【作者】 张军；

【导师】 郭启勇；

【作者基本信息】 中国医科大学 ， 影像医学与核医学， 2004， 硕士

【摘要】 目的 恶性梗阻性黄疸是由于各种恶性肿瘤或癌性淋巴结侵袭压迫胆管，并在临床上引起黄疸的一组病例。对于恶性梗阻型黄疸的治疗传统的方法为外科手术，疗效肯定，对于那些失去手术机会的患者，近年来的治疗方法为经皮肝穿刺引流术，并于胆管留置支撑器，多为留置金属内支架与金属内涵管，文献报道较多，疗效得到肯定，但对于二者之间的临床疗效对比研究尚匮乏。本文旨在研究此两种方法对于缓解恶性梗阻性黄疸患者出现二次黄疸的时间有无差异从而判定二者的临床效果。 方法 一 研究对象 共收集恶性梗阻性黄疽患者24例，男性18例，女性6例，年龄39-83岁，平均61.4岁。其中原发胆管癌16例，胃癌术后淋巴结转移侵袭胆管3例，胰头癌2例，肝癌3例。将24例患者分成两组，一组(17例)留置金属支架，另一组(7例)留置塑料内涵管。 二 实验仪器及材料 试验仪器：日本SHIMADZU公司生产的SDU-500C普通超声探测仪，1250毫安数字减影监视系统(DSA)。 手术器材：5F肝胆管穿刺针，0.035inch超滑引导钢丝，6-8F多侧孔引流导管，76％复方泛影葡胺造影剂。 试验所需胆管支撑器：国产自膨胀式网状金属支架，规格为直径10mm，长度4-8cm不等(价位在6000-8000元)；进口8.5F多侧孔塑料内涵管(价位在3000元左右)。试验方法：先行经皮经肝胆管引流术(percu-taneous transhePatic chdangio目冠p场’皿d drainage:月℃D)即在B超引导下用SF套管针经皮经肝穿刺左和/或右肝内胆管，透视下行胆道造影，明确胆管狭窄的部位及程度，然后经穿刺针外套管跟人导丝，导丝通过狭窄段后撤除外套管，经导丝跟人多侧孔引流导管完成内引流。不能完成内引流者先行外引流3一7天，待胆管壁水肿消退后再完成内引流。内引流7一10天左右行胆管造影，若扩张胆管回缩近正常，狭窄部位显示清晰，透视下行胆管内金属支架或内涵管留置术。其中支架留置后保留引流管3一5天，关闭引流管，之后再次造影，确定支架膨胀良好，胆汁引流通畅后拔管。留置内涵管者造影后直接拔管。所有患者在完成该治疗后定期行TAE或TAI(u彻s旧卜te五al elnbolizatio可i面sion)治疗l一3次。 观察指标:24例患者中17例患者留置自膨胀式金属支架26枚，7例患者留置塑料内涵管10枚.以两组患者留置支撑器前胆红素下降指标和出现二次黄疽的时间为观察指标。 三统计学处理 两组患者例数不等，采用秩和检验及t检验，以a二0.05为检验标准。结果 124例患者均顺利行PrCD并留置了胆管支撑器，无明显并发症出现。 2治疗前后胆红素指标下降水平无显著差异(P>0.2)，具有可比性。 3两组患者出现二次梗阻性黄疽的时间具有统计学意义(P<0 .05)，支架组出现二次梗阻性黄疽的时间长塑料内涵管组。 4内涵管组出现再狭窄后可成功地将内涵管推至十二指肠(2例)。结论 1经皮肝脏穿刺引流治疗方法安全有效，适应症广，并发症少。 2金属支架留置术治疗恶性梗阻性黄疽的临床效果优于内涵管，出现二次梗黄时间明显延长。 3塑料内涵管的优势在于可移动性，出现再次梗阻后可将其推送至十二指肠，且价位便宜。更多还原

【Abstract】 PrefacePatient with malignant obstructive jaundice is caused by various malignant tumor or carcinogenic lymph nodes which invade and press bile duct and lead to jaundice. The traditional treatment for malignant obstructive jaundice is surgical method which has firm effect. Recent method for the patient who lost operative chance is PTCD and stent deployed - usually metallic and plastic stent - within bile duct. This method is reported by many document and has firm effect. But now the research of therapeutic effect comparison between both method is insufficient.ObjectiveOur research aim at the difference between the time at which patient of malignant obstructive jaundice with the two method appear secondary jaundice, therefore we can judge the clinical therapeutic effect between both methods.Methods/materialsObject of study: collection of 24 patient with malignant obstructive jaundice include 18 males and 6 females whose age range from 39 to 83 and is about 61. 4 in average. There are 16 patients with carcinoma of bile duct, 3 patients with lymph nodes metastasis invading bile duct after operation of gastric carcinoma, 2patients with carcinoma of pancreatic head, 3 patients with hepatic carcinoma. We divide the 26 patients into two groups. One group with 17 patients included has the treatment of metallic stent deployed, and the other group with 7 patients included has plastic stent deployed.Experimental method;Experimental devices:Operative instrument:Experimental method: PTCD was performed firstly. Puncture left or right intrahepatic bile duct using needle (COOK, 5F, for bileduct) , then followed cholangiography which was to define the site and extent of bile stenosis. Guide-wires were put through the stenostic parts, and take out the drivepipe of needles, and then various drainage catheters with multipore were put into the bile duct through guidewires. Thus the inner drainage had been completed so far. Sometimes inner drainage was not performed easily, a drainage catheter should be inserted to the bile ducts firstly for 3 -7days, and after drainage the guide-wires should be easier in putting in to duodenum. Cholangiography was performed at 7 - 10 days after inner drainage. If the dilating bile duct contract back to normal size and the picture of stenotic part was detected clearly, then metallic or plastic stent should be deployed in bile ducts under the guidance of fluorosco-py. For the cases who were deployed metallic stent, the drainage catheters should be closed and retained in the bile ducts for 3 - 5 days, and then cholangiography was perfored again to make sure whether the stent expand well or not. If the stents had got good position and well expanded, the drainage catheters should be removed after cholangiography. For the cases who were deployed plastic stent, the drainage catheters should be removed instantly after stent deployed and while it was proved that stent had got well position by cholangiography. TAE or TAI procedures were performed regularly for 1 - 3 times in all patients after the bile duct stenting.Observeing Index: In the 24 patients, 26 self - expanding metallic stents were deployed in 17 patients, and 10 plastic stents were deployed hi 7 patients. The decreasing value of bilirubin of patient before stent deployed and the time at which they appear secondary jaundice were chosen as observative index.Statistical management: because the number of two group was not equal, log test and t test were 4used, and = 0.05 was taken as test standard.ResultPTCD and bile duct stenting were performed successfully in all of 24 patients without any severe complications.There was no significant statistical difference of bilirubin decreasing value between before and after treatment ( P > 0.2 ).There was statistic difference in the time of secondary jaundice appearing of both group ( P < 0. 05 ). The duration of secondary jaundice in metallic stent goup was longer than the plastic stent group.The plastic stents was pushed to the duodenum successfully in 2 case更多还原