经皮肝穿刺胆管—胃十二指肠内引流治疗梗阻性黄疸动物实验研究
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摘要
目的 通过动物实验研究初步探讨经皮肝穿刺胆管——胃十二指肠内引流治疗梗阻性黄疸，特别是常规介入放射学技术不能解除梗阻的顽固性胆道梗阻，安全性和有效性以及相关的一些技术问题。材料与方法 健康杂种家猪20只，雄性9只，雌性11只，行胆总管结扎，建立梗阻性黄疸动物模型。术后14天，随机分成两组：(1)经皮肝穿刺胆管——胃十二指肠内引流组(A组，n=10)：在DSA引导下行经皮肝穿刺胆管——胃十二指内引流，置入内引流管。(2)模型对照组(B组，n=10)：单纯行外科性胆总管结扎后，未行干预治疗措施。在不同时间段内抽血检查，观察总胆红素(TBIL)、直接胆红素(DBIL)、谷丙转氨酶(ALT)，白蛋白(ALB)，比较各组间及干预前后差异，观察不同时间段肝脏病理学和影像学改变。结果A组介入技术成功率100％，其中1只死于经皮肝穿刺胆管——胃十二指肠内引流介入术后第11天，死亡原因：消化道出血。并发症发生率50％，主要为胆管出血、发热。B组分别死于胆总管结扎术后23天至32天，平均生存时间为28.3天。实验动物随梗阻时间的延长，TBIL、DBIL、ALT呈持续升高，经引流后TBIL、DBIL、ALT下降明显，ALB随胆管梗阻时间延长，有所下降。影像学表明：胆总管结扎后14天肝内胆管扩张明显，介入治疗后肝内胆管未见明显梗阻、扩张征象。病理示经介入治疗肝组织结构明显好转，肝内胆管未见明显梗阻、扩张征象。结论 经皮肿穿刺胆管——胃十二指肠内引流术是治疗胆管梗阻，特别是常规介入放射学技术不能成功的顽固性胆道梗阻，是安全、有效的、微创的治疗方法，是介入放射学又一新的治疗手段，可以考虑选择性地应用于临床，进一步研究其有效性和安全性。
Objective To evaluate the safety and efficacy of percutaneous transhepatic gastrobiliary duodenal internal drainage therapy for obstructive biliary, especially refractory obstructive biliary, with an animal experimental study and several technicals points involved in this method discussed. Materials and Methods 20 cases of local ,healthy, crossbred pigs , including 9 males and 11 females ,their common bile ducts were ligated. They were randomly divided into two groups :One group (Group A ,n=10 ) called percutaneous transhepatic gastrobiliary duodenal internal drainage interventional treatment group, with percutaneous transhepatic gastrobiliary duodenal internal drainage after common bile ligation's 14 days, the other ( Group B , n=10 ) called control group, with only common bile duct ligation. The liver function levels including TBIL,DBIL,ALT,ALB are determined in plasma in the special time. The liver tissues were HE dyed and inspected with optical microscope. CT scan of liver was performed. Results Technica
l success rate was 100% in Group A. One case was died of gastrointestinal bleeding after percutaneous transhepatic gastrobiliary duodenal internal drainage therapy the list day and the complications occurred in 50%,mainly included biliary hemobilia, fever in group A. All animals died during the 23 rd to 32 nd day after common bile duct ligation in group B. The mean survival time was 28.3 days . The contents of TBIL ,DBIL, ALT continuously increased and were obviously declined after percutaneous transhepatic gastrobiliary duodenal internal drainage therapy. The liver tissue was rebuilt and inspected without biliary obstruction signs. Conclusion The percutaneous
transhepatic gastrobiliary duodenal internal drainage was quite safe and effective palliative therapy for obstructive biliary, especially refractory obstructive biliary.
Objective To evaluate the safety and efficacy of percutaneous transhepatic gastrobiliary duodenal internal drainage therapy for obstructive biliary, especially refractory obstructive biliary, with an animal experimental study and several technicals points involved in this method discussed. Materials and Methods 20 cases of local ,healthy, crossbred pigs , including 9 males and 11 females ,their common bile ducts were ligated. They were randomly divided into two groups :One group (Group A ,n=10 ) called percutaneous transhepatic gastrobiliary duodenal internal drainage interventional treatment group, with percutaneous transhepatic gastrobiliary duodenal internal drainage after common bile ligation's 14 days, the other ( Group B , n=10 ) called control group, with only common bile duct ligation. The liver function levels including TBIL,DBIL,ALT,ALB are determined in plasma in the special time. The liver tissues were HE dyed and inspected with optical microscope. CT scan of liver was performed. Results Technica
l success rate was 100% in Group A. One case was died of gastrointestinal bleeding after percutaneous transhepatic gastrobiliary duodenal internal drainage therapy the list day and the complications occurred in 50%,mainly included biliary hemobilia, fever in group A. All animals died during the 23 rd to 32 nd day after common bile duct ligation in group B. The mean survival time was 28.3 days . The contents of TBIL ,DBIL, ALT continuously increased and were obviously declined after percutaneous transhepatic gastrobiliary duodenal internal drainage therapy. The liver tissue was rebuilt and inspected without biliary obstruction signs. Conclusion The percutaneous
transhepatic gastrobiliary duodenal internal drainage was quite safe and effective palliative therapy for obstructive biliary, especially refractory obstructive biliary.
