经皮经肝胆道引流术治疗恶性梗阻性黄疸的疗效观察
摘要
目的：探讨介入治疗恶性梗阻性黄疸的效果及价值,并分析影响患者生存时间的相关因素。方法：回顾性分析我院2006年-2010年恶性梗阻性黄疸病例146例,其中男84例、女62例,平均年龄(63±13)岁,所有患者术前均行彩色B超或CT或MRI检查,并行实验室检查。先行经皮经肝胆道穿刺,随后针对不同部位的梗阻分别置入引流管行胆道引流(PTBD)或置入胆道内支架(PTBS);术后给予抗感染、保肝、抗肿瘤及对症治疗,复查影像学或生化变化；术后1周,37例行肝动脉化疗栓塞(TACE);并对其中139例通过门诊及电话随访；另外还对性别、年龄、病因、梗阻部位及生化指标等因素对生存时间的影响进行了分析。结果：146例病例均成功穿刺并置入引流管(105例)及植入支架(41例),手术成功率100%,术后129例患者黄疸等症状好转,总有效率88.4%；PTBD及支架引流术前总胆红素(TB)、血清丙氨酸转氨酶(ALT)、直接胆红素(DB)、血清碱性磷酸酶(ALP)、γ-谷氨酰转肽酶(γ-GT)及血清白蛋白水平较术后降低,进行独立样本t检验,三种不同引流方法在减轻黄疸,改善肝功能,延长生存期方面差异有统计学意义(P<0.05)；PTBS减轻黄疸的幅度优于PTBD,但黄疸缓解的比例组间无差异；37例患者术后1周接受了TACE治疗,对治疗前后TB.DB.ALT.ALP行t检验,有统计学差异(P<0.05)；三种引流方式对生存率影响有显著性差异(P=0.000)；单纯外引流组、内外引流组及胆道支架组的中位生存期分别为3.3月、5.0月及7.3月,PTBS组在生存期方面亦优于PTBD组,术前TB及白蛋白水平对预后有意义。结论：PTBD/PTBS是治疗恶性梗阻性黄疸的一种有效的姑息性治疗方法,能有效减轻黄疸,缓解临床症状,尽可能在早期行PTBD/PTBS,以最大程度改善患者生活质量。术后行TACE治疗可明显加快胆红素水平下降的幅度,术前TB及白蛋白水平是影响术后生存时间的主要因素,对患者的预后可做初步预测。
Objecfive:Malignant obstructive jaundice is a common disease clinically, and when diagnose, most of the patients have lost the opportunity of operative eradication, operation. PTBD/PTBS have become one of the main therapeutic method of malignant obstructive jaundice which has lost operative opportunity. They have certain curative effect, small trauma and liess complication. This study aim at the clinical outcome and its relative influencing factors of interventional therapy in dealing malignant obstructive jaundice(MOJ). Methods:Between October 2006 and February 2010, one hundred and forty six MOJ patients,84 males and 62 females, aged(63±13), underwent interventional therapy:105 patients received percutaneous transhepatic biliary drainage(PTBD) including external drainage or external-internal drainage, and 41 underwent percutaneous transhepatic biliary stent(PTBS) implantation. No major complications associated with the execution of PTBD occurred. The various symptoms caused by jaundice, such as anorexia, itching, nausea, abdominal pain and fever, were relieved in one hundred and twenty nine patients within one week after PTBD.3-7days after the procedure, total bilirubin(TB), direct bilirubin(DB), alanine transaminase(ALT), alkaline phosphatase(ALP), y-glutamyl transpeptidase(y-GT) and albumin were examined. One week after,37 of the patients underwent transcatheter arterial chemoembolization(TACE). Results:One week after drainage, the levels of ALT, TB, DB, ALP,γ-GT and albumin of the patients underwent PTBD and PTBS all decreased in comparison with the baseline level(P<0.05). The levels of the PTBS group were significantly lower than those of the PTBD group, but the difference was not statistically significant among these 3 groups. The levels of ALT, TB, and DB of 37 patients underwent TACE all decreased in comparison with those before the treatment(P<0.05). The mean survival time of the external drainage group and external-internal drainage group was 3.3 and 5.0 months respectively, the PTBS group was 7.3 months. Conclusions:PTBD/PTBS is a technically feasible, and safe and clinically efficacious treatment for malignant biliary obstruction. It can relieve the clinical symptom and alleviate jaundice effectually; Therefore, the patients should receive PTBD in the early time in order to improve the life quality maximumly. Furthermore, TACE therapy following PTBD and PTBS will be significantly beneficial to decrease TB of MOJ patients.
Objecfive:Malignant obstructive jaundice is a common disease clinically, and when diagnose, most of the patients have lost the opportunity of operative eradication, operation. PTBD/PTBS have become one of the main therapeutic method of malignant obstructive jaundice which has lost operative opportunity. They have certain curative effect, small trauma and liess complication. This study aim at the clinical outcome and its relative influencing factors of interventional therapy in dealing malignant obstructive jaundice(MOJ). Methods:Between October 2006 and February 2010, one hundred and forty six MOJ patients,84 males and 62 females, aged(63±13), underwent interventional therapy:105 patients received percutaneous transhepatic biliary drainage(PTBD) including external drainage or external-internal drainage, and 41 underwent percutaneous transhepatic biliary stent(PTBS) implantation. No major complications associated with the execution of PTBD occurred. The various symptoms caused by jaundice, such as anorexia, itching, nausea, abdominal pain and fever, were relieved in one hundred and twenty nine patients within one week after PTBD.3-7days after the procedure, total bilirubin(TB), direct bilirubin(DB), alanine transaminase(ALT), alkaline phosphatase(ALP), y-glutamyl transpeptidase(y-GT) and albumin were examined. One week after,37 of the patients underwent transcatheter arterial chemoembolization(TACE). Results:One week after drainage, the levels of ALT, TB, DB, ALP,γ-GT and albumin of the patients underwent PTBD and PTBS all decreased in comparison with the baseline level(P<0.05). The levels of the PTBS group were significantly lower than those of the PTBD group, but the difference was not statistically significant among these 3 groups. The levels of ALT, TB, and DB of 37 patients underwent TACE all decreased in comparison with those before the treatment(P<0.05). The mean survival time of the external drainage group and external-internal drainage group was 3.3 and 5.0 months respectively, the PTBS group was 7.3 months. Conclusions:PTBD/PTBS is a technically feasible, and safe and clinically efficacious treatment for malignant biliary obstruction. It can relieve the clinical symptom and alleviate jaundice effectually; Therefore, the patients should receive PTBD in the early time in order to improve the life quality maximumly. Furthermore, TACE therapy following PTBD and PTBS will be significantly beneficial to decrease TB of MOJ patients.
