恶性梗阻性黄疸介入治疗的疗效分析

Efficacy of percutaneous transhepatic biliary drainage for treatment of malignant obstructive jaundice

目的回顾性分析无法手术的恶性梗阻性黄疸的经皮肝穿胆道引流治疗疗效和相关影响因素。方法无法手术切除恶性梗阻性黄疸住院病人233例。常规经皮肝穿刺胆道造影后,放置外引流管或内外引流管及金属内支架留置,用以解除胆管梗阻。临床观察治疗前后总胆红素、BUN等生化指标改变,并观察生存时间、引流有效时间。结果全部病人经皮经肝穿刺胆道引流手术成功。治疗后总胆红素明显下降,由3492±1556mmol/L降至1789±1412mmol/L(t=1790,P=0000)。术前合并感染62例,术后控制23例,术后新发胆道感染27例,胸部感染2例,术后存在感染68例。30d内死亡30例,死亡组与非死亡组比较,术前术后胆红素差异显著,年龄差异显著,并与蛋白相关,与术后ALT、Cr相关、与HBDH、BUN相关,术后51例出现再梗阻,7例引流管脱落。全组生存中位时间73个月,通畅中位时间140个月。结论经皮经肝穿刺胆汁引流,可有效缓解黄疸,改善由于梗阻性黄疸引起的各种症状。对于老年人或身体状况较差的病人应慎重,术后应及时控制感染,条件许可情况下,尽量放置支架。

Objective To investigate the therapeutic efficacy of percutaneous transhepatic biliary drainage (PTBD) for malignant biliary obstruction and its affecting factors. Methods A total of 233 patients with malignant biliary obstruction were treated in our hospital with PTBD by placement of metallic stent and/or plastic tubes. After percutaneous transhepatic cholangiography, the dilated biliary duct was punctured and the metallic stent or plastic catheter withdrawn. The patients were followed up with clinical and radiographic evaluation. Meanwhile, the serum levels of total protein, hemoglobin, ALT, HBDH, ALP, GGT, BUN and Cr were determined. Procedure-and device-related complications were recorded. The patients' survival and stent potency were calculated with Kaplan-Meier survival analysis. Results PTBD was successfully performed in all the patients. Stent placement was conducted in 136 patients. Of these 136 patients, 100 were treated with only 1 stent, 20 had 2 stents for bilateral drainage and 16 had 2 stents for long stricture. The other 97 patients received plastic catheters. The serum level of total bilirubin reduced from 349.2±155.6 mol/L before to 178.9±141.2 mmol/L after PTBD (t=17.90, P=0.000). Sixty-two patients had incorporative infection before PTBD and 23 of them were cured after the procedure. Twenty-nine patients got inflammation after the procedure. Thirty patients died within 30 d. The mortality within 30 d was related to age and serum levels of bilirubin, protein and BUN etc. After PTBD, the re-occlusion occurred in 51 patients and catheters broke off in 7. The median survival time was 7.3 month and median patency time was 14 months. Conclusions PTBD can provide good palliative drainage. It can also improve other conditions caused by biliary obstruction.