Percutaneous transhepatic cholangiography vs endoscopic ultrasound-guided biliary drainage:A systematic review

BACKGROUND Percutaneous transhepatic cholangiography is a diagnostic and therapeutic procedure that involves inserting a needle into the biliary tree,followed by the immediate insertion of a catheter.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a novel technique that allows BD by echoendoscopy and fluoroscopy using a stent from the biliary tree to the gastrointestinal tract.AIM To compare the technical aspects and outcomes of percutaneous transhepatic BD(PTBD)and EUS-BD.METHODS Different databases,including PubMed,Embase,clinicaltrials.gov,the Cochrane library,Scopus,and Google Scholar,were searched according to the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses to obtain studies comparing PTBD and EUS-BD.RESULTS Among the six studies that fulfilled the inclusion criteria,PTBD patients underwent significantly more reinterventions(4.9 vs 1.3),experienced more postprocedural pain(4.1 vs 1.9),and experienced more late adverse events(53.8%vs 6.6%)than EUS-BD patients.There was a significant reduction in the total bilirubin levels in both the groups(16.4-3.3μmol/L and 17.2-3.8μmol/L for EUSBD and PTBD,respectively;P=0.002)at the 7-d follow-up.There were no significant differences observed in the complication rates between PTBD and EUSBD(3.3 vs 3.8).PTBD was associated with a higher adverse event rate than EUSBD in all the procedures,including reinterventions(80.4%vs 15.7%,respectively)and a higher index procedure(39.2%vs 18.2%,respectively).CONCLUSION The findings of this systematic review revealed that EUS-BD is linked with a higher rate of effective BD and a more manageable procedure-related adverse event profile than PTBD.These findings highlight the evidence for successful EUS-BD implementation.

Improving rehabilitation and quality of life after percutaneous transhepatic cholangiography drainage with a rapid rehabilitation model

BACKGROUND Percutaneous transhepatic cholangiography drainage(PTCD)effectively treats biliary obstruction.However,patients must maintain the drainage tube after hospital discharge,which may interfere with daily life and work,potentially causing psychological distress.Postoperative rehabilitation is crucial,and strengthened nursing interventions can shorten recovery time.AIM The aim was to evaluate an inpatient model to shorten rehabilitation duration and improve quality of life after PTCD.METHODS A total of 118 patients with malignant obstructive jaundice who were admitted to our hospital between May 2018 and January 2021 were included and divided into observational(with therapy)and control(no therapy)groups of 59 each.RESULTS The observational group had fewer hospitalization days than the control group.The complication,the PTCD fixed-tube prolapse,and tube-related admission rates within 3 mo after PTCD were significantly lower in the observation group than in the control group(P<0.05).The fatigue,pain,nausea,vomiting,pruritus,emaciation,and fever scores after PTCD decreased in both groups compared with the scores before PTCD(P<0.05).The quality of life scores after the intervention were higher in the observation than in the control group(P<0.05).CONCLUSION The model promoted rehabilitation after PTCD,reduced post-PTCD complications,and the tube-related admissions in the 3 mo after the procedure,and improved the quality of life.

Portal vein thrombosis following percutaneous transhepatic cholangiography-An unusual presentation of Prothrombin (Factor Ⅱ) gene mutation

Portal vein thrombosis is an uncommonly reported complication of percutaneous transhepatic cholangiography (PTC). A thorough review of the available literature shows no reported cases. In this case, a 29 year old female presented on two separate occasions with portal vein thrombosis following PTC without drain placement. This unusual complication of image guided percutaneous biliary access is unreported in the literature and prompted evaluation of the patient's coagulation parameters. A thrombophilia screen demonstrated a mutation in the Prothrombin (Factor Ⅱ) gene. A thorough literature review shows no reported cases of portal vein thrombosis following percutaneous biliary access, is an unusual complication, and should raise suspicion of an underlying pro-coagulant state.

Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures(BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal(UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy.Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.CASE SUMMARY We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography(PTC) in both cases and after 6-weeks' maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy(PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically,and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.CONCLUSION PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.

