高位胆道恶性梗阻介入治疗

Interventional treatment of high-position malignant biliary obstruction

目的探讨肝管汇合处恶性梗阻经皮肝穿刺内支架置入操作难点与对策。方法对23例高位胆道恶性梗阻病人采用经皮肝穿刺胆道支架置放及内外引流术（PTBD）。分别观察介入成功率，并发症发生率，血清胆红素下降情况，随访胆道支架维持通畅时间和病人生存期。结果23例首次介入成功22例，占95．65％；21例总胆红素明显下降（下降百分比〉60％），2例无效（下降百分比〈10％）；谷丙转氨酶（GPT）和谷草转氨酶（GOT）明显下降，平均18d恢复正常。术后发热2例（38℃），胆道出血1例，右上腹部疼痛6例，穿刺点周围局限性腹膜炎1例，GPT升高3例，经止血抗炎护肝对症治疗后2～5d后症状消失；引流管滑脱1例；无大出血、胆汁瘘等严重并发症。全组平均生存期8．5个月。结论肝管汇合处恶性梗阻支架置放操作难度大，导丝通过梗阻段是关键，正确掌握操作方法可显著提高手术成功率。

Objective To explore the difficulty and strategy of percutaneous transheptic stenting for the junction of malignant hepatic duct obstruction. Method Twenty-three patients with highly malignant biliary obstruction received percutaneous transheptic biliary drainage （PTBD） by placement of stent and/or internal-external drainage tube. All the 23 patientws were followed up to determine the successful rate of surgery, the incidence of complications, decreased serum level of bilirubin, patency time of biliary stent and survival time. Results The initial operation was sucessful in 22 cases, ac counting for 95.65%. Twenty-one patients had significant decline in total bilirubin （60%） and 2 had not （10%）. The levels of alanine aminotransferase （GPT） and aspartate aminotransferase （GOT） decreased markedly and returned to nomral in an average of 18 d. After operation, 2 patients had fever, 1 biliary tract bleeding, 6 pain in the right upper abodminal region, 1 localized peritonitis around the puncture point, 3 GPT increase and 1 drainage tube slip. There were no serious complications such as hemorrhea and biliary fistula etc. The symptoms of all these complications disappeared in 2 to 5 days through haemostasis, anti-inflammatory therapy and liver function protection. The median survival time was 8.5 months. Conclusion Although the merging of malignant hepatic duct obstruction stenting is difficult, try to pass through the obstruction by guide wire and master the right methods of operation can significantly improve the successful rate of surgery.