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经皮肝穿刺胆管引流术联合胆道支架植入术治疗高位恶性梗阻性黄疸的效果及预后影响因素分析
Clinical effect of percutaneous transhepatic cholangial drainage combined with biliary stent implantation in treatment of high malignant obstructive jaundice and the influencing factors for prognosis
文章发布日期:2019年03月08日  来源:  作者:陈伟伟,黄 坤,刘 锐,等  点击次数:262次  下载次数:54次

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【摘要】:目的探讨经皮肝穿刺胆管引流术(PTCD)联合胆道支架植入术治疗高位恶性梗阻性黄疸(MOJ)的效果及影响生存期的危险因素。方法回顾性分析解放军空军总医院肝胆外科2015年6月-2017年6月收治的92例高位MOJ患者临床资料。符合正态分布的计量资料两组间比较采用t检验,多组间比较采用方差分析,进一步两两比较采用SNK-q检验;非正态分布的计量资料两组间比较采用Mann-Whitney U检验。计数资料组间比较采用χ2检验。采用受试者工作特征曲线(ROC曲线)明确影响生存期指标的最佳截断值,根据最佳截断值进行分组,采用Kaplan-Meier法进行生存分析。多因素Cox风险模型分析明确影响患者生存期的独立危险因素。结果所有患者均获得随访,随访时间1~10个月,中位随访时间6个月。随访期间56例患者死亡,36例患者存活,中位生存期(OS)为6个月,随访末期生存率39.1%,半年生存率44.6%。14例患者出现术后并发症,并发症发生率为15.2%。术后3 d及术后1周的TBil、DBil、ALT、AST复查结果显示,上述指标水平显著下降且差异均有统计学意义(F值分别为206.264、106.161、86.332、166.857,P值均<0.05)。根据患者是否存活,采用ROC曲线进行分析,TBil最佳截断值为112.9 μmol/L,敏感度为95.12%,特异度为46.15%;ALT最佳截断值为210 U/L,敏感度为92.68%,特异度为31.58%;Alb最佳截断值为35.7 g/L,敏感度为68.29%,特异度为58.33%;RBC最佳截断值为3.56×1012/L,敏感度为6098%,特异度为69.23%。Child-Pugh分级、TBil、ALT在预测患者OS时表现出统计学差异(P值均<0.05)。多因素Cox风险模型中得出Child-Pugh C级是影响PTCD联合胆道支架植入术患者术后生存期的独立危险因素(Wald值为5.898,95%可信区间:1.373~19.465,P=0.015)。结论PTCD联合胆道支架植入术治疗MOJ患者效果较好,但是术前患者的基础肝功能对患者生存期影响较大,建议动态观察肝功能,指导临床积极治疗,以期延长患者生存期。
【Abstract】:ObjectiveTo investigate the clinical effect of percutaneous transhepatic cholangial drainage (PTCD) combined with biliary stent implantation in the treatment of high malignant obstructive jaundice (MOJ) and the risk factors for survival time. MethodsA retrospective analysis was performed for the clinical data of 92 patients with high MOJ who were admitted to Department of Hepatobiliary Surgery in Air Force General Hospital, PLA, from June 2015 to June 2017. The t-test was used for comparison of normally distributed continuous data between two groups; an analysis of variance was used for comparison between multiple groups, and the SNK-q test was used for further comparison between two groups. The Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The chi-square test was used for comparison of categorical data between groups. The receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values of influencing factors for survival time; the patients were divided into groups according to the optimal cut-off values, and the Kaplan-Meier method was used for survival analysis. The multivariate Cox proportional hazards model was used to identify the independent influencing factors for survival time. ResultsAll patients were followed up for a median time of 6 months (range 1-10 months). A total of 56 patients died and 36 survived during follow-up, with a median survival time of 6 months, a survival rate of 39.1% at the end of follow-up, and a half-year survival rate of 44.6%. Of all 92 patients, 14 experienced postoperative complications, resulting in an incidence rate of complications of 15.2%. At 3 days and 1 week after surgery, there were significant reductions in total bilirubin (TBil), direct bilirubin, alanine aminotransferase (ALT), and aspartate aminotransferase (F=206.264, 106.161, 86.332, and 166.857, all P<0.05). The ROC Curve was used to analyze the data, TBil had a sensitivity of 95.12% and a specificity of 46.15% at the optimal cut-off value of 112.9 μmol/L; ALT had a sensitivity of 92.68% and a specificity of 31.58% at the optimal cut-off value of 210 U/L; albumin had a sensitivity of 68.29% and a specificity of 58.33% at the optimal cut-off value of 35.7 g/L; red blood cell count had a sensitivity of 60.98% and a specificity of 69.23% at the optimal cut-off value of 3.56×1012/L. Child-Pugh class, TBil, and ALT showed a significant difference in predicting overall survival (all P<0.05). The multivariate Cox proportional hazards model showed that Child-Pugh class C was an independent influencing factor for survival time after PTCD combined with biliary stent implantation. ConclusionPTCD combined with biliary stent implantation has a good clinical effect in the treatment of patients with MOJ, but preoperative liver function has a great impact on survival time. Therefore, liver function should be observed dynamically to guide clinical treatment, in order to prolong the survival time of such patients.
【关键字】:黄疸, 阻塞性; 引流术; 预后; 危险因素
【Key words】:jaundice, obstructive; drainage; prognosis; risk factors
【引证本文】:CHEN WW, HUANG K, LIU R, et al. Clinical effect of percutaneous transhepatic cholangial drainage combined with biliary stent implantation in treatment of high malignant obstructive jaundice and the influencing factors for prognosis[J]. J Clin Hepatol, 2019, 35(3): 559-564. (in Chinese)
陈伟伟, 黄坤, 刘锐, 等. 经皮肝穿刺胆管引流术联合胆道支架植入术治疗高位恶性梗阻性黄疸的效果及预后影响因素分析[J]. 临床肝胆病杂志, 2019, 35(3): 559-564.

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