肝门部胆管癌术前胆汁引流方式选择的Meta分析

Meta analysis of preoperative bile drainage methods for hilar cholangiocarcinoma

目的探讨肝门部胆管癌患者不同术前胆汁引流方式术后并发症发生率情况及引流减黄疗效,以期为临床决策提供参考。方法计算机检索2007年1月-2018年6月在中国知网(CNKI)、维普(VIP)和PubMed、EMbase等数据库中关于肝门部胆管癌患者术前胆汁引流的文献,采用NOS评分评估纳入文献的质量,并采用RevMan 5.3软件对纳入文献进行Meta分析。结果本次Meta分析最终共纳入11篇文献。分析结果显示:行经内镜逆行胰胆管造影(ERCP)的患者术后胆管炎的发生率高于行经皮肝穿刺胆道引流(PTBD)的患者(RR=0.64;95%CI:0.42~0.98;P=0.0400);行PTBD的患者术后引流减黄疗效优于行ERCP的患者(RR=2.12;95%CI:1.41~3.20;P=0.0003);行ERCP的患者术后胰腺炎的发生率高于行PTBD的患者(RR=0.29;95%CI:0.15~0.57;P=0.0003);而行PTBD与ERCP的患者其术后出血情况的差异无统计学意义(RR=1.24;95%CI:0.62~2.46;P=0.5400)。行经内镜鼻胆道引流(ENBD)与行经内镜胆道支架置入术(EBS)的患者术后并发胆管炎的差异无统计学意义(RR=0.51;95%CI:0.25~1.04;P=0.0600),且行ENBD与EBS的患者术后并发胰腺炎的差异亦无统计学意义(RR=0.62;95%CI:0.29~1.32;P=0.2100)。结论对于诊断明确,需行胆汁引流的肝门部胆管癌患者,可选择行PTBD术。PTBD与ERCP相比,不但具有更高的胆汁淤积改善率,而且术后胆道感染、胰腺炎的发生率均更低,是术前胆汁引流、减黄的首选方式。

Objective To investigate the incidence of postoperative complication and the effect of drainage and jaundice reduction of several preoperative bile drainage methods for hilar cholangiocarcinoma,so as to provide a reference for clinical decision-making.Methods The literature on preoperative biliary drainage in patients with hilar cholangiocarcinoma from January 2007 to June 2018 in the databases CNKI,VIP,PubMed and EMbase was collected.The quality of the literature was analyzed using the Newcastle-Ottawa Scale(NOS),and the meta-analysis was performed using RevMan 5.3 software.Results A total of 11 articles were included in this study.The results of the meta-analysis showed that the incidence of postoperative cholangitis was higher in patients undergoing endoscopic retrograde cholangiopancreatography(ERCP)than in patients undergoing percutaneous transhepatic biliary drainage(PTBD)(RR=0.64;95% CI:0.42-0.98;P=0.0400);PTBD also had better effect of drainage and jaundice reduction(RR=2.12;95% CI:1.41-3.20;P=0.0003);the incidence of postoperative pancreatitis was higher in patients undergoing ERCP than in patients undergoing PTBD(RR=0.29;95% CI:0.15-0.57;P=0.0003);differences in postoperative bleeding between patients undergoing PTBD and ERCP was insignificant(RR=1.24;95% CI:0.62-2.46;P=0.5400).There was no significant difference in the incidence of postoperative cholangitis between patients undergoing endoscopic nasobiliary drainage(ENBD)and endoscopic biliary stenting(EBS)(RR=0.51;95% CI:0.25-1.04;P=0.0600),and there was no significant difference in the incidence of postoperative pancreatitis between patients undergoing ENBD and EBS(RR=0.62;95% CI:0.29-1.32;P=0.2100).Conclusion For patients with hepatic hilar cholangiocarcinoma who have a clear diagnosis and need bile drainage,PTBD can be recommended.Compared with ERCP,PTBD not only has a higher rate of improvement of cholestasis,but also lower incidence of postoperative biliary infection and pancreatitis.Therefore,it is the preferred method for preoperative bile drainage and jaundice reduction.