引文
[1]单鸿,罗鹏飞,李彦豪.临床介入治疗学[M].广州：广东科技出版社,1997：23-24.
[2]王小林.胆道疾病介入放射学[M].上海：复旦大学出版社,2005：183.
[3]高立兵,刘亮,江水.经皮肝穿刺胆管引流治疗高位梗阻性黄疸[J].当代医学(中国介入放射学专题),2009,15,(29)：583.
[4]Freeman ML., Carol Ovcrby. Selective MRCP and CT-targeted drainage of malignant hilar billary structures with self-expanding metallic stents[J]. Gastrointest Endosc, 2003,58(1):41-49.
[5]张学强,翟仁友.恶性梗阻性黄疸介入治疗短期预后的多因素分析[J].介入放射学杂志,2009,18,(11)：847.
[6]Iizuka T, Hoshihara Y, Hoteya O, et al. A case of gastric Cancer presenting with obstructive jaundice and responding to biweekly CPT-11 and CDDP combination administration[J]. Gan To Kagaku Ryoho,2006,33:659-661.
[7]李铎,孙家邦,孙海晨等.梗阻性黄疸时肝功能受损机制[J].中华外科杂志,1998,36：624-626.
[8]Rodrigo Castan o, Tercio L. Lopes, Oscar Alvarez, et al. Nitinol biliary stent versus surgery for palliation of distal malignant biliary obstruction[J]. Surg Endosc,2010,24: 2092-2098.
[9]罗祖炎,陈方宏,袁建华.国产胆道金属支架的临床应用[J].介入放射学杂志,2004,13(5)：433-435.
[10]Paskan J, Vavrecka A, Lesny P, et al. The sianificance of non surgical bile duct drainage in patients with icterus[J]. Rozhl Chir,1990,69(2):71-76.
[11]Rossi P, Bezzi M, Rossi P, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients[J]. Vase Intervent Radiol,1994, 5:279-285.
[12]Padillo J, Puente J, Gomez M, et al. Improved cardiac function in patients with obstructive jaundice after internal biliary drainge:hemody-namic and hormonal assessment[J]. Ann Surg,2001,234:652-656.
[13]Zhu Lidong, Chen Xiaoping. Change and significance of T-cell subsets and TNF-α in patients with advanced malignant obstructive jaundice treated by percutaneous transhepatic biliary external and internal drainage[J]. Frontiers of Medicine in China, 2007,1(4):364-368.
[14]Bonnel D, Ferrucci JT, Mueller HF, et al. Surgical and decompression in malignant biliary obstruction:A retrospective study using multi-variate risk factor analysis[J]. Radiolog,1984,152:347.
[15]田伏洲,石力,汤礼军等.胰头癌术前减黄指征的前瞻性研究[J].中华外科杂志,2006,44(23)：1614-1616.
[16]GuoYX, Li YH, Chen Y, et al. Percutaneous transhepatic metal versus plastic biliary stent in treating malignant biliary obstruction:a multiple center investigation[J]. Hepatobilary Pancreat Dis Int,2003,2:594-597.
[17]Yoshida H, Mamada Y, Taniai N, et al. One-step Palliative treatment method for obstructive jaundice caused by unresectable malignancies by percutaneous transhepatic insertion of an expandable metallic stent[J]. World J Gastroenterol,2006, 12:2423-2426.
[18]翟仁友,黄强.恶性梗阻性黄疸介入治疗常见问题的处理[J].介入放射学杂志,2007,16(10)：649-651.
[19]王健,罗鹏飞,于新发等.单通道植入T型胆道支架治疗肝门部胆管恶性梗阻5例分析[J].中国误诊学杂志,2009,18(9)：4506-4507.
[20]Dong Ⅱ Gwon, Gi-Young Ko, Hyun-Ki Yoon, et al. Prospective Evaluation of a Newly Designed T-configured Stent Graft System for Palliative Treatment of Advanced Hilar Malignant Biliary Obstructions[J]. J Vase Interv Radiol.,2010,21(9): 1410-1418.
[21]Arguedas MR, Heudebert GH, Stinnett AA, et al. Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma:a cost-effectiveness analysis[J]. Am J Gastroenterol,2002,97:898-901.
[22]向华,刘觉仕,张智明,等.胆道支架经皮置入术治疗恶性梗阻性黄疸[J].医学临床研究,2007,24(5)：810-812.
[23]钱晓军,翟仁友,戴定可等.老年人恶性梗阻性黄疸介入治疗回顾性分析[J].中华放射学杂志,2000,34：342.
[24]Roberto Gandini, S.Fabiano, Vincenzo Pipitone, et al. Management of Biliary Neoplastic Obstrution with Two Different Metallic stents Implanted in One Session[J]. Cardio Vascular and Interventional Radiology,2005,28(1):48-52.
[25]Mehmet inal, Erol Aksungur, Erol Akgul, et al. Percutaneous Placement of Metallic Stents in Malignant Biliary Obstruction:One-Stage or Two-Stage Procedure? Pre-Dilate or Not? [J]. Cardiovasc Intervent Radiol,2003,26:40-45.
