三种非手术胆管引流方法治疗肝门部恶性胆道梗阻的疗效评估

目的探讨不同非手术胆管引流方法治疗肝门部恶性胆道梗阻（MHBO）的疗效和并发症发生率。方法245例MHBO患者分为3组，其中内镜治疗组86例、经皮治疗组104例、内镜与经皮联合组（联合治疗组）55例。245例患者中，BismuthⅠ型31例、Ⅱ型24例、Ⅲ型108例、Ⅳ型74例。对各组患者的临床资料进行回顾性分析，并对其中具有可比性的数据进行统计学处理。结果内镜治疗组、经皮治疗组和联合治疗组减黄有效率分别为82．4％（56／68，除外18例近期并发胆管炎行PTBD者）、72．1％（75／104）和89．1％（49／55），其中Bismuth Ⅲ型患者减黄有效率分别为78．6％（22／28，除外7例近期并发胆管炎行PTBD者）、69．8％（30／43）和90．0％（27／30），且Ⅲ型患者中双侧引流减黄有效率89．5％（34／38）明显优于单侧引流73．0％（46／63）。内镜治疗组近期并发胆管炎19例，发生率为22．1％（19／86），明显高于经皮治疗组的5．8％（6／104）和联合治疗组的5．5％（3／55）（P均〈0．05）。Bismuth Ⅲ型及以上患者中，内镜、经皮及联合治疗组近期胆管炎发生率分别为33．3％（18／54）、6．6％（5／76）和5．8％（3／52），内镜治疗组明显高于其他两组（P〈0．05）。结论对于不能手术的MHBO，内镜和（或）经皮方法减黄治疗有效，但内镜治疗胆管炎发生率高；Bismuth Ⅲ型及以上患者内镜与经皮联合治疗胆管炎并发症发生率低，减黄效果好。

Three non-operative procedures for biliary drainage in malignant hilar biliary obstruction

Objective To evaulate the efficacy and complication of different non-operative procedures in malignant hilar biliary obstruction (MHBO). Methods The data of 245 patients with MHBO, including 31 cases of Bismuth type I , 24 of type II , 108 cases of type IE and 74 of type IV , were retrospectively analyzed. The patients were assigned into 3 groups according to therapy, including 86 patients in en-doscopy group, 104 in percutaneous biliary drainage (PTBD) group and 55 in combination group (endoscop-ic drainage plus PTBD). Results Jaundice resolution rates in endosccopy group, PTBD group and combination group were 82.4% (56/68, 18 patients underwent additional PTBD because of cholangitis in latter time), 72. 1% (75/104) and 89. 1% (49/55) , respectively. For patients of Bismuth type II, jaundice resolution rates were 78.6% (22/28, 7 patients underwent PTBD because of cholangitis in latter time) , 69.8% (30/43) and 90% (27/30), respectively. Moreover, jaundice resolution rate was significantly higher in bilateral drainage ( 89. 5% ) than that in unilateral drainage (73% ) ( P < 0. 05 ). Cholangitis was complicated in 19 cases from endoscopy group (22. 1% , 19/86) , which were significantly higher than that in PTBD group (5. 8% , 6/104) and combination group (5. 5% , 3/55) (P <0. 05). For patients of Bismuth type III and above, the occurrence rate of post-procedure cholangitis in endoscopy group (33. 3% , 18/54) was significantly higher than those of the other two groups (6. 6% , 5/76 and 5. 8% , 3/52) (P < 0.05). Conclusion For patients with unresectable MHBO, endoscopic and/or percutaneous biliary drainage are both effective for jaundice resolution, but cholangitis is complicated more often after endoscopic intervention. For those with type ID and above, combination of endoscopic and percutaneous biliary drainage can relieve jaundice with lower incidence of post-procedure cholangitis.