恶性阻塞性黄疸胆道内支架治疗及胆汁病原菌培养的临床研究
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摘要
目的
分析晚期恶性阻塞性黄疸患者胆道内支架植入术前术后各项指标的变化,评价胆道内支架治疗的疗效,并比较经皮肝穿刺胆道支架植入和经十二指肠镜胆道支架植入两种途径放置支架的优劣,随访分析支架再狭窄的原因及临床处理策略。
观察恶性阻塞性黄疸患者胆汁病原菌培养和药物敏感情况,分析其临床指导意义。
方法
对我院消化病中心2009年5月——2010年5月收治的106例恶性阻塞性黄疸进行胆道内支架治疗患者的临床资料进行分析,其中经皮肝穿刺组(PTBS)46例,经十二指肠镜治疗组(ERBD)60例,比较两组患者术后胆红素、转氨酶、转肽酶及碱性磷酸酶的变化及并发症的发生情况;对随访患者出现支架再狭窄时行胆道造影检查同时取得支架狭窄处的病理学诊断并对再狭窄进行处理。
对我院行胆道内支架植入治疗的106例恶性阻塞性黄疸患者,在诊疗过程中采集胆汁进行病原菌培养及药物敏感鉴定,分析恶性阻塞性黄疸患者胆汁病原菌培养常见病原菌谱及其耐药性。
结果
经皮肝穿刺组(PTBS)46例患者,42例支架植入成功,技术成功率91.3%;经十二指肠镜治疗组60例患者,57例支架植入成功,成功率95%。术后两组患者胆红素指标明显下降,经皮肝穿刺组术后第3天和第7天的胆红素下降率分别为36%和68%,经十二指肠镜组分别为35%和67%,与肝功能有关的转氨酶、转肽酶及碱性磷酸均明显下降。两组患者的住院时间分别是经十二指肠镜组(12.5±2.4)天和经皮肝穿刺组(20.2±3.2)天。经皮肝穿刺组8例患者术后出现不同程度的并发症,发生率为19.0%,经十二指肠镜治疗组术后有8例出现并发症,发生率为14.0%,两组患者在总并发症发生率上无显著差异。但经十二指肠镜治疗组术后有4例出现胰腺炎,发生率为7.0%,经皮肝穿刺组术后无胰腺炎病例发生,经十二指肠镜治疗组术后胰腺炎发生率高于经皮肝穿刺组(P<0.05);经皮肝穿刺治疗组术后有4例患者出现胆道感染,发生率9.5%,经十二指肠镜治疗组术后发生胆道感染病例4例,发生率为7.0%,两者比较无明显差异。低位梗阻患者术后合并胆道感染6例,发生率为10.5%,高位梗阻患者术后有2例出现胆道感染,发生率4.7%,低位梗阻患者术后胆道感染发生率高于高位梗阻患者(P<0.05)。对所有支架植入患者99例随访6个月,共随访到支架再狭窄患者18例,病理诊断显示其原因为：10例为肿瘤生长,5例为胆泥瘀积,3例为慢性炎症。
全部106例患者有64例患者胆汁病原菌培养阳性,阳性率为60.3%,共检出病原菌72株,其中革兰氏阴性菌52株,占72.2%,革兰氏阳性菌15株,占20.8%,真菌5株,占6.9%,革兰氏阴性菌对依替米星、头孢哌酮／舒巴坦及美罗培南敏感性好,而革兰氏阳性菌对万古霉素、替考拉宁敏感性好,两类细菌对临床常用的喹诺酮类及不含β-内酰胺酶抑制剂的三代头孢敏感性差,敏感率约为45%。
结论：
胆道内支架治疗是晚期恶性阻塞性黄疸患者的一种有效的姑息性治疗方法,经皮肝穿刺与经十二二指肠镜胆道支架植入两科途径相比较,两者技术成功率相似,治疗效果无明显差异,均能达到减黄和改善肝功能的目的,但经十二指肠镜治疗组住院时间明显缩短。两组患昔术后总并发症发生率相近，但经十二指肠镜治疗组患者胰腺炎发生率高于经皮肝穿刺组，在进行十二指肠镜治疗过程中应尽量避免对胰腺的损伤。低位梗阻患者术后发生胆道感染几率高于高位梗阻患者，但两种胆道支架植入途径的术后胆道感染发生几率无明显差异。支架植入术后再狭窄的主要因素是肿瘤生长、慢性炎症和胆泥淤积。
恶性阻塞性黄疸患者胆道病原菌培养以革兰氏阴性菌为主，对氨基糖式类、头孢哌酮/舒巴坦及碳青霉烯类药物敏感，而对喹诺酮类及不含内酰胺酶抑制剂的三代头孢基本耐药。
Objective
This paper is to analyze the data of preoperation and postoperation for MBOJ (malignant biliary obstructive jaundice) who biliary stent were performed and to evaluate the efficacy of biliary stent implantation and to compare the advantages of PTBS (percutaneous transhepatic biliary stent) and ERBD (endoscopic retrograde biliary drainage). In addition, it discusses the causes and the treatment of restenosis after biliary stent implantation.
