ERCP放置胆管内支架姑息治疗难以切除的恶性胆管梗阻

The effects of biliary stent on unresectable malignant biliary obstruction

目的探讨ERCP放置胆管内支架对难以切除的恶性胆管梗阻的临床治疗效果。方法对54例恶性肿瘤引起的梗阻性黄疸患者,经ERCP将导丝插入胆管并超过梗阻部位,扩张狭窄处,用推送导管将已经选择合适的引流支架置于胆管适当部位,其两端均超过梗阻段2cm以上。结果54例患者中51例插管成功,3例插管不成功的患者中1例乳头开口于憩室内,另2例肿瘤完全阻塞导丝无法通过。成功率为94.44%(51/54)。34例胆管内放置8FZ型自膨胀式金属支架,其余20例行8～10F塑料内支架引流。术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻。其中39例2周内血清总胆红素下降50%以上,血清总胆红素退至34μmol/L以下。放置胆管内支架1周后,患者血清总胆红素由术前235.45±56.67μmol/L降至78.36±37.58μmol/L,肝功能较术前显著改善(P<0.05,P<0.01)。31例胆总管下段梗阻患者与12例肝门部胆管梗阻患者相比,放置胆管内支架引流治疗1周、2周后,其胆红素下降明显优于肝门部胆管梗阻患者(P<0.01)。34例放置胆管金属支架患者中,有12例于术后2个月发生支架阻塞,再次放置塑料内支架后引流通畅,1例放置金属支架术后患者第10个月出现支架阻塞予以再次植入金属支架。另外20例放置塑料内支架者,有3例于术后1～4周出现血清总胆红素再次上升,经ERCP检查发现支架移位和阻塞,予以更换内支架,其中1例植入塑料双支架。结论经ERCP内镜下胆管放置内支架,对解除恶性胆管梗阻性黄疸、缓解症状、提高患者生存质量具有满意疗效,对胆总管下段梗阻性黄疸的疗效优于肝门部胆管梗阻。

Objective To explore the effects of endoscopic biliary stent placement on unresectable biliary obstruction caused by malignant neoplasm. Methods Fifty-four patients with obstructive jaundice due to advanced carcinoma were treated with biliary stent through ERCP （endoscopic retrograde cholangiopancre-atography）. The guide wire was inserted into the biliary duct and the stent was pushed to the properly site, with the stent surpasssing 2 cm of the obstructive site by pushing catheter. Results Fifty-one cases of 54 were successfully embedded with biliary stents, 34 cases embedded with self-expandable metal stents （EMS）, 17 cases of them embedded with plastic stents. The successful rate of biliary stent placement was 94.44% （51/54）. The level of total serum bilirubin was decreased to 34 μmol/L and decreased by 50% after drainage for 2 weeks in 39 patients. The total serum bilirubin was decreased from 235.45 ± 56.67 μmol/L to 78.36 ± 37.58 μmol/L in all patients after 1 week stenting. The levels of ALT, AST, AKP and r-GT were significantly dereased and liver function was imoroved after endoscopic therapy（P 〈 0.05, P 〈 0.01）. The total serum bilirubin was significantly decreased in the patients with distal bile common duct obstruction compared with that of patients with biliary duct obstruction at hepatic hilum caused by malignant neoplasm after 1 week or 2 weeks biliary drainage （P 〈 0.05, P 〈 0.01）. Biliary stent occlusion occurred in 2 patients embedded with EMS after 2 months, and they were placed with plastic stents into previous stents. EMS was replaced again one patient duo to obstruction after 10 months. The total serum bilirubin was increased in 5 cases embedded with plastic stent after 1 - 6 weeks because the stents were displaced and blocked. The stents were replaced and dual stents were placed in one of them. Conclusion As a new technique, endoscopic biliary stent placement could effectively extinct jaundice for patients with unresectable biliary obstruction caused by malignant neoplasm and improved the life quality. The effects on obstructive jaundice of endoscopic biliary stent placement on distal common biliary duct were better than hepatic hilum biliary duct.