：胆道支架治疗远端恶性胆道梗阻相关并发症的防治.docx

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1、最新：胆道支架治疗远端恶性胆道梗阻相关并发症的防治（完整版）【提要】远端恶性胆道梗阻患者胆道支架置入术后并发症包括胆囊炎、胰腺炎、复 发性胆道梗阻、出血和非梗阻性胆管炎等，准确地认识这些相关并发症, 及时采取有效治疗措施，对更安全有效地应用胆道支架具有重要的临床意 义。【关键词】胆道肿瘤；支架；手术后并发症；黄疸，阻塞性；远端恶 性E道梗阻梗阻由胆管癌、胰腺癌以及壶腹周围癌等引起，由于早期诊断困难，只有 约20%的患者在确诊时可以考虑手术治疗，绝大多数出现黄疸等症状时已 经失去手术机会1 ，其可继发胆道感染、肝功能衰竭及全身衰竭等症状， 有效的胆道引流对改善患者症状和预后十分重要。自1979年

2、Soehendra 等2 首次通过内镜逆行胰胆管造影术（ERCP ）置入支架治疗恶性胆道 梗阻以来，多项研究证实ERCP成功置入支架不仅能改善梗阻症状，同时 相较手术和经皮经肝胆管引流术（PTBD ）支架置入，术后并发症发生率、 死亡率更低，住院时间更短34 ,因此内镜下胆道支架置入术已成为远 端恶性胆道梗阻姑息治疗的首选方案56 1对于可切除的远端恶性胆道 梗阻，目前不推荐常规术前引流，其会增加引流后和手术相关并发症的发 生率7-8 ,对于继发严重并发症或接受新辅助治疗的患者，术前引流是 重要的是在死亡或手术前具有更长的通畅时间和更少的并发症。对于目前 市场现有的塑料或金属支架，支架梗阻的问

3、题仍然是影响其疗效的重要原 因，随着支架置入途径不断完善，支架类型及材料改进，期待能够有一种 理想支架或新的治疗方法，可有效解决恶性胆道梗阻支架置入术后相关并 发症的问题。参考文献1 Vincent A, Herman J, Schulick R, et al. Pancreatic cancer(J. Lancet, 2011,378(9791):607-620. DOI: 10.1016/S0140-6736(10)62307-0.2 Soehendra N, Reynders-Frederix V. Palliative bile duct drainage - a new endosc

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7、iary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline-updated October 2017(J.Endoscopy, 2018,50(9):910-930. DOI: 10.1055/a-0659-9864.7 van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cance

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11、 of expandable metallic biliary stents in resectable pancreatic cancer(J. Am J Gastroenterol, 2005,100(9):2056-2061. DOI: 10.1111/j.1572-0241.2005.42031.x.12 Tringali A, Hassan C, Rota M, et al. Covered vs. uncovered self-expandable metal stents for malignant distal biliary strictures: a systematic

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14、ts for palliation in patients with malignant extrahepatic biliary obstruction: a systematic review and network meta-analysisJ. J Pers Med, 2021,11(2). pulished online ahead of print. DOI: 103390/jpm 11020086.16 Cao J, Peng C, Ding X, et al. Risk factors for post-ERCP cholecystitis: a single-center r

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17、metallic stent placement in distal malignant biliary obstruction. Dig Endosc,2018,30(3):380-387. DOI: 10.1111/den.12991.20 Suk KT, Kim HS, Kim JW, et al. Risk factors for cholecystitis after metal stent placement in malignant biliary obstruction J. Gastrointest Endosc, 2006,64):522-529.DOI:10.1016/j

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19、allic stents with cholecystitis and stent migration in malignant biliary stricturefJ. Gastrointest Endosc, 2018,87(4):1061-1070. DOI: 10.1016/j.gie.2O17.08.024.23 Almadi MA, Barkun AN, Martel M. No benefit of covered vs uncovered self-expandable metal stents in patients with malignant distal biliary

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33、ol stents with partially covered stainless stents as a historical control in a multicenter study of distal malignant biliary obstruction: the WATCH study(J. Gastrointest Endosc, 2012,76(1):84-92. DOI: 10.1016/j.gie.2O12.02.039.41 Kitano M, Yamashita Y, Tanaka K, et al. Covered self-expandable metal

