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胆道支架植入术联合经皮肝穿刺胆管引流术治疗不同类型恶性梗阻性黄疸的效果观察
Clinical effect of biliary stenting combined with percutaneous transhepatic cholangial drainage in treatment of different types of malignant obstructive jaundice
文章发布日期:2018年12月17日  来源:  作者:刘锐,黄坤,陈伟伟,等  点击次数:266次  下载次数:50次

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【摘要】:目的探讨不同类型恶性梗阻性黄疸(MOJ)患者行经皮肝穿刺胆管引流术(PTCD)联合胆道支架植入术的临床疗效及手术经验。方法回顾性分析2013年7月-2018年7月北京空军总医院收治的185例MOJ患者行PTCD联合胆道支架植入术的早期临床疗效。主要观察指标包括:梗阻部位及类型;术前与术后3~5 d、6~10 d相关血液学指标,如TBil、DBil、ALT、AST、ALP、GGT等;支架植入情况。正态分布的计量资料2组间比较采用t检验,3组间比较采用方差分析;非正态分布的计量资料2组间比较采用Mann-Whitney U检验,3组间比较采用Kruskal-Wallis H检验。计数资料组间比较采用χ2检验。结果185例患者中低位梗阻102例,高位梗阻75例,胆管全程梗阻4例,吻合口梗阻4例。所有患者均成功施行PTCD+胆道支架植入术,并置管引流,技术成功率为100%。185例患者共植入233枚支架,所有患者术后黄疸减退,食欲增加,肝功能恢复,其中显效146例,有效39例。低位梗阻患者手术疗效优于高位梗阻(χ2=10.866,P=0.001);高位Ⅰ型梗阻单、双支架引流效果以及手术前后胆红素水平比较,差异均无统计学意义(P值均>0.05),而高位Ⅱ、Ⅲ、Ⅳ型梗阻双支架引流效果优于单支架(χ2=6.412,P=0.011),双支架引流术后6~10 d TBil、DBil水平显著低于单支架引流(t值分别为2.62、2.06,P值均<0.05)。结论PTCD联合胆道支架植入术能够改善MOJ患者肝功能与食欲,提高患者生活质量。对于低位梗阻患者的疗效显著高于高位梗阻;同时对于高位Ⅱ、Ⅲ、Ⅳ型梗阻,建议行双支架引流。对于胆管全程梗阻及吻合口梗阻,支架植入也具有很好的临床疗效;对于胆道合并十二指肠梗阻者,可行胆道联合十二指肠支架植入术。
【Abstract】:ObjectiveTo investigate the clinical effect and surgical experience of percutaneous transhepatic cholangial drainage (PTCD) combined with biliary stenting in patients with different types of malignant obstructive jaundice (MOJ). MethodsA retrospective analysis was performed for the early clinical outcomes of 185 patients with MOJ who were admitted to Beijing Air Force General Hospital from July 2013 to July 2018 and underwent PTCD combined with biliary stenting. Major observation indices included location and type of obstruction, related hematological parameters before surgery and at 3-5 and 6-10 days after surgery, including total bilirubin (TBil), direct bilirubin (DBil), alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transpeptidase, and stent implantation. The t-test was used for comparison of normally distributed continuous data between two groups, and an analysis of variance was used for comparison between three groups; the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups, and the Kruskal-Wallis H test was used for comparison between three groups. The chi-square test was used for comparison of categorical data between groups. ResultsOf all 185 patients, 102 had low-level obstruction, 75 had high-level obstruction, 4 had complete biliary obstruction, and 4 had anastomotic obstruction. All patients underwent PTCD+biliary stenting successfully, and catheter drainage was performed with a technical success rate of 100%. A total of 233 stents were implanted for 185 patients, and all patients had reduced jaundice, increased appetite, and improved liver function after surgery, among whom 146 had marked response and 39 had response. The patients with low-level obstruction had a significantly better surgical outcome than those with high-level obstruction (χ2=10.866, P=0.001). There was no significant difference in bilirubin between the patients with type I high-level obstruction who underwent single-stent drainage and those who underwent double-stent drainage before and after surgery (P>0.05). The patients with type Ⅱ/Ⅲ/Ⅳ high-level obstruction who underwent double-stent drainage had a significantly better outcome than those underwent single-stent drainage (χ2=6.412, P=0.011), as well as significantly lower levels of TBil and DBil at 6-10 days after stent drainage (t=2.62 and 2.06, P<0.05). ConclusionPTCD combined with biliary stenting can improve liver function, appetite, and quality of life in patients with MOJ, and patients with low-level obstruction have significantly better outcomes than those with high-level obstruction. Double-stent drainage is recommended for patients with type Ⅱ/Ⅲ/Ⅳ high-level obstruction. Biliary stenting also has a good clinical effect in patients with complete biliary obstruction and anastomotic obstruction, and biliary and duodenal stenting can be performed for patients with biliary obstruction combined with duodenal obstruction.
【关键字】:黄疸, 阻塞性; 胆道支架; 经皮肝穿刺胆管引流术; 治疗结果
【Key words】:jaundice, obstructive; biliary stent; percutaneous transhepatic cholangial drainage; treatment outcome
【引证本文】:LIU R, HUANG K, CHEN WW, et al. Clinical effect of biliary stenting combined with percutaneous transhepatic cholangial drainage in treatment of different types of malignant obstructive jaundice[J]. J Clin Hepatol, 2019, 35(1): 131-137. (in Chinese)
刘锐, 黄坤, 陈伟伟, 等. 胆道支架植入术联合经皮肝穿刺胆管引流术治疗不同类型恶性梗阻性黄疸的效果观察[J]. 临床肝胆病杂志, 2019, 35(1): 131-137.

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