金属支架姑息治疗恶性梗阻性黄疸的术后随访及生存分析

Long-term retrospective annlysis of metallic stents in malignant biliary obstruction

目的:回顾分析经皮肝穿刺置入金属支架治疗恶性胆道梗阻患者的支架通畅率和生存率及其影响因素。方法:收集北京肿瘤医院自2000年1月1日至2006年4月1日收治的共计152例因恶性病变导致梗阻性黄疸并接受经皮肝穿刺胆道引流(PTCD)和胆道支架治疗的患者,根据梗阻病因不同,有胆管癌患者35例,胰腺癌患者32例,肝癌或肝转移者61例,胃肠道术后以及淋巴结肿大压迫者24例。其中置入金属支架者71例,共计使用86枚支架。术后随访间期为3个月。用生存分析统计方法计算术后患者的累积生存率及支架通畅率(life table analysis)。用Kaplan-Meier(log-rank test)对比分析各分组间预后生存时间的差异。建立COX比例风险模型分析各危险因素对生存时间的影响,计算各影响因素的相对危险度。结果:仅有6例胆道支架患者出现术后再狭窄,支架通畅的中位时间为314天。患者术后平均中位生存时间为215天,3、6、9个月的生存率分别为79.1%、51.7%、26.8%。肝门区梗阻的患者比下段梗阻的患者预后更差(P≤0.05)。结论:金属支架在恶性梗阻性黄疸患者的生存期间足以保证通畅引流,支架再狭窄率低,性能可靠,肝门区梗阻的患者比肝外胆管梗阻的患者预后差。

Objective ： To analyze and evaluate of the long-term follow-up data of 152 patients with inoperable malignant biliary obstruction who underwent percutaneous placement of metallic stents. Methods： From 2000 through 2006, 152 consecutive patients with malignant biliary obstruction were treated with PTCD or placement of metallic stents. The causes of obstruction were bile duct carcinoma （ n = 35 ）, pancreatic carcinoma （ n = 32）, hepatocellular carcinoma and metastatic （ n = 61 ）, lymphadenopathy in the hepatoduodenal ligament （ n = 24）. We used 86 stents ： 31 Cook Zilver Stents, 25 Sinus Superflex Stents,12 Wall Stents,3 Sinus-s Iliaca Stents,3 ZA-S Bliary Design Stents,5 Smart Stents and 7 other stents. Every three months we followed up all patients except those who died. Patient survival and stent patency rates were estimated by life-table analysis. The Kaplan-Meier method （log-rank test） was used to compare the patency and survival rates among different groups. And the COX regression model was established to compare the relative risks. Results： The overall median length of patency of all stents was 314 days. The median length of survival for the entire patient group was 215 days. The survival rate was 79.1% ,51.7% and 26.8% after 3, 6, and 9 months, respectively. Six patients developed recurrent jaundice or cholangitis. The patients with hepatic hilar obstruction group indicated worse prognosis （P ≤0.05 ）. Conclusion： Metallic stents showed a favorable patency rate with regard to patient survival. In patients with hilar obstruction, the clinical prognosis was worse than that in patients with common bile duct （CBD） obstruction. We believe that the placement of metallic stents is the procedure of choice for palliation of malignant biliary obstruction.