恶性高位梗阻性黄疸的介入疗效评价及引流方式选择
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摘要
目的:探讨恶性高位胆道梗阻患者经皮肝胆道引流方式及胆道支架置入对术后疗效影响,为临床选择适当的治疗方式提供依据.方法:河北医科大学第四医院介入放射科2009-05/2013-03诊治的76例恶性高位梗阻性患者,其中男性42例,女性34例,年龄42-78岁,平均64.2岁,其中肝门部胆管癌及术后复发42例,胆囊癌13例,肝癌6例,胰腺癌、胃癌及贲门癌肝门部转移15例.参照肝门部胆管癌的Bismuth-Corlette分型,将肝门部胆道梗阻分为5型,Ⅰ型16例,Ⅱ型23例,Ⅲa型19例,Ⅲb型3例,Ⅳ型15例.根据引流方式及支架置入数量将治疗患者分为单侧引流组及双侧引流组,根据是否有左右支胆管完全分离将单侧引流组分为完全引流组及优势侧引流组.术后4 wk复查,以总胆红素下降幅度作为近期疗效的观察指标,并观察单侧引流组与双侧引流组指标的差异性.引流术后各组间总胆红素的下降值用两样本的t检验,非参数乘积限估计法(KaplanMeier)进行生存期分析.结果:治疗后总胆红素下降明显,由338.52mmol/L±93.21 mmol/L降至128.13 mmol/L±52.17 mmol/L差异具有显著统计学意义(P<0.05).单侧引流组总胆红素下降值为99.19mmol/L±53.81 mmol/L,双侧引流组总胆红素下降值为104.62 mmol/L±63.12 mmol/L,下降值两样本t检验示P>0.05,无显著性差异.单侧引流组和双侧引流组生存率分别进行KaplanMeier分析,差异无显著性.结论:对于高位梗阻性黄疸,多支多通道引流通畅是治疗原则,但对于BismuthⅢ-Ⅳ型患者,优势侧胆管充分引流也可达到满意的治疗效果.经皮肝穿刺引流或内支架治疗仍是治疗高位胆道梗阻的有效姑息方法,可明显提高患者生活质量.
AIM:To investigate the therapeutic effect of percutaneous transhepatic biliary drainage and biliary stent placement in patients with malignant hilar biliary obstruction to provide a basis for clinical selection of appropriate treatments.METHODS:Clinical data for 76 patients with malignant hilar biliary obstructive jaundice treated at the Fourth Hospital of Hebei Medical University were analyzed retrospectively. Fortytwo patients were men and 34 were women.Their age ranged from 42 to 76 years, with a mean value of 64.2 years. The majority of patients(42/69) had hilar bile duct carcinoma or postoperative recurrence. Other primary diseases included gallbladder carcinoma(n = 13), liver cancer(n = 6), hepatic metastasis of pancreatic,gastric and cardiac cancer(n = 14). Based on the Bismuth-Corlette classification, we divided the cases into five types:I(n = 16), II(n = 23), IIIa(n = 19), IIIb(n = 3) and IV(n = 15). All patients had complete clinical data, stable diseases and no absolute contraindications on intervention.Renal and liver function was examined in all patients to estimate the decreasing range of total bilirubin, which can be an index of short-term curative effect. The differences in total bilirubin change and survival between the unilateral and bilateral drainage groups were also compared.RESULTS:Total bilirubin decreased significantly after treatment(338.52 mmol/L ± 93.21mmol/L vs 128.13 mmol/L ± 52.17 mmol/L, P< 0.05). The decrease in total bilirubin showed no significant difference between the unilateral drainage group and the bilateral drainage group(99.19 mmol/L ± 53.81 mmol/L vs 104.62mmol/L ± 63.12 mmol/L, P > 0.05). There was also no significant difference in survival rate between the unilateral drainage group and bilateral drainage group.CONCLUSION:For high obstructive jaundice,multi-channel drainage is preferred. For patients with Bismuth III-IV disease, biliary drainage can also achieve satisfactory therapeutic effect. Biliary drainage and stent placement are safe and effective methods for relieving biliary obstruction, reducing bilirubin and lengthening the survival time.
