经内镜胆道支架治疗梗阻性黄疸

Endoscopic Stent for Obstructive Jaundice of Biliary

目的:探讨梗阻性黄疸时塑料和镍钛记忆合金镀金网状支架内镜置入的操作技术及其临床疗效。方法:本组塑料支架组129例,包括:十二指肠乳头炎性狭窄28例,胆总管下段炎性狭窄16例,老年胆总管巨大结石11例,胆漏17例,胆管外科损伤狭窄10例,肝移植术后胆管吻合口狭窄34例,肝门部胆管狭窄8例,胰腺癌5例;镀金支架组42例,包括:中下段胆管癌15例,肝门部胆管癌8例,十二指肠乳头癌9例,胰腺癌10例。所有病人均行ERCP以证实狭窄部位及其程度,选择合适的支架。经十二指肠镜插入导丝至梗阻远端,狭窄明显者沿导丝进行球囊扩张;在X线监视下沿导丝用支架推送器将支架送至狭窄远端2cm。术后观察病人黄疸改善情况,同时观察肝功能、血清淀粉酶变化,并随访3-6月。结果:本组支架均一次置入成功,成功率100%。镍钛记忆合金网状支架置入后1周,患者血清总胆红素(STB)下降68.50%,谷丙转氨酶(ALT)下降64.37%,r-谷胺酰转肽酶(r-GT)下降51.12%,碱性磷酸酶(ALP)下降45.10%;塑料支架置入后1周,STB下降64.24%,ALT下降59.70%,r-GT下降52.83%,ALP下降44.61%。早期并发症包括:高淀粉酶血症、ERCP术后胰腺炎、胆管炎,晚期并发症有支架堵塞。镀金支架组随访期间有4例(14.29%)死于肿瘤进展。结论:经内镜塑料和镍钛记忆合金镀金网状支架治疗胆道梗阻性黄疸安全、有效、并发症少;塑料支架在胆漏及胆道损伤治疗中的应用为肝胆外科手术并发症的治疗提供了较好的弥补手段。

Objective： To study the technique of placement of memory alloy plating gold mesh stent and plastic stent for obstructive jaundice of biliary,and to assess its clinical effectiveness. Methods： The patients with plastic stents included papilla of duodenum inflammational strictures（n=28）, common bile duct inflammational strictures （n=16）, choledocholithiasis （n=l 1）. bile leak （n=17）, bile duct surgery injury（n=10）, Biliary tract strictures post liver transplantation （n=34）, Stenosis of bile duct of porta hepatis （n=8） pancreatic carcinoma （n---5）. The patients with plating gold stents included common bile duct carcinoma （n=15）, hilar cholangiocarcinoma （n=8）, papilla of Vater carcinoma（n=9）, pancreatic carcinoma （n=10）. Under fluoroscopic guidance the stent was inserted into biliary obstruction sites from oral cavity in all cases. Complications, liver function and blood serum amylase were investigated during the study period. Results： Successful stent placement was achieved in all cases.After operation of 7 days,in mesh stent groups,the rates of descent of blood serum total bilirubin, glutamic-pyruvic transaminase, r-glutamyl transpeptidase and alkaline phosphatase were 68.50%, 64.37%, 51.12% and 45.10% respectively. In plastic stent group,the rates of descent of STB, ALT, r-GT and AKP were 64.24%, 59.70%, 52.83%, 44.61% respectively. Early complication included post- ERCP pancreatitis, cholangititis. Occlusion of stent was the major late complication. Conclusion： Memory alloy plating gold biliar3） mesh stent and plastic stent were a safe and efficacious method for malignant and benign biliary obstruction,and improves patient＇s living quality. Plastic stent was an efficient complement for therapy of bile leak and bile duct injury.