恶性阻塞性黄疸介入治疗临床研究
|
摘要
目的:研究B超结合透视行胆道引流的技术经验;比较PTBD和PTBS的并发,近期疗效和长期疗效;分析短期死亡病例的术前危险因素。材料和方法:210例阻塞性黄疸患者,在B超结合透视引导下行胆道引流术。其中161例置入塑料引流管,49例置入金属支架。临床诊断肝癌32例、胆管癌61例、胆囊癌10例、胰腺癌17例,转移癌62例,诊断不明确而诊为肝门占位者28例。术前总胆红素平均320.12 umol/l,直接胆红素183.75umol/l。随访资料通过电话回访或是复检记录获取。所有数据均采用spss13.0软件包进行统计,采用的统计检验方法为,两独立样本均数t检验,四格表资料卡方分析,单向方差分析,Kaplan-meier生存分析。结果:技术成功率为百分之百,金属支架组15例,术后3～5天血清总胆红素平均下降178.04±42.32umol/l,直接胆红素平均下降83.97±23.63 umol/l,塑料引流管组28例,术后3～5天血清总胆红素平均下降95.67±34.28umol/l,直接胆红素平均下降49.84±28.21umol/l,两者的差别有显著性统计学意义(P=0.017,P=0.035)。金属支架组28例,术后6～9天血清总胆红素平均下降188.22±79.90umol/l,塑料引流管组126例,术后6～9天血清总胆红素平均下降141.39±65.32umol/l,两者的差别有显著性统计学意义(P=0.014),术后6～9天两者直接胆红素下降值没有显著性差异(P=0.567)。金属支架组并发生发生率为8%,塑料引流管组为52%,前者远低于后者(P=0.000),且大部分并发症与穿刺程序无关。金属支架组和塑料引流管组的中位通畅期和中位生存期分别是197天,245天和60天,148天,两组比较均有统计学差异,P<0.05。二个月内死亡危险因素有高龄,较差的肝功能,异常的肾功能,术前感染,肿瘤侵及范围和血红蛋白含量。结论:B超结合透视引导下行胆道引流简便安全,成功率高。金属支架较塑料引流管近期和远期疗较好。有条件患者,应尽量置入金属支架。
Objective: to evaluate the technique of PTCD under the guidence of ultrasound with DSA;to compare the complications,short-term and long-term clinical efficacy of plastic drainage catheters with metalic stents;to analyse the risk factors of early mortality.Materials and Methods:210 cases of malignant obstructive jaundice,of which 161 cases of plastic drainage catheters placement and 49 cases of metalic stents implantation,included 32 patients with clinical diagnosis of hepatocellular carcinoma, cholangiocarcinoma 61 cases, 10 cases of gallbladder cancer, 17 cases of pancreatic cancer. 62 patients with metastatic cancer, and 28 cases were diagnosed as hilar mass.The mean serum total bilirubin before treatment was 320.12 umol/l,and direct bilirubin 183.75 umol/l. Follow-up information obtained through telephone review or reinterventional records.All datas were analysed with spss11.5 statistical software package.The statistical test methods included two independent samples t test, chi-square analysis for table 4 georgia, one-way analysis of variance and Kaplan-meier survival analysis. Results : The success rate of technique was 100%.3~5days after treatment, the serum total bilirubin of 15 metalic stents cases decreased 178.04±42.32umol/l, and direct bilirubin fell 83.97±23.63 umol/l.28 plastic cathers : 95.67±34.28umol/l, 49.84±28.21umol/l. The differences between metalic stent group and plastic drainage catheter group were statistically significant (P = 0.017. P =0.035). After 6-9 days, the serum total bilirubin of 28 cases of metalic stent group fell 188.22±79.90umol/l,and of 126 cases of plastic drainage catheter group was 141.39±65.32umol/l. The difference had statistic significance (P = 0.014).But the decline value of direct bilirubin was no significant difference.The complication rate of metalic stent group was 8%(4/49), 52%(84/161) of plastic drainage catheter group .The former was far lower than the later(P=0.000). Most of them have no relation with the puncture procedure. The median patency period and the median survival time of the group of plastic drainage catheter were 60 days , 148 days,the metalic stent 197 days, 245 days. There were statistically significant differences(P<0.05). Risk factors are age, poor liver function, abnormal renal function, infection before treatment, and the site of tumor invasion and hemoglobin content.Conclusion: PTCD under the guidence of ultrasound with DSA is a safe ,simple method with a high success rate in treatment of malignant obstructive jaundice.Metalic stents have better short-term and long-term efficacy.
