胆总管梗阻患者不同支架治疗的疗效观察

经十二指肠镜放置胆管内支架是目前治疗梗阻性黄疸的有效办法,可使患者解除黄疸,改善症状,延长生命.金属支架通畅期高于塑料支架[1],但价格较昂贵,塑料单支架通畅期短,引黄效果欠佳,为弥补上述两者的不足,我院于2006年1月以来对胆总管梗阻者采取胆总管塑料双支架引流,与近5年来放置胆总管金属支架及塑料单支架患者资料进行比较,总结如下.     

恶性梗阻性黄疸内镜下逆行胰胆管造影引流术后疗效观察

目的探讨恶性梗阻性黄疸经内镜下逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)引流术后的疗效。方法 60例恶性肿瘤引起的梗阻性黄疸患者,通过ERCP术置入胆管支架,观察插管成功率、肝功能变化及并发症发生情况。结果 60例患者中57例插管成功,成功率为95.0%(57/60)。57例插管成功的患者中9例胆管内放置金属支架,2例行单纯鼻胆管引流,3例行塑料内支架+鼻胆管引流,其余43例行8.5~10F塑料内支架引流术。术后患者黄疸及皮肤瘙痒等表现减轻或消失。术后1周,患者丙氨酸转移酶(ALT)、天冬氨酸转移酶(AST)、血清总胆红素(TBIL)、直接胆红素(DBIL)、碱性磷酸酶(ALP)、r-谷氨酰基转移酶(GGT)均显著降低(P0.05)。9例行胆管金属支架置入的患者中,1例于术后5个月发生支架阻塞,行胆泥清理并置入塑料支架后金属支架引流通畅。1例单纯鼻胆管引流患者20 d后获得外科手术治疗机会,另1例经鼻胆管引流1个月后肝功能恢复正常,得以行外科根治性手术治疗,43例行胆管塑料支架置入的患者中,8例于术后1~4周出现TBIL水平再次上升,行ERCP检查明确为支架移位或阻塞,给予更换支架,其中有1例更换为金属支架,3例置入塑料双支架。结论通过ERCP术放置胆管引流治疗恶性梗阻性黄疸,对于患者黄疸等症状的改善及生存质量的提高具有确切疗效。     

塑料内支架治疗恶性胆管梗阻的经济效益分析

经十二指肠镜放置内支架是公认的治疗恶性梗阻性黄疸的有效办法,它能在患者存活期内有效地缓解黄疸、全面改善症状和营养状况。虽然已证实金属支架与塑料支架在减黄效果上并无差异[1,2],但由于国内外对2种支架的经济-效益关系分析角度不同,因而对如何选择2种支架仍有争     

经内镜胆道支架置入治疗35例恶性梗阻性黄疸疗效分析

目的探讨经十二指肠镜逆行胰胆管造影（ER-CP）置入胆道内支架治疗恶性梗阻性黄疸的临床疗效。方法 35例恶性梗阻性黄疸的患者,均行ERCP（经内镜逆行胰胆管造影）术,根据情况置入不同规格支架,观察治疗效果和3个月、6个月生存率。结果 32例患者插管成功,插管成功率为91.43%,其中10例置入金属支架,22例置入塑料支架。术后并发急性胰腺炎2例（6.25%）,经治疗后痊愈。成功置入支架的32例患者术后黄疸逐渐消退,皮肤瘙痒等症状明显缓解或消失,血清总胆红素从（230.85±83.81）μmol/L下降到术后1周（121.88±52.27）μmol/L（P〈0.01）,支架组随访26例中总体3个月、6个月存活分别达到92.30%及76.92%。结论经十二指肠镜逆行胰胆管造影（ERCP）置入胆道内支架治疗恶性胆道梗阻疗效确切,对于解除恶性梗阻性黄疽、缓解症状、提高患者生存质量、延长生命具有较满意效果。     

恶性梗阻性黄疸的治疗策略新进展

大多数胰腺癌及壶腹周围癌可以表现出恶性梗阻性黄疸,治疗主要包括缓解症状,改善并发症发病率及死亡率.首选的治疗方案是内镜下胆道支架置入.最近,使用塑料支架和自费的金属支架的研究数据表明金属支架的开放时间更长,是否需要治疗梗阻性黄疸及使用何种方法治疗主要根据临床情况而定.对于肿瘤可切除的患者,术前胆道引流仅仅适用于手术会被推迟和存在黄疸并发症的患者;对于局部浸润化疗后可手术切除的患者,使用自费的金属支架更优于塑料支架;对于不可手术的侵袭性的患者,支架的使用类型根据患者的生存预期而定.当内镜放置支架失败时,超声引导下的胆道引流,经皮肝穿胆道引流或行旁路手术都是合适的治疗方案.     