It analyzes their type and clinical meaning by observing the biliary pathogen and drug sensitivity in patients with MBOJ.
Methods
The clinical data of106patients with MBOJ of treatment by ERBD (60patients) and PTBS (46patients) in digestive disease center from May2009to May2010were analysized. The data of BIL and hepatic function and complications after PTBS and ERBD were compared. Cholangio-pancreatography and pathological diagnosis of the patients with biliary restenosis were performed. At the same time extra treatment was taken to deal with the biliary restenosis. The bile of106patients with MBOJ of treatment by biliary stent implantation in this hospital were detected and cultured and the pathogenic bacteria causing biliary infection were analyzed respectively.
Results
Effective biliary stent implantation was achieved in42out of46patients (91.3%) treated with PTBS and in57out of60patients (95.0%) treated with ERBD. And jaundice reduction rate was36%(third day) and68%(seventh day) in PTBS, and was35%(third day) and67%(seventh day) in ERBD. ALT ALP and γ-GGT after biliary stent implantation decreased and hepatic function was improved. The hospitalization was (12.5±2.4) days in ERBD and (20.2±3.2) days in PTBS.
The complication rate of PTBS was19.0%, and the complication rate of ERBD was14.0%(P<0.05). There was no significant difference between ERBD and PTBS in total complications.
Pancreatitis occured in4patients (7.0%) of ERBD and no occurred in patients of PTBS. There was significant difference between ERBD and PTBS. Biliary infection occurred in4patients (7.0%) of ERBD and occurred in4patients (9.5%) of PTBS. There was no significant difference between ERBD and PTBS. But biliary infection occurred in6patients (10.5%) of low order obstruction and occurred in2patients (4.7%) of high order obstruction. There was significant difference between low order obstruction and high order obstruction.
Among18patients of restenosis with the pathological diagnosis,10restensis were caused by tumor growth,5were caused by bile sand and3were due to chronic inflammation.
The bile of64patients from106patients with MBOJ had bacteria and the positive rate was60.3%. In all the72strains,52strains (72.2%) were Gram-negative bacilli and Gram-positive cocci accounted for20.8%and fungi accounted for6.9%.
Gram-negative bacilli were sensitive to etimicin sulfate, imipenem and cefoperazone/sulbactam and Gram-positive cocci were sensitive to vancomycin. Linezolid and teicoplanin. Both Gram-negative bacilli and Gram-positive cocci was resistant to carbostyril and third generation cephems.
Conclusion
Both ERBD and PTBS are palliative and efficient procedures to relieve MBOJ, which are similar in technical success rates and clinical efficacv and total complications. But ERBD is advantageous in hospital stay than PTBS, and it has high complication of pancreatitis. Biliary infection occurs more in low order obstruction than high order obstruction.
Tumor growth, chronic inflammation and bile sand are main causes of the restenosis after biliary metal stent implantation.
Among the pathogens of MBOJ, Gram-negative bacilli are the most common, which is most sensitive to carbapenems, aminoglycoside and cefoperazone/sulbactam, which is resistant to the carbostyril and third generation cephems that are widely clinically.
