内镜下同期放置双侧金属支架或双侧塑料支架治疗肝门部恶性胆道梗阻

Simultaneous bilateral biliary metal stents versus plastic stents under endoscope for treatment of malignant hilar biliary obstruction

目的比较经内镜同期置入双侧金属支架或双侧塑料支架治疗肝门部恶性胆道梗阻(MHBO)的疗效及安全性。方法选取2007年5月至2011年12月需要进行双侧胆道引流的142例MHBO患者,其中32例采用双侧金属支架胆道引流(双金属支架组),110例采用双侧塑料支架胆道引流(双塑料支架组),统计内镜操作成功率、术后减黄有效率、内镜逆行胆胰管造影(ERCP)术后并发症及支架通畅期。结果全组操作成功率为100%。双金属支架组和双塑料支架组术后减黄有效率分别为96.9%(31/32)和88.2%(97/110),组间差异无统计学意义(P>0.05)。双金属支架组和双塑料支架组ERCP术后分别出现2例和6例胆管炎,经抗炎对症、更换支架或置入鼻胆管处理后症状缓解;双塑料支架组出现2例支架部分滑脱。两组均未发生胰腺炎、消化道出血、穿孔及ERCP相关性死亡病例。至研究终点,双金属支架组和双塑料支架组分别有2例和4例因其他原因死亡,死亡时胆道内支架均通畅;双金属支架组和双塑料支架组分别有8例和29例再发梗阻性黄疸,予以重新置入或更换塑料支架处理。两组ERCP术后并发症发生率差异无统计学意义(P>0.05)。双金属支架组的中位通畅期为(248.53±138.61)d,双塑料支架组的中位通畅期为(101.76±38.53)d,经Log-rank检验差异有统计学意义(P<0.001)。结论对于BismuthⅡ型或双侧胆管均已受侵、无法手术的MHBO,如果胆道引流范围许可、患者的预计生存期>3个月,双金属支架行胆道引流更具优势。

Objective To compare the safety and efficacy of simultaneous bilateral biliary metal stents with plastic stents under endoscope for treatment of malignant hilar biliary obstruction （MHBO）. Methods From May 2007 to December 2011, 142 MHBO patients were selected for this study, with 32 receiving bilateral metal stent drainage and 110 receiving bilateral plastic stent drainage. The success rate of endoscopic operations, postoperative jaundice-reducing effect, post-endoscopic retrograde cholangiopancreatography （ERCP） complications, and stent patency period were observed. Results The procedures were successful in all patients in the two groups. The postoperative jaundice-reducing effect rates were 96.9~ （31/32） in the metal stent group and 88.2 ~ （97/110） in the plastic stent group （P）0.05）. Two patients in the metal stent group and six in the plastic stent group had post-ERCP cholangitis, which was relieved by anti-inflammatory intervention, replacement of stents or endoscopic nasobiliary drainage. Two patients in the plastic stent group had stent slip. There were no pancreatitis, gastrointestinal bleeding, perforation or ERCP-related deaths in the two groups. Two patients in the metal stent group and 4 in the plastic stent group died, and the biliary stents were patent until they died. Eight patients in metal stent group and 29 patients in the plastic stent group developed recurrent obstructive jaundice, which were treated by reimplantation or replacement of the plastic stents. The post-ERCP complication rates were similar in the two groups （P〉0.05）. The median patency period of the metal stent was （248.53±138.61） d and that of the plastic stent was （101.76± 38.53） d, showing significant difference by Log-rank test （P〈0. 001）. Conclusion For Bismuth 11-type, bilateral bile duct invaded, or non-resectable MHBO patients, if biliary drainage range permits and the expected survival period 〉3 months, double metal stent biliary drainage has more advantages.