引文
[1] Tibble JA, Cairns SR. Role of endoscopic endoprostheses in proximal malignant biliary obstruction .J Hepatobiliary pancreat Surg, 2001,8(2):118-123
[2] Nishio H, Miyata K, Hanai M, et al. Resection of an icteric type hepatoma with tumor thrombi filling the right posterior bile duet. Hepatogastroenterology ,2002,49(48):1682-1685
[3] Molonar W, Stockum AE. Relief of obstructive jaundice through percutaneous transhepatic Cathetere new therapeutic mothod. AJR, 1979,122:356-367
[4] 吴安乐，颜志平，王建华，等．恶性梗阻性黄疸的微创法引流．临床放射学杂志，2002，21(6)：448-451
[5] Barth KH . Percutaneous biliary drainage for high obstructive. Radiologic clinics of North America, 1990,28(6):1223
[6] Yoshioka J, sakagvchi H, Yosshimura H et al. Expandble metauic biliary endoprosthesesa; preliminary clinical evaluation. Radiology, 1990,177:253-257.
[7] Lammer J, Hansegger KA ,Flucking F, et al. Common dile duct obstruction due to malignancg:treatment with plastic versus metal stents. Radiology, 1996,201(1)167-172.
[8] Lammer J, klein GE ,kleinert R, et al. obstructive jaundice:use of expandable metal endoprosthesis for biliary drainage work in progress. Radiology, 1990,177:789-792
[9] A. Adam, N.chetty, E. Yeung, et al. Self-Expandable Stainless Steel Endoprostheses for Treatment of Malignant Bile Duct Obstruction. AJR, 2000,156:321-325
[10] Wig JD, kumar H, Suri S, Gupta, NM. Usefulness of percutaneous transhepatic biliary drainage in patients with surgical jaundice;a prospective randomised study .J Assoc Physicians lndia ,1999 ,47(3):271-274
[11] 姜卫剑，吴青海，杨秀英，等．金属内支架姑息性治疗恶性梗阻性黄疸(附35例报告)．介入放射学杂志，1998，7(3)：138-14011
[12] 王诚，徐浩，顾玉明，等．金属内支架在治疗胆管恶性梗阻中的应用．徐州医学院报，2000，20(4)：226-228
[13] 施海彬，李麟荪，徐泽宽，等．介入性胆管内引流术治疗恶性梗阻性黄疸，江苏医药杂志，2002，28(7)：484-48
[14] Shim CS, Lee YH, Cho YD. et al. Preliminag results of a new covered biliary metal stent for malignant biliary obstraction. Endoscory, 1998,30:345-350
[15] Mark Ryan, Peter F. Hahn, Giles W. Boland, et al. Percutaneous gastrostomy with T-Fastener gastropexy:Result of 316 Consecutive procedures. Radiology, 1997,203,496-500
[16] Giles Soulez, EricTherasse, Vincent L Olive, et al. Left Hepaticogastrostomy for Biliary Obstructive:Long-term Results. Radiology, 1997,204:780-786
[17] Bismuth H, Corlette MB. Intrahepatic Cholangioenteric anastomosis in carcinoma of hilus of the liver. Surg Gynecot Obstet ,1975,140:170-178
[18] Soulez G, Gagner M, rherasse E, et al .Malignant biliary obstruction:preliminary results of palliative treatment with hepaticogastrostomy under fluoroscopic, endoscopic, and Laparoscopic guidance. Radiology ,1994,1992:241-246
[19] 吴问汉，杨尹默，黄莛庭．梗阻性黄疽性黄疽胆红素代谢的实验研究．中华肝
胆外科杂志，2001：7(5)：288-291
[20] Lee JW, Han JK, Kim TK, Choi BI, et al. Obstructive jaundice in hepatocellular carcinoma:reponse after percutaneous transhepatic biliary drainage and prognostic factors. Cardiovase Intervent Radiology, 2002,25(3):176-9
