ERCP在原发性肝癌围术期胆道并发症诊治中的应用

doi:10.16139/j.1007-9610.2023.04.011

摘要/Abstract

摘要：

目的：回顾本中心应用经内镜逆行胰胆管造影术（endoscopic retrograde cholangio-pancreatography, ERCP）在原发性肝癌围术期胆道并发症临床诊治中的经验。方法：回顾性分析2016年10月至2023年6月我院原发性肝癌诊治过程中围术期因胆道并发症行ERCP治疗病人的临床资料。依据胆道并发症行ERCP的指征，病例分为胆管癌栓组、胆管狭窄组和胆漏组。统计分析原发性肝癌围术期不同类型胆道并发症病人的基线资料、ERCP治疗前后的实验室指标、治疗转归等数据。结果：总计25例行25例次ERCP，其中23例插管成功，成功率92.0%。胆管狭窄14例次，主要行胆道球囊扩张、探条扩张、支架植入、鼻胆管引流治疗；胆漏6例次，主要行支架植入、鼻胆管引流治疗；胆管癌栓5例次，主要行网篮及气囊取栓、支架植入、鼻胆管引流治疗。ERCP治疗后病人血清总胆红素、血清直接胆红素、γ-谷氨酰转移酶较治疗前明显下降（P<0.05）。术后平均血淀粉酶（85.0±69.4）（21~306） U/L。所有病例均无出血、消化道穿孔、胰腺炎及其他ERCP相关并发症发生。结论：原发性肝癌围术期胆道并发症以胆管狭窄最为常见。对于有胆道并发症的原发性肝癌围术期病人，行ERCP治疗安全、有效。

关键词: 内镜逆行胰胆管造影术, 原发性肝癌, 围术期, 胆道并发症

Abstract:

Objective: To review the experience of using endoscopic retrograde cholangio-pancreatography (ERCP) in the clinical diagnosis and treatment of biliary complications during perioperative period of primary liver cancer at our hospital. Methods: A retrospective analysis was conducted on the clinical data of patients undergoing ERCP treatment for biliary complications during perioperative period of primary liver cancer at our hospital from October 2016 to June 2023. According to the indications of ERCP for biliary complications, the cases were divided into bile duct tumor thrombus group, bile duct stricture group, and bile leakage group. The baseline data, laboratory test results before and after ERCP treatment, treatment outcomes, and other datas of the patients with different types of biliary complication were statistically analyzed. Results: A total of 25 patients underwent 25 cases of ERCP, among which 23 patients were successfully cannulated, with a success rate of 92.0%. There were 14 cases of bile duct stenosis, mainly treated with biliary balloon dilation, probe dilation, stent implantation, and nasobiliary drainage; 6 cases of bile leakage, mainly treated with stent implantation and nasobiliary drainage; 5 cases of bile duct tumor thrombus, mainly treated with net basket and balloon thrombectomy, stent implantation, and nasobiliary drainage. After ERCP treatment, the patient's serum total bilirubin, serum direct bilirubin, and γ-glutamyl transferase significantly decreased compared to those before the treatment (P<0.05). The postoperative average amylase was (85.0±69.4)(21-306) U/L. No bleeding, gastrointestinal perforation, pancreatitis, or other ERCP-related complications occurred in all cases. Conclusions: Bile duct stricture is the most common biliary complication during the perioperative period of primary liver cancer. For these patients with biliary complications during perioperative period of primary liver cancer ERCP treatment is safe and effective.

Key words: Endoscopic retrograde cholangio-pancreatography, Primary liver cancer, Perioperative period, Biliary complication

中图分类号:

叶枫, 龚笑勇, 任家俊, 蔡强, 陈胜. ERCP在原发性肝癌围术期胆道并发症诊治中的应用[J]. 外科理论与实践, 2023, 28(04): 355-360.

YE Feng, GONG Xiaoyong, REN Jiajun, CAI Qiang, CHEN Sheng. Application of ERCP in diagnosis and treatment of biliary complications during perioperative period of primary liver cancer[J]. Journal of Surgery Concepts & Practice, 2023, 28(04): 355-360.