[26]Inal M, Akgnt E, Aksungnr E, et al. Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction:unilobar versus bilobar drainage[J]. J Vase Interv Radiol,2003,14:1409-1416.
[27]冯博,石强,徐克.跨越Vater壶腹胆道支架置入术治疗恶性低位胆道梗阻(附32例报告)[J].中国临床医学影像杂志,2008,19(4)：265-267.
[28]Cherian George, Oliver Richard Byass, James Edmund Ian Cast. Interventional radiology in the management of malignant biliary obstruction[J]. World J Gastrointest Oncol,2010 March,2(3):146-150.
[29]Jeong YW, Shin KD, Kim SH, e al. The safety assessment of percutaneous transhepatic transpapillary stent insertion in malignant obstructive jaundice:regarding the risk of pancreatitis and the effect of preliminary endoscopic sphincterotomy[J]. Korean J Gastroenterol.2009,54(6):390-394.
[30]Gu YK, Fan WJ, Wei HW, et al. Interventional management of severe complications after percutaneous transhepatic cholangic drainage and percutaneous implantation of biliary stents[J]. Zhonghua Yi Xue Za Zhi,2008,88(41):2916-2919.
[31]王生海,吕德元.胆道手术并发胆心综合征16例[J].中国急救医学,1996,5：309.
[32]田伟军,徐青,谢宗贵.硬膜外麻醉下胆道支架植入术[J].介入放射学杂志,2002,11(1)：59-60.
[33]Van Delden, O.M.and J.S.Lameris, Percutaneous drainage and stenting for palliation of malignant bile duct obstruction[J]. Eur Radiol,2008,18(3):448-456.
[34]Sut M, Kennedy R, McNamee J, et al. Long-term results of percutaneous transhepatic cholangiographic drainage for palliation of malignant biliary obstruction [J]. J Palliat Med.,2010,13(11):1311-1313.
[35]Lee JW, Han JK, Kim TK, et al. Obstructive jaundice in hepatocellular carcinoma: response after percutaneous transhepatic biliary drainage and prognostic factors[J]. Cardiovasc Intervent Radiol,2002,25:176-179.
[36]P. C. Robson, N. Heffernan, M. Gonen, et al. Prospective Study of Outcomes after Percutaneous Biliary Drainage for Malignant Biliary Obstruction[J]. Ann Surg Oncol, 2010,17:2303-2311.
[37]钱晓军,戴定可,翟仁友.恶性梗阻性黄疸介入治疗的疗效分析[J].中华肝胆外科杂志,2004,10：752-755.
[38]施海斌,李麟荪,徐泽宽,等.经皮胆道引流术治疗恶性梗阻性黄疸[J].介入放射学杂志,2001,10(5)：292-295.
[39]Cherian George, Oliver Richard Byass, James Edmund Ian Cast. Interventional radiology in the management of malignant biliary obstruction[J]. World J Gastrointest Oncol,2010,2(3):146-150.
[40]Lee JW, Han JK, Kim TK, et al. Obstructive jaundice in hepatocellular carcinoma: response after percutaneous transhepatic biliary drainage and prognostic factors[J]. Cardiovasc Intervent Radiol,2002,25:176-179.
[41]Elias N. Brountzos, Nikolaos Ptochis, Irene Panagiotou, et al. A Survival Analysis of Patients with Malignant Biliary Strictures Treated by Percutaneous Metallic Stenting[J]. Cardiovasc Intervent Radiol,2007,30:66-73.
[42]Neal CP, Thomasset SC, Bools D, et al. Combined percutaneous-endoscopic stenting of malignant biliary obstruction:results from 106 consecutive procedures and identification of factors associated with adverse outcome[J]. Surg Endosc,2010,24(2): 423-31.
[43]王小林,陈颐,程洁敏等.胆道支架置放治疗恶性梗阻性黄疸的预后因素分析附15例报告[J].复旦学报(医学版),2002,11：476-479.
[44]李茂全,张家兴,陆晨晖等.恶性梗阻性黄疸介入综合治疗[J].中华医学杂志,2008,88(39)：2473-2477.
[45]郭鹏,谢春明,杨敏玲等.恶性梗阻性黄疸双介入治疗的临床研究[J].当代医学,2010,16(5)：31-33.
[46]Thomas B.Brunner, Dieter Schwab, Thomas Meyer, et al. Chemoradiation May Prolong Survival of Patients with Non-Bulky Unresectable Extrahepatic Biliary Carcinoma[J]. Strahlenther Onkol,2004,180:751-757.
[47]Gianpaolo Carrafiello, Domenico Lagana, Elisa Cotta, et al. Radiofrequency Ablation of Intrahepatic Cholangiocarcinoma:Preliminary Experience[J]. Cardiovasc Intervent Radiol,2010,33:835-839.
[48]吴海江,管峦,崔宁等.胆道支架置入联合内外放疗治疗恶性阻塞性黄疸的临床观察[J].中华全科医师杂志,2008,7(10)：707-708.
[1]Schoder M, Rossi P, Uflacker R, et al. Malignant biliary obstruction:treatment with ePTFE-FEP-covered endoprostheses initial technical and clinical experiences in a multicenter trial[J]. Radiology,2002,225(1):35-42.
[2]Shigeta H, Nagino M, Kamiya J, et al. Bacteremia after hepatectomy:ananalysis of a single-center,10-year experience with 407 patients[J]. Langenbeck Arch Surg,2002, 387(3-4):117-124.
[3]van Delden OM, Lameris JS. Percutaneous drainageM and stenting for palliation of malignant bile duct obstruction[J]. Eur Radiol,2008,18:448-456.
[4]Baijal SS, Dhiman RK, Gup ta S, et al. Percutaneous transhepatic biliary drainage in the management of obstructive jaundice[J]. Trop Gastroenterol,1997,18(1):167-171.
[5]王成刚,沈杰,龚高全等.肝癌合并梗阻性黄疸的双介入治疗临床研究[J].中 国现代医生,2008,46(19)：7-9.
