高位恶性梗阻性黄疸并发症分析及预后影响因素探讨

发布时间：2018-02-04 03:40

本文关键词： 梗阻性黄疸并发症预后因素　出处：《山西医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：目的:讨论恶性病变造成的高位胆道梗阻,其原发病及介入手术操作等所导致的相关并发症,并对影响预后的多种因素进行分析,旨在尽量减少并发症的发生,同时为综合评估患者预后及指导临床决策提供依据。方法:收集山西医科大学第二医院介入治疗科2009年8月~2014年12月,经病理和(或)影像学检查确诊的恶性高位胆道梗阻患者,完善相关术前检查,对无手术禁忌症的入选患者在DSA透视或B超引导下行经皮经肝胆道穿刺引流术和(或)支架置入术。如患者一般状态允许,可考虑择期放置胆道内支架进行胆汁内引流和(或)病灶供血动脉置管化疗等后续治疗。介入手术后复查,收集患者一般资料及术前术后临床检查资料,并进行1.统计术后并发症发生种类及发病率,并分析主要并发症发生原因2.将术后患者按预后情况分为预后差、预后良两组,统计相关指标(性别、年龄、ALT、AST、ALB、TBIL、ALP、GGT等)应用非条件logistic回归分析,先进行单因素分析,选出影响预后的因素,再将这些因素行多因素分析,得出logistic方程,分析过程中统计水准为α=0.05,即P0.05认为有统计学意义。结果:1.入选本研究的病例共76例,男性41例,女性35例,术前诊断肝门部胆管癌31例,胆囊癌肝门部转移15例,肝门部肝癌10例,恶性肿瘤肝门部淋巴结转移8例,壶腹部癌肝门部转移12例。因诱发胆心反射停止手术3例,其余均成功行PTCD和(或)支架置入术。行双侧引流+双侧支架5例,右侧引流+支架26例,左侧引流+支架10例,单纯右侧引流20例,单纯左侧引流10例,手术未成功3例,外院行引流+支架置入术后狭窄,于我科再行治疗2例。2.主要由原发病因素造成的并发症:电解质紊乱30例,低蛋白血症24例,贫血18例,胆系感染10例,急性肾功能衰竭9例;介入手术相关并发症:胆道出血2例,肝脓肿2例,围手术期死亡5例,急性胰腺炎7例,应激性溃疡1例,穿刺针道转移1例,胆心反射3例,支架内狭窄3例。各并发症发生率为:胆系感染13.16%;电解质紊乱39.47%;急性肾衰11.84%;胆道出血2.63%;肝脓肿2.63%;围手术期死亡6.58%;低蛋白血症31.58%;贫血23.68%;急性胰腺炎9.21%;应激性溃疡1.39%;穿刺针道转移1.39%;胆心反射3.95%;支架内再狭窄3.95%。3.影响预后的因素有年龄(P=0.006)、A/G(P=0.018)、ALB(P=0.025)、梗阻部位I(P=0.006),对预后无明显影响的因素为ALT(P=0.265)、TBIL(P=0.258)、性别(P=0.421)、GGT(P=0.856)、AST(P=0.497)、ALP(P=0.514),进一步得出logistic方程为Logistic(p)=1.332+0.681*年龄-0.215*A/G-0.335*ALB+1.587*梗阻部位I。结论:1.常见并发症多由原发病变造成,发生率由高到低依次为电解质紊乱、低蛋白血症、贫血、胆系感染,急性肾衰;胆道出血、急性胰腺炎、应激性溃疡、穿刺针道转移、胆心反射、术后支架再狭窄等介入相关并发症发生率较低。介入手术能以较小的手术风险有效解除梗阻,减轻原发病造成的症状。2.年龄、A/G、ALB、梗阻部位与预后相关,ALT、TBIL、性别、GGT、AST、ALP与预后无明显关系,年龄为危险因素,年龄愈大,预后愈差,同时A/G比值降低及ALB值降低也为危险因素,提示预后不良。临床工作中应结合影响预后的因素综合评价患者基本情况,严格选择符合手术适应症的患者进行介入治疗,尤其对于年龄较大、一般状态较差等导致预后不良的危险因素较多的患者,提出科学合理的治疗方案,个体化治疗,望达到最好的临床获益。
[Abstract]:Objective: to discuss the high malignant biliary obstruction lesions caused by the complications due to the primary disease and interventional surgical operation, and the influences of various factors on the prognosis were analyzed, in order to minimize the occurrence of complications, and to evaluate the prognosis and guiding clinical decision-making provide a basis. Methods: interventional treatment of the second hospital of Shanxi Medical University in August 2009, ~2014 in December, confirmed by pathology and (or) patients with high malignant biliary obstruction diagnosed by imaging examination, improve the preoperative examination, no operative contraindications of patients enrolled in DSA fluoroscopy or ultrasound guided percutaneous transhepatic biliary drainage and (or) stenting. If the patients conditions allow and consider undergoing internal biliary drainage and biliary stent placement (or) lesions artery chemotherapy. The follow-up treatment tube after surgical intervention were collected with a General information and clinical examination data before and after surgery, and postoperative complications were 1. statistical types and incidence, and analyzes the main causes of complications in 2. postoperative patients according to prognosis for poor prognosis, prognosis of benign and two groups, statistical indicators (gender, age, ALT, AST, ALB, TBIL. ALP, GGT, etc.) and non conditional logistic regression analysis, single factor analysis, selected prognostic factors, then multivariate analysis for these factors, the logistic equation, the statistical level analysis process is a =0.05 P0.05 that has statistical significance. Results: 1. patients were enrolled in this study 76 patients, male 