经皮胆道支架联合支架内外^(125)I粒子植入治疗肝门部胆管癌研究

Research on Treatment of Hilar Cholangiocarcinoma through ^(125)I Seed Implantation Via Percutaneous Biliary Stent Combined with Internal and External Stents

目的探讨肝门部胆管癌患者在施行经皮胆道支架成形术的基础上,联合支架内外放射性125I粒子植入治疗肝门部胆管癌的疗效。方法选择失去根治性手术时机或不愿意行外科手术治疗的23例肝门部胆管癌患者。所有患者均有明显黄疸表现,其中Ⅰ型4例,Ⅱ型7例,Ⅲ型7例,Ⅳ型5例。所有患者先行经皮穿刺胆道造影确认胆管梗阻的范围及长度并选用相匹配的胆道金属支架,准确置入胆管的狭窄段,粒子条装入塑料管,经8F胆道引流管送入所需照射部位;待黄疸减退肝功能基本正常后,行CT引导下经皮穿刺肝门部胆管癌放射性粒子植入术治疗。Ⅰ、Ⅱ、Ⅲ型患者序贯行单支架成形术+支架内粒子条及经皮穿刺支架外粒子植入;Ⅳ型患者,需要行多支架或多支引流,随后配合支架内粒子条及经皮穿刺支架外粒子植入。随访观察患者肝功能、肿瘤大小、并发症、肿瘤标志物、胆道支架通畅情况及生存期。结果 23例肝门部胆管癌患者,均成功施行经皮胆道支架成形术,中位支架通畅期为19个月,中位生存期为17个月,术后患者的胆红素均降至正常或接近正常,总胆红素值与术前相比有统计学差异(t=9.271,P=0.000),直接胆红素值与术前相比有统计学差异(t=7.751,P=0.000),术后并发症少,少数仅有轻微不良反应,总体疗效高,有效率为74%。结论经皮胆道支架成形术联合支架内外放射性125I粒子植入治疗肝门部胆管癌创伤小、安全性高,手术简单,可以治疗不同程度肿瘤并有效保持胆道支架通畅,患者生存期较长,疗效满意。

Objective To explore the curative effect of placing radioactive seed strips through the biliary stent combined with the implantation of radioactive 12sI seeds by percutaneous puncture for the treatment of hilar cholangiocarcinoma based on the condition that the patient diagnosed with hilar cholangiocarcinoma had received percutaneous biliary stent assisted angioplasty. Methods 23 cases of the hilar cholangiocarcinoma patients who did not receive the radical operation or were reluctant to receive the surgical treatment were selected. All the patients obviously showed jaundice. Among these patients, 4 were characterized as type I , 7 were characterized as type Ⅱ , 7 were characterized as type m, and 5 were characterized as type IV. All the patients initially underwent percutaneous puncture cholangiography so as to confirm the scope and length of bile duct obstruction, select metallic biliary stent with a proper length and diameter, implant precisely into a nar- row segment of the bile duct and then leave 8F biliary drainage tube through the internal stent. Lastly, the silent stock tube loaded with seed strips was sent to the required irradiated part via the biliary drainage tube; the percutaneous puncture was performed for the treatment of hilar cholangiocarcinoma lead by CT after jaundice was slowly diminished and the liver func- tion returned to the normal level. Patients in type I , type lI , type Ill generally needed to receive the single stent assisted angioplasty ＋ in stent seed strips and the percutaneous puncture seed implantation outside of stent. Patients in type IV needed multiple stents and multiple drainage combined with in-stent seed strips and percutaneous puncture seed implanta- tion outside of stent. Follow-up observation shall be given to patients after operation to observe change of liver function, the change of tumor size, complication, tumor marker, biliary stent＇ s circulation status and the lifetime. Results 23 cases of the hilar cholangiocarcinoma patients have successively received percutaneous biliary stent-assisted angioplasty. The mean circulation period of stent was 19 months, and the mean survival was 17 months. The total bilirubin of patients after operation averagely decreased to the normal level（ t = 9. 271 ,P = 0. 000）, and direct bilirubin value also showed significant difference （t =7. 751 ,P = 0. 000）. All the patients successively receiving radioactive seed implantation in and outside of stent had not clearly suffered from adverse reactions. Conclusion The percutaneous biliary stent-assisted angioplasty combined with the implantation of radioactive seeds in and outside of the stent for the treatment of hilar cholangiocarcinoma had minimal trauma and few complications. Its operation was simple with mild pain. It could cure cancers to varying degrees and effectively keep the biliary stent unobstructed with a long surviving time and a satisfactory efficacy.