Percutaneous intraductal radiofrequency ablation for treatment of biliary stent occlusion: A preliminary result

AIM To assess the feasibility and effectiveness of a novel application of percutaneous intraductal radiofrequency(RF) for the treatment of biliary stent obstruction. METHODS We specifically report a retrospective study presenting the results of percutaneous intraductal RF in patients with biliary stent occlusion. A total of 43 cases involving biliary stent obstruction were treated by placing an Endo HPB catheter and percutaneous intraductal RF was performed to clean stents. The stent patency was evaluated by cholangiography and follow-up by contrast enhanced computed tomography or ultrasound after the removal of the drainage catheter.RESULTS Following the procedures, of the 43 patients, 40 survived and 3 died with a median survival of 80.5(range: 30-243) d. One patient was lost to followup. One patient had the stent patent at the time of last follow-up. Two patients with stent blockage at 35 d and 44 d after procedure underwent percutaneous transhepatic drain insertion only. The levels of bilirubin before and after the procedure were 128 ± 65 μmol/L and 63 ± 29 μmol/L, respectively. There were no related complications(haemorrhage, bile duct perforation, bile leak or pancreatitis) and all patients' stent patency was confirmed by cholangiography after the procedure, with a median patency time of 107(range: 12-180) d.CONCLUSION This preliminary clinical study demonstrated that percutaneous intraductal RF is safe and effective for the treatment of biliary stent obstruction, increasing the duration of stent patency, although randomized controlled trials are needed to confirm the effectiveness of this approach.

超声引导下经皮肝穿刺胆管引流与内镜逆行胰胆管造影会师术的临床价值

目的 探讨超声引导下经皮肝穿刺胆管引流(PTCD)与内镜逆行胰胆管造影(ERCP)会师术的临床应用价值。方法 选取我院常规行ERCP治疗困难或失败患者17例,应用超声引导下PTCD与ERCP会师术完成诊断及治疗,比较术前及术后2 d临床症状及实验室指标的差异,观察并发症发生情况。结果 17例患者均成功完成PTCD与ERCP会师术治疗,其中采取右侧肝内胆管穿刺16例,左侧肝内胆管穿刺1例;对胆总管结石患者行内镜下取石和鼻胆管放置,对胆管梗阻或狭窄患者行胆管扩张及支架置入术。会师术前与术后2 d血白细胞计数、丙氨酸氨基转移酶、天门冬氨酸氨基转移酶及血清淀粉酶水平比较,差异均无统计学意义;总胆红素、直接胆红素水平比较,差异均有统计学意义(均P<0.01)。术后患者胆管梗阻症状完全解除,均无严重并发症发生。结论 超声引导下PTCD与ERCP会师术成功率高、安全性好,具有较好的临床价值。

肝移植术后胆道吻合口狭窄的诊疗进展

近年来,随着器官保存、手术技术、围手术期管理及免疫抑制方案的发展,肝移植手术成功率和受者生存率明显提高,已成为终末期肝病患者的最佳治疗方案。但胆道并发症依然是肝移植术后常见的并发症,尤其是胆道吻合口狭窄,严重的胆道吻合口狭窄不仅会增加治疗成本,还会导致移植物丢失,甚至影响受者生存率。因此,胆道吻合口狭窄的及时诊断和治疗对于提高肝移植术后受者生存率至关重要。本文就肝移植术后胆道吻合口狭窄的危险因素、临床症状、诊断及治疗进行综述,以期为肝移植术后胆道吻合口狭窄的研究和诊疗提供新的思路,进一步提高肝移植手术效果和受者生存质量。

胆道超声造影引导PTCD治疗梗阻性黄疸的临床研究

目的 探讨胆道超声造影(ultrasound cholangiography, USC)引导经皮经肝穿刺胆道引流术(percutaneous transhepatic cholangial drainage, PTCD)治疗梗阻性黄疸的应用价值。方法 选取2021年1月至2023年2月于吉首大学第一附属医院行PTCD治疗的88例梗阻性黄疸患者作为研究对象,根据穿刺引导方式的不同分为USC组和数字减影血管造影(digital subtraction angiography, DSA)组,其中USC组48例,DSA组40例。所有患者均采取了PTCD治疗,USC组采取USC引导,DSA组采取DSA引导。比较两组患者的穿刺次数、手术时间、手术前后肝功能变化及并发症发生情况。结果 与DSA组相比,USC组穿刺次数更少,手术时间更短(P<0.01);两组患者术后第7 d血清总胆红素(total bilirubin, TBIL)、直接胆红素(direct bilirubin, DBIL)、丙氨酸氨基转移酶(alanine aminotransferase, ALT)、天冬氨酸氨基转移酶(aspartate aminotransferase, AST)水平均较术前降低,但降低程度两组间比较无明显差异(P>0.05)。结论 USC引导下PTCD与DSA引导下PTCD治疗梗阻性黄疸患者的疗效无明显差异,但采用USC引导能有效缩短手术时间,减少穿刺次数,该方法更安全,更简便,值得临床推广应用。

