超声引导下肝内胆管穿刺引流术在老年高位恶性胆道梗阻患者中的临床应用效果
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摘要
目的探讨超声引导下肝内胆管穿刺引流术在老年高位恶性胆道梗阻患者中的临床应用效果。方法选取2013年8月至2016年8月在首都医科大学附属北京佑安医院诊治的老年高位恶性胆道梗阻患者146例,采用随机数字表法分为观察组和对照组,每组73例。观察组采用超声引导下肝内胆管穿刺引流术治疗;对照组采用CT引导下肝内胆管穿刺引流术治疗。术前及术后7 d时检测患者血清总胆红素和直接胆红素水平。观察患者术后7 d并发症发生情况。术后随访12个月观察预后情况。结果观察组一次穿刺成功率为100.0%(73/73);对照组一次穿刺成功率为95.9%(70/73),有3例在二次穿刺时才获得成功。术后7 d,2组血清总胆红素和直接胆红素水平均较术前明显降低,且观察组血清总胆红素和直接胆红素水平明显低于对照组[(166±76)μmol/L比(202±78)μmol/L、(141±57)μmol/L比(178±61)μmol/L],差异均有统计学意义(均P<0.05)。观察组并发症发生率明显低于对照组[4.1%(3/73)比24.7%(18/73)],差异有统计学意义(P<0.05)。对照组患者生存期为(9.4±1.3)个月,观察组生存期为(10.0±1.4)个月,但组间比较差异无统计学意义(P>0.05)。2组术后1、2、3、6、12个月生存率比较差异均无统计学意义(均P>0.05)。结论超声引导下肝内胆管穿刺引流在老年高位恶性胆道梗阻患者的应用可提高穿刺成功率,有利于患者肝功能的恢复,减少术后并发症的发生,延长患者的生存时间。
Objective To analyze the clinical effect of ultrasound-guided intrahepatic bile duct puncture and drainage on elderly patients with malignant hilar biliary obstruction. Methods A total of 146 elderly patients with malignant hilar biliaiy obstruction were enrolled from August 2013 to August 2016 in Beijing YouAn Hospital,Capital Medical University. The patients were randomly divided into observation group and control group, with73 cases in each group. The observation group was treated with ultrasound-guided intrahepatic bile duct puncture and drainage. The control group was treated with CT-guided intrahepatic bile duct puncture and drainage. Serum levels of total bilirubin and direct bilirubin were tested before and 7 d after operation. Occurrence of complications was observed in 7 d after operation. Prognosis of patients was followed up in 12 months after operation. Results The first time successful puncture rate was 100. 0%(73/73) in observation group and 95. 9%(70/73) in control group. At 7 d after operation, serum levels of total bilirubin and direct bilirubin significantly decreased compared to those before operation; serum levels of total bilirubin and direct bilirubin in observation group were significantly lower than those in control group [( 166 ± 76) μmol/L vs(202 ± 78) μmol/L,( 141 ± 57) μmol/L vs(178 士61) μmol/L](P < 0. 05). Incidence of postoperative complications in observation group was significantly lower than that in control group[4.1%(3/73) vs 24. 7%(18/73)](P <0.05). Survival time of patients [(9. 4 士1. 3)months vs(10. 0 ± 1.4)months] and the 1-,2-, 3-,6-and 12-month survival rates showed no significant differences between observation group and control group( P >0. 05). Conclusion Intrahepatic bile duct puncture and drainage with guidance of ultrasound treating elderly patients with malignant hilar biliary obstruction can improve the first time successful puncture rate, promote liver function recovery, reduce complications and improve postoperative survival.
Objective To analyze the clinical effect of ultrasound-guided intrahepatic bile duct puncture and drainage on elderly patients with malignant hilar biliary obstruction. Methods A total of 146 elderly patients with malignant hilar biliaiy obstruction were enrolled from August 2013 to August 2016 in Beijing YouAn Hospital,Capital Medical University. The patients were randomly divided into observation group and control group, with73 cases in each group. The observation group was treated with ultrasound-guided intrahepatic bile duct puncture and drainage. The control group was treated with CT-guided intrahepatic bile duct puncture and drainage. Serum levels of total bilirubin and direct bilirubin were tested before and 7 d after operation. Occurrence of complications was observed in 7 d after operation. Prognosis of patients was followed up in 12 months after operation. Results The first time successful puncture rate was 100. 0%(73/73) in observation group and 95. 9%(70/73) in control group. At 7 d after operation, serum levels of total bilirubin and direct bilirubin significantly decreased compared to those before operation; serum levels of total bilirubin and direct bilirubin in observation group were significantly lower than those in control group [( 166 ± 76) μmol/L vs(202 ± 78) μmol/L,( 141 ± 57) μmol/L vs(178 士61) μmol/L](P < 0. 05). Incidence of postoperative complications in observation group was significantly lower than that in control group[4.1%(3/73) vs 24. 7%(18/73)](P <0.05). Survival time of patients [(9. 4 士1. 3)months vs(10. 0 ± 1.4)months] and the 1-,2-, 3-,6-and 12-month survival rates showed no significant differences between observation group and control group( P >0. 05). Conclusion Intrahepatic bile duct puncture and drainage with guidance of ultrasound treating elderly patients with malignant hilar biliary obstruction can improve the first time successful puncture rate, promote liver function recovery, reduce complications and improve postoperative survival.