Objective: to evaluate the technique of PTCD under the guidence of ultrasound with DSA;to compare the complications,short-term and long-term clinical efficacy of plastic drainage catheters with metalic stents;to analyse the risk factors of early mortality.Materials and Methods:210 cases of malignant obstructive jaundice,of which 161 cases of plastic drainage catheters placement and 49 cases of metalic stents implantation,included 32 patients with clinical diagnosis of hepatocellular carcinoma, cholangiocarcinoma 61 cases, 10 cases of gallbladder cancer, 17 cases of pancreatic cancer. 62 patients with metastatic cancer, and 28 cases were diagnosed as hilar mass.The mean serum total bilirubin before treatment was 320.12 umol/l,and direct bilirubin 183.75 umol/l. Follow-up information obtained through telephone review or reinterventional records.All datas were analysed with spss11.5 statistical software package.The statistical test methods included two independent samples t test, chi-square analysis for table 4 georgia, one-way analysis of variance and Kaplan-meier survival analysis. Results : The success rate of technique was 100%.3~5days after treatment, the serum total bilirubin of 15 metalic stents cases decreased 178.04±42.32umol/l, and direct bilirubin fell 83.97±23.63 umol/l.28 plastic cathers : 95.67±34.28umol/l, 49.84±28.21umol/l. The differences between metalic stent group and plastic drainage catheter group were statistically significant (P = 0.017. P =0.035). After 6-9 days, the serum total bilirubin of 28 cases of metalic stent group fell 188.22±79.90umol/l,and of 126 cases of plastic drainage catheter group was 141.39±65.32umol/l. The difference had statistic significance (P = 0.014).But the decline value of direct bilirubin was no significant difference.The complication rate of metalic stent group was 8%(4/49), 52%(84/161) of plastic drainage catheter group .The former was far lower than the later(P=0.000). Most of them have no relation with the puncture procedure. The median patency period and the median survival time of the group of plastic drainage catheter were 60 days , 148 days,the metalic stent 197 days, 245 days. There were statistically significant differences(P<0.05). Risk factors are age, poor liver function, abnormal renal function, infection before treatment, and the site of tumor invasion and hemoglobin content.Conclusion: PTCD under the guidence of ultrasound with DSA is a safe ,simple method with a high success rate in treatment of malignant obstructive jaundice.Metalic stents have better short-term and long-term efficacy.
引文
1. Bismuth H,Castaing D,Truynor O.Ressection:prionity of surgery in the treatment of bilarcancer.World J Surg.1988,12:39-47.
2.Henson DE,Albores Saavedra J,Corle D.Carcinoma of the extrahepatic bile ducts:histologic types,stage of disease,grade,and,survival rates.Cancer. 1992,70:1498-1501.
3. A N Kimmings,S J H van Deventer,H Obertop, et al.Endotoxin,cytokines,and endotoxin binding proteins in obstructive jaundice and after preoperative biliary drainage.Gut,2000,46:725-731.
4.田伟军,徐青,谢宗贵.硬膜外麻醉下胆道支架置入术.介入反射学杂志,2002,11:59-60.
5. Yee CAN,Ho,C-S.Complications of percutaneous biliary drainage:benign versus malignant diseases.AJR,1987,148:1207-1209.
6. Khardori N,Wong E,Carrasco,CH,et al.Infections associated with biliary drainage procedures in patients with cancer.Rev Infect Dis,1991,13:587-591.
7. Hochwald SN,Burke EC,Jarnagin WR,et al. Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma.Arch Surg, 1999 ,134:261-266.
8. Howard TJ,Yu J,Greene RB,et al. Influence of bactibilia after preoperative biliary stenting on postoperative infectious complications.J Gastrointest Surg. 2006,10:523-531.
9.陈晓明,罗鹏飞,邵培坚等.肝胆系统非血管性介入放射学中的并发症分析.临床放射学杂志,2000,19:205-207.
