Grey-scale ultrasonography and percutaneous transhepatic cholangiography in biliary tract disease.

Fifty-one patients with suspected obstructive jaundice and 14 without jaundice in whom disease of the biliary tract was suspected but infusion cholangiography had been unhelpful were examined by grey-scale ultrasonography and percutaneous transhepatic cholangiography and the findings analysed retrospectively. Grey-scale ultrasonography distinguished between obstructive and hepatocellular jaundice in 35 out of 46 patients (76%) and indicated the site of the obstruction in 27 (58%) and the cause of the obstruction in 13 (28%). Percutaneous transhepatic cholangiography distinguished between obstructive and hepatocellular jaundice in 42 of the patients (91%) and indicated the site of the obstruction in 42 (91%) and the cause in 29 (63%). In the 14 patients without jaundice percutaneous transhepatic cholangiography showed bile-duct stones in one an ampullary stenosis in three. It is concluded that grey-scale ultrasonography and percutaneous transhepatic cholangiography are complementary examinations and that ultrasonography should always be undertaken first as it is a non-invasive procedure that may provide the surgeon with all the diagnostic information he requires. Percutaneous transhepatic cholangiography should be performed when grey-scale ultrasonography has shown dilated bile ducts but failed to provide adequate diagnostic information. Cholangiography is also required when preoperative percutaneous drainage of the bile duct is contemplated. In those patients in whom grey-scale ultrasonography shows non-dilated ducts endoscopic retrograde cholangiopancreatography is probably the contract examination of choice.     

SPECIALTY CONFERENCE: The Treatment of Retained Gallstones

Various techniques are available to evaluate patients suspected of having common duct stones before an operation on the biliary tract. In patients without jaundice, intravenous cholangiography with tomography may provide satisfactory visualization of the biliary system and its contents. Sonography and computerized axial tomography are useful noninvasive methods. Endoscopic retrograde and transhepatic cholangiography are invasive techniques; but, when successful, they provide the most precise preoperative information obtainable about the presence or absence of stones in the biliary system. The most appropriate diagnostic procedures must be carefully selected for each patient. Each year in 3,000 to 4,000 cases, stones are found remaining in the bile ducts after common duct exploration for the removal of stones. Retained stones can be treated by nonoperative extraction, by irrigation techniques and by surgical removal. Extraction methods probably deserve first consideration, if experienced personnel are available. The technique of irrigation of the common bile duct with cholic acid or other solutions, although limited in success, may also be tried; if these procedures fail, then reoperation is indicated.     

Percutaneous Transhepatic Cholangiography—Report of a Technique

Percutaneous transhepatic cholangiography was carried out in 30 patients with jaundice of unknown cause. The examination was successful in 24, and the correct diagnosis was established before operation in 23.Among the specialized radiographic procedures useful in the differential diagnosis of jaundice, the percutaneous transhepatic cholangiogram is simple and reliable. It will distinguish intrahepatic from extrahepatic biliary obstruction. In benign structures, it can give a good anatomical and pathological definition of the problem which faces the surgeon. Occasionally, it may make operation unnecessary.Serious complications are hemorrhage and bile peritonitis. The incidence is low and by careful management they can be avoided.     