引文
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[9]孙佳威,周航,王显翔,等.一步法超声引导经皮经肝胆道引流术治疗高龄胆道梗阻的探讨[J].中华老年多器官疾病杂志,2016,15(7):500-503.DOI:10.11915/j.issn.1671-5403.2016.07.118.Sun JW,Zhou H,Wang XX,et al.One-step ultrasound-guided percutaneous transhepatic cholangiographic drainage in treatment ofbile duct obstruction in the elderly[J].Chinese Journal of Multiple Organ Diseases in the Elderly,2016,15(7):500-503.DOI:10.11915/j.issn.1671-5403.2016.07.118.
[10]戴社教,李红,王深皓,等.超声结合X线引导治疗恶性梗阻性黄疸的临床应用[J].实用放射学杂志,2012,28(12):1933-1935.DOI:10.3969/j.issn.1002-1671.2012.12.029.Dai SJ,Li H,Wang SH,et al.Clinical application of ultrasound and X ray guided treatment of malignant obstructive jaundice[J].Journal of Practical Radiology,2012,28(12):1933-1935.DOI:10.3969/j.issn.1002-1671.2012.12.029.
[11]Guiu B,Bize P,Demartines N,et al.Simultaneous biliary drainage and portal vein embolization before extended hepatectomy for hilar cholangiocarcinoma:preliminary experience[J].Cardiovasc Intervent Radiol,2014,37(3):698-704.DOI:10.1007/s00270-013-0699-7.
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[13]Park DH,Jeong SU,Lee BU,et al.Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP(with video)[J].Gastrointest Endosc,2013,78(1):91-101.DOI:10.1016/j.gie.2013.01.042.
[14]伍海翔,许国辉,李政文,等.超声联合DSA对高位恶性梗阻性黄疸行PTCD的临床应用[J].肿瘤预防与治疗,2013,26(3):151-154.DOI:10.3969/j.issn.1674-0904.2013.03.009.Wu HX,Xu GH,Li ZW,et al.Clinical application of PTCD for high level malignant obstructive jaundice using ultrasound in combination with DSA[J].Journal of Cancer Control and Treatment,2013,26(3):151-154.DOI:10.3969/j.issn.1674-0904.2013.03.009.
[15]Kawakubo K,Isayama H,Sasahira N,et al.Clinical utility of an endoscopic ultrasound-guided rendezvous technique via various approach routes[J].Surg Endosc,2013,27(9):3437-3443.DOI:10.1007/s00464-013-2896-5.
[16]Dhir V,Vivekanandarajah S,Bhandari S,et al.Endoscopic ultrasound-guided cholangiography and intraluminal needle puncture through a tight subhilar bile duct stricture for biliary stenting following failed ERCP[J].Endoscopy,2013,45(Suppl 2):E5-6.DOI:10.1055/s-0032-1326121.
[17]吴英超,杨金炜,李冠海,等.改良经皮经肝胆道引流术治疗恶性高位胆管梗阻的应用研究[J].中国现代医学杂志,2013,23(17):81-83.DOI:10.3969/j.issn.1005-8982.2013.17.018.Wu YC,Yang JW,Li GH,et al.Application of improved percutaneous transhepatic biliary drainage in the treatment of malignant hilar biliary obstruction[J].China Journal of Modern Medicine,2013,23(17):81-83.DOI:10.3969/j.issn.1005-8982.2013.17.018.
[18]Chaudhary S,Klein M,Mehrotra B,et al.Utility of immunocytochemistry in diagnosing leptomeningeal metastases from an intrahepatic cholangiocarcinoma[J].Diagn Cytopathol,2014,42(1):54-57.DOI:10.1002/dc.22946.
[2]Hamano G,Kubo S,Takemura S,et al.Comparison of clinicopathological characteristics between patients with occupational and non-occupational intrahepatic cholangiocarcinoma[J].J Hepatobiliary Pancreat Sci,2016,23(7):389-396.DOI:10.1002/jhbp.353.
[3]Shimizu H,Kato A,Takayashiki T,et al.Peripheral portal veinoriented non-dilated bile duct puncture for percutaneous transhepatic biliary drainage[J].World J Gastroenterol,2015,21(44):12628-12634.DOI:10.3748/wjg.v21.i44.12628.
[4]Tanaka M,Inoue Y,Mise Y,et al.Laparoscopic deroofing for polycystic liver disease using laparoscopic fusion indocyanine green fluorescence imaging[J].Surg Endosc,2016,30(6):2620-2623.DOI:10.1007/s00464-015-4526-x.
