基于倾向评分匹配的ERCP与PTCD治疗恶性梗阻性黄疸的疗效比较

Comparison of ERCP and PTCD based on propensity score matching in the treatment of malignant obstructive jaundice

目的采用基于倾向评分匹配法(PSM)来比较经内镜逆行胰胆管造影术(ERCP)和经皮肝穿刺胆道引流术(PTCD)治疗恶性梗阻性黄疸的疗效。方法回顾性分析了苏州大学附属第一医院消化内科和介入科2019年1月至2023年12月期间确诊为恶性梗阻性黄疸(MOJ)患者的临床资料。根据不同手术方式将228例患者分成ERCP组(n=104)和PTCD组(n=168),将患者性别、年龄、BMI、病因、梗阻部位、梗阻时间、合并疾病、总胆红素、直接胆红素、血清Na^(+)、血清K^(+)、白细胞、谷丙转氨酶、谷草转氨酶14个因素作为匹配的协同变量,按照1:1的最邻近匹配法进行PSM,比较两组患者手术情况、术后情况、术后2周生化指标变化情况以及术后并发症发生情况。结果(1)本研究纳入272例患者中ERCP组104例、PTCD组168例,两组患者间的病因、梗阻部位、合并疾病、血清K^(+)以谷丙转氨酶等资料比较,差异有统计学意义(P均<0.05);将两组样本经PSM处理后,每组剩余82例研究对象匹配成功,两组的各项资料比较均无显著统计学差异性(P均>0.05)。(2)两组患者的手术成功率比较无显著统计学差异性(P均>0.05),ERCP组的手术时间和术中出血量均低于PTCD组(P均<0.05);但是经PSM匹配后两组的手术时间和术中出血量比较,差异均无显著统计学意义(P>0.05)。(3)两组患者术后第1、3、7天的VAS评分、术后总有效率以及住院费用比较,差异均无显著统计学意义(P均>0.05),但ERCP组的术后住院时间低于PTCD组,比较差异有显著统计学意义(P<0.05);但经PSM匹配后ERCP组术后第1天、第2天的VAS评分以及术后住院时间均低于PTCD组,比较差异均有显著统计学意义(P均<0.05)。(4)两组患者术后2周的总胆红素、血清K^(+)、谷丙转氨酶比较,差异均有显著统计学意义(P均<0.05)经PSM匹配后两组的血清术K^(+)和谷丙转氨酶比较仍有显著统计学差异性(P<0.05);但两组的总胆红素比较,差异无显著统计学意义(P>0.05)。(5)两组患者的各项术后并发症比较均无显著统计学差异性(P均>0.05);经PSM匹配后两组之间的急性胰腺炎、穿刺道出血、导管引流不畅发生率比较,差异均有显著统计学意义(P均<0.05)。结论对于恶性梗阻性黄疸患者而言选用ERCP与PTCD技术均有效,ERCP术后患者的肝功能恢复更快、住院时间较短,同时出血及导管不畅等并发症更少,但是继发急性胰腺炎的概率也更大,两种术式各有各的优势及不足。

Objective Using propensity score matching(PSM)to compare the efficacy of endoscopic retrograde cholangiopancreatography(ERCP)and percutaneous transhepatic cholangiopancreatography(PTCD)in the treatment of malignant obstructive jaundice.Methods The clinical data of patients with malignant obstructive jaundice(MOJ)diagnosed in the digestive department and intervention department of The First Affiliated Hospital of Soochow University from January 2019 to December 2023 were retrospectively analyzed.228 patients were divided into ERCP group(n=104)and PTCD group(n=168)according to different surgical methods.The 14 factors of patient gender,age,BMI,etiology,obstruction location,obstruction time,combined diseases,total bilirubin,direct bilirubin,serum Nat,serum K^(+),leukocyte,alanine aminotransferase,aspartate aminotransferase were used as the matching covariates.PSM was performed according to the 1:1 nearest neighbor matching method,and the surgical conditions of the two groups were compared Postoperative condition,biochemical index changes 2 weeks afer operation,and postoperative complications.Results(1)Among 272 patients included in this study,104 patients in ERCP group and 168 patients in PTCD group.There were significant differences between the two groups in etiology,obstruction location,combined diseases,serum K^(+)and alanine aminotransferase(P<0.05);After PSM treatment of the two groups of samples,the remaining 82 subjects in each group were successfully matched,and there was no significant statistical difference between the two groups(P>0.05).(2)There was no significant difference in the surgical success rate between the two groups(P>0.05).The operation time and intraoperative bleeding volume of ERCP group were lower than those of PTCD group(P<0.05);However,there was no significant difference in the operation time and intraoperative bleeding between the two groups after PSM matching(P>0.05).(3)There was no significant difference between the two groups in VAS score,total effective rate and hospitalization cost on the lst,3rd and 7th day after operation(P>0.05),but the postoperative hospitalization time in ERCP group was lower than that in PTCD group,and the difference was statistically significant(P<0.05);However,after PSM matching,the VAS score and postoperative hospital stay of ERCP group on the lst and 2nd day after operation were lower than those of PTCD group,and the difference was statistically significant(P<0.05).(4)There were significant differences in total bilirubin,serum K*,and alanine aminotransferase between the two groups 2 weeks after operation(P<0.05);After PSM matching,there was still significant statistical difference in serum K*and alanine aminotransferase between the two groups(P<0.05);However,there was no significant difference in total bilirubin between the two groups(P>0.05).(5)There was no significant difference in postoperative complications between the two groups(P>0.05);After PSM matching,there were significant differences between the two groups in the incidence of acute pancreatitis,puncture tract bleeding,and catheter drainage obstruction(P<0.05).Conclusion For patients with malignant obstructive jaundice,ERCP and PTCD are effective.After ERCP,patients'liver function recovers faster,the length of hospital stay is shorter,and there are fewer complications such as bleeding and catheter obstruction,but the probability of secondary acute pancreatitis is also greater.Both methods have their own advantages and disadvantages.