[6]Soulez G, Gagner M, Therasse E, et al. Malignant biliary obstruction:Premilinary results of palliative treatment with hepaticogastrostomy under fluoroscopic, endoscopic and laparoscopic guidance[J]. Radiology,1994,192:241.
[7]Rossi P, Bezzi M, Rossi M, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients[J]. J Vase Interv Radiol,1994, 5(2):279-285.
[8]于平,戴定可,钱小军等.胆管引流术或支架置入术围手术期并发症的临床研究[J].中华肿瘤杂志,2009,31(12)：923-924.
[9]张勇春,顾占军,邓晓涛等.经皮胆管内支架放置术并发症及发生意外情况的处理方法[J].中华放射学杂志,2002,36：1084-1086.
[10]向华,刘觉仕,张智明等.胆道支架经皮置入术治疗恶性梗阻性黄疸[J].医学临床研究,2007,24(5)：810-812.
[11]Roberto Gandini, S.Fabiano, Vincenzo Pipitone, et al. Management of Biliary Neoplastic Obstrution with Two Different Metallic stents Implanted in One Session[J]. Cardio Vascular and Interventional Radiology,2005,28(1):48-52.
[12]于凤海,陆蕊,陆正华等.胆道梗阻患者行ERCP治疗失败后行PTC与ERCP对接的研究体会[J].中华消化内镜杂志,2008,25(12)：652-654.
[13]郭元新,陈勇,李彦豪.金属内支架、塑料内涵管治疗胆管梗阻成本效果分析研究现状[J].中华放射学杂志,2001,35：226-227.
[14]Eschelman DJ, Shapiro MJ, Bonn J, et al. Malignant biliary duct obstruction: long-term experience with Gianturco stents and combinedmodality radiation therapy[J]. Radiology,1996,200(3):717-724.
[15]TOSHIO TSUYUGUCHI, TADAHIRO TAKADA, MASARU MIYAZAKI, et al. Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas[J]. J Hepatobiliary Pancreat Surg,2008,15: 69-73.
[16]Cady B, Jenkins RI, Steele GD Jr, et al. Surgical margin in hepatic resection for colorectal metastasis:a critical and improvable determinant of outcome[J]. Ann Surg, 1998,227:566-571.
[17]Coldwell D. Non-surgical hepatic tumor ablations[M].4th.Singapore:Asian Pacific Congress of cardiovascular and interventional radiology,2000:123.
[18]Seong J. Recent developments in radiotherapy of hepatocellular carcinoma[J]. Korean J Hepatol,2004,10(4):241-247.
[19]罗开元.实用组织间植入内放射治疗恶性肿瘤学[M].北京,人民卫生出版社,2008：351-352.
[20]范卫君,张亮,顾仰葵等.CT导向下高频介入热治疗在肝内胆管癌治疗中价值[J].中华医学杂志,2008,88(25)：1759-1761.
[21]郑建伟,唐涛,肖宝来等.内磁场在磁靶向治疗胆道恶性肿瘤中作用的实验研究[J].北京医学,2006,28：726-729.
[22]Padillo J, Puente J, Gomez M, et al. Improved cardiac function in patients with ob structive jaundice after internal biliary drainge:hemody-namic and hormonal assess-ment[J]. Ann Surg,2001,234:652-656.
[23]Zhu Lidong, Chen Xiaoping. Change and significance of T-cell subsets and TNF-α in patients with advanced malignant obstructive jaundice treated by percutaneous transhepatic biliary external and internal drainage[J]. Frontiers of Medicine in China, 2007,1(4):364-368.
[24]朱芳来,凌安生.胆道内支架置入治疗恶性梗阻性黄疸疗效观察[J].实用临床医学,2008,9(1)：48-50.
[25]冯博,石强,徐克.跨越Vater壶腹胆道支架置入术治疗恶性低位胆道梗阻(附32例报告)[J].中国临床医学影像杂志,2008,19(4)：265-267.
[26]Yu Li Sol, Chang Won Kim, Ung Bae Jeon, et al. Early Infectious Complications of Percutaneous Metallic Stent Insertion for Malignant Biliary Obstruction[J]. AJR, 2010,194:261-265.
[27]Arguedas MR, Heudebert GH, Stinnett AA, et al. Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma:a cost-effectiveness analysis[J]. Am J Gastroenterol,2002,97:898-904.
[28]Brountzos EN, Ptochis N, Panagiotou I, et al. A survival analysis of patients with malignant biliary strictures treated by percutaneous metallic stenting[J]. Cardiovasc Intervent Radiol,2007,30(1):66-73.
[29]Hong HP, Kim SK, Seo TS. Percutaneous metallic stents in patients with obstructive jaundice due to hepatocellular carcinoma[J]. J Vase Interv Radiol,2008,19(5): 748-754.
[30]Tsuyuguchi T, Takada T, Miyazaki M, et al. Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas[J]. J Hepatobiliary Pancreat Surg,2008,15:69-73.
[31]曹广,杨仁杰.金属支架姑息治疗恶性梗阻性黄疽的术后随访及生存分析[J].北京大学学报,2008,409(2)：121-124.
[32]Hatzidakis A, Krokidis M, Kalbakis K, et al. ePTFE/FEP-covered metallic stents for palliation of malignant biliary disease:can tumor ingrowth be prevented?[J]. Endoscopy,2007,39(4):319-24.
[33]E Kullman, F Frozanpor, C Soderlund, et al. Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction:results from a randomized,multicenter study[J]. Gastrointest Endosc, 2010,72(5):915-23.
[34]JJ Telford, DL Carr-Locke, TH Baron, et al. A randomized trial comparing uncovered and partially covered self-expandable metal stents in the palliation of distal malignant biliary obstruction[J]. Gastrointestinal Endoscopy,2010,72(5):907-914.
[35]丁广成,刘新疆,朱晓民等.胆汁引流联合立体定向三维适形放疗治疗中晚期胰腺癌38例[J].肿瘤研究与临床,2008,20(11)：765-767.
