【作者】 王广川；

【导师】 张春清；

【作者基本信息】 山东大学 ， 内科学， 2009， 硕士

【摘要】 目的:恶性梗阻性黄疸是临床上较常见的疾病,大多数在诊断时已经丧失手术根治的机会,外科胆肠吻合手术创伤大。经皮经肝胆道引流管引流或内支架置入引流,已成为不能外科手术切除的癌性梗阻性黄疸的主要治疗方法之一,其疗效确切,创伤小,并发症少。在本研究旨在探讨不同部位胆道梗阻的介入治疗操作技巧,并随访观察经皮经肝胆道引流不同部位恶性梗阻性黄疸的治疗效果,探讨和分析影响生存时间的相关因素。方法:恶性梗阻性黄疸患者83例,术前均行彩色B超检查,并详细阅读CT或常规、凝血时间、肝功等检查。包括①肝门部梗阻33例,②肝总管梗阻15例,③胆总管梗阻35例。针对不同部位的梗阻分别采用引流管植入外引流、内外引流;内支架植入:单支架植入;“Y”型双支架植入,“T”型双支架植入等方式引流。术后观察给予抗感染、保肝、抗肿瘤及对症治疗,复查B超,肝功等指标,并对其中55例通过门诊及电话随访0.4-28月,运用Kaplan-Meier乘积限法计算生存时间及生存曲线。比较不同部位胆道梗阻患者的近期疗效和生存时间。另外还对一些临床常见的因素对生存时间的影响进行了分析。结果:83例经皮经肝胆管穿刺操作全部成功,成功率100%。其中5例行单纯外引流,9例行内外引流,78例行支架植入。术后一周平均血清总胆红素由术前的327.90±170.24μmol/L下降为172.45±137.46μmol/L(P＜0.001)。55例得到随访,随访率66.3%。总体有效率为89.16%(74/83),平均生存时间10.32±1.38月;肝门部梗阻患者近期有效率为84.85%(28/33),显效率为30.30%(10/33),平均生存时间9.59±1.80月;肝总管梗阻患者的近期有效率为86.67%(13/15),显效率为66.67%(10/15),平均生存时间5.46±1.60月;胆总管梗阻患者的近期有效率为94.30%(33/35),显效率为60%(21/35),平均生存时间12.64±2.44月。并发症发生率15.66%(13/83),30天内死亡率6.02%(5/83)。当总胆红素水平在341μmol/L以下、血清白蛋白水平在31g/L以上、血红蛋白在95g/L以上时,患者生存时间较长,预后较好。结论:(1)经皮经肝胆道引流术是治疗恶性梗阻性黄疸的一种有效姑息方法。能有效的缓解临床症状,减轻黄疸。因此对于恶性梗阻性黄疸患者应尽可能在早期行经皮经肝穿刺引流术,最大限度改善患者生活质量。(2)针对梗阻部位的不同,可采用经皮经肝单支架植入,“Y”型或“T”型支架植入。手术成功率高,易于推广应用。(3)术前胆红素水平,血清白蛋白水平和血红蛋白水平是术后生存时间的相关因素,可以用来初步预测患者的预后,可以为手术时机及引流管或内支架植入的选择提供参考。更多还原

【Abstract】 Objective: Malignant obstructive jaundice is a commen disease clinically, and when diagnose ,most of the patients have lost the opportunity of operative eradication, which causing sever trauma , high mortality and short life span after operation. PTCD have become one of the main therapeutic method of malignant obstructive jaundice which have lost operative opportunity. They have certain curative effect, small trauma and little complication. This study aim at discussing operative skill of interventional therapy in different location of obstruction and following up the curative effect of different therapy of PTCD, to probe into and analyze the correlative factor which affect the curative effect in short time and life span.Methods: 83 patients of malignant bile duct obstruction were included in this study, including: 35 cases of common bile duct obstruction, 15 cases of common hepatic duct obstruction, and 33 cases of hilar obstruction. They were treated with different therapy of PTCD, according to the different type of bile duct obstruction. The lately curative effect observed. And then 55 (66.3%) of them were followed up by 0.4-28 months and were observed survival time. We analyze different of survival time between the different location of biliary obstruction and different therapy types of PTBD. In addition we analyze the affect of other common factors to the survival time.Results: In my study, all of the 83 patients cases were treated technological successful (100%), and stents were placed in 78 cases, external drainage in 5 cases and internal /external drainage tube in 9 cases. Their clinical symptom are better than that before operation. The serllm total bilirubin decreased from 327.90±170.24μmol/L to 172.45±137.46μmol/L one week after the procedure(P<0.001). The lately clinical effective rate is 89.16% (74/83), and the mean survival time is 10.32±1.38 months. The clinical outcome of three different types of bile duct obstruction is like this: 1) common bile duct obstruction, with a lately clinical effective rate of 94.30% (33/35), and the mean survival time of 12.64±2.44 months. 2) common hepatic duct obstruction with a lately clinical effective rate of 86.67% (13/15), and the mean survival time of 5.46±1.60 months. 3) hilar obstruction with a lately clinical effective rate of 84.85% (28/33), and the mean survival time of 9.59±1.80months. 15 cases of common hepatic duct obstruction, and 33 cases of hilar obstruction. Five cases died within 1 month (6.02%) after operate. Complications occurred in 13 cases (15.66%). The value of preoperative serum total bilirubin, albumin and hemoglobin is the relatedfactors influencing survival time.Conclusion:(1) PTCD is an effective palliative method of therapy in malignant obstructive jaundice. It can release the clinical symptom and alleviate Jaundic effectually, hence the patients should receive PTCD in the early time to improve the life quality maximumly.(2) The therapy of PTCD should be chosen, according to the different type of bile duct obstruction.(3) The value of preoperative serum total bilirubin, albumin and hemoglobin is the related factors influencing survival time.And they can forecast the prognosis initially and provide consult for the choice of operative way.更多还原