Abstract Objective To investigate the efficacy and complications stent implantation in the treatment of malignant biliary obstruction. Methods 46 patients with malignant biliary obstruction were accepted in the DSA guided percutaneous transhepatic biliary stenting. 46 cases placed biliary stents, shared bracket 50, of which 13 were double bracket, 4 patients passing through the hepatic artery chemotherapy and (or) embolism. The jaundice total effective rate of 85.4%. Stent blockage five cases. Major complications: sepsis, 3 cases of liver damage and six cases. Conclusion stent implantation success rate, jaundice effective, safe and simple method of treatment in the palliative treatment of malignant biliary obstruction.
Key words bracket; intervention; malignant biliary obstruction
Malignant biliary obstruction due to bile duct cancer, liver cancer, pancreatic cancer and metastatic cancer malignancy have a higher prevalence, often discovered at an advanced stage. Stenting is the preferred method of treatment of biliary obstruction, retrospective analysis of our hospital from May 2003 to July 2005, with complete data malignant biliary obstruction underwent stent implantation, has made a good effect, are as follows.
1 Data and methods
1.1 Clinical data The group of 46 cases, male 37 cases, 9 females, aged 38 to 92 years, with an average of 68.7 years old. Before treatment combined pathology diagnosed by B ultrasound, CT, MR. Cholangiocarcinoma in 17 cases, 15 cases of metastatic cancer, liver cancer six cases, three cases of pancreatic cancer, ampullary cancer, gallbladder 1 cases.
1.2 treatment before surgery given antibiotics and other supportive therapy, understanding of the heart, lung, renal function, preoperative 0.5h intramuscular pethidine 50mg, heart, blood pressure, oxygen saturation, heart electric guardianship observed under DSA, first PTC angiography showed that the site of obstruction, scope, extent, trial loach guidewire through the narrow section, if not by external drainage with 8.5 F 10.2 F (Cook Company) outside the drainage pipe line, drainage about one week after placing biliary stents; through you can replace the hard guide wire stents before external drainage catheter; through the narrow segment more difficult, difficult to pass the stent delivery is expected along the guide wire into the balloon catheter (balloon diameter of 4 ~~ 6mm, length 20mm), pre-expansion of the narrow section of stents. The imaging showed duodenum involvement simultaneously through the mouth, esophagus, stomach, duodenum stent implantation.
Viable the TAI and (or) TAE 1.3 stents commonly used 5 Fu 1000 to 1500mg DDP 60 ~~ 80mg, the THP 40 ~~ 60mg or MMC 10 ~ 14mg three drugs combination therapy, the tumor blood supply, dyeing obvious super-selective catheterization, chemotherapy drugs used lipiodol emulsion embolization lipiodol commonly ~~ 10ml. Each arterial chemotherapy interval of 4-7 weeks. All patients were followed up.
1.4 statistical methods at all levels values are ± s and data applications t test, with P <0.05 was considered significant sexual.