AIM:To investigate the therapeutic effect of percutaneous transhepatic biliary drainage and biliary stent placement in patients with malignant hilar biliary obstruction to provide a basis for clinical selection of appropriate treatments.METHODS:Clinical data for 76 patients with malignant hilar biliary obstructive jaundice treated at the Fourth Hospital of Hebei Medical University were analyzed retrospectively. Fortytwo patients were men and 34 were women.Their age ranged from 42 to 76 years, with a mean value of 64.2 years. The majority of patients(42/69) had hilar bile duct carcinoma or postoperative recurrence. Other primary diseases included gallbladder carcinoma(n = 13), liver cancer(n = 6), hepatic metastasis of pancreatic,gastric and cardiac cancer(n = 14). Based on the Bismuth-Corlette classification, we divided the cases into five types:I(n = 16), II(n = 23), IIIa(n = 19), IIIb(n = 3) and IV(n = 15). All patients had complete clinical data, stable diseases and no absolute contraindications on intervention.Renal and liver function was examined in all patients to estimate the decreasing range of total bilirubin, which can be an index of short-term curative effect. The differences in total bilirubin change and survival between the unilateral and bilateral drainage groups were also compared.RESULTS:Total bilirubin decreased significantly after treatment(338.52 mmol/L ± 93.21mmol/L vs 128.13 mmol/L ± 52.17 mmol/L, P< 0.05). The decrease in total bilirubin showed no significant difference between the unilateral drainage group and the bilateral drainage group(99.19 mmol/L ± 53.81 mmol/L vs 104.62mmol/L ± 63.12 mmol/L, P > 0.05). There was also no significant difference in survival rate between the unilateral drainage group and bilateral drainage group.CONCLUSION:For high obstructive jaundice,multi-channel drainage is preferred. For patients with Bismuth III-IV disease, biliary drainage can also achieve satisfactory therapeutic effect. Biliary drainage and stent placement are safe and effective methods for relieving biliary obstruction, reducing bilirubin and lengthening the survival time.
引文
1 章诺贝,黄年根.肝门部胆管癌Bismuth分型与经内镜胆道塑料支架引流术后并发症及退黄效果之间的关系.世界华人消化杂志2011;19:529-532
2 Bismuth H,Castaing D,Traynor O.Resection or palliation:priority of surgery in the treatment of hilar cancer.World J Surg 1988;12:39-47[PMID:2449769 DOI:10.1007/BF01658484]
3 Cowling MG,Adam AN.Internal stenting in malignant biliary obstruction.World J Surg 2001;25:355-39;discussion 355-359[PMID:11343193]
4 Chahal P,Baron TH.Endoscopic palliation of cholangiocarcinoma.Curr Opin Gastroenterol 2006;22 :551-560[PMID:16891889 DOI:10.1097/01.mog.0000239872.12081.a4]
5 詹茜,沈柏用.肝门胆管癌的治疗进展.世界华人消化杂志2009;17:3313-3317
6 Coons H.Metallic stents for the treatment of biliary obstruction:a report of 100 cases.Cardiovasc Intervent Radiol 1992;15:367-374[PMID:1335840 DOI:10 .1007/BF02734120]
7 钱晓军,翟仁友,戴定可,于平.恶性高位胆道黄疽介人治疗.中国肿瘤临床2002;29:66-67
8 Iwano H,Ryozawa S,Ishigaki N,Taba K,Senyo M,Yoshida K,Sakaida I.Unilateral versus bilateral drainage using self-expandable metallic stent for unresectable hilar biliary obstruction.Dig Endosc2011;23:43-48[PMID:21198916 DOI:10.1111/j.1443-1661.2010.01036.x]
9 Inal M,Akgül E,Aksungur E,Seydao lu G.Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction:unilobar versus bilobar drainage.J Vasc Interv Radiol 2003;14 :1409-1416[PMID:14605106 DOI:10.1097/01.RVI.0000096762.74047.A6]
