渐进性球囊扩张联合胆道持续引流治疗胆肠吻合术后吻合口良性狭窄

Step-by-step balloon dilatation combined with continueous biliary drainage for benign biliary-enteric anastomosis stricture

目的评价渐进性球囊扩张联合胆道持续引流治疗胆肠吻合术后吻合口良性狭窄的安全性和可行性。方法回顾性分析2008年1月至2014年3月收治的49例胆肠吻合术后吻合口良性狭窄患者临床及影像学资料。所有患者术前均行彩色超声、MR和/或增强CT及内镜下或DSA下吻合口活检病理证实为吻合口良性狭窄,其中23例患者采用经皮肝穿渐进性球囊(初始直径8 mm;第2个月直径10 mm;第3个月直径12 mm)扩张联合引流管持续引流(6个月)方式治疗(研究组);26例患者采用单次经皮肝穿球囊(直径6或8 mm球囊)扩张联合引流管置入(6个月)治疗(对照组)。比较两组患者术后临床症状缓解情况,术后并发症的发生率以及吻合口通畅时间。结果所有患者手术操作均顺利完成,未见手术相关并发症,如胆道出血,穿孔等发生。术后1周两组患者的血清胆红素下降明显,组间比较未见明显差异(P<0.05)。3个月时两组患者吻合口通畅率未见明显差异,但在6、12和24个月时研究组的吻合口通畅率显著高于对照组(P<0.05)。研究组中,3例患者分别于11.2、14.3和17.6个月出现复发黄疸,MRI及增强CT证实吻合口狭窄复发,给予再次的球囊扩张和引流管置入治疗。对照组16例患者在球囊扩张术后3.1至17.1个月再次出现黄疸,其中1例患者死于播散性血管内凝血,余15例患者给予再次的球囊扩张和引流管置入治疗。结论渐进性球囊扩张联合胆道持续引流是治疗胆肠吻合术后吻合口良性狭窄的安全、有效的微创手术。

Objective To evaluate the safety and feasibility of step-by-step balloon dilatation combined with contineous biliary drainage in treating benign biliary-enteric anastomosis stricture. Methods The clinical data and imaging materials of 49 patients with benign biliary-enteric anastomosis stricture, who were admitted to authors＇ hospital during the period from January 2008 to March 2014 to receive treatment, were retrospectively analyzed. Before treatment, the diagnosis of benign biliaryenteric anastomosis stricture was confirmed in all patients by color Doppler ultrasound, MRI and/or contrast-enhanced CT scan, endoscopic or DSA-guided anastomosis biopsy. Among the 49 patients, 23 patients （study group ） were treated with percutaneous transhepatic step-by-step balloon dilatation （the diameter of used balloon was 8 mm initially, then 10 mm balloon was used in the second month, and 12 mm balloon was used in the third month） together with contineous biliary drainage （lasting for 6 months）; 26 patients （control group） were treated with single percutaneous transhepatie balloon dilatation （balloon diameter of 6 mm or 8 mm） plus biliary drainage （lasting for 6 months）. The improvement of clinical symptoms, the incidence of postoperative complications, and the anastomotic patency rate were compared between the two groups. Results Technical success was obtained in all patients. No procedure-related complications, such as biliary tract hemorrhage and perforation, occurred. One week after the treatment, the difference in bilirubin level between the two groups was not statistically significant （P〉0.05）. Although the difference in 3-month anastomotic patency rate between the two groups was not statistically significant, the 6-month, 12-month and 24-month anastomotic patency rates of the study group were significantly higher than those of the control group （P〈0.05）. Three patients in the study group developed recurrent jaundice at 11.2, 14.3 and 17.6 months after treatment respectively; MRI and contrast- enhanced CT scan confirmed the diagnosis of anastomotic stricture recurrence, and balloon dilatation together with drainage tube placement had to be carried out again. In the control group, 16 patients developed recurrent jaundice within 3.1-17.1 months after balloon dilatation management, among them one patient died of disseminated intravascular coagulation and the remaining 15 patients received balloon dilatation together with drainage tube placement again. Conclusion For benign biliary-enteric anastomosis strictures, step-by-step balloon dilatation combined with persistent biliary drainage is a safe and effective minimally-invasive treatment.