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中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2021, Vol. 10 ›› Issue (06) : 564 -569. doi: 10.3877/cma.j.issn.2095-3232.2021.06.007

临床研究

PTCD与ERCP+ENBD在恶性梗阻性黄疸姑息性治疗中疗效比较
郭志唐1, 白锦峰1, 孙敏1, 滕毅山1, 李世思1, 陈章彬1,†()   
  1. 1. 650101　昆明医科大学第二附属医院肝胆胰外科三病区
  • 收稿日期:2021-08-09 出版日期:2021-09-23
  • 通信作者: 陈章彬

Comparison of efficacy between PTCD and ERCP+ENBD in palliative treatment of malignant obstructive jaundice

Zhitang Guo1, Jinfeng Bai1, Min Sun1, Yishan Teng1, Shisi Li1, Zhangbin Chen1,†()   

  1. 1. Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital of Kunming Medical University, Kunming 650101, China
  • Received:2021-08-09 Published:2021-09-23
  • Corresponding author: Zhangbin Chen
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郭志唐, 白锦峰, 孙敏, 滕毅山, 李世思, 陈章彬. PTCD与ERCP+ENBD在恶性梗阻性黄疸姑息性治疗中疗效比较[J]. 中华肝脏外科手术学电子杂志, 2021, 10(06): 564-569.

Zhitang Guo, Jinfeng Bai, Min Sun, Yishan Teng, Shisi Li, Zhangbin Chen. Comparison of efficacy between PTCD and ERCP+ENBD in palliative treatment of malignant obstructive jaundice[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2021, 10(06): 564-569.

目的

探讨PTCD与ERCP +内镜下鼻胆管引流术（ENBD）在恶性梗阻性黄疸姑息性治疗中的疗效。

方法

回顾性分析2018年12月至2020年1月在昆明医科大学第二附属医院诊治的68例恶性梗阻性黄疸患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男37例，女31例；年龄27~85岁，中位年龄63岁。根据减黄术式分为PTCD组（36例）与ERCP+ENBD组（32例）。观察两组患者的黄疸缓解率及围手术期情况等。两组住院时间、住院费用比较采用t检验，率的比较采用χ2检验或Fisher确切概率法。

结果

两组患者治疗后黄疸、皮肤瘙痒临床症状及肝功能较术前均有所改善。PTCD组高位梗阻黄疸缓解率为91%（20/22），明显优于ERCP+ENBD组的50%（6/12） （χ2=7.222，P<0.05）。而ERCP+ENBD组低位梗阻黄疸缓解率为95%（18/19），明显优于PTCD组的64%（9/14） （χ2=5.024，P<0.05）。PTCD组与ERCP+ENBD组术后总并发症发生率分别为17%（6/36）、32%（10/31），差异无统计学意义（χ2=2.228，P>0.05）。ERCP+ENBD组术后急性胰腺炎发生率为13%（4/31），明显高于PTCD组的0（P=0.026）。PTCD组住院时间和费用分别为（15.6±2.7）d、（2.5±0.4）万元，明显少于ERCP+ENBD组的（18.7±2.3）d、（2.7±0.3）万元（t=-5.140，-2.910；P<0.05）。

结论

PTCD与ERCP+ENBD在治疗恶性梗阻性黄疸方面均可获得有效的临床效果，PTCD更适用于高位梗阻患者，而ERCP+ENBD更适用于低位梗阻患者。两种术式各具优劣，需根据患者病情综合考虑选择，才能使患者切实受益。

关键词: 引流术, 经皮经肝胆道引流术, 胰胆管造影术，内窥镜逆行, 内镜下鼻胆管引流术, 黄疸，阻塞性, 疗效比较研究
Objective

To compare the efficacy of percutaneous transhepatic cholangial drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) + endoscopic nasobiliary drainage (ENBD) in the palliative treatment of malignant obstructive jaundice.

Methods

Clinical data of 68 patients with malignant obstructive jaundice admitted to the Second Affiliated Hospital of Kunming Medical University from December 2018 to January 2020 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 37 patients were male and 31 female, aged from 27 to 85 years, with a median age of 63 years. All patients were divided into the PTCD (n=36) and ERCP+ENBD groups (n=32). The jaundice remission rate and perioperative conditions between two groups were observed. The length of hospital stay and hospitalization expense between two groups were compared by t test. The rate comparison was conducted by Chi-square test or Fisher's exact probability test.

