单人经口胆道镜与射频消融术同台诊治不可切除肝外胆管癌的可行性与安全性研究

Feasibility and safety of single peroral choledochoscopy combined with endoscopic radiofrequency ablation for the diagnosis and treatment of unresectable extrahepatic bile duct carcinoma

摘要:

目的 探讨单人经口胆道镜联合射频消融术（radiofrequency ablation，RFA）同台诊治不可切除肝外胆管癌的可行性和安全性。方法 回顾2013年1月至2022年1月期间在杭州市第一人民医院治疗的90例可疑肝外胆管癌患者资料，根据诊治过程最终纳入69例，分为常规分次组（n=34）：先经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography， ERCP）+细胞刷或单人经口胆道镜检查取得活检组织，待获得阳性病理结果再次行ERCP+RFA；同台诊治组（n=35）：行ERCP经单人经口胆道镜检查胆道并对病灶行直视下活检，对术中快速病理结果确定为恶性肿瘤的患者同台行RFA。对比两组操作成功率、术后胆红素恢复情况、ERCP次数、术后不良事件发生率、住院时间及费用。结果 两组患者均成功完成内镜下RFA，操作成功率100.0%（69/69）。分次组和同台组总胆红素术后下降50%及以上的患者比例差异无统计学意义［52.94%（18/34）比57.14%（20/35），χ2=0.27，P=0.604］。分次组ERCP次数明显多于同台组［（2.59±0.50）次/人比（1.00±0.00）次/人］，差异有统计学意义（t=3.13，P=0.002）。分次组和同台组术后总体不良事件发生率差异无统计学意义［（67.65%（23/34）比65.71%（23/35），χ2=2.83 ，P=0.626］。分次组住院时间明显长于同台组，差异有统计学意义［（17.41±9.13） d比（7.91±3.48） d，t=5.32，P=0.001］。分次组住院费用明显多于同台组，差异有统计学意义［（37 127.88±3 763.77）元比（23 980.69±4 767.15）元，t=6.61，P=0.001］。结论 单人经口胆道镜直视下诊断+活检联合RFA同台诊治不可切除肝外胆管癌可减少ERCP次数，并且不增加术后不良事件发生率，是一种安全有效且具有较高成本-效益比的诊治方法。

Abstract:

Objective To investigate the feasibility and safety of single peroral choledochoscopy combined with radiofrequency ablation (RFA) for nonresectable extrahepatic cholangiocarcinoma (EHCC). Methods A total of 90 patients with suspected EHCC treated in Hangzhou First People''s Hospital from January 2013 to January 2022 were reviewed. According to the diagnosis and treatment process, 69 patients were finally included and divided into two groups. Thirty-four patients were assigned to the routine group: biopsy tissues were obtained by endoscopic retrograde cholangiopancreatography (ERCP)+ cell brush or single peroral choledochoscopy, and then ERCP+RFA were performed again after positive pathological results were obtained. In the combination group, 35 patients underwent single peroral choledochoscopy under ERCP, and biopsy of the lesions was obtained under direct vision, and RFA was performed on the patients identified as malignant tumors based on rapid pathologic results. Operation success rate, postoperative bilirubin recovery, ERCP times, postoperative adverse event incidence, length of hospital stay and cost were compared between the two groups. Results All patients in both groups successfully completed RFA with the operation success rate of 100.0% (69/69). There was no significant difference in the proportion of patients with ≥50% decrease in total bilirubin between the routine group and the combination group [52.94% (18/34) VS 57.14% (20/35), χ2=0.27, P=0.604]. The number of ERCP in the routine group was significantly higher than that in the other group, with significant difference (2.59±0.50 times/person VS 1.00±0.00 times/person, t=3.13, P=0.002). There was no significant difference in the overall incidence of postoperative adverse events between the two groups [67.65% (23/34) VS 65.71% (23/35), χ2=2.83, P=0.626]. The length of hospital stay in the routine group was significantly longer than that in the combination group, with significant difference (17.41±9.13 days VS 7.91±3.48 days, t=5.32, P=0.001). The hospitalization cost in the routine group was significantly higher than that in other group, with significant difference (37 127.88±3 763.77 yuan VS 23 980.69 ±4 767.15 yuan, t=6.61, P=0.001). Conclusion Single peroral choledochoscopy combined with biopsy and RFA in the same operation for unresectable EHCC can reduce the number of ERCP without increasing the incidence of postoperative adverse events. It is a safe and effective method with high cost-benefit ratio.