[36]郑爱青,于金明,徐瑾等.立体定向适形放疗剂量对晚期胆管癌治疗疗效的影响[J].中国癌症杂志,2004,14(4)：339-342.
[37]Tsujino K, Landry JC, Smith RG, et al. Definitive radiation therapy for extrahepatic bileduct carcinoma[J]. Radiology,1995,196 (1):275.
[38]李玉,王宁,田起和等.金属支架联合立体定向适形放疗治疗肝门部胆管癌[J].中华放射肿瘤学杂志,2005,14(1)：39-41.
[39]丁田贵,尹立杰,高众等.胆道介入支架联合立体定向放射治疗恶性梗阻性黄疸[J].中华放射医学与防护杂志,2006,26(3)：265-266.
[40]游洋,常钢,孟凡喆.胆道支架置入联合碘125粒子腔内照射治疗恶性梗阻性黄疸的临床应用[J].西安交通大学学报(医学版),2007,28(2)：1-2.
[41]杜学明,许建辉,郎建华等.多学科技术联合1251治疗癌梗阻性黄疸[J].介入放射学杂志,2008,17(5)：346-348.
[42]何贵金,鞠光,高沁怡等.103钯放射性支架对胆管癌细胞bcl-2表达的影响和意义[J].中华肝胆外科杂志,2009,15(1)：70-71.
[43]杨莉莉,曹贵文,崔新江等.双介入治疗肝门部胆管癌的临床应用研究[J].医学影像学杂志,2010,20(2)：270-273.
[44]Gyoo-Sik Jung, Jin-Do Huh, Sang Uk Lee. Bile Duct:Analysis of Percutaneous Transluminal Forceps Biopsy in 130 PatientsSuspected of Having Malignant Biliary Obstruction[J]. Radiology,2002,224:725-730.
[45]陈颐,颜志平,王建华等.表阿霉素在恶性梗阻性黄疸治疗中的应用[J].中华肿瘤杂志,2006,28(5)：397-399.
[46]李茂全,张家兴,陆晨晖等.恶性梗阻性黄疸介入综合治疗[J].中华医学杂志, 2008,88(39)：2473-2477.
[47]郭鹏,谢春明,杨敏玲等.恶性梗阻性黄疸双介入治疗的临床研究[J].当代医学,2010,16(5)：31-33.
[48]韩新巍,李臻.胆管癌并阻塞性黄疽的影像学诊断及介入治疗现状与进展[J].世界华人消化杂志,2008,16(29)：3253.
[49]Xiao-Ju Qian, Ren-You Zhai, Ding-Ke Dai. et al. Treatment of malignant biliary obstruction by combined percutaneous transhepatic biliary drainage with local tumor treatment[J]. World J Gastroenterol,2006,12(2):331-335.
[50]范卫君,吴沛宏,张亮,等.Ⅲ、Ⅳ型肝门区胆管腺癌的介入治疗[J].中华放射学杂,2005,39：925-929.
[51]Khan SA, Davidson BR, Goldin R, et al. Guidelines for the diagnosis and treatment of cholangiocarcinoma:consensus document[J]. Gut,2002,51 Suppl 6:VI1-VI9.
[52]纪卫,张献南,胡建军.三维适形放疗联合动脉灌注化疗治疗局部晚期胰腺癌的临床疗效观察[J].实用肿瘤学杂志,2008,22(3)：272-274.
[2]王小林.胆道疾病介入放射学[M].上海：复旦大学出版社,2005：183.
[3]高立兵,刘亮,江水.经皮肝穿刺胆管引流治疗高位梗阻性黄疸[J].当代医学(中国介入放射学专题),2009,15,(29)：583.
[4]Freeman ML., Carol Ovcrby. Selective MRCP and CT-targeted drainage of malignant hilar billary structures with self-expanding metallic stents[J]. Gastrointest Endosc, 2003,58(1):41-49.
[5]张学强,翟仁友.恶性梗阻性黄疸介入治疗短期预后的多因素分析[J].介入放射学杂志,2009,18,(11)：847.
[6]Iizuka T, Hoshihara Y, Hoteya O, et al. A case of gastric Cancer presenting with obstructive jaundice and responding to biweekly CPT-11 and CDDP combination administration[J]. Gan To Kagaku Ryoho,2006,33:659-661.
[7]李铎,孙家邦,孙海晨等.梗阻性黄疸时肝功能受损机制[J].中华外科杂志,1998,36：624-626.
[8]Rodrigo Castan o, Tercio L. Lopes, Oscar Alvarez, et al. Nitinol biliary stent versus surgery for palliation of distal malignant biliary obstruction[J]. Surg Endosc,2010,24: 2092-2098.
[9]罗祖炎,陈方宏,袁建华.国产胆道金属支架的临床应用[J].介入放射学杂志,2004,13(5)：433-435.
[10]Paskan J, Vavrecka A, Lesny P, et al. The sianificance of non surgical bile duct drainage in patients with icterus[J]. Rozhl Chir,1990,69(2):71-76.
[11]Rossi P, Bezzi M, Rossi P, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients[J]. Vase Intervent Radiol,1994, 5:279-285.
[12]Padillo J, Puente J, Gomez M, et al. Improved cardiac function in patients with obstructive jaundice after internal biliary drainge:hemody-namic and hormonal assessment[J]. Ann Surg,2001,234:652-656.
[13]Zhu Lidong, Chen Xiaoping. Change and significance of T-cell subsets and TNF-α in patients with advanced malignant obstructive jaundice treated by percutaneous transhepatic biliary external and internal drainage[J]. Frontiers of Medicine in China, 2007,1(4):364-368.
[14]Bonnel D, Ferrucci JT, Mueller HF, et al. Surgical and decompression in malignant biliary obstruction:A retrospective study using multi-variate risk factor analysis[J]. Radiolog,1984,152:347.
