本文關(guān)鍵詞： 梗阻性黃疸 并發(fā)癥 預(yù)后因素　出處：《山西醫(yī)科大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:討論惡性病變造成的高位膽道梗阻,其原發(fā)病及介入手術(shù)操作等所導(dǎo)致的相關(guān)并發(fā)癥,并對影響預(yù)后的多種因素進(jìn)行分析,旨在盡量減少并發(fā)癥的發(fā)生,同時(shí)為綜合評估患者預(yù)后及指導(dǎo)臨床決策提供依據(jù)。方法:收集山西醫(yī)科大學(xué)第二醫(yī)院介入治療科2009年8月~2014年12月,經(jīng)病理和(或)影像學(xué)檢查確診的惡性高位膽道梗阻患者,完善相關(guān)術(shù)前檢查,對無手術(shù)禁忌癥的入選患者在DSA透視或B超引導(dǎo)下行經(jīng)皮經(jīng)肝膽道穿刺引流術(shù)和(或)支架置入術(shù)。如患者一般狀態(tài)允許,可考慮擇期放置膽道內(nèi)支架進(jìn)行膽汁內(nèi)引流和(或)病灶供血?jiǎng)用}置管化療等后續(xù)治療。介入手術(shù)后復(fù)查,收集患者一般資料及術(shù)前術(shù)后臨床檢查資料,并進(jìn)行1.統(tǒng)計(jì)術(shù)后并發(fā)癥發(fā)生種類及發(fā)病率,并分析主要并發(fā)癥發(fā)生原因2.將術(shù)后患者按預(yù)后情況分為預(yù)后差、預(yù)后良兩組,統(tǒng)計(jì)相關(guān)指標(biāo)(性別、年齡、ALT、AST、ALB、TBIL、ALP、GGT等)應(yīng)用非條件logistic回歸分析,先進(jìn)行單因素分析,選出影響預(yù)后的因素,再將這些因素行多因素分析,得出logistic方程,分析過程中統(tǒng)計(jì)水準(zhǔn)為α=0.05,即P0.05認(rèn)為有統(tǒng)計(jì)學(xué)意義。結(jié)果:1.入選本研究的病例共76例,男性41例,女性35例,術(shù)前診斷肝門部膽管癌31例,膽囊癌肝門部轉(zhuǎn)移15例,肝門部肝癌10例,惡性腫瘤肝門部淋巴結(jié)轉(zhuǎn)移8例,壺腹部癌肝門部轉(zhuǎn)移12例。因誘發(fā)膽心反射停止手術(shù)3例,其余均成功行PTCD和(或)支架置入術(shù)。行雙側(cè)引流+雙側(cè)支架5例,右側(cè)引流+支架26例,左側(cè)引流+支架10例,單純右側(cè)引流20例,單純左側(cè)引流10例,手術(shù)未成功3例,外院行引流+支架置入術(shù)后狹窄,于我科再行治療2例。2.主要由原發(fā)病因素造成的并發(fā)癥:電解質(zhì)紊亂30例,低蛋白血癥24例,貧血18例,膽系感染10例,急性腎功能衰竭9例;介入手術(shù)相關(guān)并發(fā)癥:膽道出血2例,肝膿腫2例,圍手術(shù)期死亡5例,急性胰腺炎7例,應(yīng)激性潰瘍1例,穿刺針道轉(zhuǎn)移1例,膽心反射3例,支架內(nèi)狹窄3例。各并發(fā)癥發(fā)生率為:膽系感染13.16%;電解質(zhì)紊亂39.47%;急性腎衰11.84%;膽道出血2.63%;肝膿腫2.63%;圍手術(shù)期死亡6.58%;低蛋白血癥31.58%;貧血23.68%;急性胰腺炎9.21%;應(yīng)激性潰瘍1.39%;穿刺針道轉(zhuǎn)移1.39%;膽心反射3.95%;支架內(nèi)再狹窄3.95%。3.影響預(yù)后的因素有年齡(P=0.006)、A/G(P=0.018)、ALB(P=0.025)、梗阻部位I(P=0.006),對預(yù)后無明顯影響的因素為ALT(P=0.265)、TBIL(P=0.258)、性別(P=0.421)、GGT(P=0.856)、AST(P=0.497)、ALP(P=0.514),進(jìn)一步得出logistic方程為Logistic(p)=1.332+0.681*年齡-0.215*A/G-0.335*ALB+1.587*梗阻部位I。結(jié)論:1.常見并發(fā)癥多由原發(fā)病變造成,發(fā)生率由高到低依次為電解質(zhì)紊亂、低蛋白血癥、貧血、膽系感染,急性腎衰;膽道出血、急性胰腺炎、應(yīng)激性潰瘍、穿刺針道轉(zhuǎn)移、膽心反射、術(shù)后支架再狹窄等介入相關(guān)并發(fā)癥發(fā)生率較低。介入手術(shù)能以較小的手術(shù)風(fēng)險(xiǎn)有效解除梗阻,減輕原發(fā)病造成的癥狀。2.年齡、A/G、ALB、梗阻部位與預(yù)后相關(guān),ALT、TBIL、性別、GGT、AST、ALP與預(yù)后無明顯關(guān)系,年齡為危險(xiǎn)因素,年齡愈大,預(yù)后愈差,同時(shí)A/G比值降低及ALB值降低也為危險(xiǎn)因素,提示預(yù)后不良。臨床工作中應(yīng)結(jié)合影響預(yù)后的因素綜合評價(jià)患者基本情況,嚴(yán)格選擇符合手術(shù)適應(yīng)癥的患者進(jìn)行介入治療,尤其對于年齡較大、一般狀態(tài)較差等導(dǎo)致預(yù)后不良的危險(xiǎn)因素較多的患者,提出科學(xué)合理的治療方案,個(gè)體化治療,望達(dá)到最好的臨床獲益。
[Abstract]:Objective: to discuss the high malignant biliary obstruction lesions caused by the complications due to the primary disease and interventional surgical operation, and the influences of various factors on the prognosis were analyzed, in order to minimize the occurrence of complications, and to evaluate the prognosis and guiding clinical decision-making provide a basis. Methods: interventional treatment of the second hospital of Shanxi Medical University in August 2009, ~2014 in December, confirmed by pathology and (or) patients with high malignant biliary obstruction diagnosed by imaging examination, improve the preoperative examination, no operative contraindications of patients enrolled in DSA fluoroscopy or ultrasound guided percutaneous transhepatic biliary drainage and (or) stenting. If the patients conditions allow and consider undergoing internal biliary drainage and biliary stent placement (or) lesions artery chemotherapy. The follow-up treatment tube after surgical intervention were collected with a General information and clinical examination data before and after surgery, and postoperative complications were 1. statistical types and incidence, and analyzes the main causes of complications in 2. postoperative patients according to prognosis for poor prognosis, prognosis of benign and two groups, statistical indicators (gender, age, ALT, AST, ALB, TBIL. ALP, GGT, etc.) and