10 Srinivas R.Puli,Matthew L.Bechtold,Jyotsna Bk Reddy,Mainor R.Antillon,David L.Carr-locke.unilateral vs bilateral metallic stents for malignant hilar obstruction:A meta-analysis and systematic review of risks.Gastrointest Endosc 2009;69:AB156[DOI:10.1016/j.gie.2009.03.261]
11 Veal DR,Lee AY,Kerlan RK,Gordon RL,Fidelman N.Outcomes of metallic biliary stent insertion in patients with malignant bilobar obstruction.J Vasc Interv Radiol 2013;24:1003-1010[PMID:23796087DOI:10.1016/j.jvir.2013.03.020]
12 许林锋,陈耀庭,张靖,陈斌,崔斌,杨志刚.T/Y型胆管支架治疗肝门部恶性梗阻性黄疸的临床应用价值.临床放射学杂志2007;26:911-913
13 邹建伟,倪才方,刘一之,朱晓黎,金泳海,陈珑,张栋,孙鸽,孙玲芳.不同类型高位恶性胆道梗阻的介入治疗.临床放射学杂志2011;30:1523-1526
14 刘岩,杨光,于友涛,刘瑞宝,李任飞,张同,申宝忠.经皮肝穿刺胆道支架置放结合动脉化疗栓塞治疗恶性梗阻性黄疸.世界华人消化杂志2004;12:1495-1497
15 Tsai HM,Chuang CH,Lin XZ,Chen CY.Factors relating to the short term effectiveness of percutaneous biliary drainage for hilar cholangiocarcinoma.World J Gastroenterol 2009;15:5206-5210[PMID:19891021 DOI:10.3748/wjg.15.5206]
16 林炜,张春阳,黄桂华,周永财,徐宪文,赵艳红,曾庆春,张曦彤.肝门部恶性梗阻性黄疸介入减黄术预后多因素分析.中国普通外科杂志2010;19:929-932
2 Bismuth H,Castaing D,Traynor O.Resection or palliation:priority of surgery in the treatment of hilar cancer.World J Surg 1988;12:39-47[PMID:2449769 DOI:10.1007/BF01658484]
3 Cowling MG,Adam AN.Internal stenting in malignant biliary obstruction.World J Surg 2001;25:355-39;discussion 355-359[PMID:11343193]
4 Chahal P,Baron TH.Endoscopic palliation of cholangiocarcinoma.Curr Opin Gastroenterol 2006;22 :551-560[PMID:16891889 DOI:10.1097/01.mog.0000239872.12081.a4]
5 詹茜,沈柏用.肝门胆管癌的治疗进展.世界华人消化杂志2009;17:3313-3317
6 Coons H.Metallic stents for the treatment of biliary obstruction:a report of 100 cases.Cardiovasc Intervent Radiol 1992;15:367-374[PMID:1335840 DOI:10 .1007/BF02734120]
7 钱晓军,翟仁友,戴定可,于平.恶性高位胆道黄疽介人治疗.中国肿瘤临床2002;29:66-67
8 Iwano H,Ryozawa S,Ishigaki N,Taba K,Senyo M,Yoshida K,Sakaida I.Unilateral versus bilateral drainage using self-expandable metallic stent for unresectable hilar biliary obstruction.Dig Endosc2011;23:43-48[PMID:21198916 DOI:10.1111/j.1443-1661.2010.01036.x]
9 Inal M,Akgül E,Aksungur E,Seydao lu G.Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction:unilobar versus bilobar drainage.J Vasc Interv Radiol 2003;14 :1409-1416[PMID:14605106 DOI:10.1097/01.RVI.0000096762.74047.A6]
10 Srinivas R.Puli,Matthew L.Bechtold,Jyotsna Bk Reddy,Mainor R.Antillon,David L.Carr-locke.unilateral vs bilateral metallic stents for malignant hilar obstruction:A meta-analysis and systematic review of risks.Gastrointest Endosc 2009;69:AB156[DOI:10.1016/j.gie.2009.03.261]
11 Veal DR,Lee AY,Kerlan RK,Gordon RL,Fidelman N.Outcomes of metallic biliary stent insertion in patients with malignant bilobar obstruction.J Vasc Interv Radiol 2013;24:1003-1010[PMID:23796087DOI:10.1016/j.jvir.2013.03.020]
12 许林锋,陈耀庭,张靖,陈斌,崔斌,杨志刚.T/Y型胆管支架治疗肝门部恶性梗阻性黄疸的临床应用价值.临床放射学杂志2007;26:911-913
13 邹建伟,倪才方,刘一之,朱晓黎,金泳海,陈珑,张栋,孙鸽,孙玲芳.不同类型高位恶性胆道梗阻的介入治疗.临床放射学杂志2011;30:1523-1526
14 刘岩,杨光,于友涛,刘瑞宝,李任飞,张同,申宝忠.经皮肝穿刺胆道支架置放结合动脉化疗栓塞治疗恶性梗阻性黄疸.世界华人消化杂志2004;12:1495-1497
15 Tsai HM,Chuang CH,Lin XZ,Chen CY.Factors relating to the short term effectiveness of percutaneous biliary drainage for hilar cholangiocarcinoma.World J Gastroenterol 2009;15:5206-5210[PMID:19891021 DOI:10.3748/wjg.15.5206]
16 林炜,张春阳,黄桂华,周永财,徐宪文,赵艳红,曾庆春,张曦彤.肝门部恶性梗阻性黄疸介入减黄术预后多因素分析.中国普通外科杂志2010;19:929-932