三种方式同期放置双侧金属支架治疗肝门胆管恶性梗阻的比较研究

A comparative study of three approaches of simultaneous bilateral metal stenting in the management of malignant hilar biliary obstruction

目的探讨内镜下3种方式同期平行放置双侧金属支架治疗无法手术切除肝门胆管恶性梗阻的疗效。方法回顾性分析2012年1月—2019年2月期间上海东方肝胆外科医院采用内镜下同期平行放置双侧金属支架治疗无法手术切除肝门胆管恶性梗阻(BismuthⅡ~Ⅳ型)的118例患者资料。按照支架放置方式分为3组:双侧支架均跨越十二指肠主乳头(long long-stent by stent,LL-SBS)组(53例)、单侧支架跨越十二指肠主乳头(long short-SBS,LS-SBS)组(53例)和双侧支架均不跨越十二指肠主乳头(short short-SBS,SS-SBS)组(12例)。主要观察指标包括临床成功率、支架通畅期、内镜下双侧胆管再干预成功率和生存时间。结果3组的临床成功率分别为96.2%(51/53)、98.1%(52/53)、91.7%(11/12),支架通畅期分别为9.2个月(8.0~10.3个月)、11.6个月(6.8~16.4个月)、8.1个月(3.7~12.5个月),患者生存时间分别为6.7个月(4.6~8.8个月)、7.6个月(5.7~9.4个月)、7.1个月(0.7~13.6个月),以上指标3组间比较差异均无统计学意义(P>0.05);在内镜下双侧胆管再干预成功率上,LL-SBS组为12/13,LS-SBS组为0/10,SS-SBS组为1/5,差异有统计学意义(P<0.001)。结论平行放置胆管双侧金属支架是治疗肝门胆管恶性梗阻的一项有效的内镜引流技术;双侧支架均跨越十二指肠主乳头的方式可以提高双侧胆管再干预的成功率。

Objective To compare the efficacy of three approaches of parallel-style bilateral metal stenting in the management of unresectable malignant hilar biliary obstruction.Methods Data of 118 patients with unresectable malignant hilar biliary obstruction(Bismuth typeⅡ-Ⅳ)treated by endoscopic bilateral metal stenting in Oriental Hepatobiliary Surgery Hospital from January 2012 to February 2019 were retrospectively studied.According to the method of stent placement,patients were divided into three groups,both stents crossing the main duodenal papilla(long long-stent by stent,LL-SBS)group(53 cases),one stent crossing the papilla(long short-SBS,LS-SBS)group(53 cases)and no stent crossing the papilla(short short-SBS,SS-SBS)group(12 cases).The main outcomes,clinical success rate,stent patency,success rate of re-intervention of both intrahepatic systems and overall survival,were compared among the three groups.Results There were no significant differences in clinical success rate[96.2%(51/53),98.1%(52/53),and 91.7%(11/12)],median stent patency[9.2(8.0-10.3)months,11.6(6.8-16.4)months,and 8.1(3.7-12.5)months]or overall survival time[6.7(4.6-8.8)months,7.6(5.7-9.4)months,and 7.1(0.7-13.6)months]among the three groups(all P>0.05).The success rate of endoscopic re-intervention of both intrahepatic systems was 12/13,0/10,and 1/5 in LL-SBS,LS-SBS and SS-SBS groups,respectively(P<0.001).Conclusion Parallel-style bilateral metal stenting is an effective endoscopic modality in the treatment of malignant hilar biliary obstruction,and LL-SBS may improve the success rate of endoscopic re-intervention to both intrahepatic systems.