内镜下金属支架引流术治疗肝门部胆管癌和肝外恶性胆道梗阻临床观察

临床上恶性胆道梗阻性疾病预后较差。对于不能手术切除者，通常选择内镜下置人胆道支架以解除梗阻，然而该技术对进展期肝门部肿瘤的疗效报道不一。目的：探讨内镜下金属支架引流术对肝门部胆管癌和肝外恶性胆道梗阻的疗效和并发症发生情况。方法：纳入上海交通大学附属第一人民医院2006年6月～2009年6月收治的82例接受ERCP下置入自膨式金属胆道支架引流治疗的恶性胆道狭窄患者，根据病变部位分为肝门部胆管癌组和肝外恶性胆道梗阻组，对其ERCP参数和术后6个月随访记录进行回顾性分析，并分析随访期间急性胆管炎发生的危险因素。结果：两组支架置入成功率均为100％。与肝外恶性胆道梗阻组相比，肝门部胆管癌组术后1周总胆红素降低显效率较低，术后6个月内急性胆管炎发生率增高，初次发生时间提前，支架再狭窄率增高（P=0．000）。ERCP术中括约肌切开为随访期间发生急性胆管炎的危险因素（P=0．004，OR：8．196）。结论：内镜下金属支架引流术对肝门部胆管癌的疗效不及肝外恶性胆道梗阻，且更易早期发生急性胆管炎和支架再狭窄，术中括约肌切开可增加术后急性胆管炎的发生风险。

Clinical Observation of Endoscopic Biliary Metallic Stent Drainage in Management of Hilar Cholangiocarcinoma and Extrahepatic Malignant Biliary Obstruction

Background:The prognosis for malignant biliary obstructive diseases is poor.For unresectable lesions,endoscopic biliary stent drainage was usually applied to palliate obstruction.However,controversies exist regarding the therapeutic effect of this technique for advanced hilar cholangiocarcinoma.Aims:To assess the therapeutic effect and complications of endoscopic biliary metallic stent drainage in management of hilar cholangiocarcinoma and extrahepatic malignant biliary obstruction.Methods:A total of 82 patients with malignant biliary obstructive diseases were enrolled from Jun.2006 to Jun.2009 at Shanghai First People’s Hospital,Shanghai Jiaotong University.All patients received endoscopic biliary drainage by using self-expandable metallic stent,and were divided into hilar cholangiocarcinoma group and extrahepatic malignant biliary obstruction group.ERCP-related parameters and data of a 6-month follow-up were retrospectively reviewed,and the risk factors for acute cholangitis were analyzed.Results:Stents were placed successfully in both two groups.When compared with extrahepatic malignant biliary obstruction group,the efficacy of total bilirubin reduction was significantly lower one week after the procedure in hilar cholangiocarcinoma group,while the incidence of acute cholangitis increased,the first onset time of cholangitis shortened,and the rate of restenosis increased in 6-month follow-up(P= 0.000).Sphincterotomy in ERCP procedure was the risk factor for acute cholangitis(P = 0.004,OR:8.196). Conclusions:Endoscopic biliary metallic stent drainage for hilar cholangiocarcinoma is inferior to that for extrahepatic malignant biliary obstruction,and is prone to developing early acute cholangitis and restenosis.Sphincterotomy may increase the risk of post-ERCP acute cholangitis.