经皮肝穿刺胆道引流术与逆行胰腺胆管造影术对结石性梗阻性黄疸患者的疗效比较研究

目的:比较经皮肝穿刺胆道引流术(PTCD)与逆行胰腺胆管造影术(ERCP)对结石性梗阻性黄疸患者的治疗效果。方法:选取海军军医大学第三附属医院东方肝胆外科医院于2016年3月～2018年4月间收治的结石性梗阻性黄疸患者80例。按照介入治疗术式的异同将患者分为ERCP组(n=40,给予ERCP治疗)和PTCD组(n=40,给予PTCD治疗),记录两组手术时间、术中出血量、住院费用、住院时间、治疗成功率、黄疸缓解率、并发症发生情况,比较两组术前、术后1 d、术后7 d肝功能指标情况。结果:两组患者手术时间、术中出血量、治疗成功率、黄疸缓解率比较差异无统计学意义(P0.05),ERCP患者住院费用少于PTCD组患者,住院时间亦短于PTCD组患者(P0.05)。两组患者术后1 d、术后7 d丙氨酸转氨酶(ALT)、总胆红素(TBIL)、直接胆红素(DBIL)水平均较术前降低,且两组患者术后7 d上述指标水平低于术后1 d(P0.05),ERCP组术后1 d、术后7 d ALT、TBIL、DBIL水平与PTCD组比较差异无统计学意义(P0.05)。两组患者术后并发症总发生率比较差异无统计学意义(P0.05)。结论:PTCD、ERCP治疗结石性梗阻性黄疸,均能有效改善患者临床症状和肝功能,且手术安全性相当,但ERCP可明显减少住院时间和住院费用。     

Brushing cytology in biliary tract obstruction

During a period of eight years (1980 to 1987), cytologic samples were obtained by brushing and reverse screw devices from 54 patients undergoing transhepatic cholangiography for evaluation of obstructive jaundice. Eight patients were excluded from this study, seven for inadequate follow-up and one because of unsatisfactory cytologic material. Of the remaining cases, 32 were cytologically diagnosed as adenocarcinomas; all but one patient proved to have malignant disease by histologic examination and/or through clinical follow-up. These included 21 pancreatic carcinomas, 6 bile duct carcinomas, 1 ampullary carcinoma, 1 gallbladder carcinoma and 2 metastatic carcinomas. In one case, the diagnosis of malignancy was found to be in error upon review of the cytologic smears. Of 14 patients with negative cytologic diagnoses, 7 were found to have malignant neoplasms and 7 had benign diseases. These findings indicate that, while a positive cytologic diagnosis is a reliable indicator of a malignant biliary obstruction, a negative result does not exclude malignancy.     

Potentialities of transcutaneous and transhepatic cholangiography as a method of studying diseases of the bile excretory system]

Comprehensive examinations of 62 patients with jaundice of obscure origins involved transcutaneous transhepatic cholangiography carried out in all the patients, hepatolymphography in 60 cases, relaxation duodenography in 31, angiography in 41, ultrasonic examination of the liver in 31, endoscopic retrograde pancreatocholangiography in 28 and liver scanning in 19 patients. These studies have extended the knowledge on the biliferous system status in obturation and parenchymatous jaundices and helped define the role of transcutaneous transhepatic cholangiography among the invasive methods of radiologic examinations and pararadiologic methods.     

X-ray diagnosis of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) should be regarded as a disease of the bile tracts which is difficult to diagnose rather than a rare disease. Combined radiodiagnostic investigation in the preoperative period is of great importance. Direct methods of an induced contrast study of the biliferous system (transcutaneous transhepatic cholangiography, endoscopic retrograde pancreatocholangiography) play a major role in the diagnosis of PSC. The authors present 11 cases, describing in detail x-ray semiotics of various sites of PSC and its differential diagnosis with similar diseases.     

La cholangiographie percutanée transhépatique avec aiguille "fine" de Chiba.

In 40 patients percutaneous transhepatic cholangiography was performed by means of the "skinny" Chiba needle. The intrahepatic bile ducts were visualized in 100% of the patients with dilated ducts and in 67% of those with ducts of normal calibre. The results compare to those in the literature and demonstrate the usefulness as well as the reduced morbidity of this new procedure. Therefore nonvisualization of the intrahepatic bile ducts by this method signifies that the ducts are not dilated.     