[15]田伏洲,石力,汤礼军等.胰头癌术前减黄指征的前瞻性研究[J].中华外科杂志,2006,44(23)：1614-1616.
[16]GuoYX, Li YH, Chen Y, et al. Percutaneous transhepatic metal versus plastic biliary stent in treating malignant biliary obstruction:a multiple center investigation[J]. Hepatobilary Pancreat Dis Int,2003,2:594-597.
[17]Yoshida H, Mamada Y, Taniai N, et al. One-step Palliative treatment method for obstructive jaundice caused by unresectable malignancies by percutaneous transhepatic insertion of an expandable metallic stent[J]. World J Gastroenterol,2006, 12:2423-2426.
[18]翟仁友,黄强.恶性梗阻性黄疸介入治疗常见问题的处理[J].介入放射学杂志,2007,16(10)：649-651.
[19]王健,罗鹏飞,于新发等.单通道植入T型胆道支架治疗肝门部胆管恶性梗阻5例分析[J].中国误诊学杂志,2009,18(9)：4506-4507.
[20]Dong Ⅱ Gwon, Gi-Young Ko, Hyun-Ki Yoon, et al. Prospective Evaluation of a Newly Designed T-configured Stent Graft System for Palliative Treatment of Advanced Hilar Malignant Biliary Obstructions[J]. J Vase Interv Radiol.,2010,21(9): 1410-1418.
[21]Arguedas MR, Heudebert GH, Stinnett AA, et al. Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma:a cost-effectiveness analysis[J]. Am J Gastroenterol,2002,97:898-901.
[22]向华,刘觉仕,张智明,等.胆道支架经皮置入术治疗恶性梗阻性黄疸[J].医学临床研究,2007,24(5)：810-812.
[23]钱晓军,翟仁友,戴定可等.老年人恶性梗阻性黄疸介入治疗回顾性分析[J].中华放射学杂志,2000,34：342.
[24]Roberto Gandini, S.Fabiano, Vincenzo Pipitone, et al. Management of Biliary Neoplastic Obstrution with Two Different Metallic stents Implanted in One Session[J]. Cardio Vascular and Interventional Radiology,2005,28(1):48-52.
[25]Mehmet inal, Erol Aksungur, Erol Akgul, et al. Percutaneous Placement of Metallic Stents in Malignant Biliary Obstruction:One-Stage or Two-Stage Procedure? Pre-Dilate or Not? [J]. Cardiovasc Intervent Radiol,2003,26:40-45.
[26]Inal M, Akgnt E, Aksungnr E, et al. Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction:unilobar versus bilobar drainage[J]. J Vase Interv Radiol,2003,14:1409-1416.
[27]冯博,石强,徐克.跨越Vater壶腹胆道支架置入术治疗恶性低位胆道梗阻(附32例报告)[J].中国临床医学影像杂志,2008,19(4)：265-267.
[28]Cherian George, Oliver Richard Byass, James Edmund Ian Cast. Interventional radiology in the management of malignant biliary obstruction[J]. World J Gastrointest Oncol,2010 March,2(3):146-150.
[29]Jeong YW, Shin KD, Kim SH, e al. The safety assessment of percutaneous transhepatic transpapillary stent insertion in malignant obstructive jaundice:regarding the risk of pancreatitis and the effect of preliminary endoscopic sphincterotomy[J]. Korean J Gastroenterol.2009,54(6):390-394.
[30]Gu YK, Fan WJ, Wei HW, et al. Interventional management of severe complications after percutaneous transhepatic cholangic drainage and percutaneous implantation of biliary stents[J]. Zhonghua Yi Xue Za Zhi,2008,88(41):2916-2919.
[31]王生海,吕德元.胆道手术并发胆心综合征16例[J].中国急救医学,1996,5：309.
[32]田伟军,徐青,谢宗贵.硬膜外麻醉下胆道支架植入术[J].介入放射学杂志,2002,11(1)：59-60.
[33]Van Delden, O.M.and J.S.Lameris, Percutaneous drainage and stenting for palliation of malignant bile duct obstruction[J]. Eur Radiol,2008,18(3):448-456.
[34]Sut M, Kennedy R, McNamee J, et al. Long-term results of percutaneous transhepatic cholangiographic drainage for palliation of malignant biliary obstruction [J]. J Palliat Med.,2010,13(11):1311-1313.
[35]Lee JW, Han JK, Kim TK, et al. Obstructive jaundice in hepatocellular carcinoma: response after percutaneous transhepatic biliary drainage and prognostic factors[J]. Cardiovasc Intervent Radiol,2002,25:176-179.
[36]P. C. Robson, N. Heffernan, M. Gonen, et al. Prospective Study of Outcomes after Percutaneous Biliary Drainage for Malignant Biliary Obstruction[J]. Ann Surg Oncol, 2010,17:2303-2311.
[37]钱晓军,戴定可,翟仁友.恶性梗阻性黄疸介入治疗的疗效分析[J].中华肝胆外科杂志,2004,10：752-755.
[38]施海斌,李麟荪,徐泽宽,等.经皮胆道引流术治疗恶性梗阻性黄疸[J].介入放射学杂志,2001,10(5)：292-295.
[39]Cherian George, Oliver Richard Byass, James Edmund Ian Cast. Interventional radiology in the management of malignant biliary obstruction[J]. World J Gastrointest Oncol,2010,2(3):146-150.
[40]Lee JW, Han JK, Kim TK, et al. Obstructive jaundice in hepatocellular carcinoma: response after percutaneous transhepatic biliary drainage and prognostic factors[J]. Cardiovasc Intervent Radiol,2002,25:176-179.
[41]Elias N. Brountzos, Nikolaos Ptochis, Irene Panagiotou, et al. A Survival Analysis of Patients with Malignant Biliary Strictures Treated by Percutaneous Metallic Stenting[J]. Cardiovasc Intervent Radiol,2007,30:66-73.
