三种姑息减黄手术治疗恶性梗阻性黄疸临床对比分析

目的：比较不同姑息减黄手术治疗恶性梗阻性黄疸的临床效果。 方法：回顾性分析2007年1月—2012年1月期间收治的37例恶性梗阻性黄疸需姑息减黄患者临床资料，其中14例行经典Roux-en-Y胆肠吻合术式（经典内引流组），12例行改良胆肠襻式吻合术（改良内引流组），11例行体外胆汁转流术（外引流组）。比较3组的减黄疗效、术中与术后指标及生存情况。 结果：3组术后总胆红素水平均较术前明显下降，但3种术式的减黄效果相近（P>0.05）。改良内引流组和外引流组较经典内引流组手术时间、术中出血量、肠功能恢复时间及术后住院时间均明显减少，外引流组的住院费用少于经典内引流组与改良内引流组，手术时间、出血量较改良内引流组更加减少（均P<0.05）。经典内引流组术后2例（14.2%）发生反流性胆管炎，而改良内引流组和外引流组无反流性胆管炎发生。3组术后中位生存期差异无统计学意义（P>0.05）。 结论：改良胆肠襻式吻合术治疗恶性梗阻性黄疸疗效确切，术后器官功能恢复快，可以作为姑息减黄的首选术式，而体外胆汁转流术操作简单，创伤小、费用低，适于在基层医院推广。

Comparison of three surgical methods for palliative biliary drainage in malignant obstructive jaundice

Objective: To compare the clinical effects of three different procedures for palliative biliary drainage in malignant obstructive jaundice. Methods: The clinical data of 37 patients with malignant obstructive jaundice requiring palliative biliary drainage admitted from January 2007 to January 2012 were retrospectively analyzed. Of the patients, 14 cases underwent Roux-en-Y hepaticojejunostomy (conventional internal drainage group), 12 cases underwent modified loop-type biliary-enteric anastomosis (modified internal drainage group) and 11 cases underwent extracorporeal bile shunt (external drainage group). The jaundice reduction effects, intra- and postoperative parameters and survival status among the 3 groups were compared. Results: The postoperative total bilirubin level was significantly decreased in all the 3 groups compared with their preoperative levels, and the jaundice reduction effects of the 3 procedures were similar (P>0.05). The operative time, intraoperative blood loss, time to gastrointestinal function recovery and length of postoperative hospital stay in both modified internal drainage group and external drainage group were significantly reduced compared with conventional internal drainage group, and in external drainage group, the hospitalization cost was significantly lower than that in both conventional internal drainage group and modified internal drainage group and furthermore, the operative time and intraoperative blood loss were even less than those in modified internal drainage group (all P<0.05). Reflux cholangitis occurred in 2 cases (14.2%) in conventional internal drainage group in control group, but in none of the cases in either modified internal drainage group or external drainage group. There was no statistical difference in median postoperative survival among the 3 groups (P>0.05). Conclusion: Modified loop-type biliary-enteric anastomosis has demonstrable efficacy in treatment of malignant obstructive jaundice with quick recovery of organ functions, and can be considered as the first option for palliative biliary drainage. The extracorporeal bile shunt is a simple, minimally invasive procedure with less cost, so it is worthy to be applied in primary-level hospitals.