低位恶性梗阻性黄疸术前胆道引流方式的选择

The choice of preoperative biliary drainage for malignant obstructive jaundice of distal bile duct

目的探究手术治疗低位恶性梗阻性黄疸行术前减黄最佳胆道引流方式。方法收集2015年1月-2018年12月解放军总医院第一医学中心行手术治疗的低位恶性梗阻性黄疸患者166例,其中男性87例,女性79例,年龄25.0~80.0(59.9±10.6)岁。依据术前胆道引流方式分为未引流组85例、经皮肝穿胆道引流术(PTBD)组56例、内镜逆行胆道引流术(ERBD)组25例;根据术式分为胰十二指肠根治性切除术116例、姑息性胆肠吻合术50例。分析不同术前胆道引流方式下术中抽取胆汁细菌培养阳性率,分析行胰十二指肠切除术和姑息性胆肠吻合术不同术前引流方式下围手术期情况的差异。结果胆汁细菌培养阳性率未引流组、PTBD组、ERBD组分别为22.4%(19/85)、28.6%(16/56)、100%(25/25),ERBD组阳性率高于PTBD组和未引流组,差异具有统计学意义(P<0.05);多种细菌占比ERBD组高于PTBD组和未引流组[64.0%(16/25)比12.5%(2/16)比5.3%(1/19)],差异具有统计学意义(P<0.05);常见致病菌比例ERBD组高于PTBD组和未引流组[97.8%(45/46)比89.5%(17/19)比66.7%(14/21)],差异具有统计学意义(P<0.05)。胰十二指肠切除术手术时间ERBD组长于PTBD组和未引流组[(334.5±48.3)min比(289.4±39.5)min比(303.9±57.1)min],差异具有统计学意义(P<0.05);出血量PTBD组少于ERBD组和未引流组[(268.8±128.4)ml比(388.2±181.6)ml比(366.1±220.4)ml],差异具有统计学意义(P<0.05);三种引流方式胰十二指肠切除术术后并发症发生率差异无统计学意义(P>0.05);临床相关术后胰瘘未引流组、PTBD组、ERBD组分别为6.8%(4/59)、10.0%(4/40)、29.4%(5/17),ERBD组较未引流组高,差异具有统计学意义(P<0.05)。姑息性胆肠吻合术患者各组手术时间、出血量、术后住院时间、并发症发生情况差异均无统计学意义(P>0.05)。结论对于预接受胰十二指肠根治性切除术并且需要术前胆道引流的患者,与ERBD比较,PTBD是更为合适的选择。

Objective In order to optimize the mode of biliary drainage,we compared the different drainage methods of preoperative biliary drainage in the treatment of malignant obstructive jaundice of distal bile duct.Methods From January 2015 to December 2018,166 cases of distal biliary malignant obstructive jaundice treated by operation in the First Medical Center of PLA General Hospital were collected.According to the preoperative biliary drainage mode,85 cases were divided into non drainage group,56 cases in PTBD group and 25 cases in ERBD group;according to the operation mode,116 cases were divided into radical pancreatoduodenectomy group and 50 cases were divided into palliative cholangiojejunostomy group,each group was divided into three groups according to the drainage mode.Chi square test and ANOVA were used to compare the results of bile bacterial culture and perioperative conditions of each group.Results The positive rate of bile bacteria culture in non drainage group,PTBD group and ERBD group is 22.4%(19/85),28.6%(16/56)and 100%(25/25).The positive rate in ERBD group is higher than that in PTBD group and non drainage group,the difference is statistically significant(P<0.05).The proportion of multiple bacteria in ERBD group is higher than that in PTBD group and non drainage Group[64.0%(16/25)vs.12.5%(2/16)vs.5.3%(1/19)],the difference is statistically significant(P<0.05).The proportion of common pathogens in ERBD group is higher than that in PTBD group and non drainage Group[97.8%(45/46)vs.89.5%(17/19)vs.66.7%(14/21)],the difference is statistically significant(P<0.05).In pancreatoduodenectomy group,the operation time of ERBD group is significantly longer than that of PTBD group and non drainage group[(334.5±48.3)min vs.(289.4±39.5)min vs.(303.9±57.1)min],the difference is statistically significant(P<0.05).The amount of bleeding in PTBD group is less than that in ERBD group and non drainage group[(268.8±128.4)ml vs.(388.2±181.6)ml vs.(366.1±220.4)ml],the difference is statistically significant(P<0.05).There is no significant difference in the incidence of complications after pancreatoduodenectomy among three ways of drainage(P>0.05).The incidence of clinically relevant postoperative pancreatic fistula is 6.8%(4/59),10.0%(4/40)and 29.4%(5/17)in non drainage group,PTBD group and ERBD group.ERBD group is higher than non drainage group,the difference is statistically significant(P<0.05).In palliative cholangiojejunostomy,there is no significant difference in operation time,amount of bleeding,postoperative hospital stay and complications among all groups(P>0.05).Conclusion Compared with ERBD,PTBD is a more suitable choice for patients who need preoperative biliary drainage before pancreatoduodenectomy.