[21] Posner MC, Burt ME, Stome MD, et al.Amodelofreversible obstructive jaundice in the rat .J surg Res, 1990,48:204-210
[22] 曲瑞瑶，曲柏林，曾文红．大鼠实验性脾虚证胃电波和胃活动波的研究．中国中西医结合杂志，1994，14(3)：156-158
[23] Kelly K A, Code C F. Canine gastric Pace maker. J Am physiol, 1971,220:112-128
[24] Summers R W, Anurus S, Green J. Jejunal manometry patterns in health partial intestinal obstruction and pseudo-obstruction. Gastroenterology ,1993,85:1290-1300
[25] Clinqi, Ahiskali, Oktar, et al. Biliary decompression reduces the susceptibilility to ethanol-induced ulcer in jaundiced rats. Physiol-Res, 2002,51(6):619-627
[26] Rheault MJ, Legros G, Nyhus LM. Reflux gastritis. Dig Surg, 1998;5:5-16
[27] 刘海，王炳煌，张炳颜，等，梗阻性黄疽肝脏损伤的研究进展．临床肝胆病杂志，1996，3(12)：125-128
[28] Chistopher J, Ingoldly MD, Gilber I AD. Endotoxemia in human obstructive jaundice. Am J surg, 1984,6(147):766-971
[29] 龚建平，韩本立，罗丁，等．急性胆管感染肘肠粘膜屏障损伤的研究．中华实验外科杂志，1991，3(8)115-117
[30] Greve JM, Maessen JG, Tiebosch T, et al. Prevention of postoperative complications in jaundice rats. Ann surg, 1990,212:212-217
[31] Rothschild JG, Kaplam MM, Millan VG, et al .Management of biliary
obstruction .Arch Surg, 1989,124:556-560
[32] Guoma DJ, Coelho Jcu, Moody FG, et al. The effect of preoperative internal and external biliary drainage on mortality of jaundiced rats .Archives of Surgery, 1987,122:556-560
[33] 王宇，薛建国．梗阻性黄疸手术时机的选择．中华肝胆外科杂志，1998：51(4)：251-253
[34] Chang H, Katoh J, Chidas, et al .Direct effects of endothelin in the rat kidney. Am J physiol, 1990;2(258):397-403
[35] 王今达．90年代多脏器衰竭综合征；SIRS和MODS．中国危重急救医学，1995；6(7)：324-327
[36] 黎沾良．全身炎症反应综合征和多器官功能障碍综合征．《中国实用外科杂志》
[37] Thompson JN, Cohen J, Moore RH, et al. endotoxemin in obstructive jaundice, observations on cause and clinical significance. Am J Surg, 1998:155-314
[38] 汤宁泉．梗阻性黄疽与肾功能衰竭关系的研究．国外医学外科学分册，1994；6(18)：351-353
[2] Nishio H, Miyata K, Hanai M, et al. Resection of an icteric type hepatoma with tumor thrombi filling the right posterior bile duet. Hepatogastroenterology ,2002,49(48):1682-1685
[3] Molonar W, Stockum AE. Relief of obstructive jaundice through percutaneous transhepatic Cathetere new therapeutic mothod. AJR, 1979,122:356-367
[4] 吴安乐，颜志平，王建华，等．恶性梗阻性黄疸的微创法引流．临床放射学杂志，2002，21(6)：448-451
[5] Barth KH . Percutaneous biliary drainage for high obstructive. Radiologic clinics of North America, 1990,28(6):1223
[6] Yoshioka J, sakagvchi H, Yosshimura H et al. Expandble metauic biliary endoprosthesesa; preliminary clinical evaluation. Radiology, 1990,177:253-257.
[7] Lammer J, Hansegger KA ,Flucking F, et al. Common dile duct obstruction due to malignancg:treatment with plastic versus metal stents. Radiology, 1996,201(1)167-172.
