不同胆道引流治疗恶性梗阻性黄疸的预后分析

发布时间：2018-01-27 04:12

  本文关键词： 恶性梗阻性黄疸 经皮肝穿刺胆道引流 经内镜塑料胆道支架 经内镜金属胆道支架 生存预后　出处：《南京医科大学》2017年博士论文　论文类型：学位论文

【摘要】：目的:探讨不同胆道引流方式治疗恶性梗阻性黄疸的效果、并发症、引流通畅情况、生存预后分析;对部分患者的生存预后和生活质量进行分析评估;对应用胆管内超声技术的梗阻性黄疸患者的胆道引流特点进行分析。方法:自2008年12月至2014年10月期间,选择152例经皮肝穿刺或经内镜胆道引流的恶性梗阻性黄疸患者,分为四组:经皮肝穿刺胆道引流、经内镜塑料胆道支架、经内镜金属胆道支架、经内镜金属胆道支架联合塑料支架;收集临床资料并分析生存预后的影响因素。选择41例恶性梗阻性黄疸患者,分别经内镜鼻胆管引流、经内镜胆道支架置入、经内镜逆行胰胆管造影联合化疗或放疗;采用SF-36量表和恶性梗阻性黄疸特异性量表QLQ-MOJ11进行生活质量评分并统计分析。选择108例怀疑恶性胆道狭窄的患者,均进行经内镜逆行胰胆管造影和胆管内超声检查,收集临床资料并统计分析。结果:1.经皮肝穿刺胆道引流、经内镜胆道塑料支架引流、经内镜胆道金属支架引流、经内镜胆道金属支架联合塑料支架引流这四种胆道引流方式成功率分别为54.2%,59.1%,70.8%,80.6%;并发症的发生率分别为62.5%,27.2%,31.3%,16.7%;平均引流通畅时间分别为46天,82天,142天,164天;平均生存时间分别为191天,266天,284天,436天。通过COX风险回归分析,肝功能Child分级、年龄、感染、肿瘤分期是死亡的危险因素,而性别、引流的方法则减少死亡的风险。2.影响患者生活质量的危险因素包括胆红素、CA199、CEA、ALP、GGT。TBIL≥100umol/L,CA199≥200U/m1,ALP≥200U/L,GGT≥200 U/L 均预示生活质量较差。ERCP联合化疗或放疗的患者情感角色分数明显增加。生存曲线显示中位生存时间是10.2月;患者经内镜鼻胆管引流、经内镜胆道支架置入、经内镜逆行胰胆管造影联合化疗或放疗的中位生存时间分别为8.2月,8.2月,18.3月。3.通过内镜逆行胰胆管造影和胆管内超声技术的应用,胆道狭窄及梗阻性黄疸病因诊断的特异性、敏感性、准确性分别为67%,97%,99%。按照胆道梗阻部位分为:病变位于胆管分叉及左右肝管分隔即Bismuth Ⅱ(n=5,4.6%),病变超过胆管分叉并累及左右肝管即Bismuth Ⅲ(n=27,25%),病变已累及左右肝管及Ⅱ级胆管开口即Bismuth Ⅳ(n=7,6.5%),胆总管中上段(n=35,32.4%),肝管中下段(n=5,4.6%),胰头区域(n=29,26.9%)。胆道狭窄的平均长度为3.4±1.3cm;塑料支架的长度范围从5cm到15cm;金属支架的长度范围从1cm到10cm。结论:经内镜胆道金属支架联合塑料支架引流可以提高胆道引流的成功率,减少并发症,延长引流通畅时间和生存时间。ERCP联合放疗或化疗可以有效改善生活质量和延长生存时间。在ERCP过程中应用胆管内超声技术有助于区分良恶性胆道狭窄,判断梗阻水平,显示胆道狭窄长度;有助于选择胆道引流支架的类型和长度。
[Abstract]:Objective: to investigate the effect, complications, unobstructed drainage and survival prognosis of malignant obstructive jaundice treated by different biliary drainage methods. The survival prognosis and quality of life of some patients were analyzed and evaluated. The characteristics of biliary drainage in patients with obstructive jaundice by intrabiliary ultrasound were analyzed. Methods: from December 2008 to October 2014. 152 cases of malignant obstructive jaundice with percutaneous hepatic puncture or endoscopic biliary drainage were divided into four groups: percutaneous hepatic puncture biliary drainage, endoscopic plastic biliary stent and endoscopic metallic biliary stent. Endoscopic metallic biliary stents combined with plastic stents; Clinical data were collected and prognostic factors were analyzed. 41 patients with malignant obstructive jaundice were treated with endoscopic nasobiliary drainage and endoscopic biliary stent implantation. Endoscopic retrograde cholangiopancreatography combined with chemotherapy or radiotherapy; The quality of life (QOL) was evaluated by SF-36 and QLQ-MOJ11. 108 patients with suspected malignant biliary stricture were selected. All patients underwent endoscopic retrograde cholangiopancreatography and intrabile duct ultrasonography. Clinical data were collected and analyzed statistically. Results 1. Percutaneous hepatic drainage and endoscopic biliary plastic stent drainage were performed. The successful rates of endoscopic biliary metal stent drainage and endoscopic biliary metal stent combined with plastic stent drainage were 54.2% and 70.8% respectively. The incidences of complications were 62.5 and 27.2and 31.3and 16.7respectively. The mean drainage patency time was 46 days 82 days 142 days and 164 days respectively. The mean survival time was 191d / 266d / 284days / 436days respectively. By COX risk regression analysis, liver function Child grade, age and infection were found. Tumor staging is a risk factor for death, while gender and drainage methods reduce the risk of death. 2. The risk factors affecting the quality of life of patients include bilirubin CA199CEACEA ALP. GGT.TBIL 鈮，

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