图/表 2

表1

表2

参考文献 30

[1]	WEI W, ZENG H, ZHENG R, et al. Cancer registration in China and its role in cancer prevention and control[J]. Lancet Oncol, 2020, 21(7):e342-e349. doi: 10.1016/S1470-2045(20)30073-5 pmid: 32615118
[2]	LIU Z, JIANG Y, YUAN H, et al. The trends in incidence of primary liver cancer caused by specific etiologies: results from the Global Burden of Disease Study 2016 and implications for liver cancer prevention[J]. J Hepatol, 2019, 70(4):674-683. doi: S0168-8278(18)32616-3 pmid: 30543829
[3]	NAGARAJU G P, DARIYA B, KASA P, et al. Epigenetics in hepatocellular carcinoma[J]. Semin Cancer Biol, 2022, 86(3):622-632. doi: 10.1016/j.semcancer.2021.07.017 URL
[4]	OMATA M, CHENG A L, KOKUDO N, et al. Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update[J]. Hepatol Int, 2017, 11(4):317-370. doi: 10.1007/s12072-017-9799-9 pmid: 28620797
[5]	XU L, LI G, YANG B. Establishment of a risk assessment system for complications of hepatectomy based on preoperative variables[J]. iLIVER, 2022, 1(4):217-224. doi: 10.1016/j.iliver.2022.09.004 URL
[6]	DE SOUZA G M V, Ribeiro I B, Funari M P, et al. Endoscopic retrograde cholangiopancreatography drainage for palliation of malignant hilar biliary obstruction——stent-in-stent or side-by-side? A systematic review and meta-analysis[J]. World J Hepatol, 2021, 13(5):595-610. doi: 10.4254/wjh.v13.i5.595 URL
[7]	MATSUSHITA K, KAGEYAMA K, KAMEDA N, et al. Obstructive jaundice following transarterial chemoembolization for hepatocellular carcinoma with bile duct invasion[J]. J Clin Int Radiol ISVIR, 2021, 5(2):127-130.
[8]	GRECA R, SILVA M C, COSTA L, et al. Intraductal hepatocellular carcinoma leading to obstructive jaundice[J]. Adv Res Gastroentero Hepatol, 2021, 16(4):555941.
[9]	WANG H, MAO Y, ZHANG C, et al. Prediction of effective percutaneous transhepatic biliary drainage in patients with hepatocellular carcinoma: a multi-central retrospective study[J]. Liver Research, 2022, 6(4):269-275. doi: 10.1016/j.livres.2022.11.008 URL
[10]	JIANG W, FU X, WANG G, et al. Effect of biliary tract invasion with obstructive jaundice on the prognosis of patients with unresectable hepatocellular carcinoma[J]. Acad Radiol, 2023, 30(3):483-491. doi: 10.1016/j.acra.2022.08.010 URL
[11]	PARK S E, NAM I C, BAEK H J, et al. Effectiveness of ultrasound-guided percutaneous transhepatic biliary drainage to reduce radiation exposure: a single-center experience[J]. PLoS One, 2022, 17(11):e0277272. doi: 10.1371/journal.pone.0277272 URL
[12]	MAULAT C, REGIMBEAU J M, BUC E, et al. Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial[J]. Br J Surg, 2020, 107(7):824-831. doi: 10.1002/bjs.11405 pmid: 31916605
[13]	JUNG D H, IKEGAMI T, BALCI D, et al. Biliary reconstruction and complications in living donor liver transplantation[J]. Int J Surg, 2020, 82S:138-144.
[14]	DE GREGORIO M A, FOHLEN A, GOODWIN M, et al. The global reading room: postoperative benign biliary stricture[J]. Am J Roentgenol, 2022, 218(1):188-189. doi: 10.2214/AJR.21.26235 URL
[15]	GÖRGEC B, BENEDETTI CACCIAGUERRA A, LANARI J, et al. Assessment of textbook outcome in laparoscopic and open liver surgery[J]. JAMA Surg, 2021, 156(8):e212064. doi: 10.1001/jamasurg.2021.2064 URL
[16]	WANG J, ZHAO J P, WANG J J, et al. The impact of bile leakage on long-term prognosis in primary liver cancers after hepatectomy: a propensity-score-matched study[J]. Asian J Surg, 2020, 43(5):603-612. doi: S1015-9584(19)30788-2 pmid: 31611103
[17]	VINING C C, KUCHTA K, AL ABBAS A I, et al. Bile leak incidence, risk factors and associated outcomes in patients undergoing hepatectomy: a contemporary NSQIP propensity matched analysis[J]. Surg Endosc, 2022, 36(8):5710-5723. doi: 10.1007/s00464-021-08938-5
[18]	HIRATA H, KUWATANI M, ABO D. Sharp recanalization and rendezvous technique for biliary occlusions due to spacious bile leak after hepatectomy[J]. J Hepatobiliry Pancreat Sci, 2021, 28(8):e38-e39.
[19]	KOCH M, GARDEN O J, PADBURY R, et al. Bile lea-kage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery[J]. Surgery, 2018, 149(5),680-688. doi: 10.1016/j.surg.2010.12.002 URL
[20]	MARTIN A N, NARAYANAN S, TURRENTINE F E, et al. Clinical factors and postoperative impact of bile leak after liver resection[J]. J Gastrointest Surg, 2018, 22(4):661-667. doi: 10.1007/s11605-017-3650-4 pmid: 29247421
[21]	ANDREATOS N, AMINI N, GANI F, et al. Albumin-bilirubin score: predicting short-term outcomes including bile leak and post-hepatectomy liver failure following hepatic resection[J]. J Gastrointest Surg, 2017, 21(2):238-248. doi: 10.1007/s11605-016-3246-4 pmid: 27619809
[22]	LIU Q, CHEN J, LI H, et al. Hepatocellular carcinoma with bile duct tumor thrombi: correlation of magnetic resonance imaging features to histopathologic manifestations[J]. Eur J Radiol, 2010, 76(1):103-109. doi: 10.1016/j.ejrad.2009.05.020 pmid: 19501994
[23]	TAMADA K, ISODA N, WADA S, et al. Intraductal ultrasonography for hepatocellular carcinoma with tumor thrombi in the bile duct: comparison with polypoid cholangiocarcinoma[J]. J Gastroenterol Hepatol, 2001, 16(7):801-805. doi: 10.1046/j.1440-1746.2001.02527.x URL
[24]	YU X H, XU L B, LIU C, et al. Clinicopathological cha-racteristics of 20 cases of hepatocellular carcinoma with bile duct tumor thrombi[J]. Dig Dis Sci, 2011, 56(1):252-259. doi: 10.1007/s10620-010-1256-8 URL
[25]	NANASHIMA A, TOMINAGA K, YONEI A, et al. A rare case of intrahepatic cholangiocarcinoma with tumor thrombus in the bile duct[J]. Clin J Gastroenterol, 2021, 14(1):275-282. doi: 10.1007/s12328-020-01275-5 pmid: 33125633
[26]	WU J Y, HUANG L M, BAI Y N, et al. Imaging features of hepatocellular carcinoma with bile duct tumor thrombus: a multicenter study[J]. Front Oncol, 2021, 11:723455. doi: 10.3389/fonc.2021.723455 URL
[27]	CONTICCHIO M, MAGGIALETTI N, RESCIGNO M, et al. Hepatocellular carcinoma with bile duct tumor thrombus: a case report and literature review of 890 patients affected by uncommon primary liver tumor presentation[J]. J Clin Med, 2023, 12(2):423. doi: 10.3390/jcm12020423 URL
[28]	SCHAIBLE A, SCHEMMER P, HACKERT T, et al. Location of a biliary leak after liver resection determines success of endoscopic treatment[J]. Surg Endosc, 2017, 31(4):1814-1820. doi: 10.1007/s00464-016-5178-1 pmid: 27534659
[29]	TAKISHIN Y, KUWATANI M, SAKAMOTO N. Spiral stent placement for bile leakage after hepatobiliary surgery[J]. Endoscopy, 2022, 54(4):E174-E175. doi: 10.1055/a-1463-2776 URL
[30]	QIN L X, TANG Z Y. Hepatocellular carcinoma with obstructive jaundice: diagnosis, treatment and prognosis[J]. World J Gastroenterol, 2003, 9(3):385-391. doi: 10.3748/wjg.v9.i3.385 URL

