经内镜逆行胰胆管造影胆道支架置入术治疗恶性胆道狭窄的临床分析

Clinical analysis of endoscopic retrograde cholangiopancreatography biliary stent implantation in treatment of malignant biliary stricture

目的探讨不可切除恶性胆道狭窄(MBS)患者行经内镜逆行胰胆管造影(ERCP)胆道支架置入引流的疗效及总生存的影响因素。方法回顾性分析福建医科大学孟超肝胆医院、山西白求恩医院及空军军医大学西京消化病医院2013年5月至2016年10月因MBS行ERCP胆道支架置入术的346例患者的临床资料,并分析疗效、并发症以及影响总生存的危险因素。结果经ERCP胆道支架置入术后患者总胆红素、γ⁃谷氨酰转肽酶、碱性磷酸酶、丙氨酸氨基转移酶水平均较术前下降(均P<0.01)。术后感染发生率为14.7%(51/346),其中胆系感染发生率为13.0%(45/346),术后胰腺炎(PEP)发生率为4.6%(16/346)。患者ERCP术后中位总生存时间为131.0 d(70.3 d,246.5 d)。多因素Cox回归分析显示,肝门部胆管狭窄(HR=1.85,95%CI 1.44~2.38,P<0.01)、术前胆红素水平超过正常值上限5倍(HR=1.75,95%CI 1.30~2.36,P<0.01),糖类抗原199水平超过正常值上限10倍(HR=1.27,95%CI 1.00~1.61,P=0.050)、有血管及器官转移(HR=1.32,95%CI 1.04~1.69,P=0.023)及退黄效果不佳(HR=1.37,95%CI 1.02~1.85,P=0.037)是影响ERCP胆道支架置入术后患者总生存的独立危险因素。结论ERCP胆道支架置入术可安全有效地用于治疗MBS。肝门部胆管狭窄、术前胆红素水平超过正常值上限5倍、糖类抗原199水平超过正常值上限10倍、有血管及器官转移和退黄效果不佳的ERCP胆道支架置入术后MBS患者可能总生存较差。

Objective To explore the efficacy of endoscopic retrograde cholangiopancreatography(ERCP)biliary stent implantation in patients with unresectable malignant biliary stricture(MBS)and the influencing factors of overall survival.Methods The clinical data of 346 patients who underwent ERCP biliary stent implantation due to MBS from May 2013 to October 2016 in Xijing Digestive Disease Hospital of Air Force Military Medical University,Shanxi Bethune Hospital and Mengchao Hepatobiliary Hospital of Fujian Medical University were retrospectively analyzed,and the efficacy,complications and risk factors affecting overall survival were also analyzed.Results After ERCP biliary stent implantation,the levels of total bilirubin,γ⁃glutamyl transpeptidase,alkaline phosphatase and alanine aminotransferase were lower than those before surgery(all P<0.01).The incidence of infection after operation was 14.7%(51/346),and the incidence of biliary infection was 13.0%(45/346).The incidence of post⁃ERCP pancreatitis(PEP)was 4.6%(16/346).The median survival time after ERCP was 131.0 d(70.3 d,246.5 d).Multivariate Cox regression analysis showed that the independent risk factors affecting the overall survival patients included the hilar bile duct stenosis(HR=1.85,95%CI 1.44-2.38,P<0.01),preoperative bilirubin level exceeding the upper limit of normal level by 5 times(HR=1.75,95%CI 1.30-2.36,P<0.01),carbohydrate antigen 199 level exceeding the upper limit of normal level by 10 times(HR=1.27,95%CI 1.00-1.61,P=0.050),vascular and organ metastasis(HR=1.32,95%CI 1.04-1.69,P=0.023),and the poor jaundice decreasing level(HR=1.37,95%CI 1.02-1.85,P=0.037).Conclusions The ERCP biliary stent implantation is a safe and effective therapy for MBS.ERCP biliary stent implantation MBS patients with hilar bile duct stenosis,preoperative bilirubin levels more than 5 times of the upper limit of normal level,carbohydrate antigen 199 levels more than 10 times of the upper limit of normal level,vascular and organ metastasis,and poor jaundice decreasing level may have poor overall survival.