- 放置胆道内支架姑息治疗难以切除的恶性胆道梗阻
- 作者:范震|发布时间:2008-09-23|浏览量:2212次
ERCP放置胆道内支架姑息治疗难以切除的恶性胆道梗阻54例临床分析
杭州市第一人民医院消化科
范震 张啸 张筱凤 吕文 林秀英 郭英辉 黄平
[摘要] 目的 探讨ERCP放置胆道内支架对难以切除恶性胆道梗阻的临床治疗效果。方法 54例恶性肿瘤引起的梗阻性黄疸患者,经ERCP内镜下放置胆道内支架解除胆道梗阻性黄疸,经ERCP将导丝插入胆道并超过梗阻部位,扩张狭窄后,用推送导管将已经选择合适的引流支架推送至胆道合适部位,其近端均超过梗阻段2cm以上。结果 54例患者中49例插管成功,5例插管不成功,其中1例乳头开口于憩室内,另4例肿瘤完全阻塞导丝无法通过。成功率为90.74%(49/54)。其中32例胆道内放置8F Z型自膨胀式金属支架外,其余17例行8-10F塑料内支架引流。术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻。其中39例2周内血清总胆红素下降50%以上,血清总胆红素退至34umol/L以下。放置胆道内支架1W后,患者血清总胆红素由术前235.45±56.67umol/L降至78.36±37.58umol/L,肝功能较术前显著改善(p<0.05,p<0.01)。31例胆总管下段梗阻患者与12例肝门部胆管梗阻患者相比,放置胆道内支架引流治疗1W、2W后,其胆红素下降明显优于肝门部胆管梗阻(p<0.01)。32例放置胆道金属支架患者中,有12例于术后2个月发生支架阻塞,再次放置塑料内支架后引流通畅,1例放置金属支架术后患者第10个月才出现支架阻塞予以再次植入金属支架。另外17例放置塑料内支架者,有3例放置塑料内支架者于术后1-4周出现血清总胆红素再次上升,经ERCP检查发现支架移位和阻塞,予以更换内支架,其中1例植入塑料双支架。结论 经ERCP内镜下胆道放置内支架,解除恶性胆道梗阻性黄疸,对缓解症状、提高患者生存质量具有满意疗效,对胆总管下段部位梗阻性黄疸治疗效果优于肝门部胆管梗阻。杭州市第一人民医院消化内科范震
[关键词] ERCP,胆道支架,胆道梗阻,内镜治疗
Study on the effects of biliary stent on unresectable malignant biliary obstruction in 54 patients
Zhen Fan, Xiao Zhang, Xiaofeng Zhang, Wen Lv, Xiuying Lin, Yinghui Guo, Haitao Huang. Department of gastroenterology, first people’s hospital of Hangzhou city, Hangzhou, China
[Abstract] Objective To explore the effects of endoscopic biliary stent placement on unresectable biliary obstruction caused by malignant neoplasm.Methods 54 patients with obstructive jaundice due to advanced carcinoma were treated with biliary stent through ERCP(endoscopic retrograde cholangiopancreatography).First, the guide wire was successfully inserted into the biliary duct and the stent pushed to the properly site and surpasss 2cm of the obstructive site by pushing catheter. Results 51 cases of 54 were successfully embedded with biliary stent, 34 cases embedded with self-expandable metal stent(EMS), 17 cases of them embedded with plastic stent to drain. The successful rate of biliary stent placement was 94.44%(51/54). The level of total serum bilirobin was decreased to 34umol/L and decreased by 50% after drainage for 2 weeks in 39 patients.The total serum bilirobin was decreased from 235.45±56.67umol/L to 78.36±37.58umol/L in all patients after drainage for 1 week. Stent The levels of ALT、AST、AKP and r-GT were significantly dereased and liver function was imoroved after endoscopic therapy(p<0.05,p<0.01). The total serum bilirubin was decreased obviously in the patients with distal bile commen duct obstruction than that of patients with hepatic hilum biliary duct obstruction caused by malignant neoplasm after 1 week or 2 weeks drainage of biliary stents (p<0.05,p<0.01). Biliary stent occlusion occurred again in 2 patients embedded with EMS after 2 months, which were placed plastic stent again into previous stent. Another 1 patient was replaced EMS again duo to obstruction after 10 months. The total serum bilirobin was increased in the other 5 cases embedded with plastic stent after 1-6 weeks because of the stents displaced and blocked. The stents were replaced and 1 case of them placed dual stent. Conclusion As an new technique, endoscopic biliary stent placement could effectively extinct jaundice for patients with unresectable biliary obstruction caused by malignant neoplasm and improved the life quality. The effects on obstructive jaundice of endoscopic biliary stent placement on distal common biliary duct were better than hepatic hilum biliary duct.