以ALATS球囊行经皮经肝十二指肠乳头肌扩张顺行排石术治疗胆总管结石

目的观察以14 mm ALATS球囊行经皮经肝十二指肠乳头肌扩张顺行排石术(PTPBD)治疗胆总管结石(CBDS)的效果及其安全性。方法回顾性分析40例接受直径14 mm ALATS球囊PTPBD治疗的CBDS患者,其中5例合并肝内胆管结石;CBDS最大径8~29 mm,19例最大径<14 mm(小结石组),21例≥14 mm(大结石组)。记录技术成功率、推石时间、围手术期并发症及不良反应。结果38例(38/40,95.00%)技术成功、2例技术失败,组间差异无统计学意义(P=0.269);推石时间16~62 min,平均(31.83±10.84)min。38例技术成功者中,术后6 h 30例诉轻度疼痛,6例感中度、2例诉重度疼痛,经对症治疗后均于48 h内缓解。围手术期未见胆管或肠管穿孔、胰腺炎等并发症。结论直径14 mm ALATS球囊用于PTPBD治疗CBDS效果较好且安全。

经皮肝穿刺胆道造影术下胆管活检的临床研究

目的 探索经皮肝穿刺胆道造影术 (PTC)下胆道活检的可行性和敏感性。方法 31例阻塞性黄疸患者 ,在行经皮经肝穿刺胆道内外引流术 (PTCD)中 ,进行PTC下胆道活检。通过经皮经肝胆道穿刺通道向胆道内送入 8F鞘 ,活检钳经鞘内送入并对病变狭窄段行胆道钳夹活检 ,获取多个标本 ,行组织病理学检查。结果 31例患者 30例获得组织病理学诊断 (敏感性 96 .8% )。结论 PTC下胆道活检是一种简单易行。

MRCP与ERCP、PTC诊断胆道梗阻性疾病的对比研究

目的 :探讨磁共振胰胆管成像 (MRCP)加梗阻部位薄层扫描或增强扫描、内镜逆行胰胆管造影 (ERCP)、经皮肝穿刺胆道造影 (PTC)对胆道梗阻的诊断价值。材料和方法 :回顾性分析 42例临床怀疑胆道梗阻患者的MRCP资料 (包括薄层或增强扫描 ) ,并与 18例ERCP、9例PTC比较 ,所有病例均经手术病理证实。结果 :MRCP加梗阻部位薄层扫描或增强扫描对胆管梗阻诊断准确率为 90 .5 % ,ERCP为 88.9% ,PTC为 88.9%。结论 :MRCP加梗阻部位薄层扫描或增强扫描对胆管梗阻具有重要诊断价值。

普通B超探头引导下经皮经肝胆道引流术38例体会

目的和穿刺探头相比,探讨普通B超探头引导下经皮经肝胆道引流术(percutaneous transhepaticcholangial drainage,PTCD)的优越性。方法回顾性分析38例晚期恶性胆道梗阻患者行PTCD术的资料,总结穿刺的经验和方法,并同使用专用穿刺探头的穿刺方法作比较。结果1次穿刺成功率为65.8%(25/38);2次穿刺成功率为86.8%(33/38);3次及3次以上穿刺成功率为100%。1例发生胆漏,1例术后死于心力衰竭。结论普通B超探头引导下PTCD术具有方法简单、对设备要求不高且成功率较高的特点,便于在临床广泛开展。