Results

After treatments, the clinical symptoms of jaundice, skin itching and liver function of patients were improved in two groups. In the PTCD group, the remission rate of high-position obstructive jaundice was 91%(20/22), significantly higher than 50%(6/12) in the ERCP+ENBD group (χ2=7.222, P<0.05). In the ERCP+ENBD group, the remission rate of low-position obstructive jaundice was 95%(18/19), significantly higher compared with 64%(9/14) in the PTCD group (χ2=5.024, P<0.05). The overall incidence of postoperative complications in the PTCD and ERCP+ENBD groups were 17%(6/36) and 32%(10/31), respectively. No statistical significance was noted between two groups (χ2=2.228, P>0.05). In the ERCP+ENBD group, the incidence of postoperative acute pancreatitis was 13%(4/31), significantly higher compared with 0 in the PTCD group (P=0.026). In the PTCD group, the length of hospital stay and hospitalization expense were (15.6±2.7) d and (2.5±0.4)×104 yuan, significantly less than (18.7±2.3) d and (2.7±0.3)×104 yuan in the ERCP+ENBD group (t=-5.140, -2.910; P<0.05).

Conclusions

Both PTCD and ERCP+ENBD are effective treatments for malignant obstructive jaundice. PTCD is more suitable for patients with high-position obstructive jaundice, whereas ERCP+ENBD is recommended for those with low-position obstructive jaundice. Both operations have its own advantages and limitations. Conditions of the patients should be considered when making therapeutic option, which can only bring clinical benefits to the patients.

