胆管内外引流治疗内镜难治性恶性胆道梗阻的对比研究

Treatment of refractory malignant biliary obstraction:comparing results of percutaneous transhepatic biliary drainage with external catheters or endoscopic metallic stenting

目的 比较经皮经肝穿刺胆管金属支架内引流术与导管外引流术治疗内镜难治性恶性胆道梗阻的疗效及并发症。方法 回顾性分析 1999年 9月至 2 0 0 2年 8月上海长海医院对内镜难治性恶性胆道梗阻患者施行经皮经肝穿刺胆管引流术的资料 ,比较两种引流术前后和引流术间肝功能的差异及并发症。共 2 7例患者 (2 9例次 )入选。其中 ,内引流组 13例 (13例次 ) ,男 9例 ,女 4例 ,平均年龄 6 2 5岁 ;外引流组 15例 (16例次 ) ,男 9例 ,女 6例 ,平均年龄 6 0 8岁。结果 术前 2～ 4d及术后5～ 7d血清总胆红素 (TB)在内引流组分别为 (2 79 19± 10 8 15 ) μmol/L和 (15 8 0 2± 99 97) μmol/L ,外引流组为 (2 6 1 0 9± 10 6 4 8) μmol/L和 (172 81± 10 6 4 8) μmol/L。血清直接胆红素 (DB)内引流组为(2 2 6 83± 84 0 3) μmol/L和 (132 5 7± 80 16 ) μmol/L ,外引流组为 (2 0 8 0 3± 95 0 3) μmol/L和 (14 2 6 1±83 74 ) μmol/L。术前两组间TB和DB差异无显著性 (P >0 0 5 ) ;术后两组TB和DB均较术前显著降低 (P <0 0 1) ;术后TB和DB降低幅值在内引流组显著高于外引流组 (P <0 0 5 )。内引流组 1例出现胆漏和肠梗阻 ,1例出血 ;外引流组 2例导管移位和脱落 ,1例导管堵塞 ,1例出血 。

Objective To compare the initial results and adverse events of percutaneous transhepatic biliary drainage with external catheters or metallic stents for refractory malignant biliary obstruction. Methods To review the data of those patients with refractory malignant biliary obstruction treated with external catheters or metallic stents in Changhai hospital from Sept.1999 to Aug.2002. Liver function tests were determined 2 to 4 days prior to and 5 to 7 days after the procedures and adverse events were recorded. A total of 13 metallic stents were implanted in 13 patients (9 men,4 women, mean age, 62.5 years) and 16 external catheters were implanted in 15 patients (9 men, 6 women, mean age, 60.8 years). Results The mean serum total bilirubin concentration prior to and after the procedures were (279.19±108.15) μmol/L and (158.02±99.97) μmol/L in the metallic stents group,(261.09±106.48) μmol/L and (172.81±106.48) μmol/L in the external catheters group. The mean serum direct bilirubin concentration were (226.83±84.03) μmol/L and (132.57±80.16) μmol/L,(208.03±95.03) μmol/L and (142.61±83.74) μmol/L in the two groups. There is no significant difference of the mean serum total and direct bilirubin concentrations between the two groups prior to the procedures ( P >0.05), but either the mean serum total or direct bilirubin concentration after the procedures in the two groups was significantly lower than that prior to the procedures ( P <0.01). The percentage of changes was significantly greater in the metallic stents group than that in the external catheters group ( P <0.01). Two patients with 3 complications occurred in the metallic stents group, including bile leakage and bleeding (1) and duodenal obstruction (1). Five complications occurred in the external catheters group, including catheter migration (2), catheter occlusion (1), bile leakage (1)and bleeding (1). Conclusions Percutaneous transhepatic biliary drainage is a reliable and safe therapy for refractory malignant biliary obstruction. The initial results suggest that the potential patency of percutaneous transhepatic biliary drainage with self-expandable metal stent is more rapid and effective than that with external catheters.