[Key words] ERCP(endoscopic retrograde cholangiopancreatography), biliary stent, malignant biliary obstruction,therapeutic endoscopy
讨论
随着诊断水平和手术技术的进步,恶性胆道梗阻手术切除率已有明显提高,如肝门部胆管癌根治切除率已从以往的<15%提高到35.8%。但仍有许多患者就诊时已不能作手术根治,此时,传统上常选择胆道内、外引流。自1974年首先有人报道经皮经肝穿刺胆道减压引流术(PTCD)治疗梗阻性黄疸获得成功后,使其成为缓解梗阻性黄疸的一项重要姑息性介入放射学治疗方法。PTCD引流胆汁,缓解症状效果较好,但易发生引流管堵塞、感染、脱落和机体内环境稳态失衡等并发症,患者需长期携带引流袋,生活质量明显下降[1]。直到1985年Gianturco和Palmaz分别研制出不锈钢Z型自张式和球囊扩张式内支架使ERCP内镜下放置胆道内支架得以迅速发展。随着新介入器材开发和金属内支架的改进,使得金属内支架具有对胆道狭窄部位膨胀支撑力大和组织相容性好,不易堵塞、不易脱落、置放灵活等优点[2-4]。与PTCD经皮经肝穿刺放置胆道内支架相比,ERCP内镜下放置胆道内支架具有很大优势:(1)患者痛苦小、易接受。(2)创伤小、安全性大,适应范围广,特别对高龄且一般情况差、不能或不宜外科手术病例可采用此法。(3)对高位胆管癌,原发性肝癌及肝门淋巴结或肝内转移引起的高位梗阻性黄疸有较大优势,而外科手术难以切除或难度太大。(4)对已经手术探查不能减轻黄疸的病例仍可采用内支架治疗。国外关于内支架治疗恶性胆道梗阻非随机性、回顾性疗效分析显示了良好的支架开通率,并使患者生存期相对延长。其中一报道对使用55枚39例患者治疗结果显示,30天支架再阻塞率为24.2%,支架开通率6个月、12个月分别为71%和42%,平均开通时间为12.4个月[5]。另一报道对28例患者治疗结果显示平均生存期为14.6个月,且76%患者无黄疸或胆囊炎发生[7]。有报道在金属支架表面覆盖一层聚氨基甲酸乙酯,可有效阻止肿瘤向支架网眼内生长,延长支架畅通引流时间[5-6,8]。
本组病例放置胆道内支架后,血清总胆红素由235.45±56.67umol/L于术后1W降至78.36±37.58umol/L,症状好转,瘙痒消失或减轻。因此,ERBD或EMBD对手术难以切除的恶性胆道梗阻具有胆汁引流确实可靠,创伤小,生活质量提高等优点。ERBD在某些病例甚至是唯一可供选择的治疗方法。在对某些诊断不明确的阻塞性黄疸行内镜治疗同时,也提供了重要的诊断依据,从而提高手术切除率,缩短住院时间和减小手术创伤。本组有5例患者治疗前诊断不明确,通过ERCP而确诊。另外,统计结果显示,肝门部胆管梗阻放置支架治疗1W及2W的引流效果较胆总管下段梗阻为差(p<0.5),其原因可能与原发疾病及支架引流范围大小不同所致。
近年来,胆道金属支架发展迅速,金属支架优势和缺点也已明显。优点在于金属支架释放膨张后外径可达7-10 mm,远非塑料支架可比,且金属丝与细菌接触面积小,并可为胆道黏膜上皮细胞所覆盖,可预防细菌滋生,保持支架持久通畅,所以通畅性能显著优于塑料支架。有文献报道金属支架6个月的阻塞率仅15%,明显低于塑料支架(60%-70%)[1,9]。但金属支架十分昂贵,其价格是塑料支架的数倍,对于估计生存期较短晚期肿瘤患者,或胆管受侵极广,引流效果有限的患者,昂贵金属支架并不比塑料支架有太大的优越性。对于ERBD和EMBD选择,一方面要考虑患者经济承受能力,但更重要的是充分估计患者存活时间及支架引流时间,预计生存时间超过4个月,引流全肝胆系40%以上者,考虑使用金属支架,否则放置塑料支架具有更高的费-效比[10-12]。
ERCP内镜下放置胆道内支架需注意以下几点:(1)金属支架通畅性好,再狭窄发生率低。金属支架通畅期多为5个月以上,临床上如估计患者生存期少于4个月时,可选用塑料内支架。(2)金属支架选择应根据梗阻部位和长度、金属支架种类、支架末端放置位置等因素综合考虑。长度选择应以支架扩张后的长度为准,有的金属支架释放后长度会缩短。在确定支架长度时应留有余地,支架完全扩张后超出肿瘤两端长度应超过2cm,以防肿瘤生长早期堵塞支架。(3)对于肝门部肿瘤,因胆道梗阻范围较广泛,估计引流效果较差或有严重胆管炎时,放置金属支架要慎重。应先行其他过渡性引流如ENBD或ERBD,当引流效果满意、炎症控制后再改放金属支架较为稳妥。金属支架较昂贵,且放置后难以取出,对于胆道良性病变应避免放置胆道金属支架。(4)胆总管肿瘤可与PTCD配合放置支架:本组2例胰头癌患者,先行ERCP,导丝无法通过胆管狭窄段,ERCP内镜下放置胆道内支架失败,后行PTCD循导丝放置内支架成功。(5)影响EMBD远期疗效的重要原因是支架堵塞,主要是肿瘤组织向支架内生长或胆泥及肿瘤坏死组织堵塞支架。在堵塞的支架中再放置金属或塑料支架往往仍能有效地解除梗阻。(6)植入支架后对于胆汁稠厚引流不畅者应同时放置多侧孔鼻胆引流管行内外引流,术后每日用生理盐水+丁胺卡那霉素经ENBD冲洗引流,特别对于有出血的患者,能防止引流管或支架阻塞。