全覆膜金属支架与塑料支架在不可切除的远端胆道 恶性梗阻中的应用对比研究

目的探讨经内镜逆行胆胰管造影术（endoscopic retrograde cholangiopancreatography,ERCP）下胆道全覆膜金属支架及塑料支架置入治疗远端胆道恶性梗阻性黄疸的有效性及安全性。方法回顾性分析并总结2012年11月—2018年12月收治的52例接受ERCP下全覆膜金属支架（WallFlex）置入和40例胆道塑料支架置入治疗不可切除的恶性梗阻性黄疸患者的操作成功率、临床成功率、通畅时间、堵塞率、再干预次数、总费用等临床资料。结果ERCP 操作成功率两组均为100.0%（92/92）,金属支架组和塑料支架组临床成功率分别为94.2%（49/52）和75.0%（30/40）（χ2 =6.89,P<0.01）。两组生存时间比较,差异无统计学意义（6.5个月比7.2个月, χ2=0.25,P>0.05）。金属支架组中位通畅时间较塑料支架组明显延长（182.0 d 比 84.0 d,P<0.01）。两组胰腺炎（χ2 =0.2,P>0.05）及胆管炎发生率(χ2 =0.2,P>0.05）比较差异无统计学意义。金属支架组发生堵塞的概率要明显少于塑料支架组 [7.8%（4/51）比 25.0%（10/40）, χ2 =5.25,P<0.05],在再次干预次数方面,金属支架组要明显少于塑料支架组（0.06 次比 0.38次,t=2.91,P<0.01）。塑料支架组和金属支架组在总费用上比较差异无统计学意义（42 956.1元比 44 851.5元,t=1.84,P=0.07）。结论ERCP下全覆膜金属支架置入对于不可切除的远端胆道恶性梗阻患者是一种安全、有效、经济的治疗方法,在通畅时间及再次干预次数等方面要明显优于塑料支架。     

ERCP放置胆管内支架姑息治疗难以切除的恶性胆管梗阻

目的探讨ERCP放置胆管内支架对难以切除的恶性胆管梗阻的临床治疗效果。方法对54例恶性肿瘤引起的梗阻性黄疸患者,经ERCP将导丝插入胆管并超过梗阻部位,扩张狭窄处,用推送导管将已经选择合适的引流支架置于胆管适当部位,其两端均超过梗阻段2cm以上。结果54例患者中51例插管成功,3例插管不成功的患者中1例乳头开口于憩室内,另2例肿瘤完全阻塞导丝无法通过。成功率为94.44%(51/54)。34例胆管内放置8FZ型自膨胀式金属支架,其余20例行8～10F塑料内支架引流。术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻。其中39例2周内血清总胆红素下降50%以上,血清总胆红素退至34μmol/L以下。放置胆管内支架1周后,患者血清总胆红素由术前235.45±56.67μmol/L降至78.36±37.58μmol/L,肝功能较术前显著改善(P<0.05,P<0.01)。31例胆总管下段梗阻患者与12例肝门部胆管梗阻患者相比,放置胆管内支架引流治疗1周、2周后,其胆红素下降明显优于肝门部胆管梗阻患者(P<0.01)。34例放置胆管金属支架患者中,有12例于术后2个月发生支架阻塞,再次放置塑料内支架后引流通畅,1例放置金属支架术后患者第10个月出现支架阻塞予以再次植入金属支架。另外20例放置塑料内支架者,有3例于术后1～4周出现血清总胆红素再次上升,经ERCP检查发现支架移位和阻塞,予以更换内支架,其中1例植入塑料双支架。结论经ERCP内镜下胆管放置内支架,对解除恶性胆管梗阻性黄疸、缓解症状、提高患者生存质量具有满意疗效,对胆总管下段梗阻性黄疸的疗效优于肝门部胆管梗阻。     