分析晚期恶性阻塞性黄疸患者胆道内支架植入术前术后各项指标的变化,评价胆道内支架治疗的疗效,并比较经皮肝穿刺胆道支架植入和经十二指肠镜胆道支架植入两种途径放置支架的优劣,随访分析支架再狭窄的原因及临床处理策略。
观察恶性阻塞性黄疸患者胆汁病原菌培养和药物敏感情况,分析其临床指导意义。
方法
对我院消化病中心2009年5月——2010年5月收治的106例恶性阻塞性黄疸进行胆道内支架治疗患者的临床资料进行分析,其中经皮肝穿刺组(PTBS)46例,经十二指肠镜治疗组(ERBD)60例,比较两组患者术后胆红素、转氨酶、转肽酶及碱性磷酸酶的变化及并发症的发生情况;对随访患者出现支架再狭窄时行胆道造影检查同时取得支架狭窄处的病理学诊断并对再狭窄进行处理。
对我院行胆道内支架植入治疗的106例恶性阻塞性黄疸患者,在诊疗过程中采集胆汁进行病原菌培养及药物敏感鉴定,分析恶性阻塞性黄疸患者胆汁病原菌培养常见病原菌谱及其耐药性。
结果
经皮肝穿刺组(PTBS)46例患者,42例支架植入成功,技术成功率91.3%;经十二指肠镜治疗组60例患者,57例支架植入成功,成功率95%。术后两组患者胆红素指标明显下降,经皮肝穿刺组术后第3天和第7天的胆红素下降率分别为36%和68%,经十二指肠镜组分别为35%和67%,与肝功能有关的转氨酶、转肽酶及碱性磷酸均明显下降。两组患者的住院时间分别是经十二指肠镜组(12.5±2.4)天和经皮肝穿刺组(20.2±3.2)天。经皮肝穿刺组8例患者术后出现不同程度的并发症,发生率为19.0%,经十二指肠镜治疗组术后有8例出现并发症,发生率为14.0%,两组患者在总并发症发生率上无显著差异。但经十二指肠镜治疗组术后有4例出现胰腺炎,发生率为7.0%,经皮肝穿刺组术后无胰腺炎病例发生,经十二指肠镜治疗组术后胰腺炎发生率高于经皮肝穿刺组(P<0.05);经皮肝穿刺治疗组术后有4例患者出现胆道感染,发生率9.5%,经十二指肠镜治疗组术后发生胆道感染病例4例,发生率为7.0%,两者比较无明显差异。低位梗阻患者术后合并胆道感染6例,发生率为10.5%,高位梗阻患者术后有2例出现胆道感染,发生率4.7%,低位梗阻患者术后胆道感染发生率高于高位梗阻患者(P<0.05)。对所有支架植入患者99例随访6个月,共随访到支架再狭窄患者18例,病理诊断显示其原因为：10例为肿瘤生长,5例为胆泥瘀积,3例为慢性炎症。
全部106例患者有64例患者胆汁病原菌培养阳性,阳性率为60.3%,共检出病原菌72株,其中革兰氏阴性菌52株,占72.2%,革兰氏阳性菌15株,占20.8%,真菌5株,占6.9%,革兰氏阴性菌对依替米星、头孢哌酮／舒巴坦及美罗培南敏感性好,而革兰氏阳性菌对万古霉素、替考拉宁敏感性好,两类细菌对临床常用的喹诺酮类及不含β-内酰胺酶抑制剂的三代头孢敏感性差,敏感率约为45%。
结论：
胆道内支架治疗是晚期恶性阻塞性黄疸患者的一种有效的姑息性治疗方法,经皮肝穿刺与经十二二指肠镜胆道支架植入两科途径相比较,两者技术成功率相似,治疗效果无明显差异,均能达到减黄和改善肝功能的目的,但经十二指肠镜治疗组住院时间明显缩短。两组患昔术后总并发症发生率相近，但经十二指肠镜治疗组患者胰腺炎发生率高于经皮肝穿刺组，在进行十二指肠镜治疗过程中应尽量避免对胰腺的损伤。低位梗阻患者术后发生胆道感染几率高于高位梗阻患者，但两种胆道支架植入途径的术后胆道感染发生几率无明显差异。支架植入术后再狭窄的主要因素是肿瘤生长、慢性炎症和胆泥淤积。
恶性阻塞性黄疸患者胆道病原菌培养以革兰氏阴性菌为主，对氨基糖式类、头孢哌酮/舒巴坦及碳青霉烯类药物敏感，而对喹诺酮类及不含内酰胺酶抑制剂的三代头孢基本耐药。
Objective
This paper is to analyze the data of preoperation and postoperation for MBOJ (malignant biliary obstructive jaundice) who biliary stent were performed and to evaluate the efficacy of biliary stent implantation and to compare the advantages of PTBS (percutaneous transhepatic biliary stent) and ERBD (endoscopic retrograde biliary drainage). In addition, it discusses the causes and the treatment of restenosis after biliary stent implantation.
