本文關(guān)鍵詞： 惡性梗阻性黃疸 經(jīng)皮肝穿刺膽道引流 經(jīng)內(nèi)鏡塑料膽道支架 經(jīng)內(nèi)鏡金屬膽道支架 生存預(yù)后　出處：《南京醫(yī)科大學(xué)》2017年博士論文　論文類(lèi)型：學(xué)位論文

【摘要】：目的:探討不同膽道引流方式治療惡性梗阻性黃疸的效果、并發(fā)癥、引流通暢情況、生存預(yù)后分析;對(duì)部分患者的生存預(yù)后和生活質(zhì)量進(jìn)行分析評(píng)估;對(duì)應(yīng)用膽管內(nèi)超聲技術(shù)的梗阻性黃疸患者的膽道引流特點(diǎn)進(jìn)行分析。方法:自2008年12月至2014年10月期間,選擇152例經(jīng)皮肝穿刺或經(jīng)內(nèi)鏡膽道引流的惡性梗阻性黃疸患者,分為四組:經(jīng)皮肝穿刺膽道引流、經(jīng)內(nèi)鏡塑料膽道支架、經(jīng)內(nèi)鏡金屬膽道支架、經(jīng)內(nèi)鏡金屬膽道支架聯(lián)合塑料支架;收集臨床資料并分析生存預(yù)后的影響因素。選擇41例惡性梗阻性黃疸患者,分別經(jīng)內(nèi)鏡鼻膽管引流、經(jīng)內(nèi)鏡膽道支架置入、經(jīng)內(nèi)鏡逆行胰膽管造影聯(lián)合化療或放療;采用SF-36量表和惡性梗阻性黃疸特異性量表QLQ-MOJ11進(jìn)行生活質(zhì)量評(píng)分并統(tǒng)計(jì)分析。選擇108例懷疑惡性膽道狹窄的患者,均進(jìn)行經(jīng)內(nèi)鏡逆行胰膽管造影和膽管內(nèi)超聲檢查,收集臨床資料并統(tǒng)計(jì)分析。結(jié)果:1.經(jīng)皮肝穿刺膽道引流、經(jīng)內(nèi)鏡膽道塑料支架引流、經(jīng)內(nèi)鏡膽道金屬支架引流、經(jīng)內(nèi)鏡膽道金屬支架聯(lián)合塑料支架引流這四種膽道引流方式成功率分別為54.2%,59.1%,70.8%,80.6%;并發(fā)癥的發(fā)生率分別為62.5%,27.2%,31.3%,16.7%;平均引流通暢時(shí)間分別為46天,82天,142天,164天;平均生存時(shí)間分別為191天,266天,284天,436天。通過(guò)COX風(fēng)險(xiǎn)回歸分析,肝功能Child分級(jí)、年齡、感染、腫瘤分期是死亡的危險(xiǎn)因素,而性別、引流的方法則減少死亡的風(fēng)險(xiǎn)。2.影響患者生活質(zhì)量的危險(xiǎn)因素包括膽紅素、CA199、CEA、ALP、GGT。TBIL≥100umol/L,CA199≥200U/m1,ALP≥200U/L,GGT≥200 U/L 均預(yù)示生活質(zhì)量較差。ERCP聯(lián)合化療或放療的患者情感角色分?jǐn)?shù)明顯增加。生存曲線顯示中位生存時(shí)間是10.2月;患者經(jīng)內(nèi)鏡鼻膽管引流、經(jīng)內(nèi)鏡膽道支架置入、經(jīng)內(nèi)鏡逆行胰膽管造影聯(lián)合化療或放療的中位生存時(shí)間分別為8.2月,8.2月,18.3月。3.通過(guò)內(nèi)鏡逆行胰膽管造影和膽管內(nèi)超聲技術(shù)的應(yīng)用,膽道狹窄及梗阻性黃疸病因診斷的特異性、敏感性、準(zhǔn)確性分別為67%,97%,99%。按照膽道梗阻部位分為:病變位于膽管分叉及左右肝管分隔即Bismuth Ⅱ(n=5,4.6%),病變超過(guò)膽管分叉并累及左右肝管即Bismuth Ⅲ(n=27,25%),病變已累及左右肝管及Ⅱ級(jí)膽管開(kāi)口即Bismuth Ⅳ(n=7,6.5%),膽總管中上段(n=35,32.4%),肝管中下段(n=5,4.6%),胰頭區(qū)域(n=29,26.9%)。膽道狹窄的平均長(zhǎng)度為3.4±1.3cm;塑料支架的長(zhǎng)度范圍從5cm到15cm;金屬支架的長(zhǎng)度范圍從1cm到10cm。結(jié)論:經(jīng)內(nèi)鏡膽道金屬支架聯(lián)合塑料支架引流可以提高膽道引流的成功率,減少并發(fā)癥,延長(zhǎng)引流通暢時(shí)間和生存時(shí)間。ERCP聯(lián)合放療或化療可以有效改善生活質(zhì)量和延長(zhǎng)生存時(shí)間。在ERCP過(guò)程中應(yīng)用膽管內(nèi)超聲技術(shù)有助于區(qū)分良惡性膽道狹窄,判斷梗阻水平,顯示膽道狹窄長(zhǎng)度;有助于選擇膽道引流支架的類(lèi)型和長(zhǎng)度。
[Abstract]:Objective: to investigate the effect, complications, unobstructed drainage and survival prognosis of malignant obstructive jaundice treated by different biliary drainage methods. The survival prognosis and quality of life of some patients were analyzed and evaluated. The characteristics of biliary drainage in patients with obstructive jaundice by intrabiliary ultrasound were analyzed. Methods: from December 2008 to October 2014. 152 cases of malignant obstructive jaundice with percutaneous hepatic puncture or endoscopic biliary drainage were divided into four groups: percutaneous hepatic puncture biliary drainage, endoscopic plastic biliary stent and endoscopic metallic biliary stent. Endoscopic metallic biliary stents combined with plastic stents; Clinical data were collected and prognostic factors were analyzed. 41 patients with malignant obstructive jaundice were treated with endoscopic nasobiliary drainage and endoscopic biliary stent implantation. Endoscopic retrograde cholangiopancreatography combined with chemotherapy or radiotherapy; The quality of life (QOL) was evaluated by SF-36 and QLQ-MOJ11. 108 patients with suspected malignant biliary stricture were selected. All patients underwent endoscopic retrograde cholangiopancreatography and intrabile duct ultrasonography. Clinical data were collected and analyzed statistically. Results 1. Percutaneous hepatic drainage and endoscopic biliary plastic stent drainage were performed. The successful rates of endoscopic biliary metal stent drainage and endoscopic biliary metal stent combined with plastic stent drainage were 54.2% and 70.8% respectively. The incidences of complications were 62.5 and 27.2and 31.3and 16.7respectively. The mean drainage patency time was 46 days 82 days 142 days and 164 days respectively. The mean survival time was 191d / 266d / 284days / 436days respectively. By COX risk regression analysis, liver function Child grade, age and infection were found. Tumor staging is a risk factor for death, while gender and drainage methods reduce the risk of death. 2. The risk factors affecting the quality of life of patients include bilirubin CA199CEACEA ALP. GGT.TBIL 鈮，

本文編號(hào)：1467531