Key words: Drainage, Percutaneous transhepatic cholangial drainage, Cholangiopancreatography, endoscopic retrograde, Endoscopic nasobiliary drainage, Jaundice, obstructive, Comparative effectiveness research
图1 一例恶性梗阻性黄疸患者超声引导下PTCD造影图注：示肝内胆管扩张
图2 一例恶性梗阻性黄疸患者ERCP+ENBD造影图注：示胆总管下段狭窄；ENBD为内镜下鼻胆管引流术
表1 PTCD和ERCP+ENBD组恶性梗阻性黄疸患者一般资料比较
组别 例数 年龄（岁，±s） 性别（例） 原发病（例） 梗阻部位（例） 梗阻时间（d，±s）
男 女 胰头癌 壶腹癌 胆管癌 高位 低位
PTCD组 36 61±14 17 19 9 4 23 22 14 18±5
ERCP+ENBD组 32 62±10 20 12 13 5 14 13 19 19±5
统计值   t=-0.420 χ2=1.594 χ2=2.802 χ2=2.846 t=-0.645
P值   0.676 0.207 0.246 0.091 0.521
表2 PTCD和ERCP+ENBD组恶性梗阻性黄疸患者围手术期肝功能比较（±s）
组别 例数 术前
TB（μmol/L） DB（μmol/L） ALT（U/L） ALP（U/L） GGT（U/L）
PTCD组 36 340±107 239±38 215±40 526±92 522±95
ERCP+ENBD组 32 381±91 242±41 203±23 534±68 535±106
t值   -1.682 -0.305 1.575 -0.705 -0.525
P值   0.097 0.761 1.121 0.380 0.601
组别 例数 术后7 d
TB（μmol/L） DB（μmol/L） ALT（U/L） ALP（U/L） GGT（U/L）
PTCD组 36 139±29 113±27 69±14 198±38 203±34
ERCP+ENBD组 31a 147±31 116±32 65±10 210±49 198±41
t值   -1.104 -0.370 1.374 -1.131 0.564
P值   0.274 0.713 0.174 0.262 0.575
表3 PTCD和ERCP+ENBD组恶性梗阻性黄疸患者术后并发症及满意度比较（例）
组别 例数 并发症 满意度
出血 胆漏 胆道感染 急性胰腺炎 导管脱落 很满意 满意
PTCD组 36 2 2 1 0 1 12 14
ERCP+ENBD组 31a 1 0 5 4 0 13 8
χ2值   0.211 - 3.642 - - 1.311
P值   0.646 0.183 0.056 0.026 0.350 0.519
[1]
Parodi A, Fisher D, Giovannini M, et al. Endoscopic management of hilar cholangiocarcinoma[J]. Nat Rev Gastroenterol Hepatol, 2012, 9(2):105-112.
[2]
吴刚. 经皮肝穿刺胆道支架置放术治疗恶性胆道梗阻性黄疸的临床疗效[J]. 中国现代普通外科进展, 2017, 20(7):555-557．
[3]
Xu XJ, Li JJ, Wu J, et al. A systematic review and metaanalysis of intraluminal brachytherapy versus stent alone in the treatment of malignant obstructive jaundice[J]. Cardiovasc Inter Radiol, 2018, 41(2):206-217．
[4]
金龙，邹英华. 梗阻性黄疸经皮肝穿刺胆道引流及支架植入术专家共识(2018)[J]. 中国介入影像与治疗学, 2019, 16(1):2-7.
[5]
Kikuyama M, Shirane N, Kawaguchi S, et al. New 14-mm diameter Niti-S biliary uncovered metal stent for unresectable distal biliary malignant obstruction[J]. World J Gastrointest Endosc, 2018, 10(1): 16-22．
[6]
Ignee A, Baum U, Schuessler G, et al. Contrast-enhanced ultrasound-guided percutaneous cholangiography and cholangiodrainage (CEUS-PTCD)[J]. Endoscopy, 2009, 41(8):725-726.
[7]
Li TF, Ren KW, Han XW, et al. Percutaneous transhepatic cholangiobiopsy to determine the pathological cause of anastomotic stenosis after cholangiojejunostomy for malignant obstructive jaundice[J]. Clin Radiol, 2014, 69(1):13-17.
[8]
Pan H, Liang Z, Yin TS, et al. Hepato-biliary-enteric stent drainage as palliative treatment for proximal malignant obstructive jaundice[J]. Med Oncol, 2014, 31(3):853.
[9]
Pai M, Valek V, Tomas A, et al. Percutaneous intraductal radio frequency ablation for clearance of occluded metal stent in malignant biliary obstruction: feasibility and early results[J]. Cardiovasc Intervent Radiol, 2014, 37(1):235-240.
[10]
马少军，翟仁友，赵峰. 恶性梗阻性黄疸的介入治疗进展[J/CD]. 中华介入放射学电子杂志, 2016, 4(2):119-123．
[11]
孙英豪，徐红新，于洋, 等. 经皮穿刺胆道引流管及内支架置入治疗恶性阻塞性黄疸[J]. 临床肝胆病杂志, 2010, 26(1):84-85．
[12]
赵诗葳，沈子贇，王建承, 等. 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(4):301-305．
[13]
de Mestral C. Simple pharmacological prophylaxis for post-ERCP pancreatitis[J]. Lancet, 2016, 387(10035):2265-2266.
[14]
Druyts E, Thorlund K, Humphreys S, et al. Interpreting discordant indirect and multiple treatment comparison meta-analyses: an evaluation of direct acting antivirals for chronic hepatitis C infection[J]. Clin Epidemiol, 2013(5):173-183.
[15]
蒋孙路，黄强，翟东升. 经内镜逆行胰胆管造影术和经皮肝穿刺胆道引流术治疗恶性梗阻性黄疸的疗效对比[J]. 中国内镜杂志, 2018, 24(1):75-79．
[16]
Cozzi G, Severini A, Civelli E, et al. Percutaneous transhepatic biliary drainage in the management of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts[J]. Cardiovasc Intervent Radiol, 2006, 29(3):380-388.
[17]
Leng JJ, Zhang N, Dong JH. Percutaneous transhepatic and endoscopic biliary drainage for malignant biliary tract obstruction:a meta-analysis[J]. World J Surg Oncol, 2014, 12(1):272.
[18]
张东，陶杰，石磊等. 肝门部胆管癌根治术后并发症影响因素分析[J/CD]. 中华肝脏外科手术学电子杂志，2018，7(4)：280-283.
[19]
Fortmeier D, Mastmeyer A, Schröder J, et al. A virtual reality system for PTCD simulation using direct visuo-haptic rendering of partially segmented image data[J]. IEEE J Biomed Health Inform, 2016, 20(1):355-366.
[20]
许俊，张秀芳，晁明, 等. 超声引导经皮肝胆道引流术治疗恶性胆道梗阻102例分析[J]. 中华超声影像学杂志, 2004, 13(7): 30-32．
[21]
Piñol V, Castells A, Bordas JM, et al. Percutaneous self-expanding metal stents versus endoscopic polyethylene endoprostheses for treating malignant biliary obstruction: randomized clinical trial[J]. Radiology, 2002, 225(1):27-34.
[22]
Burke DR, Lewis CA, Cardella JF, et al. Quality improvement guidelines for percutaneous transhepatic cholangiography and biliary drainage[J]. J Vasc Interv Radiol, 2003, 14(9 Pt 2):S243-246.
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