10. Yoshida H, Mamada Y, Taniai N,et al. Fracture of an expandable metallic stent placed for biliary obstruction due to common bile duct carcinoma. J Nippon Med Sch. 2006,73:164-168.
11. Ruinemans GM, van Zanten RA, Rakic S,et al. Abdominal pain following placement of an endoprosthesis in the biliary duct. Ned Tijdschr Geneeskd. 2006, 150:1466-1469.
12. Miller G, Yim D, Macari M,et al. Retroperitoneal perforation of the duodenum from biliary stent erosion. Curr Surg.2005,62:512-515.
13. Van Berkel AM, van Marle J, Groen AK,et al. Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy. Endoscopy. 2005, 37:729-734.
14. Sung JJY, Chung SCS: Endoscopic stenting for palliation of malignant biliary obstruction. A review of progress in the last 15 years. Dig Dis Sci ,1995,40:1167–1173.
15. Speer AG, Cotton PB, Rode J, et al. Biliary stent blockage with bacterial biofilm. A light and electron microscopy study. Ann Intern Med ,1998,108:546–553.
16.王小林.胆道疾病介入放射学.第一版.上海,复旦大学出版社,2005.183-205.
17. Lee BH, Choe DH, Lee JH,et al. Metallic stents in malignant biliary obstruction: prospective long-term clinical results. AJR Am J Roentgenol. 1997 ,168:741-745.
18. Rossi P, Bezzi M, Rossi M,et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients. J Vasc Interv Radiol. 1994 ,5:279-85.
19. Chiou YY, Tseng HS, Chiang JH,et al. Percutaneous placement of metallic stents in the management of malignant biliary obstruction. J Formos Med Assoc. 2005 ,104:738-743.
20. Becker CD, Glattli A, Maibach R,et al. Percutaneous palliation of malignant obstructive jaundice with the Wallstent endoprosthesis: follow-up andreintervention in patients with hilar and non-hilar obstruction. J Vasc Interv Radiol. 1993 ,4:597-604.
21. Schmassmann A, von Gunten E, Knuchel J,et al. Wallstents versus plastic stents in malignant biliary obstruction: effects of stent patency of the first and second stent on patient compliance and survival. Am J Gastroenterol. 1996 ,91:654-659.
22. Pedersen FM, Lassen AT, Schaffalitzky de Muckadell OB. Randomized trial of stent placed above and across the sphincter of Oddi in malignant bile duct obstruction. Gastrointest Endosc. 1998 ,48:574-579.
23. Uchida N, Tsutsui K, Ezaki T,et al. Estimation of the stent placement above the intact sphincter of Oddi against malignant bile duct obstruction. J Gastroenterol. 2005,40:291-296.
24. Leung JW, Libby ED, Morck DW,et al. Is prophylactic ciprofloxacin effective in delaying biliary stent blockage? Gastrointest Endosc. 2000,52:175-182.
25. Libby ED, Leung JW. Prevention of biliary stent clogging: a clinical review. Am J Gastroenterol. 1996 .91:1301-1308.
26. Reddy DN, Banerjee R, Choung OW. Antireflux biliary stents: are they the solution to stent occlusions? Curr Gastroenterol Rep. 2006 ,8:156-160.
27. Nakai Y, Isayama H, Komatsu Y,et al. Efficacy and safety of the covered Wallstent in patients with distal malignant biliary obstruction. Gastrointest Endosc. 2005 ,62:742-748.
28. Park do H, Kim MH, Choi JS,et al. Covered versus uncovered wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. Clin Gastroenterol Hepatol. 2006 ,4:790-796.
29. Sciume C, Geraci G, Pisello F,et al. Prevention of clogging of biliary stents by administration of levofloxacin and ursodeoxycholic acid. Chir Ital. 2004, 56:831-837.
30. Yuan-Xing Guo, Yan-Hao Li, Yong Chen,et al. Percutaneous transhepatic metal versus plastic biliary stent in treating malignant biliary obstruction: a multiple center investigation. HBPD Int 2003; 2: 594-597.
31. Yeoh KG, Zimmerman MJ, Cumningham JT, et al. Comparative costs of metal versus plastic biliary stent strategies for malignant obstructive jaundice by decision analysis. Gastrointest Endosc 1999;49(4 pt 1):466-471.