[5]Qin JP,Tang SH,Jiang MD,et al.Contrast enhanced computed tomography and reconstruction of hepatic vascular system for transjugular intrahepatic portal systemic shunt puncture path planning[J].World J Gastroenterol,2015,21(32):9623-9629.DOI:10.3748/wjg.v21.i32.9623.
[6]Dhir V,Itoi T,Fockens P,et al.Novel ex vivo model for hands-on teaching of and training in EUS-guided biliary drainage:creation of"Mumbai EUS"stereolithography/3D printing bile duct prototype(with videos)[J].Gastrointest Endosc,2015,81(2):440-446.DOI:10.1016/j.gie.2014.09.011.
[7]Tellez-Avila FI,Bernal-Mendez AR,Guerrero-Vázquez CG,et al.Diagnostic yield of EUS-guided tissue acquisition as a first-line approach in patients with suspected hilar cholangiocarcinoma[J].Am J Gastroenterol,2014,109(8):1294-1296.DOI:10.1038/ajg.2014.169.
[8]Paik WH,Park DH,Choi JH,et al.Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy[J].World J Gastroenterol,2014,20(17):5051-5059.DOI:10.3748/w.jg.v20.i17.5051.
[9]孙佳威,周航,王显翔,等.一步法超声引导经皮经肝胆道引流术治疗高龄胆道梗阻的探讨[J].中华老年多器官疾病杂志,2016,15(7):500-503.DOI:10.11915/j.issn.1671-5403.2016.07.118.Sun JW,Zhou H,Wang XX,et al.One-step ultrasound-guided percutaneous transhepatic cholangiographic drainage in treatment ofbile duct obstruction in the elderly[J].Chinese Journal of Multiple Organ Diseases in the Elderly,2016,15(7):500-503.DOI:10.11915/j.issn.1671-5403.2016.07.118.
[10]戴社教,李红,王深皓,等.超声结合X线引导治疗恶性梗阻性黄疸的临床应用[J].实用放射学杂志,2012,28(12):1933-1935.DOI:10.3969/j.issn.1002-1671.2012.12.029.Dai SJ,Li H,Wang SH,et al.Clinical application of ultrasound and X ray guided treatment of malignant obstructive jaundice[J].Journal of Practical Radiology,2012,28(12):1933-1935.DOI:10.3969/j.issn.1002-1671.2012.12.029.
[11]Guiu B,Bize P,Demartines N,et al.Simultaneous biliary drainage and portal vein embolization before extended hepatectomy for hilar cholangiocarcinoma:preliminary experience[J].Cardiovasc Intervent Radiol,2014,37(3):698-704.DOI:10.1007/s00270-013-0699-7.
[12]Jurczyk MF,Zhu B,Villa C,et al.Cytomorphology of intraductal oncocytic papillary neoplasm of the liver[J].Diagn Cytopathol,2014,42(10):895-898.DOI:10.1002/dc.23073.
[13]Park DH,Jeong SU,Lee BU,et al.Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP(with video)[J].Gastrointest Endosc,2013,78(1):91-101.DOI:10.1016/j.gie.2013.01.042.
[14]伍海翔,许国辉,李政文,等.超声联合DSA对高位恶性梗阻性黄疸行PTCD的临床应用[J].肿瘤预防与治疗,2013,26(3):151-154.DOI:10.3969/j.issn.1674-0904.2013.03.009.Wu HX,Xu GH,Li ZW,et al.Clinical application of PTCD for high level malignant obstructive jaundice using ultrasound in combination with DSA[J].Journal of Cancer Control and Treatment,2013,26(3):151-154.DOI:10.3969/j.issn.1674-0904.2013.03.009.
[15]Kawakubo K,Isayama H,Sasahira N,et al.Clinical utility of an endoscopic ultrasound-guided rendezvous technique via various approach routes[J].Surg Endosc,2013,27(9):3437-3443.DOI:10.1007/s00464-013-2896-5.
[16]Dhir V,Vivekanandarajah S,Bhandari S,et al.Endoscopic ultrasound-guided cholangiography and intraluminal needle puncture through a tight subhilar bile duct stricture for biliary stenting following failed ERCP[J].Endoscopy,2013,45(Suppl 2):E5-6.DOI:10.1055/s-0032-1326121.
[17]吴英超,杨金炜,李冠海,等.改良经皮经肝胆道引流术治疗恶性高位胆管梗阻的应用研究[J].中国现代医学杂志,2013,23(17):81-83.DOI:10.3969/j.issn.1005-8982.2013.17.018.Wu YC,Yang JW,Li GH,et al.Application of improved percutaneous transhepatic biliary drainage in the treatment of malignant hilar biliary obstruction[J].China Journal of Modern Medicine,2013,23(17):81-83.DOI:10.3969/j.issn.1005-8982.2013.17.018.
[18]Chaudhary S,Klein M,Mehrotra B,et al.Utility of immunocytochemistry in diagnosing leptomeningeal metastases from an intrahepatic cholangiocarcinoma[J].Diagn Cytopathol,2014,42(1):54-57.DOI:10.1002/dc.22946.