2.1 46 cases of malignant biliary obstruction were puncture placed successfully. From surgery the first day of the signs and symptoms are improved. 21 cases the right approach, the approach in eight cases, 17 cases for a dual approach. All patients placed stents are placed outside the drainage or external drainage, shared the 50 bracket, including 13 cases of double stent, three cases of duodenal stents. Stent diameter of 8mm, a length of 40 ~~ 100mm. Eight cases the guide wire in the first operation failed to pass the obstruction segment, placed drainage tubes, until by obstruction paragraph after stent implantation, the rest placed a successful, four cases of stent occlusion stents again. Boston 3 cases of duodenal stents (diameter 22mm, length 90mm). The right and left hepatic duct obstruction, stent due to economic reasons, on one side, the other side is placed outside the drainage tube 11 cases. 1 patient with liver fibrosis hardens, the first one stent failed to pass damage, the replacement of the stent implantation success. The implanted stent placed by drainage tube 7 ~ 10d, in jaundice basic subsided, unobstructed drainage, patients in stable condition after extubation without infection. The jaundice total effective rate of 85.4%, preoperative, postoperative 1 to 3d to 7d checking serum total bilirubin (STB), alanine aminotransferase (ALT), aspartate aminotransferase (AST) changes, as shown in Table 1. Table 146 patients with stent implantation, the postoperative part liver function indicators change Note: STB: normal: from 5 to 17.1μmol / L; ALT: normal: 0 ~ 40U / L; AST: normal: 0 ~ 45U / L. Compared with preoperative * P <0.05, ** and postoperative days 1-3 compared to P <0.052.2 surgery hemobilia 13 cases, application of hemostatic agents after treatment without further bleeding. Sepsis in 3 cases, the use of antibiotic treatment and maintain internal and external drainage unobstructed cure. 9 cases of retrograde infection, stent stenosis in 3 cases, and 1 case due to poor stent position, resulting in stent retraction within the narrow section, had stents again. 1 A 92-year-old woman, after stent implantation heart rate fell from 65 beats / min to 42 beats / min after intramuscular atropine 1mg no rise in heart rate, implantation of a temporary pacemaker, heart rate increased to 65 to 70 times / points, stable condition after surgery patients, the survival period of up to 3 months. 5 patients had varying degrees of liver dysfunction. In three cases, within 30 days of death, accounting for 6.5% died because of liver failure, gastrointestinal bleeding and systemic failure. 3 patients with multivessel bile duct obstruction after surgery a few days STB declined and then was progressively increased, and death within 60 days.
Serum total bilirubin 2.3 4 cases to be dropped, the liver function was restored, the line TAE surgery and (or) TAI surgery, a month, up to 4 times, three patients in the postoperative January death of three patients survived for more than 6 months, patients have survived 2 years.
Biliary stenting palliative treatment of malignant biliary obstruction is a minimally invasive treatment can be repeated, can effectively relieve malignant biliary obstruction, its effect with a surgical shunt comparable . Can significantly improve survival time and quality of life for patients with unresectable tumors, is also the further treatment of the tumor to create conditions the domestic reporting success rate of 98.6% . Operation technology, PTC line to find the right bile duct is the first step to successful operation, the guide wire can be passed obstruction was the key to the success of surgery. For the guidewire is temporarily unavailable through the the obstruction segment of patients first PTCD surgery, after stent implantation, avoid hard and fast operation, perforation of the bile duct wall to prevent the guide wire. For the prevention and treatment of stent poor drainage, postoperative Orders placed drainage tube 1 to 2 weeks, bile duct patency of drainage tubes were removed, no fever before the drainage tubes angiography confirmed. After conventional intravenous antibiotics and hemostatic agents, and saline plus gentamicin rinse the outside drainage tube to prevent clogging.
Jaundice basic subsided after stent implantation, the drainage tube can be removed after the infection was controlled. Placed a stent can be simple common bile duct obstruction, the lower end of stent try not to exceed the ampulla avoid retrograde biliary bacteria into the cause infection. Bilateral hepatic duct obstruction should put one of each bracket. Due to economic and other reasons, some patients with stents only on one side, the other side is placed outside the drainage. We use the self-expanding biliary stents, therefore, does not require conventional balloon dilatation, only can not be stent delivery or review of the opening is not ideal, consider balloon dilation . The stent restenosis affect the long-term effect, caused by the the stent stenosis reasons  is a variety of reasons granulation tissue formation, tumor growth and cholestasis. The three cases in this group after 3,5 and 6 months restenosis. The foreign study confirmed biocompatible  biodegradable polylactic acid scaffold degradation can be absorbed in the body, in the bile duct expansion patency time of up to six months or more, and better application prospects. Reported in the literature  the postoperative joint the TAI surgery and (or) TAE surgery, can delay jaundice recurrence and prolong the lives of patients.
Foreign literature  stenting complications: postoperative sepsis, bleeding requiring transfusion, cholangitis reflection of the gall heart surgery, peritonitis, pancreatitis, cholecystitis, etc.. The group 1 patients consider patients older, temporary pacemaker implantation.