2例 ,1例经非手术疗法治愈 ,1例再手术治愈。结论 腹腔镜胆囊切除联合手术能安全、有效、经济地处理多种腹部疾病 。