术前胆道引流方式对合并梗阻性黄疸病人胰十二指肠切除术的影响

doi:10.16139/j.1007-9610.2020.04.007

摘要/Abstract

摘要：

目的：研究术前胆道引流方式对围术期并发症发生的影响。方法：回顾本中心2012年1月至2019年12月共448例术前胆道引流低位恶性梗阻性黄疸病人完成胰十二指肠切除术的临床资料。238例行经皮肝穿刺胆道引流术（percutaneous transhepatic cholangial drainage, PTCD）,210例行内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography, ERCP）引流。行ERCP引流的病人中,101例行内镜胆道支架置入术（endoscopic bi-liary stenting,EBS）,其余109例接受鼻胆管胆道引流术。分析不同胆道引流方式的操作失败率及围术期并发症发生。结果：相比于PTCD,ERCP的操作失败率较高（P=0.034）。ERCP术后胰瘘及再次手术发生率较高（P=0.005和P=0.025）。亚组分析,EBS组的术后总体并发症发生率比PTCD组高（P=0.014）,主要体现在胰瘘及再次手术发生率（P<0.001和P=0.041）。其他并发症发生率差异无统计学意义。结论：对于低位恶性梗阻性黄疸病人,在胰十二指肠切除术前使用PTCD进行胆道引流比ERCP有更大的优势。

关键词: 梗阻性黄疸, 胆道引流, 经皮肝穿刺胆道引流术, 内镜逆行胰胆管造影术, 内镜胆道支架置入术

Abstract:

Objective To explore the impact of preoperative biliary drainage methods on perioperative complications. Methods Clinical data of 448 patients of malignant distal biliary obstruction with jaundice who underwent pancreaticoduodenectomy and received preoperative biliary drainage were collected from January 2012 to December 2019. Among them, 238 patients received percutaneous transhepatic cholangial drainage(PTCD) as PTCD group and 210 patients received endoscopic retrograde cholangiopancreatography (ERCP) as ERCP group, including 101 cases with endoscopic biliary sten-ting (EBS) as EBS group and 109 cases with endoscopic nasobiliary drainage. The intervention unsuccess rate and perio-perative complications of different biliary drainage methods were analyzed. Results Intervention unsuccess rate of ERCP was higher than that of PTCD (P=0.034). Postoperative pancreatic fistula rate and reoperation rate were higher in ERCP group than those in PTCD group, respectively (P=0.005 and P=0.025). In analysis of subgroup, overall postoperative complication rate in EBS group was higher than that in PTCD group (P=0.014), and pancreatic fistula rate and reoperation rate in EBS group were higher than those in PTCD group (P<0.001 and P=0.041). There was no statistical difference in other complications between groups. Conclusions PTCD could be used as biliary drainage method with greater advantage than ERCP for the patients of malignant distal biliary obstruction with jaundice before pancreaticoduodenectomy.

Key words: Obstructive jaundice, Biliary drainage, Percutaneous transhepatic cholangial drainage, Endoscopic retrograde cholangiopancreatography, Endoscopic biliary stenting

中图分类号:

R575

赵诗葳, 沈子贇, 王建承, 彭承宏, 张俊, 吴卫泽. 术前胆道引流方式对合并梗阻性黄疸病人胰十二指肠切除术的影响[J]. 外科理论与实践, 2020, 25(04): 301-305.

ZHAO Shiwei, SHEN Ziyun, WANG Jiancheng, PENG Chenghong, ZHANG Jun, WU Weize. Effect of biliary drainage methods on patients with obstructive jaundice undergoing pancreaticoduodenectomy[J]. Journal of Surgery Concepts & Practice, 2020, 25(04): 301-305.

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临床特征	数据
性别（n）
男	304
女	144
平均年龄（岁）平均BMI	63.8±10.4 22.7±3.0
最终采取的引流方式（n）
ERCP EBS ENBD PTCD	210 101 109 238
手术方式（n）开腹机器人	376 72
术后病理（n）
胰腺导管腺癌胰腺神经内分泌肿瘤胆总管恶性肿瘤壶腹部腺癌十二指肠乳头恶性肿瘤	314 1 37 58 38
减黄前总胆红素（中位,IQR,μmol/L）术前总胆红素（中位,IQR,μmol/L）	250.1（188.5~335.2） 115.7（76.7~173.5）
术前引流时间（中位,IQR,d）	8.0（6.0~14.0）

项目	ERCP组	PTCD组	P值
首次减黄方式	220	228
要再次减黄	18（8.2）	8（3.5）	0.034
减黄并发症	24（10.9）	21（9.2）	0.550

项目	ERCP组（n=210）	PTCD组（n=238）	P值
总体并发症	110（52.4）	109（45.8）	0.164
围术期死亡	5（2.4）	8（3.4）	0.537
再次手术	16（7.6）	7（2.9）	0.025^a)
胰瘘	51（24.3）	33（13.9）	0.005^a)
胆瘘	7（3.3）	8（3.4）	0.987
胃肠吻合口瘘	4（1.9）	4（1.7）	0.858
腹腔感染	41（19.5）	58（24.4）	0.217
腹腔出血	19（9.0）	21（8.8）	0.934
切口感染	18（8.6）	17（7.1）	0.574
胃排空延迟	37（17.6）	35（14.7）	0.402
心功能不全	8（3.8）	9（3.8）	0.988
肺功能不全	8（3.8）	8（3.4）	0.799
肝功能不全	6（2.9）	9（3.8）	0.587
肾功能不全	4（1.9）	6（2.5）	0.659
中位术后住院时间(d)	20.5（16.0~28.0）	19.0（14.8~28.3）	0.115

项目	EBS组（n=101）	PTCD组（n=238）	P值
总体并发症	61（60.4）	109（45.8）	0.014^a)
围术期死亡	2（2.0）	8（3.4）	0.492
再次手术	8（7.9）	7（2.9）	0.041^a)
胰瘘	33（32.7）	33（13.9）	<0.001^a)
胆瘘	2（2.0）	8（3.4）	0.492
胃肠吻合口瘘	1（1.0）	4（1.7）	0.630
腹腔感染	27（26.7）	58（24.4）	0.646
腹腔出血	10（9.9）	21（8.8）	0.753
切口感染	10（9.9）	17（7.1）	0.391
胃排空延迟	16（15.8）	35（14.7）	0.789
心功能不全	4（4.0）	9（3.8）	0.937
肺功能不全	6（5.9）	8（3.4）	0.275
肝功能不全	1（1.0）	9（3.8）	0.165
肾功能不全	0	6（2.5）	0.107
中位术后住院时间(d)	21.0 （16.0~27.0）	19.0（14.8~28.3）	0.250