32. Gibney RG,Fache JS,Becker CD,et al.Combined surgical and radiologic intervention for complicated cholelithiasis in high risk patients.Radiology.1987,165:715-719.
33. Alfke H, Alfke B, Froelich JJ, et al. Treatment of malignant biliary occlusion by means of transhepatic percutaneous biliary drainage with insertion of metal stents--results of an 8-year follow-up and analysis of the prognostic parameters. Rofo. 2003 ,175:1125-1129.
34. Rai R, Dick R, Doctor N,et al. Predicting early mortality following percutaneous stent insertion for malignant biliary obstruction: a multivariate risk factor analysis. Eur J Gastroenterol Hepatol. 2000 ,12:1095-1100.
35. Inal M, Akgul E, Aksungur E,et al. Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients. Acta Radiol. 2003 ,44:139-146.
36. Arguedas MR,Heudebert GH,Stinnett AA,etal.Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma:a cost-effectiveness analysis.AmJ Gastroenterol.2002,97:898-904.
37.石景森,王炳煌.胆道外科基础与临床.第一版.北京,人民卫生出版社.2003,113-115.
38.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.中华肝胆外科杂志.2002,10:752-755.
39. Hernandez Guerrero A, Sanchez del Monte J, Sobrino Cossio S,et al. Prognostic factors of mortality in the malignant biliary obstruction unresectable after the insertion of an endoscopic stent. Rev Gastroenterol Mex. 2006 ,71:22-30.
40. Ahuja V, Garg PK, Kumar D,et al. Presence of white bile associated with lower survival in malignant biliary obstruction. Gastrointest Endosc. 2002 ,55:186-191.
41. Alfke H, Alfke B, Froelich JJ,et al. Treatment of malignant biliary occlusion by means of transhepatic percutaneous biliary drainage with insertion of metal stents--results of an 8-year follow-up and analysis of the prognostic parameters. Rofo. 2003,175:1125-1129.
1.Kim HS,Lee DK,Kim HG,et al. Features of malignant biliary obstruction affecting the patency of metallic stents: a multicenter study. Gastrointest Endosc.2002,55:359-365.
2.van Berkel AM, van Marle J, Groen AK,et al. Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy. Endoscopy. 2005 ,37:729-734.
3. Klaus A,Hausegger ,Reinhold Kleinert,et al.Malignant biliary obstruction:histologic fingings after treatment with self-expandablestents.Radiology.1992,185:461~464.
4.Chan FK, Suen M, Li JY,et al. Bile immunoglobulins and blockage of biliary endoprosthesis: an immunohistochemical study. Biomed Pharmacother. 1998,52:403-407.
5.Maillot N, Aucher P, Robert S,et al. Polyethylene stent blockage: a porcine model. Gastrointest Endosc. 2000 ,51:104-107.
6.Zhang H, Tsang TK, Jack CA,et al. Role of bile mucin in bacterial adherence to biliary stents. J Lab Clin Med. 2002 ,139:28-34.
7.Zhang H, Tsang TK, Pollack J,et al. Evaluation of role of bile flow patterns in process of in vitro stent occlusion. Dig Dis Sci. 2002 ,47:2691-2695.
8.Rerknimitr R, Fogel EL, Kalayci C,et al. Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis.Gastrointest Endosc.2002,56:885-889.
9.Leung JW, Ling TK, Kung JL,et al. The role of bacteria in the blockage of biliary stents. Gastrointest Endosc. 1988 ,34:19-22.
10.Leung JW, Liu YL, Desta T,et al. Is there a synergistic effect between mixed bacterial infection in biofilm formation on biliary stents? Gastrointest Endosc. 1998 ,48:250-257.
11.Leung JW, Liu Y, Chan RC,et al. Early attachment of anaerobic bacteria may play an important role in biliary stent blockage. Gastrointest Endosc. 2000 ,52:725-729.
12.McAllister EW, Carey LC, Brady PG,et al. The role of polymeric surface smoothness of biliary stents in bacterial adherence,biofilm deposition, and stent occlusion. Gastrointest Endosc. 1993 ,39:422-425.
13.Ahmad J,Siqueira E,Martin J,et al.Effectiveness of the Ultraflex Diamond stent for the palliation of malignant biliary obstruction.Endoscopiy.2002,34:793-796.