Analysis of 3-sulfated and nonsulfated bile acids by one-step solvolysis and high performance liquid chromatography

A facile solvolysis procedure of 3-sulfated bile acid was devised using trifluoroacetic acid, tetrahydrofuran, and methanol. The sulfate esters were completely solvolyzed within only 2 hr by the present method. The clinical utility of the solvolysis procedure and high performance liquid chromatography using immobilized 3 alpha-hydroxysteroid dehydrogenase was demonstrated in the analysis of bile acids in serum of patients with obstructive jaundice. The quantities of 3-sulfated bile acids were calculated from the difference in the amount of bile acids before and after solvolysis. A significantly large proportion of 3-sulfated glycochenodeoxycholic acid, i.e., 21.9 to 31.3% of total glycochenodeoxycholic acid, was found in the serum of patients with obstructive jaundice. Thus, the present method permits simultaneous quantitation of 3-sulfated as well as nonsulfated bile acids in biological samples.     

Radiodiagnosis of patients with primary sclerosing cholangitis

Among diseases of the hepatobiliary system, primary sclerosing cholangitis is an undetectable disorder of the biliary tract rather than a rare nosological entity, complex radiation study is of great importance in its preoperative diagnosis. Among direct methods for contrasting the biliary tract, the authors gave preference to percutaneous transhepatic cholangiography that allows the dilated biliary tract to be contrasted virtually in 100% of cases. The specific features of X-ray semiotics of primary sclerosing cholangitis were identified in 17 patients.     

两种不同手术方式治疗恶性梗阻性黄疸患者的临床疗效比较研究

目的:探讨经皮肝穿刺胆管引流术(PTCD)与经内镜逆行胰胆管造影术(ERCP)治疗恶性梗阻性黄疸的治疗效果,并进行比较分析。方法:选取2016年1月~2018年5月期间我院收治的127例恶性梗阻性黄疸患者。根据治疗术式的不同将患者分为ERCP组(n=63,采用ERCP联合金属支架置入术进行治疗)和PTCD组(n=64,采用PTCD进行治疗),比较两组患者术后5d黄疸缓解率,比较两组患者术前、术后2周肝功能指标[血清总胆红素(TBIL)、丙氨酸转氨酶(ALT)、直接胆红素(DBIL)],比较两组患者术后舒适度量表评分情况及并发症发生情况。结果:两组患者术后黄疸总缓解率比较差异无统计学意义(P0.05);PTCD组低位梗阻患者黄疸缓解率低于ERCP组,而高位梗阻患者黄疸缓解率高于ERCP组(P0.05)。两组患者术前、术后2周TBIL、ALT、DBIL比较差异无统计学意义(P0.05);两组患者术后2周TBIL、ALT、DBIL水平较术前比较均下降(P0.05)。ERCP组患者术后舒适度量表评分总分低于PTCD组,差异有统计学意义(P0.05)。PTCD组术后并发症总发生率14.06%(9/64),低于ERCP组的41.27%(26/63)(P0.05)。结论:ERCP与PTCD治疗恶性梗阻性黄疸均可改善患者肝脏功能、疗效满意,但ERCP对低位梗阻患者治疗效果优于PTCD,且术后舒适度优于PTCD,但术后并发症较多,临床应根据患者情况选择具体术式。     

Percutaneous transhepatic intrabiliary intervention in patients with cholestasis

Percutaneous transhepatic paracentesis of the biliary ducts with ultrafine needles may be included into the list of recent great advances of roentgenology. It drastically enhances the efficiency of radiation diagnosis of obstructive diffuse jaundice. The diagnostic value of this technique was even higher than that of computed tomography and, the more, ultrasound diagnosis. The potentialities of simultaneous biliary duct catheterization have expanded the range of the procedure and made it possible to combine diagnosis with the therapeutical manipulation decompression of a suprastenotic part of the dilated biliary tree.     

