恶性胆道梗阻的介入治疗策略

A strategy investigation of interventional treatment for malignant biliary obstruction

目的探讨不同平面恶性胆道梗阻的介入治疗策略。方法对15例胆总管中、下段梗阻患者,12例行经皮穿刺胆道引流,余3例由右肝管穿刺在胆总管内置入支架。对24例肝门区梗阻患者,20例行经皮穿刺胆道引流,其中15例经右侧腋中线穿刺在右肝管与胆总管之间经置入胆道引流管,3例经右侧腋中线穿刺在右肝管与左肝管之间置入胆道引流管,1例经剑突下穿刺在左肝管与胆总管之间置入胆道引流管;1例经双侧穿刺,分别在左肝管、右肝管与胆总管之间置入胆道引流管行全肝引流。4例经右侧腋中线穿刺在右肝管与胆总管之间置入支架。结果全组病例术前总胆红素、直接胆红素分别为(312.8±184.9)μmol/L、(198.9±115.7)μmol/L;术后2～48d复查分别为(139.4±109.4)μmol/L、(99.4±80.1)μmol/L。表明手术前、后的总胆红素水平及直接胆红素水平之间具有极显著性差异(P值分别为4.3×10-5、3×10-4)。全组患者中35例术后总胆红素水平较术前下降超过30%,有效率为89.7%(35/39)。结论经皮经肝穿刺胆道引流或支架置入术是姑息性治疗恶性梗阻性黄疸的有效方法;对肝门区肿瘤,宜根据Bismuth分型确定引流肝的范围及支架置入方式。

Objective To evaluate interventional strategy for malignant obstructive jaundice in different biliary level. Methods Of 15 patients with common bile duct（ CBD） middle or inferior part obstruction, 12 cases were treated by percutaneous transhepatic biliary drainage, 3 cases were treated by percutaneous transhepatic insertion of CBD stents. Meanwhile,24 new patients were treated by percutaneous transbepatic biliar7 drainage, 15 of them were treated by percutancous fight-sided puncture to place drainage tubes between fight hepatic duct （RHD） and CBD,3 of them were treated by pereutaneous right -sided puncture to place drainage tube between left hepatic duct （LHD） and RHD, 1 of them was treated by percutaneous left-sided puncture to place drainage tube between CBD and LHD, 1 of them was treated by bilateral side puncture to place drainage tubes for total liver drainage. 4 of them were treated by percutaneous right-sided puncture to place stand between RHD and CBD. Results Serum total bilirubin level （TBIL） and direct bilirubin level（DBIL） were respectively（312.8 ± 184.9） μmol/L, （ 198.9 ±115.7） μmol/L in pre-operation. After the procedure ,TBLIL and DBIL were respectively（ 139.4 ±109.4） μrnol/L, （ 99.4 ± 80.1 ） μmol/ L. T-test showed there existed significantly statistical difference between pre-and post-TBIL , also pre-and post-DBIL. （P = 4.3 × 10-5 ,3 ×10^-4）. Post-operative TBIL levels of 35 patients decreased more than 30 % of pre-operative that ,total clinical efficacy rate was 89.7% （35/39）. Conclusions The percutaneous transhepatic biliary drainage or stcnt insertion is a safe and effective palliative therapy of malignant biliary obstruction; It＇s proposed to determine volume of drained liver and method of stent insertion or drainage according to Bismuth type for malignant hepatic hilar tumor.