14. van Berkel AM,BrunoMJ,Berqman JJ,et al. A prospective randomized study of hydrophilic polymer-coated polyurethane versus polyethylene stents in distal malignant biliary obstruction.Endoscopy.2003,35:478-482.
15. Chiou YY, Tseng HS, Chiang JH,et al. Percutaneous placement of metallic stents in the management of malignant biliary obstruction. J Formos Med Assoc, 2005 ,104:738-743.
16. Uchida N, Tsutsui K, Ezaki T, et al. Estimation of the stent placement above the intact sphincter of Oddi against malignant bile duct obstruction. J Gastroenterol. 2005 ,40:291-296.
17. Pedersen FM, Lassen AT, Schaffalitzky de Muckadell OB. Randomized trial of stent placed above and across the sphincter of Oddi in malignant bile duct obstruction. Gastrointest Endosc. 1998,48:574-579.
18. Smit JM, Out MM, Groen AK,et al.A placebo-controlled study on the efficacy of aspirin and doxycycline in preventing clogging of biliary endoprostheses. Gastrointest Endosc. 1989,35:485-489.
19. Barrioz T, Ingrand P, Besson I,et al. Randomised trial of prevention of biliary stent occlusion by ursodeoxycholic acid plus norfloxacin. Lancet. 1994 ,344:581-582.
20. Sciume C, Geraci G, Pisello F,et al. Prevention of clogging of biliary stents by administration of levofloxacin and ursodeoxycholic acid. Chir Ital. 2004 Nov-Dec;56(6):831-837.
21. De Ledinghen V, Person B, Legoux JL,et al. Prevention of biliary stent occlusion by ursodeoxycholic acid plus norfloxacin: a multicenter randomized trial. Dig Dis Sci. 2000 ,45:145-150.
22. Reddy DN, Banerjee R, Choung OW. Antireflux biliary stents: are they the solution to stent occlusions? Curr Gastroenterol Rep. 2006 ,8:156-160.
23. Dua KS, Reddy ND, Rao VG,et al. Impact of reducing duodenobiliary reflux on biliary stent patency: an in vitro evaluation and a prospective randomized clinical trial that used a biliary stent with an antireflux valve. Gastrointest Endosc. 2007,Mar 23; [Epub ahead of print].
24. Alvarado R, Palmaz JC, Garcia OJ, et al. Evaluation of polymer-coated balloon-expandable stents in bile ducts. Radiology. 1989 ,170:975-978.
25. Nakai Y, Isayama H, Komatsu Y,et al. Efficacy and safety of the covered Wallstent in patients with distal malignant biliary obstruction. Gastrointest Endosc. 2005 ,62:742-748.
26. Soderlund C, Linder S. Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc. 2006 ,63:986-995.
27. Park do H, Kim MH, Choi JS,et al Covered versus uncovered wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. Clin Gastroenterol Hepatol. 2006 ,4:790-796.
28. Yoon WJ, Lee JK, Lee KH,et al. A comparison of covered and uncovered Wallstents for the management of distal malignant biliary obstruction. Gastrointest Endosc. 2006 ,63:996-1000.
29. McCafferty IJ, Ferrando JR, Thomson H. Percutaneous transhepatic use of the hydrolyser thrombectomy catheter to re-canalize an occluded biliary wallstent. Clin Radiol. 2001 ,56:328-331.
30. Bueno JT, Gerdes H, Kurtz RC. Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc. 2003,58:879-884.
31. Tham TC, Carr-Locke DL, Vandervoort J,et al. Management of occluded biliary Wallstents. Gut. 1998,42:703-707.
2.Henson DE,Albores Saavedra J,Corle D.Carcinoma of the extrahepatic bile ducts:histologic types,stage of disease,grade,and,survival rates.Cancer. 1992,70:1498-1501.
3. A N Kimmings,S J H van Deventer,H Obertop, et al.Endotoxin,cytokines,and endotoxin binding proteins in obstructive jaundice and after preoperative biliary drainage.Gut,2000,46:725-731.
4.田伟军,徐青,谢宗贵.硬膜外麻醉下胆道支架置入术.介入反射学杂志,2002,11:59-60.
5. Yee CAN,Ho,C-S.Complications of percutaneous biliary drainage:benign versus malignant diseases.AJR,1987,148:1207-1209.