It analyzes their type and clinical meaning by observing the biliary pathogen and drug sensitivity in patients with MBOJ.
Methods
The clinical data of106patients with MBOJ of treatment by ERBD (60patients) and PTBS (46patients) in digestive disease center from May2009to May2010were analysized. The data of BIL and hepatic function and complications after PTBS and ERBD were compared. Cholangio-pancreatography and pathological diagnosis of the patients with biliary restenosis were performed. At the same time extra treatment was taken to deal with the biliary restenosis. The bile of106patients with MBOJ of treatment by biliary stent implantation in this hospital were detected and cultured and the pathogenic bacteria causing biliary infection were analyzed respectively.
Results
Effective biliary stent implantation was achieved in42out of46patients (91.3%) treated with PTBS and in57out of60patients (95.0%) treated with ERBD. And jaundice reduction rate was36%(third day) and68%(seventh day) in PTBS, and was35%(third day) and67%(seventh day) in ERBD. ALT ALP and γ-GGT after biliary stent implantation decreased and hepatic function was improved. The hospitalization was (12.5±2.4) days in ERBD and (20.2±3.2) days in PTBS.
The complication rate of PTBS was19.0%, and the complication rate of ERBD was14.0%(P<0.05). There was no significant difference between ERBD and PTBS in total complications.
Pancreatitis occured in4patients (7.0%) of ERBD and no occurred in patients of PTBS. There was significant difference between ERBD and PTBS. Biliary infection occurred in4patients (7.0%) of ERBD and occurred in4patients (9.5%) of PTBS. There was no significant difference between ERBD and PTBS. But biliary infection occurred in6patients (10.5%) of low order obstruction and occurred in2patients (4.7%) of high order obstruction. There was significant difference between low order obstruction and high order obstruction.
Among18patients of restenosis with the pathological diagnosis,10restensis were caused by tumor growth,5were caused by bile sand and3were due to chronic inflammation.
The bile of64patients from106patients with MBOJ had bacteria and the positive rate was60.3%. In all the72strains,52strains (72.2%) were Gram-negative bacilli and Gram-positive cocci accounted for20.8%and fungi accounted for6.9%.
Gram-negative bacilli were sensitive to etimicin sulfate, imipenem and cefoperazone/sulbactam and Gram-positive cocci were sensitive to vancomycin. Linezolid and teicoplanin. Both Gram-negative bacilli and Gram-positive cocci was resistant to carbostyril and third generation cephems.
Conclusion
Both ERBD and PTBS are palliative and efficient procedures to relieve MBOJ, which are similar in technical success rates and clinical efficacv and total complications. But ERBD is advantageous in hospital stay than PTBS, and it has high complication of pancreatitis. Biliary infection occurs more in low order obstruction than high order obstruction.
Tumor growth, chronic inflammation and bile sand are main causes of the restenosis after biliary metal stent implantation.
Among the pathogens of MBOJ, Gram-negative bacilli are the most common, which is most sensitive to carbapenems, aminoglycoside and cefoperazone/sulbactam, which is resistant to the carbostyril and third generation cephems that are widely clinically.
引文
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