胰头癌术前减黄指征的前瞻性研究

目的 探讨胰头癌伴梗阻性黄疸患者术前减黄的必要性及其利弊。方法 将血清总胆红素（TB）〉220μmol／L的183例患者随机分入减黄组及不减黄组;减黄组92例采取超声引导下经皮经肝胆管穿刺置管引流（UPTBD）及内镜鼻胆管引流（ENBD）,对减黄组置管后3周进行手术。不减黄组91例,仅在常规术前准备后于入院5d内进行手术。对2组患者手术及术后恢复情况进行比较。结果 减黄组减黄成功的89例患者在胆道引流后TB由平均279μmol／L下降为120μmol／L,成功完成胰十二指肠切除39例（43．8％）,行单纯内引流者47例（52．8％）,单纯探查3例（3．4％）,平均术中失血250ml,术后并发症8例次（9．0％）,1例死亡。不减黄组91例中完成胰十二指肠切除24例（26．4％）,单纯内引流者58例（63．7％）,9例单纯探查（9．9％）,术中平均失血480ml,术后并发症共19例次（20．9％）,4例死亡。不减黄组中发生并发症的患者的年龄及TB水平均显著高于未发生并发症的患者。减黄后TB下降速度每周大于30％患者的肿瘤切除率、并发症发生率及住院时间均优于下降速度小于30％的患者。结论 胰头癌伴重度黄疸者术前减黄确有其必要性,尤其对老年患者,不仅可减少术中出血,增加手术安全性,提高根治率,而且术前胆道引流后黄疸是否顺利下降,还可作为预测手术风险、手术效果以及患者预后的重要指标。

Perspective of pre-operational jaundice-reducing indication in carcinoma of head of pancreas

OBJECTIVE: To explore the necessity, advantages and disadvantages of reducing the Icterus Index before operation in carcinoma of the head of pancreas. METHODS: A total of 183 patients with serum total bilirubin (TB) level higher than 220 micromol/L were randomized into 2 groups: jaundice-reducing group (92 patients) and non-reducing group (91 patients). In jaundice-reducing group, all the patients were performed ultrasound-guided percutaneous transhepatic bile duct drainage (UPTBD) and endoscopic nasobiliary drainage (ENBD). The jaundice-reducing group was operated on 3 weeks after tube placement. In non-reducing group, all the patients underwent operations only after general pre-operation routine preparation within 5 days after admission. The operation and post-operation recovery in the two groups was investigated and compared. RESULTS: In jaundice-reducing group, the level of TB decreased to 120 micromol/L from 279 micromol/L in 89 patients after biliary drainage. Of the 89 patients, pancreatoduodenectomy was successfully performed in 39 (43.8%), 47 (52.8%) underwent simple internal drainage and the other 3 were just explored. The average blood loss was 250 ml (110 - 980 ml), complications were found in 8 patients (9.0%) and one died. In non-reducing group, pancreatoduodenectomy was successfully performed in 24 (26.4%), simple internal drainage in 58 patients (63.7%) and exploration in 9 (9.9%). The average blood loss was 480 ml (320 - 1750 ml), complications were found in 19 patients (20.9%) and 4 died. In the non-reducing group, the patients with complications were older than those without complications, and the TB level was higher. The excision rate of carcinoma, incidence rate of complications and hospital time in patients whose TB decreased over 30% weekly after reducing the Icterus Index were all better than those of the rest. CONCLUSIONS: It is necessary to reduce the Icterus Index before operation in the patients with carcinoma of head of pancreas complicated with serious jaundice, especially for the elder, which can not only reduce the blood loss but also make operations safer and increase cure rate, in addition. And whether the Icterus Index decreases smoothly with biliary drainage can be used to predict the operational risk, effect and prognosis.