外科T管术后胆道再狭窄的介入治疗

The Interventional Therapy on Biliary Restenosis After Surgery T Tube Drainage Procedure

目的评价介入治疗外科T管引流后胆道再狭窄的疗效、安全性、可行性。方法回顾性分析2014年6月至2017年4月本院外科T管术后胆道再狭窄的31例患者资料,其中胆管癌9例,胆囊癌4例,胆系结石15例,肝癌2例,胃癌外科术后1例。合并胰胆管合流异常者5例。经原T管途径行介入治疗者23例,经T管造影后再行经皮肝穿刺胆道引流术（PTCD）治疗者8例。所有患者中,行球囊扩张配合引流管置入者18例,行单纯内外引流者9例,行胆道金属支架置入者4例。良性狭窄患者引流管保留2~3个月后给予拔除。患者经门诊或电话进行随访3~24个月,通过引流管造影观察疗效。结果介入手术均获成功,无相关并发症发生;术后患者肝功能均有好转。18例良性胆道狭窄患者均经原T管窦道途径行球囊扩张成型术及内外引流管（直径10.2或12 F）置入术,拔除原T管。其中15例胆石症患者恢复良好,无复发;3例胆管癌吻合口良性狭窄患者中1例于术后8个月死于肺部感染,另2例拔管后恢复可。13例恶性狭窄中,6例胆道梗阻位于T管上方,均行PTCD术;其中2例肝癌侵犯胆道患者,癌栓范围较大,行内外引流管置入;黄疸消退后分别于术后1个月、2.2个月死于肝衰竭;2例胆囊癌术后吻合口复发,行支架置入1例,内外引流管植入1例;分别于术后2.5个月、3.2个月死于肿瘤进展,2例胆管癌患者分别于术后1个月、2.2个月死于胆系感染。另7例胆道梗阻位于T管下方;经T管窦道途径置入内外引流管4例,置入金属支架3例。其中2例胆囊癌患者分别于术后3.8个月、5个月死于肿瘤进展。4例胆管癌患者于术后3.6个月、4个月、5.2个月、9个月死于肿瘤进展。1例胃癌死于肝转移、肝功能衰竭。结论外科T管引流后胆道再狭窄经介入治疗疗效确切,技术安全可行。

Objective To investigate the curative effect,safety and feasibility of the interventional therapy on biliary restenosis after surgery T tube drainage. Methods The clinical data of 31 patients who presented with biliary restenosis after surgeical T tube drainage from June 2014 to April 2017 were analyzed retrospectively. 9 patients were diagonosed as bile duct carcinoma,4 cases were considered to be gallbladder carcinoma,15 cases were diagnosed as biliary stone,2 patients presented with hepatocellular carcinoma,1 case received the surgery procedure owing to gastric carcinoma. In addition,5 cases complicated with pancreaticobiliary maljunction. 18 cases received the interventional procedure via T tube sinus tract. Percutaneous transhepatic cholangial drainage（ PTCD） was carried out after T tube visualization to 7 patients. Of all patients,18 patients received the biliary balloon expansion,4 patients received the biliary stent insertion. The drainage tube was kept for 2-3 month to biliary benign stricture patients,The follow-up time was 3-24 month and the curative effect was evaluated by drainage tube visualization. Results All the interventional procedures were successful with no related complications. The liver function improved. 18 biliary benign stricture patients received the balloon expansion via the T tube sinus tract and the drainage tube（ diameter： 10. 2-12 F） insertion,then the T tube was moved. Follow-up found one patient presenting with anastomotic benign stenosis after bile duct carcinoma operation and died of lung infection after 8 months,the other two patients got a better outcome. Of 13 biliary malignant stricture cases,the biliary obstruction of 6 cases located above the T tube and the PTCD was performed. Among them,two HCC patients presented with the large range biliary cancer embolus and received the drainage tube insertion. They died of the liver function failure at 1 mon,2. 2 mon postoperation respectively without symptoms of jaundice. Two patients with gallbladder carcinoma respectively accepted the biliary stent placement,drainage tube implantation after 2. 5 months,3. 2 months and died of tumor progression. Another two patients with cholangiocarcinoma died of biliary infection 1 month and 2. 2 months postoperatively,respectively. The biliary obstruction of 7 cases was located below the T tube,4 patients received the drainage tube insertion and 3 patients received the stent insertion via the T tube sinus tract. 2 patients with gallbladder carcinoma died of tumor progression after 3. 8 months,5 months respectively. 4 patients with cholangiocarcinoma,died of tumor progression after 3. 6 months,4 months,5. 2 months,9 months respectively. One patient with gastric carcinoma died of liver matastases. Conclusion Interventional therapy on biliary restenosis after surgical T tube drainage is safe and feasible.