内镜超声引导下胆管引流术治疗恶性梗阻性黄疸的价值（含视频）

Value of endoscopic ultrasonography-guided biliary drainage for malignant obstructive jaundice（with video）

摘要:

目的 探讨内镜超声引导下胆管引流术（EUS-BD）治疗恶性梗阻性黄疸的疗效及并发症处理。 方法 回顾性分析2016年4月至2017年1月共12例因恶性梗阻性黄疸行EUS-BD的患者临床及内镜操作资料。患者均因ERCP胆管引流失败或无法完成而改行EUS-BD，包括EUS引导下经胃经肝内胆管穿刺造瘘术（EUS-HGS）、胆管穿刺顺行金属支架置入术（EUS-AS）及经十二指肠经肝外胆管穿刺造瘘术（EUS-CDS）。记录操作完成情况、术前及术后1周内血清胆红素及肝酶水平、并发症发生及处理结果、住院天数及随访等。 结果 本组患者中2例行EUS-HGS，3例行EUS-AS，7例行EUS-CDS。术后总胆红素（t=3.462，P=0.005），直接胆红素（t=3.351，P=0.006），丙氨酸转氨酶（t=2.399，P=0.037），γ-谷氨酸转肽酶（t=3.256，P=0.031）均较术前显著下降，黄疸症状明显改善。术后发生并发症2例（16.67％）。1例EUS-HGS患者发生胆漏、胆汁性腹膜炎及气腹；1例EUS-CDS患者发生上消化道出血，均成功治疗。无急性胰腺炎、皮下气肿、气胸、纵隔气肿等并发症发生，无死亡病例。住院天数5～26 d，平均（13.75±6.92） d。 结论 在具有丰富ERCP与EUS操作经验的内镜中心，EUS-BD可作为ERCP胆管支架置入失败后的替代方法，术后需重点监护，及时发现与处理并发症。

Abstract:

Objective To analyze the efficacy of endoscopic ultrasonography-guided biliary drainage （EUS-BD） for malignant obstructive jaundice and the management of adverse events. Methods Clinical data of 12 patients with malignant obstructive jaundice， who underwent EUS-BD between April 2016 and January 2017， were retrospectively analyzed. All patients received EUS-BD after unsuccessful ERCP， including EUS-guided hepaticogastrostomy （EUS-HGS）， EUS-guided antegrade stenting （EUS-AS）， and EUS-guided choledochoduodenostomy（EUS-CDS）. Procedure outcomes， serum bilirubin and liver enzyme levels before the procedure and 1 week after， complications， treatment results， hospitalization time and follow-up were recorded. Results Two patients underwent EUS-HGS， 3 underwent EUS-AS， and 7 underwent EUS-CDS. Total bilirubin （t=3.462， P=0.005）， direct bilirubin （t=3.351， P=0.006）， alanine transaminase （t=2.399， P=0.037）， γ-glutamate transpeptidase （t=3.256， P=0.031） reduced significantly after the procedure. Two patients （16.67％） developed complications. A patient undergoing EUS-HGS developed bile leakage， biliary peritonitis， and pneumoperitoneum. A patient undergoing EUS-CDS developed upper gastrointestinal bleeding. Both patients were successfully treated. There were no other adverse events， such as acute pancreatitis， subcutaneous emphysema， pneumothorax and emphysema. No procedure-related death occurred. The mean hospital stay was 13.75 ±6.92 days （range 5-26 days）. Conclusion EUS-BD is a safe substitute after unsuccessful ERCP when performed by experienced biliary endoscopists. However， intensive care is necessary after the procedure for early detection and management of complications.