Comparative assessment of percutaneous transhepatic cholangiodrainage under roentgenoscopy and ultrasound guidance

In 1990-2000, percutaneous transhepatic cholangiodrainage was performed in 89 patients with obstructive jaundice of tumoral etiology: Groups A (n = 21) under roentgenoscopic guidance and Group B (n = 68) under ultrasound guidance (USG). The efficiency and safety of puncture of the biliary tract were comparatively evaluated in these groups. The technical success of the procedure was achieved in 81.0% of Group A patients and in 98.5% of Group B ones. USG decreased radiation load on the patient and medical staff by three times and the number of needle passes by two times. External-and-internal cholangiodrainages under USG and roentgenoscopy were performed in 55.2 and 23.8%, respectively. The incidence of complications and mortality were 5.9 and 1.5% in Group B and versus 17.6% and 4.8% in Group A. It is concluded that transhepatic cholangiodrainage under USG has some advantage over puncture of the biliary tract under roentgenoscopy.     

Intravenous cholangiography; some observations on the use of cholografin

Intravenous cholangiography with cholografin is a safe procedure, most useful for the study of patients who have had cholecystectomy and later have symptoms related to the biliary ducts. When jaundice or liver impairment is present, the examination is usually unsuccessful. However, these conditions are not absolute contraindications to the procedure. There may be failure to visualize the biliary ducts even in the presence of a normal liver. Planigraphy is helpful in eliminating confusing superimposed structures and when there is only faint visualization of the common duct. Intravenous cholecystography is only of questionable value as a supplementary examination to oral cholecystography. It may prove useful in certain instances when patients are unable to retain or absorb the oral media or where emergency operation is contemplated.     

INTRAVENOUS CHOLANGIOGRAPHY—Some Observations on the Use of Cholografin

Intravenous cholangiography with cholografin is a safe procedure, most useful for the study of patients who have had cholecystectomy and later have symptoms related to the biliary ducts.When jaundice or liver impairment is present, the examination is usually unsuccessful. However, these conditions are not absolute contraindications to the procedure. There may be failure to visualize the biliary ducts even in the presence of a normal liver.Planigraphy is helpful in eliminating confusing superimposed structures and when there is only faint visualization of the common duct.Intravenous cholecystography is only of questionable value as a supplementary examination to oral cholecystography. It may prove useful in certain instances when patients are unable to retain or absorb the oral media or where emergency operation is contemplated.     

磁共振胰胆管成像联合血清CA125、CA19-9、CEA对良恶性梗阻性黄疸的诊断价值

摘要 目的：研究磁共振胰胆管成像（MRCP）联合血清糖类抗原125（CA125）、糖类抗原19-9（CA19-9）、癌胚抗原（CEA）对良恶性梗阻性黄疸的诊断价值。方法：将医院从2018年1月～2020年2月期间收治的90例良恶性梗阻性黄疸患者纳入研究。将其按照良恶性的差异分为良性梗阻性黄疸51例以及恶性梗阻性黄疸39例。分别对所有患者进行MRCP检测,并分析良恶性梗阻性黄疸MRCP影像学表现特征的差异。此外,采集所有患者清晨空腹静脉血,检测血清CA125、CA19-9、CEA水平并进行对比。通过受试者工作特征（ROC）曲线分析明确MRCP联合血清CA125、CA19-9、CEA对良恶性梗阻性黄疸的诊断价值。结果：恶性梗阻性黄疸部位为十二指肠乳头区人数占比明显高于良性梗阻性黄疸,而胰头上区、胰头区人数占比均明显低于良性梗阻性黄疸;且恶性梗阻性黄疸梗阻重度扩张人数占比明显高于良性梗阻性黄疸,而梗阻轻度扩张人数占比明显低于良性梗阻性黄疸,差异均有统计学意义（均P＜0.05）。恶性梗阻性黄疸患者血清CA125、CEA水平均明显高于良性梗阻性黄疸患者（均P＜0.05）;而两组血清CA19-9水平对比不明显（P＞0.05）。MRCP联合血清CA125、CA19-9、CEA诊断良恶性梗阻性黄疸的曲线下面积、灵敏度、特异度、约登指数均明显高于MRCP和血清CA125、CA19-9、CEA单独诊断。结论：MRCP联合血清CA125、CA19-9、CEA对良恶性梗阻性黄疸的诊断价值较高,值得临床推广应用。     