梗阻性黄疸患者MRCP及肝胆断层MR检查对于PTC及PTBD指导作用的分析

目的 比较MRCP与PTC在梗阻性黄疸的诊断过程中的优缺点,探讨 MRCP对 PTC和 PTBD治疗的指导作用。方法 15例梗阻性黄疸患者分别进行MRCP和PTC检查,并行PTBD介入治疗,分析图像,对两种检查方法的定位、定性诊断的正确率和对胆道显示的情况进行比较。结果 MRCP与 PTC的定位诊断和定性诊断的正确率分别为:PTC100%和80%;MRCP 100%和93%。MRCP与 PTC相比在梗阻性黄疸患者中能够更好地显示肝内外胆道的情况。与MRCP检查同时进行的横断面和冠状断层图像可以准确显示胆道管腔以外的病变。在 MRCP指导下,PTBD介入治疗留置引流管单纯外引流6例,内外引流9例。引流效果满意,没有严重并发症发生。结论 梗阻性黄疸患者的MRCP及肝胆断层MRI检查,可以较PTC提供更多的诊断信息,并对PTBD提供有力的指导作用,减少并发症,提高手术成功率。

经皮肝穿刺胆道造影术下的胆道活组织检查诊断阻塞性黄疸

目的 探索PTC胆道活检的可行性和敏感性 ,指导临床治疗。方法 2 6例阻塞性黄疸 ,在行PTCD(经皮肝穿刺胆道内外引流术 )减黄术中 ,进行PTC胆道活检。此技术通过经皮经肝穿刺通道送入 8F鞘 ,将活检钳经鞘内送入并对病变狭窄段行胆道活检 ,获取多个标本 ,然后行组织病理学检查。结果 2 6例中有 2 4例获得组织病理学诊断 (敏感性 92 .3 1% )。病理报告为胆管腺癌 15例 ,胆管鳞癌 1例 ,胰腺癌 2例 ,肝癌 2例 ,胃腺癌胆总管转移 1例 ,硬化性胆管炎 1例 ,胆管慢性炎症 1例 ,胆管结石 1例 ,阴性结果 2例 ,阳性结果率为 92 .3 1%。结论 PTC下胆道活检是一种简单易行。

恶性梗阻性黄疸不同姑息治疗方法疗效观察

目的探讨不同方式的胆汁引流对治疗恶性梗阻性黄疸的疗效。方法回顾性分析该院消化内科及肝胆外科2008年-2013年97例恶性梗阻性黄疸患者的临床资料。结果 97例患者中57例行经内镜逆行胰胆管造影引流术(ERCP)术(A组),成功率94.7%(54/57),40例行经皮肝穿刺胆管/胆囊引流术(PTCD/PTGD)术(B组),成功率95.0%(38/40)。术后患者腹痛、皮肤瘙痒等不适症状明显缓解。两组患者血清总胆红素、直接胆红素和碱性磷酸酶水平术后均明显降低,差异有显著性(P<0.05)。两组患者人均手术次数和术后住院时间差异无显著性(P>0.05)。B组患者并发症的发生率较A组明显增高(P<0.05)。结论 ERCP术和PTCD/PTGD术均为有效的姑息性治疗方法。但ERCP术并发症发生率低,能明显提高患者生活质量,且考虑内镜介入治疗的安全性,故ERCP术是失去手术机会或不愿手术的恶性梗阻性黄疸患者的首选治疗。

阻塞性黄疸:经皮穿刺胆道造影下胆道钳夹活检与毛刷活检对比研究

目的 比较胆道钳夹与毛刷活检的诊断敏感率 ,探索胆道疾病病理学检查新途径。方法 连续 92例阻塞性黄疸接受经皮肝穿胆道造影 (PTC)和经皮肝穿胆道引流 (PTCD)治疗。PTCD过程中 ,影像监测下经皮经肝胆道穿刺 ,向胆道内引入活检钳和毛刷对梗阻段钳夹和毛刷活检 ,行组织病理学和细胞检查。结果 92例钳夹活检患者 90例成功获得组织块 ,技术成功率 97.8% (90 92 )。钳夹活检敏感率较毛刷活检敏感率高 (88.0 %比 76 .2 % ,χ2 =4 .2 5 1,P =0 .0 39)。结论 PTC下胆道钳夹活检操作简单 ,创伤小 ,敏感度高 ,是一种值得推广的胆道病理学诊断新途径 ,毛刷活检在胆管癌的诊断方面也具有较高的应用价值。

