第一部分

目的 探讨十二指肠乳头部肿瘤经内镜下切除的有效性和安全性。

方法 回顾性分析2015年10月至2021年1月于内镜科行内镜下十二指肠乳头部肿瘤切除的23例患者的临床病理资料，分析手术效果和术后并发症的发生情况。

结果 23例患者成功行内镜下十二指肠乳头部肿瘤切除，切除病灶大小为0.5~2.8 cm，其中整块切除21例，分块切除2例。术后出现并发症的患者11例，发生率为47.8%(11/23)，其中6例患者同时伴有2种及以上并发症，术后迟发性出血8例(34.8%)，5例患者通过内镜下止血治疗后止血，3例患者经介入栓塞治疗后出血停止；穿孔2例(8.7%)，经过抗炎、腹腔穿刺引流等保守治疗后愈合；术后胰腺炎5例(21.7%)，给予生长抑素和消炎痛栓肛塞处理后好转。术前活检提示高级别上皮内瘤变11例，低级别上皮内瘤变10例，慢性炎症2例；术后病理结果显示，腺癌4例，腺瘤19例。术前活检病理结果与术后病理的吻合率为39.1%(9/23)，其中术前活检病理低估12例(52.2%)，高估2例(8.7%)。所有患者预后良好，随访期内无死亡病例(随访时间4-55月)。

结论 对于早期十二指肠乳头部肿瘤，应当积极采取切除的治疗策略，内镜下十二指肠乳头部肿瘤切除术近期效果相对安全、有效，可以做为首选术式，但是远期效果仍需多中心、前瞻性临床研究证实。

第二部分

目的 对比三种塑料胆管支架末端开口留置方式在解除由肝门部不可切除胆管癌引起的梗阻性黄疸的临床应用效果。

方法 回顾性分析2014年4月至2020年12月期间，收治的肝门部不可切除胆管癌引起的梗阻性黄疸患者61例，行塑料胆管支架置入减黄治疗，其中胆管支架末端开口胃内留置18例，胆管支架末端开口十二指肠乳头留置31例，胆管支架末端开口十二指肠水平部留置12例。随访临床疗效、并发症，并进行结果分析。

结果 三种塑料胆管支架置入的入组患者中位年龄无统计学差异(p=0.076)，支架中位通畅时间(p=0.101) 、90天内支架梗阻率(p=0.589)、围手术期死亡率(p=1)三组术式无明显差异。三组支架的2周内发热率(p=0.003)有统计学差异(p=0.017)。

结论 三组术式在中位年龄、90天再梗阻率、支架中位通畅时间、围手术期死亡率方面无统计学差异。胆管支架末端开口十二指肠水平部留置组患者的2周内发热率低于其他两组，我们应将支架末端开口留置于十二指肠水平部作为首选置入方式。当然，此研究局限于入组人数，我们需要更多的多中心随机对照研究来进一步验证结论。

Part

Objective: To evaluate the efficacy and safety of endoscopic papillectomy of major duodenal papilla neoplasms.

Methods: We retrospectively reviewed and analyzed the clinical and pathological data, postoperative outcomes and complications of 23 patients who underwent endoscopic papillectomy of major duodenal papilla neoplasms in the Department of Endoscopy,  from October 2015 to January 2021.

Results: Endoscopic papillectomy of major duodenal papilla neoplasms was successfully performed in 23 patients. The size of resected lesions varied between 0.5 - 2.8 cm. Among them, 21 patients were conducted en bloc resection procedure and 2 patients were received piecemeal resection. Postoperative complications occurred in 11 patients, the incidence rate was 47.8% (11 / 23), of which 6 patients had two or more complications. Postoperative bleeding occurred in 8 patients (34.8%), among which five patients stopped bleeding after endoscopic hemostasis and three patients stopped after interventional embolization. Perforation occurred in 2 cases (8.7%), and healed after conservative treatment such as anti-inflammatory treatment and abdominal drainage. Five patients had pancreatitis (21.7%) and recovered after treatment with somatostatin and rectal administration of indomethacin. Preoperative biopsy showed high-grade intraepithelial neoplasia in 11 cases, low-grade intraepithelial neoplasia in 10 cases and chronic inflammation in 2 cases; Postoperative pathological results suggested that 4 cases were adenocarcinoma and 19 cases were adenoma. The coincidence rate of results between preoperative biopsy and postoperative pathology was 39.1% (9/23), and 12 cases (52.2%) were underestimated and 2 cases (8.7%) were overestimated. The prognosis of all patients was good, and there was no death event during the follow-up period (follow-up was 4-55 months).

Conclusion: Major duodenal papilla neoplasms with early stage should be treated with relatively aggressive resection. Endoscopic resection of duodenal papillary tumor is safe and effective in the short term, and can be recommended as the first choice. However, the long-term effect still needs to be validated by multi-centered and prospective studies.

Part2

Objective: To compare the clinical effect of three types of plastic biliary stent in relieving obstructive jaundice caused by unresectable hilar cholangiocarcinoma.

Methods: This was a retrospective study. We enrolled 61 patients with obstructive jaundice caused by unresectable hilar cholangiocarcinoma from April 2014 to December 2020. Plastic biliary stent placement was used to relieve jaundice, including 18 cases of intragastric indwelling at the end of biliary stent, 31 cases of duodenal indwelling at the end of biliary stent, 12 cases of duodenal indwelling at the level of biliary stent. The clinical efficacy and complications were followed up and the results were analyzed.

Results: There was no significant difference in median age (p=0.076). There was also no statistically difference in the median stent patency period (p=0.101), 90-day obstruction rate (p=0.589), peri-operative mortality (p=1) among three patient groups.  However, the fever rate within 2 weeks of the three groups were significantly different (p=0.003 respectively).

Conclusion: There was no significant difference in median age, 90-day obstruction rate, median stent patency period and peri-operative mortality among three patient groups. Patients with biliary plastic stents with ends placed at the horizontal portion of the duodenum had a lower fever rate within two weeks after implantation period compared with the two other groups. Therefore, biliary plastic stents with ends placed at the horizontal portion of the duodenum should be recommended as the preferred procedure. However, the current analysis is limited in sample size, and multi-center randomized controlled trials need to be conducted to further verify our conclusion.