恶性梗阻性黄疸患者经皮肝穿胆道引流术后胆道感染危险因素的探讨

目的 研究恶性梗阻性黄疸患者经皮肝穿胆道引流术(PTBD)后与胆道感染相关的独立危险因素.方法 因恶性梗阻性黄疸第1次行PTBD引流术,术前白细胞计数不高、无发热、不存在术前胆道感染的连续患者154例纳入研究.根据术后30 d内胆道感染发生的情况将患者分为胆道感染组和非感染组,应用单因素和多因素分析对术前20个潜在的与PTBD术后胆道感染相关的危险因素,如年龄、性别、糖尿病、肝功能分级、引流方式、是否存在未引流胆管、经内镜逆行胰胆管造影术(ERCP)或胆肠吻合手术史等进行分析.20个潜在的危险因素先行单因素分析,连续变量的比较应用Student t检验,分类变量应用x2检验；将单因素分析筛选出的可能危险因素再进行多因素Logistic分析.结果 154例患者中55例发生术后胆道感染(35.7％),即胆道感染组；99例术后未发生胆道感染,即非胆道感染组.胆道感染相关的病死率为2.6％ (4/154).154例患者中131例行术中胆汁细菌培养,胆道感染组45例,26例为阳性；非感染组86例,17例为阳性,两组差异有统计学意义(x2=19.357,P＜0.01).单因素分析显示20个潜在危险因素中,糖尿病(x2=10.470,P＜0.01)、肝功能分级(x2=36.324,P＜0.01)、存在未能引流胆管(x2=9.540,P＜0.01)、内外引流(x2=9.856,P＜0.01)、ERCP或胆肠吻合史(x2=14.196,P＜0.01)、肿瘤患者的生活质量评分(t=-3.288,P＜0.01)、Karnofsky功能状态评分(t=-2.099,P＜0.05)、丙氨酸转氨酶(t=-2.112,P＜0.05)、凝血时间(t=-3.648,P＜0.01)、血白蛋白含量(t=-2.071,P＜0.05)、白细胞计数(t=2.022,P＜0.05)、高位胆道梗阻(x2 =6.190,P＜0.05)、肝硬化病史(x2=5.439,P＜0.05)13个因素为具有统计学意义的危险因素；对这13个因素继续行多因素分析显示糖尿病(OR=5.093,P＜0.01)、肝功能分级(OR=13.412,P＜0.01)、存在未能引流胆管(OR=3.348,P＜0.05)、内外引流(OR=3.168,P＜0.05)、ERCP或胆肠吻合病史(OR=8.330,P＜0.01)为具有统计学意义的危险因素.其中糖尿病、肝功能分级、ERCP或胆肠吻合手术史为3个相关的患者因素,内外引流和存在未能引流胆管为2个与手术相关的因素.结论 PTBD是一种有效且安全的恶性梗阻性黄疸患者的姑息治疗方法.术前采取更积极的措施,如控制血糖、改善肝功能、改变引流方式、充分引流等,能够降低PTBD术后胆道感染的发生率.

Risk factors for percutaneous transhepatic biliary drainage-related cholangitis in patients with malignant obstructive jaundice: a prospective study

Objective To investigate the risk factors for percutaneous transhepatic biliary drainage (PTBD) related cholangitis in patients with malignant obstructive jaundice.Methods One hundred and fifty-four consecutive patients with malignant obstructive jaundice and without leukocytosis,fever and other manifestations of biliary tract infection received initial PTBD drainage.They were enrolled in this study.An uncontrolled prospective study was conducted of cholangitis occurrence within 30 days after PTBD.Twenty potential preoperative risk factors were assessed by univariate and multivariate analysis.Results Fifty-five patients (55/154,35.7％ ) developed PTBD-related cholangitis,which composed of cholangitis group.Other patients composed of non-cholangitis group (99/154).The cholangitis-related mortality rate was 2.6％ (4/154).Intraoperative bile culture were performed for 131 patients (131/154),including 45 in cholangitis group and 86 in non-cholangitis group.Positive result occurred in 26 patients (26/45) in cholangitis group and 17 patients (17/86) in non-cholangitis group.There was statistical significant difference between these two groups ( x2 =19.357,P ＜ 0.01 ).By univariate analysis,diabetes ( x2 =10.470,P ＜ 0.01 ),Child-Pugh C grade ( x2 =36.324,P ＜ 0.01 ),undrained biliary duct ( x2 =9.540,P ＜0.01 ),external-internal drainage ( x2 =9.856,P ＜ 0.01 ),history of ERCP or cholangiojejunostomy (x2 =14.196,P＜0.01),QOL (t =-3.288,P ＜0.01),KPS(t =-2.099,P＜0.05),ALT (t =-2.112,P＜0.05),PT (t =-3.648,P ＜0.01),albumin (t =-2.071,P ＜0.05),WBC (t =2.022,P ＜ 0.05 ),proximal obstruction ( x2 =6.190,P ＜ 0.05 ) and cirrhosis ( x2 =5.439,P ＜ 0.05 )were significantly different between cholangitis group and non-cholangitis group.By multivariate analysis,diabetes ( OR =5.093,P ＜0.01 ),Child-Pugh C grade ( OR =13.412,P ＜0.01 ),undrained biliary duct ( OR =3.348,P ＜ 0.05 ),external-internal drainage ( OR =3.168,P ＜ 0.05 ) and history of ERCP or cholangiojejunostomy (OR =8.330,P ＜ 0.01 ) remained significant difference.Conclusions PTBD is an effective and safe palliative treatment for patients with malignant obstructive jaundice.Sufficient preoperative preparation and effective control of risk factors may reduce the incidence of cholangitis after PTCD.