6. Khardori N,Wong E,Carrasco,CH,et al.Infections associated with biliary drainage procedures in patients with cancer.Rev Infect Dis,1991,13:587-591.
7. Hochwald SN,Burke EC,Jarnagin WR,et al. Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma.Arch Surg, 1999 ,134:261-266.
8. Howard TJ,Yu J,Greene RB,et al. Influence of bactibilia after preoperative biliary stenting on postoperative infectious complications.J Gastrointest Surg. 2006,10:523-531.
9.陈晓明,罗鹏飞,邵培坚等.肝胆系统非血管性介入放射学中的并发症分析.临床放射学杂志,2000,19:205-207.
10. Yoshida H, Mamada Y, Taniai N,et al. Fracture of an expandable metallic stent placed for biliary obstruction due to common bile duct carcinoma. J Nippon Med Sch. 2006,73:164-168.
11. Ruinemans GM, van Zanten RA, Rakic S,et al. Abdominal pain following placement of an endoprosthesis in the biliary duct. Ned Tijdschr Geneeskd. 2006, 150:1466-1469.
12. Miller G, Yim D, Macari M,et al. Retroperitoneal perforation of the duodenum from biliary stent erosion. Curr Surg.2005,62:512-515.
13. Van Berkel AM, van Marle J, Groen AK,et al. Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy. Endoscopy. 2005, 37:729-734.
14. Sung JJY, Chung SCS: Endoscopic stenting for palliation of malignant biliary obstruction. A review of progress in the last 15 years. Dig Dis Sci ,1995,40:1167–1173.
15. Speer AG, Cotton PB, Rode J, et al. Biliary stent blockage with bacterial biofilm. A light and electron microscopy study. Ann Intern Med ,1998,108:546–553.
16.王小林.胆道疾病介入放射学.第一版.上海,复旦大学出版社,2005.183-205.
17. Lee BH, Choe DH, Lee JH,et al. Metallic stents in malignant biliary obstruction: prospective long-term clinical results. AJR Am J Roentgenol. 1997 ,168:741-745.
18. Rossi P, Bezzi M, Rossi M,et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients. J Vasc Interv Radiol. 1994 ,5:279-85.
19. Chiou YY, Tseng HS, Chiang JH,et al. Percutaneous placement of metallic stents in the management of malignant biliary obstruction. J Formos Med Assoc. 2005 ,104:738-743.
20. Becker CD, Glattli A, Maibach R,et al. Percutaneous palliation of malignant obstructive jaundice with the Wallstent endoprosthesis: follow-up andreintervention in patients with hilar and non-hilar obstruction. J Vasc Interv Radiol. 1993 ,4:597-604.
21. Schmassmann A, von Gunten E, Knuchel J,et al. Wallstents versus plastic stents in malignant biliary obstruction: effects of stent patency of the first and second stent on patient compliance and survival. Am J Gastroenterol. 1996 ,91:654-659.
22. Pedersen FM, Lassen AT, Schaffalitzky de Muckadell OB. Randomized trial of stent placed above and across the sphincter of Oddi in malignant bile duct obstruction. Gastrointest Endosc. 1998 ,48:574-579.
23. Uchida N, Tsutsui K, Ezaki T,et al. Estimation of the stent placement above the intact sphincter of Oddi against malignant bile duct obstruction. J Gastroenterol. 2005,40:291-296.
24. Leung JW, Libby ED, Morck DW,et al. Is prophylactic ciprofloxacin effective in delaying biliary stent blockage? Gastrointest Endosc. 2000,52:175-182.
25. Libby ED, Leung JW. Prevention of biliary stent clogging: a clinical review. Am J Gastroenterol. 1996 .91:1301-1308.
26. Reddy DN, Banerjee R, Choung OW. Antireflux biliary stents: are they the solution to stent occlusions? Curr Gastroenterol Rep. 2006 ,8:156-160.
27. Nakai Y, Isayama H, Komatsu Y,et al. Efficacy and safety of the covered Wallstent in patients with distal malignant biliary obstruction. Gastrointest Endosc. 2005 ,62:742-748.
28. Park do H, Kim MH, Choi JS,et al. Covered versus uncovered wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. Clin Gastroenterol Hepatol. 2006 ,4:790-796.
