合并梗阻性黄疸的壶腹周围癌患者不同术前胆道减压方式的比较

Comparison of different preoperative decompression of biliary tract methods for patients with periampullary carcinoma complicated with obstructive jaundice

目的探讨不同胆道减压(以下称减黄)方式在合并梗阻性黄疸的壶腹周围癌患者中术前减黄效能的优劣。方法回顾性分析2015年1月至2020年9月北京协和医院收治的128例胰十二指肠切除术的胰头癌、十二指肠壶腹癌和胆总管下段癌患者的临床资料。根据胆道减压方式分组:经内镜逆行性胰胆管造影术(ERCP)放置支胆管架引流组,纳入80例患者;经皮肝穿刺胆道引流术(PTCD)组,纳入48例患者。分别在减黄前(TBpre)及手术前1周内检测血清总胆红素(TB)等指标,比较两种方式的减黄效能,进一步按照肿瘤组织学类型分组进行对照分析。结果ERCP组减黄后(TBpost),TB指标、TB下降率、减黄充分率(TB减黄后≤100μmol/L占比)均优于PTCD组[分别为(68±45)μmol/L vs(114±69)μmol/L;73.9%±16.9%vs 64.2%±21.2%;83.8%vs 56.3%]。十二指肠壶腹癌中,ERCP组TB减黄后,TB指标、TB下降率、减黄充分率均优于PTCD组[分别为(51±20)μmol/L vs(103±49)μmol/L;78.6%±10.9%vs 67.2%±14.8%;100%vs 58.3%]。在胆总管下段腺癌中,ERCP组减黄后(TBport),TB指标、TB下降率、减黄充分率均优于PTCD组[分别为(76±52)μmol/L vs(161±51)μmol/L;70.6%±18.5%vs 56.5%±10.4%;82.1%vs 11.1%]。结论对于合并梗阻性黄疸的壶腹周围癌患者,建议首选ERCP放置胆管支架术前减黄,尤其对十二指肠壶腹腺癌和胆总管下段腺癌患者更为适合。

Objective To investigate the efficacy of different methods in decompression of biliary tract(jaundice reduction)for patients with periampullary carcinoma combined with obstructive jaundice.Methods The clinical data of 128 patients with malignant jaundice treated by preoperative biliary decompression before pancreaticoduodenectomy were retrospectively analyzed in Peking Union Medical College Hospital from January 2015 to September 2020.Patients were divided into endoscopic retrograde cholangiopancreatography(ERCP)with stent placement group including 80 cases and percutaneous transhepatic cholangial drainage(PTCD)group including 48 cases according to different methods of jaundice reduction.Serological indicators including total bilirubin(TB)were monitored before jaundice reduction(TBpre)and surgery within one week respectively.The efficacy of jaundice reduction in two groups was compared and further categories were carried out according to the histological types.Results TB after jaundice reduction(TBpost),TB reduction rate and the reduction adequacy rate(the percentage of postoperative TB≤100μmol/L)in ERCP group were significantly better than those in PTCD group[(68±45)μmol/L vs(114±69)μmol/L;73.9%±16.9%vs 64.2%±21.2%;83.8%vs 56.3%].In patients with duodenal ampullary carcinoma,TBpost,TB reduction rate and the reduction adequacy rate in ERCP group were better than those in PTCD group[(51±20)μmol/L vs(103±49)μmol/L;78.6%±10.9%vs 67.2%±14.8%;100%vs 58.3%].In patients with distal cholangiocarcinoma with TBpost,TB reduction rate and the reduction adequacy rate of ERCP group were better than those of PTCD group[(76±52)μmol/L vs(161±51)μmol/L;70.6%±18.5%vs 56.5%±10.4%;82.1%vs 11.1%].Conclusions For patients with malignant obstructive jaundice,stent placement by ERCP is recommended as the first choice for preoperative jaundice reduction,especially for those with ampler carcinoma or distal cholangiocarcinoma.