[42]Neal CP, Thomasset SC, Bools D, et al. Combined percutaneous-endoscopic stenting of malignant biliary obstruction:results from 106 consecutive procedures and identification of factors associated with adverse outcome[J]. Surg Endosc,2010,24(2): 423-31.
[43]王小林,陈颐,程洁敏等.胆道支架置放治疗恶性梗阻性黄疸的预后因素分析附15例报告[J].复旦学报(医学版),2002,11：476-479.
[44]李茂全,张家兴,陆晨晖等.恶性梗阻性黄疸介入综合治疗[J].中华医学杂志,2008,88(39)：2473-2477.
[45]郭鹏,谢春明,杨敏玲等.恶性梗阻性黄疸双介入治疗的临床研究[J].当代医学,2010,16(5)：31-33.
[46]Thomas B.Brunner, Dieter Schwab, Thomas Meyer, et al. Chemoradiation May Prolong Survival of Patients with Non-Bulky Unresectable Extrahepatic Biliary Carcinoma[J]. Strahlenther Onkol,2004,180:751-757.
[47]Gianpaolo Carrafiello, Domenico Lagana, Elisa Cotta, et al. Radiofrequency Ablation of Intrahepatic Cholangiocarcinoma:Preliminary Experience[J]. Cardiovasc Intervent Radiol,2010,33:835-839.
[48]吴海江,管峦,崔宁等.胆道支架置入联合内外放疗治疗恶性阻塞性黄疸的临床观察[J].中华全科医师杂志,2008,7(10)：707-708.
[1]Schoder M, Rossi P, Uflacker R, et al. Malignant biliary obstruction:treatment with ePTFE-FEP-covered endoprostheses initial technical and clinical experiences in a multicenter trial[J]. Radiology,2002,225(1):35-42.
[2]Shigeta H, Nagino M, Kamiya J, et al. Bacteremia after hepatectomy:ananalysis of a single-center,10-year experience with 407 patients[J]. Langenbeck Arch Surg,2002, 387(3-4):117-124.
[3]van Delden OM, Lameris JS. Percutaneous drainageM and stenting for palliation of malignant bile duct obstruction[J]. Eur Radiol,2008,18:448-456.
[4]Baijal SS, Dhiman RK, Gup ta S, et al. Percutaneous transhepatic biliary drainage in the management of obstructive jaundice[J]. Trop Gastroenterol,1997,18(1):167-171.
[5]王成刚,沈杰,龚高全等.肝癌合并梗阻性黄疸的双介入治疗临床研究[J].中 国现代医生,2008,46(19)：7-9.
[6]Soulez G, Gagner M, Therasse E, et al. Malignant biliary obstruction:Premilinary results of palliative treatment with hepaticogastrostomy under fluoroscopic, endoscopic and laparoscopic guidance[J]. Radiology,1994,192:241.
[7]Rossi P, Bezzi M, Rossi M, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients[J]. J Vase Interv Radiol,1994, 5(2):279-285.
[8]于平,戴定可,钱小军等.胆管引流术或支架置入术围手术期并发症的临床研究[J].中华肿瘤杂志,2009,31(12)：923-924.
[9]张勇春,顾占军,邓晓涛等.经皮胆管内支架放置术并发症及发生意外情况的处理方法[J].中华放射学杂志,2002,36：1084-1086.
[10]向华,刘觉仕,张智明等.胆道支架经皮置入术治疗恶性梗阻性黄疸[J].医学临床研究,2007,24(5)：810-812.
[11]Roberto Gandini, S.Fabiano, Vincenzo Pipitone, et al. Management of Biliary Neoplastic Obstrution with Two Different Metallic stents Implanted in One Session[J]. Cardio Vascular and Interventional Radiology,2005,28(1):48-52.
[12]于凤海,陆蕊,陆正华等.胆道梗阻患者行ERCP治疗失败后行PTC与ERCP对接的研究体会[J].中华消化内镜杂志,2008,25(12)：652-654.
[13]郭元新,陈勇,李彦豪.金属内支架、塑料内涵管治疗胆管梗阻成本效果分析研究现状[J].中华放射学杂志,2001,35：226-227.
[14]Eschelman DJ, Shapiro MJ, Bonn J, et al. Malignant biliary duct obstruction: long-term experience with Gianturco stents and combinedmodality radiation therapy[J]. Radiology,1996,200(3):717-724.
[15]TOSHIO TSUYUGUCHI, TADAHIRO TAKADA, MASARU MIYAZAKI, et al. Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas[J]. J Hepatobiliary Pancreat Surg,2008,15: 69-73.
[16]Cady B, Jenkins RI, Steele GD Jr, et al. Surgical margin in hepatic resection for colorectal metastasis:a critical and improvable determinant of outcome[J]. Ann Surg, 1998,227:566-571.
[17]Coldwell D. Non-surgical hepatic tumor ablations[M].4th.Singapore:Asian Pacific Congress of cardiovascular and interventional radiology,2000:123.
[18]Seong J. Recent developments in radiotherapy of hepatocellular carcinoma[J]. Korean J Hepatol,2004,10(4):241-247.
[19]罗开元.实用组织间植入内放射治疗恶性肿瘤学[M].北京,人民卫生出版社,2008：351-352.
[20]范卫君,张亮,顾仰葵等.CT导向下高频介入热治疗在肝内胆管癌治疗中价值[J].中华医学杂志,2008,88(25)：1759-1761.
[21]郑建伟,唐涛,肖宝来等.内磁场在磁靶向治疗胆道恶性肿瘤中作用的实验研究[J].北京医学,2006,28：726-729.
[22]Padillo J, Puente J, Gomez M, et al. Improved cardiac function in patients with ob structive jaundice after internal biliary drainge:hemody-namic and hormonal assess-ment[J]. Ann Surg,2001,234:652-656.
[23]Zhu Lidong, Chen Xiaoping. Change and significance of T-cell subsets and TNF-α in patients with advanced malignant obstructive jaundice treated by percutaneous transhepatic biliary external and internal drainage[J]. Frontiers of Medicine in China, 2007,1(4):364-368.