PTBD患者院外带管生活体验的质性研究

目的了解PTBD患者院外带管生活的真实体验,以便制定相对应的健康教育和延续性护理方案。方法应用质性研究的现象学方法,由介入专科责任护士对带管出院1个月以上的恶性梗阻性黄疸PTBD患者进行深入访谈,运用Colaizzi七步分析法进行资料的整理和分析。结果纳入本研究患者10例,PTBD患者院外带管生活体验的主要内容包括日常生活自理能力改变,患者角色强化或缺如;担心管道脱出、感染等问题;自我形象紊乱,社交恐惧;不同程度的身体不适及负性情绪和心理压力;希望引流袋及固定材质、方式等得到改进,希望能有更便利的换药的途径等。结论 PTBD患者的生活处于不同程度的应激状态,医护人员应开展针对性的健康教育和延续性护理,包括研究器材改进等以帮助其提高自护能力、降低并发症和心理压力,从而提高生活质量。

超声引导PTC在恶性梗阻性黄疸诊断中的应用

目的总结经皮肝穿刺胆道造影(PTC)对恶性梗阻性黄疸的诊断价值并将超声引导经皮肝穿刺胆道造影(U-PTC)和常规(X-PTC)进行比较.方法将该院2001年7月～2004年3月间进行的U-PTC(12例)同X-PTC(31例)进行比较.结果二者均对恶性梗阻性黄疸的诊断提供较为丰富的信息,但U-PTC较PTC更具有优点.结论PTC在恶性梗阻性黄疸的诊断中具有自身的优势,U-PTC较PTC具有具有操作时间短、成功率高、并发症少、病人痛苦小等优点,值得在临床推广.

新型胆道射频消融导管在离体猪肝应用的实验研究

目的观察新型胆道双极射频消融导管Habib TM EndoHPB设置不同功率及持续时间的消融效果。方法在恒温下（37.0℃）使用新型胆道射频消融导管对新鲜离体猪肝进行实验，分别设置功率5、10和15W，时间60、90、120和150s。观察在不同功率／时间参数时，消融区域的温度、宏观（短轴／长轴）及微观的变化。结果设置功率5W、时间60-150s，消融区域的最高温度为42.0-54.0℃；10W、60—150s，最高温度为52.0～70.O℃；15W、60-120s，最高温度为62.0～77.0℃。10W和60、90、120及150s时，短轴长度（mm）分别为8.±0.8、9.0±0.8、9.5±0.8及10.0±0.8；长轴长度（mm）分别为21.0±1.0、23.5±1.0、25.5±1.0及30.0±1.0。5、10、15W时，短轴和长轴长度均有小幅增大，其中功率为10W及15W时，两组差异无统计学意义（P〉0.05）。镜下消融区域均出现肝组织解离、细胞间距变大、细胞广泛变性，程度随着功率和时间增加而加重，且在10W、150s及15W、120s时，出现片状液化性坏死。结论Habib TM EndoHPB导管设置功率10W、时间90至120s进行消融比较合适，在临床实际操作中可参考本实验结果进行适当的调整。

恶性阻塞性黄疸PTC胆管活检病理学与PTC影像学特征对照研究

目的评价经皮肝穿刺胆管造影术(PTC)与PTC胆管活检对阻塞性黄疸的诊断价值和临床意义。资料与方法回顾性分析资料完整并接受PTCD和胆管内支架置入治疗及PTC胆管活检的连续76例阻塞性黄疸病例,比较PTC胆管活检与PTC影像学特征的关系及并发症的发生情况。结果PTC胆管活检对恶性病变定性诊断的阳性率低于PTC间接诊断的阳性率,差异具有显著性意义(χ2=10.178,P=0.001<0.05),但PTC胆管活检对组织学定性诊断的阳性率与PTC间接诊断的阳性率比较,差异无显著性意义(χ2=2.533,P=0.111>0.05)。PTC胆管重度扩张者的胆管活检阳性率高于胆管中度和轻度扩张者的阳性率,差异具有显著性意义(H=7.991,P=0.018<0.05),PTC胆管活检阳性率与PTC阻塞形态和部位无关。结论PTC胆管造影是PTC胆管活检的基础,二者应相互结合,相互补充,共同提高PTC胆管活检的阳性率。