经ERCP途径与PTCD途径治疗恶性梗阻性黄疸疗效比较的系统评价

Comparison of clinical effect between ERCP and PTCD in treatment of malignant obstructive jaundice: a systematic review

目的系统评价经内镜逆行胰胆管造影术(ERCP)与经皮肝穿刺胆道引流术(PTCD)治疗恶性梗阻性黄疸(MOJ)的临床疗效。方法通过计算机检索数据库PubMed、EMBASE、The Cochrane Library、CNKI、万方数据库和CBM,搜索国内外公开发表的有关经ERCP途径或PTCD途径治疗MOJ的随机对照试验(RCT)和临床对照研究(CCT),检索时限从建库起到2018年5月。由两名评价员按纳入排除标准独立筛选文献、提取资料并评价纳入文献的偏倚风险后,使用Stata 12.0软件进行Meta分析。结果共纳入9个研究,其中2个RCT,7个CCT,共计994例患者。Meta分析结果显示:①手术成功率:ERCP组治疗低位MOJ手术成功率高于PTCD组(OR^=2.52,95%CI:1.26～5.04,P=0.009),而治疗高位MOJ手术成功率低于PTCD组(OR^=0.17,95%CI:0.07～0.41,P=0.000),两组总手术成功率差异无统计学意义(OR^=0.88,95%CI:0.52～1.49,P=0.631);②临床疗效:ERCP组治疗低位MOJ临床疗效高于PTCD组(O^R=5.80,95%CI:3.06～11.00,P=0.000),而治疗高位MOJ临床疗效低于PTCD组(OR^=0.13,95%CI:0.07～0.24,P=0.000),两组临床总疗效差异无统计学意义(O^R=1.10,95%CI:0.75～1.62,P=0.609);③并发症发生率:ERCP组治疗低位MOJ并发症发生率低于PTCD组(OR^=0.14,95%CI:0.06～0.32,P=0.000),而两组在高位MOJ并发症发生率(O^R=1.35,95%CI:0.66～2.78,P=0.414)和总并发症发生率(OR^=0.78,95%CI:0.39～1.57,P=0.489)上,差异无统计学意义。结论经ERCP途径和经PTCD途径治疗MOJ均可取得显著的临床疗效,对于低位梗阻患者ERCP途径更有优势,对于高位梗阻患者而言,PTCD途径更有优势。

Objective To systematically evaluate the clinical effectiveness of ERCP and PTCD in treatment of malignant obstructive jaundice. Methods We searched databases including Pubmed, EMbase, the Cochrane libarary,CNKI, Wanfang databases and CBM from inception to May, 2018, both randomized controlled trials(RCTs) and controlled clinical trials(CCT) on comparing ERCP with PTCD in malignant obstructive jaundice were collected.Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data,and assessed the risk of bias of included studies. Stata 12.0 software was used to analyse the data. Results 9 eligible studies(2 RCTs and 7 CCTs) identified were finally included involving 994 persons. The results of meta-analysis showed that: The difference in the total successful rate of operation between the two groups was not statistically significant(OR^ = 0.88, 95%CI: 0.52 ~ 1.49, P = 0.631), which of the patients with low malignant obstructive jaundice in the ERCP group was significantly higher than that in the PTCD group(OR^ = 2.52, 95%CI: 1.26 ~ 5.04, P = 0.009),which of the patients with high malignant obstructive jaundice in the ERCP group was significantly lower than that in the PTCD group(OR^ = 0.17, 95%CI: 0.07 ~ 0.41, P = 0.000). The difference in the total effective rate between the two groups was not statistically significant(OR^ = 1.10, 95%CI: 0.75 ~ 1.62, P = 0.609), which of the patients with low malignant obstructive jaundice in the ERCP group was significantly higher than that in the PTCD group(OR^ = 5.80, 95%CI: 3.06 ~ 11.00, P = 0.000), which of the patients with high malignant obstructive jaundice in the ERCP group was significantly lower than that in the PTCD group(OR^ = 0.13, 95%CI: 0.07 ~ 0.24, P = 0.000). The incidence rate of complications of low obstruction in the ERCP group was obviously lower than that in the PTCD group(OR^ = 0.14, 95%CI: 0.06 ~ 0.32, P = 0.000), while there was no significant statistical difference between two groups both in the total incidence rate of complications(O^R = 0.78, 95%CI: 0.39 ~ 1.57, P = 0.489) and the incidence rate of complications of high obstruction(O^R = 1.35, 95%CI: 0.66 ~ 2.78, P = 0.414). Conclusion Satisfactory clinical effect for patients with malignant obstructive jaundice can be achieved from both ERCP and PTCD. The treatment of ERCP is more advantageous for patients with low obstruction, while PTCD is better than ERCP in patients with high obstruction.