29. Sciume C, Geraci G, Pisello F,et al. Prevention of clogging of biliary stents by administration of levofloxacin and ursodeoxycholic acid. Chir Ital. 2004, 56:831-837.
30. Yuan-Xing Guo, Yan-Hao Li, Yong Chen,et al. Percutaneous transhepatic metal versus plastic biliary stent in treating malignant biliary obstruction: a multiple center investigation. HBPD Int 2003; 2: 594-597.
31. Yeoh KG, Zimmerman MJ, Cumningham JT, et al. Comparative costs of metal versus plastic biliary stent strategies for malignant obstructive jaundice by decision analysis. Gastrointest Endosc 1999;49(4 pt 1):466-471.
32. Gibney RG,Fache JS,Becker CD,et al.Combined surgical and radiologic intervention for complicated cholelithiasis in high risk patients.Radiology.1987,165:715-719.
33. Alfke H, Alfke B, Froelich JJ, et al. Treatment of malignant biliary occlusion by means of transhepatic percutaneous biliary drainage with insertion of metal stents--results of an 8-year follow-up and analysis of the prognostic parameters. Rofo. 2003 ,175:1125-1129.
34. Rai R, Dick R, Doctor N,et al. Predicting early mortality following percutaneous stent insertion for malignant biliary obstruction: a multivariate risk factor analysis. Eur J Gastroenterol Hepatol. 2000 ,12:1095-1100.
35. Inal M, Akgul E, Aksungur E,et al. Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients. Acta Radiol. 2003 ,44:139-146.
36. Arguedas MR,Heudebert GH,Stinnett AA,etal.Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma:a cost-effectiveness analysis.AmJ Gastroenterol.2002,97:898-904.
37.石景森,王炳煌.胆道外科基础与临床.第一版.北京,人民卫生出版社.2003,113-115.
38.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.中华肝胆外科杂志.2002,10:752-755.
39. Hernandez Guerrero A, Sanchez del Monte J, Sobrino Cossio S,et al. Prognostic factors of mortality in the malignant biliary obstruction unresectable after the insertion of an endoscopic stent. Rev Gastroenterol Mex. 2006 ,71:22-30.
40. Ahuja V, Garg PK, Kumar D,et al. Presence of white bile associated with lower survival in malignant biliary obstruction. Gastrointest Endosc. 2002 ,55:186-191.
41. Alfke H, Alfke B, Froelich JJ,et al. Treatment of malignant biliary occlusion by means of transhepatic percutaneous biliary drainage with insertion of metal stents--results of an 8-year follow-up and analysis of the prognostic parameters. Rofo. 2003,175:1125-1129.
1.Kim HS,Lee DK,Kim HG,et al. Features of malignant biliary obstruction affecting the patency of metallic stents: a multicenter study. Gastrointest Endosc.2002,55:359-365.
2.van Berkel AM, van Marle J, Groen AK,et al. Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy. Endoscopy. 2005 ,37:729-734.
3. Klaus A,Hausegger ,Reinhold Kleinert,et al.Malignant biliary obstruction:histologic fingings after treatment with self-expandablestents.Radiology.1992,185:461~464.
4.Chan FK, Suen M, Li JY,et al. Bile immunoglobulins and blockage of biliary endoprosthesis: an immunohistochemical study. Biomed Pharmacother. 1998,52:403-407.
5.Maillot N, Aucher P, Robert S,et al. Polyethylene stent blockage: a porcine model. Gastrointest Endosc. 2000 ,51:104-107.
6.Zhang H, Tsang TK, Jack CA,et al. Role of bile mucin in bacterial adherence to biliary stents. J Lab Clin Med. 2002 ,139:28-34.
7.Zhang H, Tsang TK, Pollack J,et al. Evaluation of role of bile flow patterns in process of in vitro stent occlusion. Dig Dis Sci. 2002 ,47:2691-2695.
8.Rerknimitr R, Fogel EL, Kalayci C,et al. Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis.Gastrointest Endosc.2002,56:885-889.
9.Leung JW, Ling TK, Kung JL,et al. The role of bacteria in the blockage of biliary stents. Gastrointest Endosc. 1988 ,34:19-22.
10.Leung JW, Liu YL, Desta T,et al. Is there a synergistic effect between mixed bacterial infection in biofilm formation on biliary stents? Gastrointest Endosc. 1998 ,48:250-257.