[24]朱芳来,凌安生.胆道内支架置入治疗恶性梗阻性黄疸疗效观察[J].实用临床医学,2008,9(1)：48-50.
[25]冯博,石强,徐克.跨越Vater壶腹胆道支架置入术治疗恶性低位胆道梗阻(附32例报告)[J].中国临床医学影像杂志,2008,19(4)：265-267.
[26]Yu Li Sol, Chang Won Kim, Ung Bae Jeon, et al. Early Infectious Complications of Percutaneous Metallic Stent Insertion for Malignant Biliary Obstruction[J]. AJR, 2010,194:261-265.
[27]Arguedas MR, Heudebert GH, Stinnett AA, et al. Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma:a cost-effectiveness analysis[J]. Am J Gastroenterol,2002,97:898-904.
[28]Brountzos EN, Ptochis N, Panagiotou I, et al. A survival analysis of patients with malignant biliary strictures treated by percutaneous metallic stenting[J]. Cardiovasc Intervent Radiol,2007,30(1):66-73.
[29]Hong HP, Kim SK, Seo TS. Percutaneous metallic stents in patients with obstructive jaundice due to hepatocellular carcinoma[J]. J Vase Interv Radiol,2008,19(5): 748-754.
[30]Tsuyuguchi T, Takada T, Miyazaki M, et al. Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas[J]. J Hepatobiliary Pancreat Surg,2008,15:69-73.
[31]曹广,杨仁杰.金属支架姑息治疗恶性梗阻性黄疽的术后随访及生存分析[J].北京大学学报,2008,409(2)：121-124.
[32]Hatzidakis A, Krokidis M, Kalbakis K, et al. ePTFE/FEP-covered metallic stents for palliation of malignant biliary disease:can tumor ingrowth be prevented?[J]. Endoscopy,2007,39(4):319-24.
[33]E Kullman, F Frozanpor, C Soderlund, et al. Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction:results from a randomized,multicenter study[J]. Gastrointest Endosc, 2010,72(5):915-23.
[34]JJ Telford, DL Carr-Locke, TH Baron, et al. A randomized trial comparing uncovered and partially covered self-expandable metal stents in the palliation of distal malignant biliary obstruction[J]. Gastrointestinal Endoscopy,2010,72(5):907-914.
[35]丁广成,刘新疆,朱晓民等.胆汁引流联合立体定向三维适形放疗治疗中晚期胰腺癌38例[J].肿瘤研究与临床,2008,20(11)：765-767.
[36]郑爱青,于金明,徐瑾等.立体定向适形放疗剂量对晚期胆管癌治疗疗效的影响[J].中国癌症杂志,2004,14(4)：339-342.
[37]Tsujino K, Landry JC, Smith RG, et al. Definitive radiation therapy for extrahepatic bileduct carcinoma[J]. Radiology,1995,196 (1):275.
[38]李玉,王宁,田起和等.金属支架联合立体定向适形放疗治疗肝门部胆管癌[J].中华放射肿瘤学杂志,2005,14(1)：39-41.
[39]丁田贵,尹立杰,高众等.胆道介入支架联合立体定向放射治疗恶性梗阻性黄疸[J].中华放射医学与防护杂志,2006,26(3)：265-266.
[40]游洋,常钢,孟凡喆.胆道支架置入联合碘125粒子腔内照射治疗恶性梗阻性黄疸的临床应用[J].西安交通大学学报(医学版),2007,28(2)：1-2.
[41]杜学明,许建辉,郎建华等.多学科技术联合1251治疗癌梗阻性黄疸[J].介入放射学杂志,2008,17(5)：346-348.
[42]何贵金,鞠光,高沁怡等.103钯放射性支架对胆管癌细胞bcl-2表达的影响和意义[J].中华肝胆外科杂志,2009,15(1)：70-71.
[43]杨莉莉,曹贵文,崔新江等.双介入治疗肝门部胆管癌的临床应用研究[J].医学影像学杂志,2010,20(2)：270-273.
[44]Gyoo-Sik Jung, Jin-Do Huh, Sang Uk Lee. Bile Duct:Analysis of Percutaneous Transluminal Forceps Biopsy in 130 PatientsSuspected of Having Malignant Biliary Obstruction[J]. Radiology,2002,224:725-730.
[45]陈颐,颜志平,王建华等.表阿霉素在恶性梗阻性黄疸治疗中的应用[J].中华肿瘤杂志,2006,28(5)：397-399.
[46]李茂全,张家兴,陆晨晖等.恶性梗阻性黄疸介入综合治疗[J].中华医学杂志, 2008,88(39)：2473-2477.
[47]郭鹏,谢春明,杨敏玲等.恶性梗阻性黄疸双介入治疗的临床研究[J].当代医学,2010,16(5)：31-33.
[48]韩新巍,李臻.胆管癌并阻塞性黄疽的影像学诊断及介入治疗现状与进展[J].世界华人消化杂志,2008,16(29)：3253.
[49]Xiao-Ju Qian, Ren-You Zhai, Ding-Ke Dai. et al. Treatment of malignant biliary obstruction by combined percutaneous transhepatic biliary drainage with local tumor treatment[J]. World J Gastroenterol,2006,12(2):331-335.
[50]范卫君,吴沛宏,张亮,等.Ⅲ、Ⅳ型肝门区胆管腺癌的介入治疗[J].中华放射学杂,2005,39：925-929.
[51]Khan SA, Davidson BR, Goldin R, et al. Guidelines for the diagnosis and treatment of cholangiocarcinoma:consensus document[J]. Gut,2002,51 Suppl 6:VI1-VI9.
[52]纪卫,张献南,胡建军.三维适形放疗联合动脉灌注化疗治疗局部晚期胰腺癌的临床疗效观察[J].实用肿瘤学杂志,2008,22(3)：272-274.