The application of intraoperative ultrasound during partial hepatectomy for the accurate detection and removal of intrahepatic bile duct stones

To evaluate the application of intraoperative ultrasound (IOUS) during partial hepatectomy to accurately detect and remove intrahepatic bile duct stones. Intrahepatic bile duct stones were precisely localized during surgery by using IOUS. Furthermore, guiding stone extraction, and determining the scope of liver resection and choice of surgical procedures were also evaluated using this technique. Of the 25 patients used in this study, 16 patients received a left lateral liver resection, 7 patients received a left liver resection, 1 patient had a liver resection of segments V and VI, 9 patients had common bile duct stones, and 6 patients had bile duct stones that underwent jejunal Roux-en-y anastomosis. In addition, IOUS exploration after liver resection and post-operative T-tube cholangiography showed one case with residual stones. The use of IOUS showed high diagnostic accuracy, while also rectifying the misdiagnosis and missed diagnosis of bile stones in preoperative imaging. IOUS also assisted with positioning accuracy, which is very important in determining the extent of surgical resection and choice of surgical procedure. Thus, IOUS can dynamically monitor the surgical procedure, guide the operation, and inspect the outcome of operations, therefore, effectively improving the quality of operation.     

Ultrasonographic guidance in diagnostic and therapeutic interventions in diseases of the internal organs

A hundred fifty four invasive diagnostic and therapeutical interventions were made in patients with diseases of the abdomen and retroperitoneal space under ultrasonographic guidance. Various biopsies were performed in 139 patients; positive results were achieved in 120 (86.3%) cases. In 15 patients, diagnostic biopsies were combined with therapeutical interventions, such as aspiration of cysts in the liver (n = 3) and kidney (n = 2); drainage of abscesses in the abdomen (n = 5) and liver (n = 5). Fourteen patients with mechanical jaundice caused by extrahepatic bile duct tumors or pancreatic head cancer underwent percutaneous transhepatic cholecystocholangiography followed by external drainage. Percutaneous transhepatic drainage of the gallbladder was made in 1 patient with acute cholecystitis.     

Cephalexin Levels in Human Bile in Presence of Biliary Tract Disease

Cephalexin was given to 24 patients before and after operation on the bile ducts and gall bladder. Two patients had obstructive jaundice. Samples of the bile were taken either directly from the gall bladder at operation or via the T-tube. Cephalexin was excreted in the bile, peak levels being obtained after two to three hours. These levels could be raised if probenecid was given concurrently. Higher levels were found in patients with functioning gall-bladders. A trial of cephalexin seems justified for the treatment of typhoid carriers.     

Fine needle aspiration of the liver

A total of 81 transhepatic fine needle aspiration (FNA) biopsies were performed on 78 patients to rule out focal or diffuse neoplastic disease; 87.6% were performed with ultrasound guidance, 6.1% with CT guidance, 3.7% intraoperatively and 1 using fluoroscopy during percutaneous transhepatic cholangiography. Smears of the aspirated samples were cytologically evaluated with clinical and radiologic correlation; in addition, histologic examination of cell blocks was performed in 46% of the cases, ultrastructural examination in 34% of the cases and peroxidase-antiperoxidase staining in 3 cases. Ultrastructural definition of the type of malignancy was possible in 24 cases (29%). Minor complications in two patients were pain and tenderness at the puncture site. The sensitivity for malignancy was 91%, the specificity was 100%, the predictive value of positive results was 100%, and the predictive value of negative results was 73%. This series demonstrates that FNA biopsy with ultrasound guidance can provide an accurate diagnosis of malignancy and may preempt a lengthy workup in the search for a primary tumor.