内镜支架引流治疗肝细胞肝癌所致肝门部胆管恶性梗阻的疗效分析

Efficacy of endoscopic stenting drainage for hilar biliary malignant obstruction caused by hepatocellular carcinoma

目的评估无法手术切除的肝细胞肝癌所致肝门部胆管恶性梗阻患者的内镜支架引流疗效。方法回顾性分析2012年1月—2019年1月在海军军医大学第三附属医院因无法手术切除的肝细胞肝癌导致肝门部胆管恶性梗阻而行内镜支架引流的106例患者的临床资料。根据置入支架类型的不同,分为金属支架组(30例)和塑料支架组(76例)。观察指标包括临床成功率、并发症发生率、支架通畅期及总体生存时间。采用多因素Cox回归模型分析患者支架通畅期和总体生存时间的独立预测因素。结果患者的总体临床成功率为67.9%(72/106),术后胆管炎发生率为29.2%(31/106)。金属支架组与塑料支架组的临床成功率分别为93.3%(28/30)和57.9%(44/76)(χ^(2)=12.40,P<0.001),术后胆管炎发生率分别为13.3%(4/30)和35.5%(27/76)(χ^(2)=5.12,P=0.024)。中位支架通畅期为5.2(95%CI:3.7~6.0)个月,中位总体生存时间为3.0(95%CI:2.5~3.7)个月。多因素Cox回归分析显示肝脏引流体积<30%是支架通畅期的独立预测因素(HR=2.12,95%CI:1.01~4.46,P=0.048)。BismuthⅣ型(HR=2.06,95%CI:1.12~3.77,P=0.020)、Child-Pugh C级(HR=4.09,95%CI:2.00~8.39,P<0.001)、塑料支架(HR=1.87,95%CI:1.21~2.90,P=0.005)是总体生存时间的独立预测因素。结论肝细胞肝癌一旦累及肝门部胆管预后不良。与塑料支架相比,金属支架引流在临床成功率、术后胆管炎发生率方面均具有一定优势。肝脏引流体积<30%是支架通畅期的独立预测因素,而BismuthⅣ型、Child-Pugh C级、塑料支架为总体生存时间的独立预测因素。

Objective To evaluate the efficacy of endoscopic stenting drainage for patients with malignant hilar biliary obstruction caused by unresectable hepatocellular carcinoma.Methods Data of 106 patients with malignant hilar obstruction caused by unresectable hepatocellular carcinoma who received endoscopic stenting drainage in the Third Affiliated Hospital of Naval Medical University from January 2012 to January 2019 were retrospectively analyzed.According to the different stent types,they were divided into the metal stent group(30 cases)and the plastic stent group(76 cases).The observation indexes included clinical success rate,complication incidence,stent patency and overall survival time.The independent predictors for stent patency and overall survival of patients were analyzed by multivariate Cox regression model.Results The overall clinical success rate was 67.9%(72/106)and the incidence of postoperative cholangitis was 29.2%(31/106).The clinical success rates were 93.3%(28/30)and 57.9%(44/76)(χ^(2)=12.40,P<0.001),and the incidences of postoperative cholangitis were 13.3%(4/30)and 35.5%(27/76)(χ^(2)=5.12,P=0.024)in the metal stent group and the plastic stent group,respectively.The median stent patency was 5.2(95%CI:3.7-6.0)months,and the overall survival time was 3.0(95%CI:2.5-3.7)months.Multivariate Cox regression analysis showed that hepatic drainage volume<30%was an independent predictor for stent patency(HR=2.12,95%CI:1.01-4.46,P=0.048).Bismuth typeⅣ(HR=2.06,95%CI:1.12-3.77,P=0.020),Child-Pugh class C(HR=4.09,95%CI:2.00-8.39,P<0.001)and plastic stent(HR=1.87,95%CI:1.21-2.90,P=0.005)were independent predictors for overall survival time.Conclusion Hepatocellular carcinoma involving the hilar bile duct has a poor prognosis.Compared with plastic stents,metal stents show advantages in clinical success rate and incidence of postoperative cholangitis.Hepatic drainage volume<30%is an independent predictor for stent patency,and Bismuth typeⅣ,Child-Pugh class C and plastic stent are independent predictors for overall survival time.