对不同减黄术式在低位恶性梗阻性黄疸患者行胰十二指肠切除术的疗效分析

Analysis of curative effect for different preoperative biliary drainage methods in patients undergoing pancreaticoduodenectomy with low malignant obstructive jaundice

目的探讨不同减黄术式在低位恶性梗阻性黄疸患者行胰十二指肠切除术中的疗效差异。方法回顾性分析2014年1月至2020年6月期间在贵州医科大学附属医院肝胆外科连续收治、术前考虑为低位恶性梗阻性黄疸并经术后病理学检查证实为胰腺癌、壶腹部癌、十二指肠癌或胆总管下段癌患者的临床病理资料。根据减黄术式分为经皮肝胆管穿刺引流(percutaneous transhepatic cholangial drainage,PTCD)组和经内镜下逆行胆管引流(endoscopic retrograde biliary drainage,ERBD)组,为降低选择偏倚,使用SPSS倾向性匹配模块进行倾向性评分匹配分析,比较2组患者年龄、基础疾病(高血压、糖尿病)、生化指标、减黄时间、总住院时间、术前减黄即术前胆道引流(preoperative biliary drainage,PBD)和胰十二指肠切除术后相关并发症及术后生存时间。再根据肿瘤类型分为胰腺癌组和非胰腺癌(包括壶腹部癌、十二指肠癌和胆总管下段癌)组,比较2组患者接受不同减黄手术对其治疗效果的影响。结果本研究共纳入84例患者,男43例,女41例;58例(69.0%)患者行PTCD(包括2例ERBD失败转PTCD的患者,1例PCTD因引流不畅而再次调管),26例(31.0%)患者行ERBD。PTCD组和ERBD组患者经减黄治疗后总胆红素、直接胆红素、γ-谷氨酰转肽酶和碱性磷酸酶均较减黄治疗前下降(P<0.05);丙氨酸氨基转移酶在行PTCD减黄前后变化不明显(P>0.05),而经ERBD减黄后降低明显(P<0.05);天门冬氨酸氨基转移酶在行ERBD减黄前后变化不明显(P>0.05),而经PTCD减黄后降低明显(P<0.05)。ERBD组的总住院时间和减黄时间均较PTCD组短(P<0.05)。ERBD组的PBD相关并发症(胆管炎、胰腺炎)发生率高于PTCD组而出血发生率低于PTCD组,但差异均无统计学意义(P>0.05)。在胰腺癌组患者中,接受ERBD者的减黄时间较接受PTCD者短(P=0.006),而总住院时间二者比较差异无统计学意义(P>0.05);在非胰腺癌组,接受ERBD者的总住院时间和减黄时间均较接受PTCD者短(P<0.05)。中位生存时间在所有患者中PTCD组短于ERBD组(14个月比18个月,P=0.002),其在胰腺癌患者中短于非胰腺癌患者(12个月比16个月,P=0.034),在胰腺癌患者中行ERBD和PTCD患者比较差异无统计学意义(13个月比14个月,P=0.291),而在非胰腺癌患者中行ERBD患者长于PTCD患者(20个月比15个月,P=0.008)。结论ERBD相对于PTCD能够缩短手术等待时间及总住院时间,术后中位生存时间较长,可作为低位恶性梗阻性黄疸患者术前减黄的首选术式。

Objective To investigate the efficacy of different methods of reducing jaundice in patients with low malignant obstructive jaundice undergoing pancreaticoduodenectomy.Methods A retrospective analysis was performed on the clinicopathological data of patients admitted to the Department of Hepatobiliary Surgery of The Affiliated Hospital of Guizhou Medical University from January 2014 to June 2020 who were considered to have low malignant obstructive jaundice before operation and confirmed by postoperative pathological examination as pancreatic cancer,ampulla cancer,duodenal cancer or carcinoma of the lower segment of the common bile duct.Patients were devide into percutaneous transhepatic cholangial drainage(PTCD)group and endoscopic retrograde biliary drainage(ERBD)group according to preoperative biliary drainage(PBD)methods.In order to reduce selection bias,SPSS propensity matching module was used for propensity score matching analysis.The age,basic diseases(hypertension,diabetes),biochemical indexes,time of reduction of jaundice,total hospitalization time,and postoperative complications of PBD and pancreaticoduodenectomy were compared between the 2 groups.Then,the patients were divided into pancreatic cancer group and non-pancreatic cancer group(including ampulla cancer,duodenal carcinoma and lower common bile duct carcinoma)by tumor type,and compared the effect of two groups of patients receiving different PBD methods.Results A total of 84 patients,43 males and 41 females,were included in this study,58(69.0%)patients with PTCD and 26(31.0%)patients with ERBD.After PBD the serum total bilirubin,direct bilirubin,γ-glutamyl transferase,and alkaline phosphatase of the PTCD and the ERBD groups patients were lower than before PBD,the differences were statistically significant(P<0.05).Alanine aminotransferase did not change significantly before and after PBD with PTCD(P>0.05),but decreased significantly after PBD with ERBD(P<0.05).Aspartate aminotransferase did not change significantly before and after PBD with ERBD(P>0.05),but decreased significantly after PBD with PTCD(P<0.05).The PBD time and total hospitalization time of the ERBD group were shorter than those of the PTCD group,the differences were statistically significant(P<0.05).The incidences of PBD related complications(cholangitis and pancreatitis)in the ERBD group were higher than those the PTCD group,and the incidence of bleeding in the ERBD group was lower than that the PTCD group,but the differences were not statistically significant(P>0.05).In the patients with pancreatic cancer group,the PBD time by ERBD was shorter than that of the receiving PTCD,the difference was statistically significant(P=0.006).In the non-pancreatic cancer group,the total hospitalization time and PBD time of patients receiving ERBD were shorter than those receiving PTCD,and the differences were statistically significant(P<0.05).In all patients,the median survival time of PTCD group(14 months)was shorter than that in ERBD group(18 months),P=0.002;pancreatic cancer group(12 months)was shorter than non-pancreatic cancer group(16 months),P=0.034;in non-pancreatic cancer group,ERBD group(20 months)was longer than PTCD group(15 months),P=0.008.Conclusions ERBD can shorten the waiting time of operation and hospital stay as compared with PTCD,and has a longer median survival time.It can be used as the first choice for PBD in patients with low malignant obstructive jaundice.