41 cases, female 35 cases, preoperative diagnosis of 31 cases of hilar cholangiocarcinoma, gallbladder carcinoma hepatic metastasis in 15 cases, 10 cases of hilar hepatocellular carcinoma, malignant hilar lymph node metastasis 8 cases, carcinoma of ampulla of hilar metastasis in 12 cases. Due to the induction of biliary cardiac reflex stop operation in 3 cases, the More successful for PTCD and (or) stenting. Bilateral drainage plus bilateral stent in 5 cases, right side drainage + stent in 26 cases, 10 cases of left side drainage + stent drainage in 20 cases, simple right, only the left drainage in 10 cases, no operation was successful in 3 cases, underwent drainage and stenting stenosis and in our department for treatment of 2 cases of.2. mainly by the factors of primary disease caused by complications: 30 cases of electrolyte disorder, hypoproteinemia in 24 cases, 18 cases of anemia, 10 cases of biliary infection, 9 cases of acute renal failure; interventional surgery related complications: 2 cases of biliary tract bleeding, 2 cases of liver abscess surgery 5 cases died, 7 cases of acute pancreatitis, 1 cases of stress ulcer, puncture needle tract metastasis in 1 cases, 3 cases of biliary cardiac reflex, stent stenosis in 3 cases. The incidence rate of complications was 13.16%: biliary tract infection; electrolyte disorder 39.47%; 11.84% acute renal failure; biliary tract bleeding 2.63%; 2.63% liver abscess; surgery died 6.58%; hypoproteinemia in 31.58% 23.68% 9.21%; anemia; acute pancreatitis; stress ulcer 1.39%; puncture needle tract metastasis 1.39%; bile cardiac reflex 3.95%; in stent restenosis 3.95%.3. prognostic factors were age (P=0.006), A/G (P=0.018), ALB (P=0.025), I (P=0.006), obstruction of factors had no significant effect on the pre ALT (P=0.265), TBIL (P=0.258), gender (P=0.421), GGT (P=0.856), AST (P=0.497), ALP (P=0.514), further concluded that logistic equation is Logistic (P) =1.332+0.681* age -0.215*A/G-0.335*ALB+1.587* obstruction I. conclusion: 1. common complications caused by primary disease, the incidence rate from high to low in order to electrolyte disorder, hypoproteinemia, anemia, biliary infection, acute renal failure; biliary tract hemorrhage, acute pancreatitis, stress ulcer, needle tract metastasis, biliary cardiac reflex, postoperative restenosis related support intervention with low incidence of complications. Surgical intervention with minor surgery The risk effectively relieve the obstruction symptoms of.2. age, primary disease caused by reducing A/G, ALB, the site of obstruction is related with the prognosis, ALT, TBIL, GGT, AST, sex, no obvious relationship between ALP and prognosis, age, risk factors, age, the prognosis is worse, and the ratio of A/G decreased and the decrease of ALB value for risk factors of poor prognosis. Patients should be combined with the influence of the basic situation of comprehensive evaluation of the prognostic factors in the clinical work, with strict selection of surgical indications in patients with interventional therapy, especially for older age, poor performance status as a result of many risk factors of poor prognosis of the patients, put forward scientific and reasonable treatment and individualized treatment. Is expected to achieve the best clinical benefit.

【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R735.8

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