胆管支架置入联合放疗治疗恶性梗阻性黄疸的疗效

目的探讨胆管支架置入联合放疗治疗恶性梗阻性黄疸(阻黄)的临床效果。方法回顾2009年8月至2010年12月我院收治的已失去手术机会并成功接受PTCD治疗的恶性阻黄患者45例,单纯放置胆管支架25例(对照组),联合放疗20例(观察组)。观察两组黄疸改善、复发、生存及并发症情况。结果两组治疗1 w和2 w时TB和DB水平均较治疗前显著下降(P<0.05),两组比较差异无统计学意义(P>0.05);观察组支架堵塞时间、复发时间及生存时间均明显晚于对照组,差异有统计学意义(P<0.05);观察组未发生并发症,对照组出现3例。结论相比单纯胆管支架置入,胆管支架置入联合放疗治疗恶性阻黄能有效延缓支架堵塞时间和黄疸复发时间,减少并发症,延长生存时间,值得临床推广应用。     

内镜下胆道支架治疗恶性胆道梗阻85例

目的探讨内镜下胆道支架对恶性梗阻性黄疸的治疗效果和临床应用价值。方法选择85例无法手术根治性切除的恶性胆道梗阻患者,内镜下放置胆道支架。结果85例胆管恶性梗阻患者中,行经内镜逆行胰胆管造影（ERCP）操作115例次,胆道支架放置成功109例次,操作成功率为94．78％,消除黄疸总有效率为95．41％,并发症发生率为8．26％,平均存活期约为7．4个月。结论胆道支架置入术治疗恶性梗阻性黄疸疗效确切,具有创伤小、并发症少、符合生理等特点,对无法手术根治性切除的恶性胆道梗阻患者,镜下放置胆道支架是最佳的首选治疗方法。     

经内镜胆道金属支架引流术治疗恶性胆道梗阻76例

恶性肿瘤引起的梗阻性黄疸,多需外科手术治疗,但部分患者就诊时已不能作根治性切除术.经内镜胆道金属支架引流术(endoscopic metal biliary endoprothesis,EMBE)是在经内镜塑料内支架引流术(ERBD)技术基础上为扩大支架口径、提高引流效果、延长通畅期而开发应用的.我院对76例无法行手术根治性切除的恶性胆道梗阻性黄疸患者行EMBE治疗,取得了较好疗效,报道如下.     

Palliative endoscopic treatment of malignant duodenal stenosis by metal prosthesis

PURPOSE: To evaluate the efficacy of through-the-scope metal stents for palliation of malignant duodenal stenosis. MATERIAL AND METHODS: Fourty two patients with malignant primary or secondary duodenal stenoses who were treated with a through-the-scope metal stent were analysed. When obstructive jaundice occurred either before, during, or after the initial episode of gastrointestinal luminal obstruction, a biliary stent was inserted. RESULTS: Duodenal metal stents were deployed in 40 patients. Endoprosthesis insertion led to restoration of oral intake in 39 patients. The procedure was not associated with morbidity or mortality. During a mean follow-up of 9.7 weeks, adequate oral intake was maintained in 38/39 cases. Tumour in-growth led to stent occlusion in 4 cases and re-cannulation was obtained by placement of another stent within the original stent. Obstructive jaundice occurred during the course of the illness in 32 patients and was successfully treated with a biliary metal stent in all cases. CONCLUSIONS: Endoscopically placed metal stents offer an effective, well-tolerated alternative to surgical palliation in case of incurable malignant obstruction to gastric outflow.     

Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study

BACKGROUND: The systematic use of metal stents to treat biliary obstruction is restricted by high cost compared with plastic stents. The aims of this study were to compare cost and efficacy of plastic stents and metal stents in the treatment of patients with malignant common bile duct strictures and to define factors that predict survival of these patients. METHODS: One hundred eighteen patients (mean age 75 years) with malignant strictures of the common bile duct were randomized to placement of a plastic stent or metal stent. Comparisons were made with the Mann-Whitney or chi-square test as indicated; survival rates were compared with a Cox proportional hazards model. RESULTS: There was no significant difference in survival between the two groups. Time to first obstruction was longer for patients in the metal stent group (metal stent, median not reached vs. plastic stent, 5 months; p = 0.007). The number of additional days of hospitalization, days of antibiotic therapy, and the numbers of ERCPs and transabdominal US procedures was significantly higher in the plastic stent group. After multivariate analysis, only the presence of liver metastases was independently related to survival (p < 0.0005; OR = 2.25). This variable defined a group with a shorter survival. Median survival of patients with hepatic metastasis at diagnosis was 2.7 months compared with 5.3 months for patients without liver metastasis; in the latter group, the overall cost associated with metal stents was lower than for plastic stents. CONCLUSIONS: Metal stent placement is the most effective treatment of inoperable malignant common bile duct stricture. Placement of a metal stent is cost effective in patients without hepatic metastases, whereas a plastic stent should be placed in patients with spread of the tumor to the liver.     

Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis.

BACKGROUND & AIMS: Endoscopic placement of plastic or self-expandable metal biliary stents (SEMS) relieves obstructive jaundice from pancreatic cancer. Short-length, distally placed SEMS do not preclude subsequent pancreaticoduodenectomy. We sought to determine whether SEMS placement in patients whose surgical status is uncertain is cost-effective for management of obstructive jaundice. METHODS: A Markov model was constructed to evaluate costs and outcomes associated with endoscopic biliary stenting for obstructive jaundice. Strategies evaluated were: (1) initial plastic stent with plastic stents for subsequent occlusions in nonsurgical candidates after staging (plastic followed-up by [f/u] plastic), (2) initial plastic with subsequent SEMS (plastic f/u metal), (3) initial short-length SEMS with subsequent plastic (metal f/u plastic), and (4) initial short-length SEMS with subsequent expandable metal stent (metal f/u metal). Published stent occlusion rates, ERCP complication rates and outcomes, cholangitis rates and outcomes, pancreatic cancer mortality rates, and Whipple complication rates were used. Costs were based on 2004 Medicare standard allowable charges and were accrued until all patients reached an absorbing health state (death or pancreaticoduodenectomy) or 24 cycles (24 mo) ended. RESULTS: Average costs per patient from Monte Carlo simulation were: (1) metal f/u metal, $19,935; (2) plastic f/u metal, 20,157 dollars; (3) metal f/u plastic, 20,871 dollars; and (4) plastic f/u plastic, 20,878 dollars. For initial plastic stents to be preferred over short-length metal stents, 70% or more of pancreatic cancers would need to be potentially resectable by pancreaticoduodenectomy. CONCLUSIONS: In patients undergoing ERCP before definitive cancer staging, short-length SEMS is the preferred initial cost-minimizing strategy.     

Endobiliary stents for palliation in patients with malignant obstructive jaundice

BACKGROUND: Endobiliary drainage for malignant obstructive jaundice presents a viable palliative alternative. Its role and efficacy depend on factors related to the stent, procedure, and patient. GOALS: To review the evidence in the literature in which settings plastic or metal stents are cost-effective, and whether adjuvant measures or patient-related factors affect duration of stent patency. STUDY: Using databases a literature search was performed for papers published from 1979 to April 2004. All retrieved papers reporting experimental or clinical observations were rated according to strength of evidence, and carefully analyzed. RESULTS AND CONCLUSIONS: Metal stents (Wallstent) stay patent longer than plastic stents (large-bore polyethylene with side-holes), overall median 250 and 110 days, respectively, and seem cost-effective in patients with longer than about 6 months survival, which cannot be accurately predicted. Antibiotics or choleretic agents do not prolong stent patency in clinical settings. In case of stent occlusion, indicated stent exchanges and insertion of a plastic stent, respectively, seem cost-effective in patients initially treated with plastic and metal stents.     

Metal stents: a bridge to surgery in hilar cholangiocarcinoma

BackgroundObstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self‐expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma.MethodsA retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded.ResultsOf 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively.ConclusionsSelf‐expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re‐interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.     

肝门区转移癌所致梗阻性黄疸的内镜支架引流治疗临床效果分析

目的探讨内镜治疗肝门区转移癌所致梗阻性黄疸的临床应用价值。方法2006年开始随机选择自愿应用内镜治疗的晚期肝门区转移癌所致梗阻性黄疸患者,应用内镜胆道塑料内支架技术解除胆道梗阻,观察操作成功率、生存期等评价指标。共治疗肝门转移癌梗阻性黄疸患者38例,其中肝癌13例,胆囊癌3例,胃癌14例,食管癌2例,回肠腺癌1例,胰腺癌5例。结果所有患者治疗成功且临床黄疸完全消退,随访生存期92～521d,平均（185．42±104．41）d。随访观察5例患者更换胆道支架,更换时间3～14个月,平均（8．6±4．1）个月,其中支架移位1例,胆泥阻塞2例,肿瘤阻塞2例。结论内镜支架引流术是肝门区转移癌所致梗阻性黄疸的一种有效治疗方法,具有较高的治疗成功率,可以一定程度延长患者的生存期。     

Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma: a cost-effectiveness analysis

OBJECTIVES: Obstructive jaundice frequently complicates pancreatic carcinoma and is associated with complications such as malabsorption, coagulopathy, progressive hepatocellular dysfunction, and cholangitis in addition to disabling pruritus, which greatly interferes with terminal patients' quality of life. Endoscopic placement of biliary stents decreases the risk of these complications and is considered the procedure of choice for palliation for patients with unresectable tumors. We used decision analysis with Markov modeling to compare the cost-effectivenesses of plastic stents and metal stents in patients with unresectable pancreatic carcinoma. METHODS: A model of the natural history of unresectable pancreatic carcinoma was constructed using probabilities derived from the literature. Cost estimates were obtained from Medicare reimbursement rates and supplemented by the literature. Two strategies were evaluated: 1) initial endoscopic plastic stent placement and 2) initial endoscopic metal stent placement. We compared total costs and performed cost-effectiveness analysis in these strategies. The outcome measures were quality-adjusted life months. Sensitivity analyses were performed on selected variables. RESULTS: Our baseline analysis showed that initial plastic stent placement was associated with a total cost of $13,879/patient and 1.799 quality-adjusted life months. Initial placement of a metal stent cost $13,466/patient and conferred 1.832 quality-adjusted life months. Among the variables examined, expected patient survival was demonstrated by sensitivity analyses to have the most influence on the results of the model. CONCLUSION: Initial endoscopic placement of a metal stent is a cost-saving strategy compared to initial plastic stent placement, particularly in patients expected to survive longer than 6 months.     

Managing malignant biliary obstruction in pancreas cancer: Choosing the appropriate strategy

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) has shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depends on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, percutaneous or surgical treatments are appropriate. Endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction.     

Mortality in patients undergoing covered self-expandable metal stent revisions in malignant biliary stricture: Does pathology matter?

Background and Aims

Partially covered metal stents have been extensively used for palliation of obstructive jaundice in malignant distal biliary strictures and can be removed in cases of malfunction or need for tissue diagnosis. We investigated independent predictors of mortality in patients undergoing partially covered metal stents revision (i.e., removal and replacement).

Methods

Patients with a distal malignant biliary obstruction palliated with a partially covered metal stent were followed-up prospectively over 5 years until malfunction or death. All patients who required removal of their partially covered metal stents were captured in a specific database. Multivariate analysis was performed on non-surgical patients to assess for independent predictors of death using known risk factors including type of malignancy (adenocarcinoma versus all others), age greater than 55, gender, and exposure to adjuvant chemotherapy and/or radiotherapy.

Results

Forty-two patients (28 men, mean age of 62 ± 12 years) underwent partially covered metal stents removal. Of these, biliary drainage was achieved in 38 patients by placement of a new partially covered metal stent (n = 32) or plastic stent (n = 6). The remaining 4 patients did not undergo stent replacement because of refusal (2), resolution of obstruction (1) and unrelated death (1). Long-term follow-up post removal in patients who were not surgical candidates (n = 31) was 35 weeks (95% CI 28–40), with a survival rate of 29% at 10 months. Logistic regression analysis in the 31 patients with unresectable disease showed that a histologic diagnosis of adenocarcinoma was associated with increased mortality post partially covered metal stents revision.

Conclusions

Partially covered metal stents revision should be undertaken especially when dealing with a non-adenocarcinoma type cancer.     

Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas

Together with biliary drainage, which is an appropriate procedure for unresectable biliary cancer, biliary stent placement is used to improve symptoms associated with jaundice. Owing to investigations comparing percutaneous transhepatic biliary drainage (PTBD), surgical drainage, and endoscopic drainage, many types of stents are now available that can be placed endoscopically. The stents used are classified roughly as plastic stents and metal stents. Compared with plastic stents, metal stents are of large diameter, and have long-term patency (although they are expensive). For this reason, the use of metal stents is preferred for patients who are expected to survive for more than 6 months, whereas for patients who are likely to survive for less than 6 months, the use of plastic stents is not considered to be improper. Obstruction in a metal stent is caused by a tumor that grows within the stent through the mesh interstices. To overcome such problems, a covered metal stent was developed, and these stents are now used in patients with malignant distal biliary obstruction. However, this type of stent has been reported to have several shortcomings, such as being associated with the development of acute cholecystitis and stent migration. In spite of these shortcomings, evidence is expected to demonstrate its superiority over other types of stent.