数字减影血管造影下经皮经肝胆管不同引流方式治疗高位恶性胆管梗阻的临床疗效比较

Clinical Effectiveness of Percutaneous Transhepatic Biliary Drainage via Different Approaches Guided by Digital Subtraction Angiography for the Treatment of Malignant High Biliary Obstruction

目的比较数字减影血管造影(DSA)下经皮经肝胆管不同引流方式治疗高位恶性胆管梗阻(MHBO)的临床疗效。方法选取2010年1月—2014年1月河北医科大学第四医院收治的MHBO患者164例,根据治疗方式不同将其分为胆管完全外引流组(A组)18例、优势侧胆管外引流组(B组)34例、胆管单支架植入并对侧外引流组(C组)48例、胆管双支架植入组(D组)64例。记录4组患者术前3 d内及术后3、7、14 d肝功能指标[丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、总胆红素(TBIL)、直接胆红素(DBIL)]差值及术后第21天TBIL;观察患者近期并发症发生情况以及其近、远期疗效。结果胆管不同引流方式与时间在ALT、AST、TBIL、DBIL差值上存在交互作用(P<0.05),胆管不同引流方式、时间在ALT、AST、TBIL、DBIL差值上的主效应显著(P<0.05)。D组胆心反射、胆管出血、穿刺点疼痛发生率高于其余A、B组,低于C组(P<0.05),电解质紊乱发生率低于其余3组(P<0.05)。4组患者近期有效率比较,差异无统计学意义(P=0.70)。4组患者1年生存率比较,差异无统计学意义(P=0.62)。4组生存曲线比较,差异有统计学意义(P<0.01)。C、D组中位生存期长于A组(P<0.05);D组中位生存期长于B、C组(P<0.05)。结论 MHBO减黄效果的关键在于胆管引流范围,随着胆管引流范围的增加,减黄效果越好,且胆管内引流优于外引流。胆管双支架植入内引流恢复了胆汁的肝肠循环,不仅能够迅速退黄并恢复肝功能,而且能提高患者的生存质量、延长生存期。

Objective To compare the clinical effectiveness of percutaneous transhepatic cholangial drainage（ PTCD）via different approaches guided by digital subtraction angiography（ DSA） for the treatment of malignant high biliary obstruction（ MHBO）. Methods One hundred and sixty-four patients with MHBO who received treatment in Fourth Hospital of Hebei Medical University from January 2010 to January 2014 were enrolled and divided into 4 groups according to the treatment： 18 cases received DSA-guided complete external drainage of biliary tract（ group A）,34 cases received DSA-guided external drainage of biliary tract via the site observed to bring the most favorable outcome（ group B）,48 cases received biliary single stent implantation combined with external drainage of biliary tract via the area contralateral to the stent implantation site（ group C）,and 64 cases received biliary double stent implantation（ group D）. Level of biochemical indicators of hepatic function,such as alanine transaminase（ ALT）,aspartate transaminase（ AST）,total bilirubin（ TBIL） and direct bilirubin（ DBIL）measured within 3 days before surgery and on the 3 rd,7 th,14 th days after surgery,and TBIL measured at 21 st day after surgery were recorded. Also,perioperative complications of therapy were recorded. According to the levels of biochemical indicators of hepatic function measured during the follow-up period,the short-term and long-term effects achieved in the groups were evaluated. Results Both the approach and duration of biliary drainage produced interactive effects on the changes in the levels of biochemical indicators of hepatic function（ ALT,AST,TBIL,DBIL）（ P 0. 05）,and both of them exerted main effects on the changes in biochemical indicators of hepatic function（ ALT,AST,TBIL,DBIL）（ P 0. 05）. Biliary-cardiac reflex,bile duct bleeding and pain at the puncture site occurred more frequently in group D compared with group A,B,but lower than group C（ P 0. 05）; while electrolyte disturbance occurred less frequently in group D rather than in other three groups（ P 0. 05）. No significant difference was seen in the short-term effect（ χ2= 1. 405,P = 0. 70）. No obvious difference was found in 1-year survival rate（ χ2= 1. 801, P = 0. 62）. The survival curves of the 4 groups were compared, the difference was statistically significant（ P 0. 01）. Median survival time was found to be longer in groups C and D than that in group A（ P 0. 05）. Compared with group D,groups B and C demonstrated shorter median survival time（ P 0. 05）. Conclusion The effect of reducing MHBO-induced jaundice is determined by the size of drained area. The greater the drained area is the better effect of reducing jaundice will be achieved. Therefore,internal biliary drainage is better than external biliary drainage. Biliary double stent implantation used for internal biliary drainage can recover the bile enterohepatic circulation, rapidly reduce the MHBO-induced jaundice,recover the hepatic function,improve the quality of life and prolong the survival time.