金属支架姑息性治疗160例恶性梗阻性黄疸的临床观察

目的 探讨胆道金属支架(EMBS)植入术治疗恶性梗阻性黄疸的临床价值.方法 160例行EMBS植入术的恶性梗阻性黄疸患者为支架组,以30例同样失去手术机会但因经济条件所限经皮经肝穿刺胆道引流(PTCD)外引流治疗者为PTCD组.回顾性研究其支架通畅率、胆红素下降情况及并发症的发生情况.随访间期为3个月,Kaplan-Meier(1og-rank test)生存期分析比较支架组与PTCD组术后生存期差异.结果 2组患者厌食、皮肤瘙痒、尿色深染等症状较前均有不同程度改善;支架组总胆红素水平和直接胆红素水平治疗前[(218.78±2.29)、(128.82±2.40)μmoL/L]、治疗后7 d[(134.90±2.34)、(81.28 ±2.34)μmoL/L]、14 d[(83.18±2.40)、(51.29±2.45)μmol/L]、21 d[(40.74±2.29)、(25.70±2.40)μmol/L]比较均有不同程度的下降(P均=0.000),PTCD组总胆红素水平和直接胆红素水平治疗前[(223.57±2.58)、(127.60±2.59)μmoL/L]、治疗后7 d[(145.68±2.57)、(79.78±2.70)μmoL/L]、14 d[(87.57 ±2.58)、(58.36±2.46)μmol/L]、21d[(38.65±2.20)μmol/L,(29.46±2.20)μmoL/L]比较均有不同程度的下降(P均=0.000);但2组同期胆红素值的比较差异均无统计学意义(P均>0.05).支架组34例术后发生并发症,发生率为20.62%,有9例发生两种或两种以上并发症.PTCD组18例患者出现并发症,发生率为60.00%.支架组失访14例,136例患者死亡,支架组中位生存时间214 d;PTCD组无失访,30例患者均死亡,中位生存时间为75.5 d,生存期分析表明支架组生存时间较PTCD组长(P=0.000).结论 EMBS植入术治疗恶性梗阻性黄疸效果显著,相比PTCD外引流,支架内引流并发症少、恢复快,提高患者生存质量、延长生存期,是恶性梗阻性黄疸的一种理想的姑息性治疗方法.

Clinical observation of metallic intra-biliary stents for palliative management of 160 malignant obstructive jaundice patients

Objective To study clinical value of percutaneous intrabiliary expandable metallic biliary stenting (EMBS) for treatment of malignant obstructive jaundice. Methods One hundred and sixty patients with malignant obstructive jaundice were treated with EMBS ( EMBS group) . Thirty patients underwent only external drainage by PTCD were recruited as control. The patency rate of stent,decline of bilirubin and the complication were analyzed retrospectively. Both groups were followed up for three months. The Kaplan-Meier method (log-rank test) was used to compare the survival period between the two groups. Results Anorexia,skin pruritus and color of urine alleviated at a certain degree in both groups.In the EMBS group,plasma total bilirubin was(218. 78 ±2. 29) μmol/L pre-stent,and decreased to (134. 90 ±2. 34), (83. 18 ±2.40) , (40. 74 ±2. 29) μmol/L at the 7,14,21 days after the stenting, respectively; direct bilirubin was (128.82 ±2.40) μmol/L pre-stent, and decreased to (81.28 ± 2. 34), (51. 29 ±2. 45) and (25. 70 ±2.40)μmol/L at the 7,14,21 days after the stenting ( P =0. 000). In the PTCD group,plasma total bilirubin was (223. 57 ± 2. 58) μmol/L pe-stent, and decreased to ( 145. 68 ± 2. 57 ) ,(87.57 ±2.58) ,(38.65 ±2. 20) μmol/L at the 7,14,21 days after the stenting,respectively;direct bilirubin was (127. 6 ±2. 59)μmol/L pre-stent,and decreased to (79. 78 ±2. 70) ,(58. 36 ±2. 46) and (29.46 ±2. 20)μmol/L at the 7,14,21 days after the stenting,respectively ( P <0.001 ). No significant difference was found between the two groups at any time point ( P > 0. 05). Complications occurred in 34 patients in the EMBS group and the incidence rate was 20. 62% . Two or more complications occurred in 9 patients. In the PTCD group, complications occurred in 60.00% of the patients. In the EMBS group, 14 patients were failed to follow up, and 136 died. The median length was 214 days. In the PTCD group,all patients were followed up and all died,with a median length of survival of 75. 5 days. The survival analysis showed that the EMBS group survived longer than the PTCD group (P =0. 000). Conclusions EMBS placement showed better effect than PTCD. Compared to PTCD, internal drainage of metallic stents lead few complications and faster recover, and can improve the life quality and prolong survival time of patient with malignant obstructive jaundice. The placement of metallic stents is recommended as a preference for palliative therapy of malignant biliary obstruction.