[8] Lammer J, klein GE ,kleinert R, et al. obstructive jaundice:use of expandable metal endoprosthesis for biliary drainage work in progress. Radiology, 1990,177:789-792
[9] A. Adam, N.chetty, E. Yeung, et al. Self-Expandable Stainless Steel Endoprostheses for Treatment of Malignant Bile Duct Obstruction. AJR, 2000,156:321-325
[10] Wig JD, kumar H, Suri S, Gupta, NM. Usefulness of percutaneous transhepatic biliary drainage in patients with surgical jaundice;a prospective randomised study .J Assoc Physicians lndia ,1999 ,47(3):271-274
[11] 姜卫剑，吴青海，杨秀英，等．金属内支架姑息性治疗恶性梗阻性黄疸(附35例报告)．介入放射学杂志，1998，7(3)：138-14011
[12] 王诚，徐浩，顾玉明，等．金属内支架在治疗胆管恶性梗阻中的应用．徐州医学院报，2000，20(4)：226-228
[13] 施海彬，李麟荪，徐泽宽，等．介入性胆管内引流术治疗恶性梗阻性黄疸，江苏医药杂志，2002，28(7)：484-48
[14] Shim CS, Lee YH, Cho YD. et al. Preliminag results of a new covered biliary metal stent for malignant biliary obstraction. Endoscory, 1998,30:345-350
[15] Mark Ryan, Peter F. Hahn, Giles W. Boland, et al. Percutaneous gastrostomy with T-Fastener gastropexy:Result of 316 Consecutive procedures. Radiology, 1997,203,496-500
[16] Giles Soulez, EricTherasse, Vincent L Olive, et al. Left Hepaticogastrostomy for Biliary Obstructive:Long-term Results. Radiology, 1997,204:780-786
[17] Bismuth H, Corlette MB. Intrahepatic Cholangioenteric anastomosis in carcinoma of hilus of the liver. Surg Gynecot Obstet ,1975,140:170-178
[18] Soulez G, Gagner M, rherasse E, et al .Malignant biliary obstruction:preliminary results of palliative treatment with hepaticogastrostomy under fluoroscopic, endoscopic, and Laparoscopic guidance. Radiology ,1994,1992:241-246
[19] 吴问汉，杨尹默，黄莛庭．梗阻性黄疽性黄疽胆红素代谢的实验研究．中华肝
胆外科杂志，2001：7(5)：288-291
[20] Lee JW, Han JK, Kim TK, Choi BI, et al. Obstructive jaundice in hepatocellular carcinoma:reponse after percutaneous transhepatic biliary drainage and prognostic factors. Cardiovase Intervent Radiology, 2002,25(3):176-9
[21] Posner MC, Burt ME, Stome MD, et al.Amodelofreversible obstructive jaundice in the rat .J surg Res, 1990,48:204-210
[22] 曲瑞瑶，曲柏林，曾文红．大鼠实验性脾虚证胃电波和胃活动波的研究．中国中西医结合杂志，1994，14(3)：156-158
[23] Kelly K A, Code C F. Canine gastric Pace maker. J Am physiol, 1971,220:112-128
[24] Summers R W, Anurus S, Green J. Jejunal manometry patterns in health partial intestinal obstruction and pseudo-obstruction. Gastroenterology ,1993,85:1290-1300
[25] Clinqi, Ahiskali, Oktar, et al. Biliary decompression reduces the susceptibilility to ethanol-induced ulcer in jaundiced rats. Physiol-Res, 2002,51(6):619-627
[26] Rheault MJ, Legros G, Nyhus LM. Reflux gastritis. Dig Surg, 1998;5:5-16
[27] 刘海，王炳煌，张炳颜，等，梗阻性黄疽肝脏损伤的研究进展．临床肝胆病杂志，1996，3(12)：125-128
[28] Chistopher J, Ingoldly MD, Gilber I AD. Endotoxemia in human obstructive jaundice. Am J surg, 1984,6(147):766-971
[29] 龚建平，韩本立，罗丁，等．急性胆管感染肘肠粘膜屏障损伤的研究．中华实验外科杂志，1991，3(8)115-117
[30] Greve JM, Maessen JG, Tiebosch T, et al. Prevention of postoperative complications in jaundice rats. Ann surg, 1990,212:212-217
[31] Rothschild JG, Kaplam MM, Millan VG, et al .Management of biliary
obstruction .Arch Surg, 1989,124:556-560
[32] Guoma DJ, Coelho Jcu, Moody FG, et al. The effect of preoperative internal and external biliary drainage on mortality of jaundiced rats .Archives of Surgery, 1987,122:556-560
[33] 王宇，薛建国．梗阻性黄疸手术时机的选择．中华肝胆外科杂志，1998：51(4)：251-253
[34] Chang H, Katoh J, Chidas, et al .Direct effects of endothelin in the rat kidney. Am J physiol, 1990;2(258):397-403
[35] 王今达．90年代多脏器衰竭综合征；SIRS和MODS．中国危重急救医学，1995；6(7)：324-327
[36] 黎沾良．全身炎症反应综合征和多器官功能障碍综合征．《中国实用外科杂志》
[37] Thompson JN, Cohen J, Moore RH, et al. endotoxemin in obstructive jaundice, observations on cause and clinical significance. Am J Surg, 1998:155-314
[38] 汤宁泉．梗阻性黄疽与肾功能衰竭关系的研究．国外医学外科学分册，1994；6(18)：351-353