11.Leung JW, Liu Y, Chan RC,et al. Early attachment of anaerobic bacteria may play an important role in biliary stent blockage. Gastrointest Endosc. 2000 ,52:725-729.
12.McAllister EW, Carey LC, Brady PG,et al. The role of polymeric surface smoothness of biliary stents in bacterial adherence,biofilm deposition, and stent occlusion. Gastrointest Endosc. 1993 ,39:422-425.
13.Ahmad J,Siqueira E,Martin J,et al.Effectiveness of the Ultraflex Diamond stent for the palliation of malignant biliary obstruction.Endoscopiy.2002,34:793-796.
14. van Berkel AM,BrunoMJ,Berqman JJ,et al. A prospective randomized study of hydrophilic polymer-coated polyurethane versus polyethylene stents in distal malignant biliary obstruction.Endoscopy.2003,35:478-482.
15. Chiou YY, Tseng HS, Chiang JH,et al. Percutaneous placement of metallic stents in the management of malignant biliary obstruction. J Formos Med Assoc, 2005 ,104:738-743.
16. Uchida N, Tsutsui K, Ezaki T, et al. Estimation of the stent placement above the intact sphincter of Oddi against malignant bile duct obstruction. J Gastroenterol. 2005 ,40:291-296.
17. Pedersen FM, Lassen AT, Schaffalitzky de Muckadell OB. Randomized trial of stent placed above and across the sphincter of Oddi in malignant bile duct obstruction. Gastrointest Endosc. 1998,48:574-579.
18. Smit JM, Out MM, Groen AK,et al.A placebo-controlled study on the efficacy of aspirin and doxycycline in preventing clogging of biliary endoprostheses. Gastrointest Endosc. 1989,35:485-489.
19. Barrioz T, Ingrand P, Besson I,et al. Randomised trial of prevention of biliary stent occlusion by ursodeoxycholic acid plus norfloxacin. Lancet. 1994 ,344:581-582.
20. Sciume C, Geraci G, Pisello F,et al. Prevention of clogging of biliary stents by administration of levofloxacin and ursodeoxycholic acid. Chir Ital. 2004 Nov-Dec;56(6):831-837.
21. De Ledinghen V, Person B, Legoux JL,et al. Prevention of biliary stent occlusion by ursodeoxycholic acid plus norfloxacin: a multicenter randomized trial. Dig Dis Sci. 2000 ,45:145-150.
22. Reddy DN, Banerjee R, Choung OW. Antireflux biliary stents: are they the solution to stent occlusions? Curr Gastroenterol Rep. 2006 ,8:156-160.
23. Dua KS, Reddy ND, Rao VG,et al. Impact of reducing duodenobiliary reflux on biliary stent patency: an in vitro evaluation and a prospective randomized clinical trial that used a biliary stent with an antireflux valve. Gastrointest Endosc. 2007,Mar 23; [Epub ahead of print].
24. Alvarado R, Palmaz JC, Garcia OJ, et al. Evaluation of polymer-coated balloon-expandable stents in bile ducts. Radiology. 1989 ,170:975-978.
25. Nakai Y, Isayama H, Komatsu Y,et al. Efficacy and safety of the covered Wallstent in patients with distal malignant biliary obstruction. Gastrointest Endosc. 2005 ,62:742-748.
26. Soderlund C, Linder S. Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc. 2006 ,63:986-995.
27. Park do H, Kim MH, Choi JS,et al Covered versus uncovered wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. Clin Gastroenterol Hepatol. 2006 ,4:790-796.
28. Yoon WJ, Lee JK, Lee KH,et al. A comparison of covered and uncovered Wallstents for the management of distal malignant biliary obstruction. Gastrointest Endosc. 2006 ,63:996-1000.
29. McCafferty IJ, Ferrando JR, Thomson H. Percutaneous transhepatic use of the hydrolyser thrombectomy catheter to re-canalize an occluded biliary wallstent. Clin Radiol. 2001 ,56:328-331.
30. Bueno JT, Gerdes H, Kurtz RC. Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc. 2003,58:879-884.
31. Tham TC, Carr-Locke DL, Vandervoort J,et al. Management of occluded biliary Wallstents. Gut. 1998,42:703-707.