non conditional logistic regression analysis, single factor analysis, selected prognostic factors, then multivariate analysis for these factors, the logistic equation, the statistical level analysis process is a =0.05 P0.05 that has statistical significance. Results: 1. patients were enrolled in this study 76 patients, male 41 cases, female 35 cases, preoperative diagnosis of 31 cases of hilar cholangiocarcinoma, gallbladder carcinoma hepatic metastasis in 15 cases, 10 cases of hilar hepatocellular carcinoma, malignant hilar lymph node metastasis 8 cases, carcinoma of ampulla of hilar metastasis in 12 cases. Due to the induction of biliary cardiac reflex stop operation in 3 cases, the More successful for PTCD and (or) stenting. Bilateral drainage plus bilateral stent in 5 cases, right side drainage + stent in 26 cases, 10 cases of left side drainage + stent drainage in 20 cases, simple right, only the left drainage in 10 cases, no operation was successful in 3 cases, underwent drainage and stenting stenosis and in our department for treatment of 2 cases of.2. mainly by the factors of primary disease caused by complications: 30 cases of electrolyte disorder, hypoproteinemia in 24 cases, 18 cases of anemia, 10 cases of biliary infection, 9 cases of acute renal failure; interventional surgery related complications: 2 cases of biliary tract bleeding, 2 cases of liver abscess surgery 5 cases died, 7 cases of acute pancreatitis, 1 cases of stress ulcer, puncture needle tract metastasis in 1 cases, 3 cases of biliary cardiac reflex, stent stenosis in 3 cases. The incidence rate of complications was 13.16%: biliary tract infection; electrolyte disorder 39.47%; 11.84% acute renal failure; biliary tract bleeding 2.63%; 2.63% liver abscess; surgery died 6.58%; hypoproteinemia in 31.58% 23.68% 9.21%; anemia; acute pancreatitis; stress ulcer 1.39%; puncture needle tract metastasis 1.39%; bile cardiac reflex 3.95%; in stent restenosis 3.95%.3. prognostic factors were age (P=0.006), A/G (P=0.018), ALB (P=0.025), I (P=0.006), obstruction of factors had no significant effect on the pre ALT (P=0.265), TBIL (P=0.258), gender (P=0.421), GGT (P=0.856), AST (P=0.497), ALP (P=0.514), further concluded that logistic equation is Logistic (P) =1.332+0.681* age -0.215*A/G-0.335*ALB+1.587* obstruction I. conclusion: 1. common complications caused by primary disease, the incidence rate from high to low in order to electrolyte disorder, hypoproteinemia, anemia, biliary infection, acute renal failure; biliary tract hemorrhage, acute pancreatitis, stress ulcer, needle tract metastasis, biliary cardiac reflex, postoperative restenosis related support intervention with low incidence of complications. Surgical intervention with minor surgery The risk effectively relieve the obstruction symptoms of.2. age, primary disease caused by reducing A/G, ALB, the site of obstruction is related with the prognosis, ALT, TBIL, GGT, AST, sex, no obvious relationship between ALP and prognosis, age, risk factors, age, the prognosis is worse, and the ratio of A/G decreased and the decrease of ALB value for risk factors of poor prognosis. Patients should be combined with the influence of the basic situation of comprehensive evaluation of the prognostic factors in the clinical work, with strict selection of surgical indications in patients with interventional therapy, especially for older age, poor performance status as a result of many risk factors of poor prognosis of the patients, put forward scientific and reasonable treatment and individualized treatment. Is expected to achieve the best clinical benefit.

【學(xué)位授予單位】：山西醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R735.8

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