Clinical features	Total （n=25）	Biliary stricture (n=14)	Bile leakage (n=6)	Bile duct tumor thrombus （n=5）	Statistical Value	P Value
Gender					χ2=0.875	0.646
Male	22	12	5	5
Female	3	2	1	0
Age (years)	55.0±9.5	53.8±11.0	58.6±8.2	53.2±9.6	F=0.570	0.574
Causes of liver cancer					χ2=2.442	0.295
Hepatitis B	18	9	4	5
Other	7	5	2	0
Clinical symptom
Abdominal pain	9	7	2	0	χ2=4.022	0.134
Jaundice	25	14	6	5	-	-
Fever	14	8	6	0	χ2=11.085	0.004
Bile drainage	6	0	6	0	χ2=25	<0.001
Asymptomatic	0	0	0	0	-	-
ERCP procedure
ENBD	6	2	1	3	χ2=4.454	0.108
Stent implantation	19	12	5	2	χ2=4.454	0.108
Balloon/probe dilation	4	3	1	0	χ2=1.261	0.532
Thrombus removal	5	0	0	5	χ2=25	<0.001
Postoperative amylase（U/L）	85.0±69.4	96.3±83.0	81.0±57.7	58.0±20.6	F=0.563	0.578

Liver function test item	Pre-ERCP	Post-ERCP	t Value	P Value
Total bilirubin (μmol/L)	98.281±45.720	34.900±12.576	7.317	<0.001
Direct bilirubin (μmol/L)	60.147±30.481	20.211±7.753	6.580	<0.001
Alkaline phosphatase (U/L)	167.321±83.124	148.046±56.851	0.985	0.334
γ-Glutamyl transferase (U/L)	68.084±30.872	52.286±21.364	2.761	0.011