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35、a H, Komatsu Y, Tsujino T, et al. A prospective randomised study of covered* versus uncovered diamond stents for the management of distal malignant biliary obstruction. Gut, 2004,53(5):729-734. DOI: 10.1136/gut.2003.018945.43 Krokidis M, Fanelli F, Orgera G, et al. Percutaneous treatment of malignan

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40、in patients with malignant distal biliary obstruction. J Gastroenterol, 2013,48(11 ):1300-1307. DOI:10.1007/S00535-013-0751-z.49 OBrien S, Hatfield AR, Craig PI, et al. A three year follow up of self expanding metal stents in the endoscopic palliation of longterm survivors with malignant biliary obs

41、truction(J). Gut, 1995,36(4):618-621. DOI: 10.1136/gut.36.4.618.50 Silvis SE, Sievert CE, Vennes JA, et al. Comparison of covered versus uncovered wire mesh stents in the canine biliary tract(J. Gastrointest Endosc, 1994,40(1):17-21. DOI: 10.1016/s0016-5107(94)70004-4.51 Sofi AA, Khan MA, Das A, et

42、al. Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysisJ. Gastrointest Endosc, 2018,87(4):944-951.e1. DOI: 10.1016/j.gie.2O17.10.029.52 Kadayifci A, Atar M, Forcione DG, et al. Radiofrequen

43、cy ablation for the management of occluded biliary metal stentsJ). Endoscopy, 2016,48(12):1096-1101. DOI: 10.1055/S-0042-115938.53 Galandi D, Schwarzer G, Bassler D, et al. Ursodeoxycholic acid and/or antibiotics for prevention of biliary stent occlusionJ. Cochrane Database Syst Rev, 2002(3):CD00304

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45、s not required for bile duct stent placement. Dig Endosc, 2014,26(1):87-92. DOI: 10.1111/den.12058.56 ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, et al. Antibiotic prophylaxis for GI endoscopyJ. Gastrointest Endosc, 2015,81(1):81-89. DOI: 10.1016/j.gie.2O14.08.008.有必要的，且临床上内镜途径更受青

46、睐9-10 o随着化学及靶向药物等 辅助治疗的进展，患者生存期及生活质量随之改善，但是支架置入后相关 并发症的问题突显出来。可切除的远端恶，性胆道梗阻术前引流后并发症的 发生率可高达90%以上11,姑息引流的恶性胆道梗阻患者并发症的发 生率在10%40%之间12 ,其主要包括胆囊炎、胰腺炎、复发性胆道 梗阻、出血和非梗阻性胆管炎等。并发症的发生风险与置入胆道支架类型、 肿瘤位置及患者情况密切相关，胆道支架可分为塑料支架以及覆膜或裸自 膨式金属支架(SEMS )，研究表明SEMS较塑料支架具有更长的通畅时间、 更少的并发症发生率及再干预次数，无论姑息引流或术前引流推荐首选 SEMS 11,13-

47、14至于哪种SEMS优先选择,目前仍无明确结论，最 近的一项Meta分析显示覆膜SEMS和裸SEMS两者的通畅时间和总体并 发症发生率差异无统计学意义15 因此我们就近两年来国内外关于远 端恶性胆道梗阻支架置入术相关并发症防治现状和研究作一综述。一、胆囊炎支架置入后胆囊炎的发生率为1.35%15.3% 16-17 其多由胆汁淤积、 缺血或两者共同导致18 ,胆囊炎可以引起腹痛，影响化疗方案及治疗 策略。内镜下胆道支架置入术后发生胆囊炎的危险因素包括：肿瘤累及胆 囊管口、置入高轴向力SEMS、SEMS长度460 mm、肿瘤侵犯胆囊的供 应动脉、造影剂流入胆囊及支架类型等。一系列的研究已证实肿瘤累

48、及胆 囊管是SEMS置入后发生胆囊炎的重要危险因素17,19-21 1 Isayama 等21 通过胆管腔内超声（IDUS ）评估肿瘤的位置，根据多因素分析, 发现肿瘤累及胆囊管使胆囊炎发生风险增加46.21倍，其原因可能是由 于肿瘤累及胆囊管口同时置入SEMS的机械压迫导致胆囊管口的狭窄或阻 塞，造成胆汁淤积。之前的研究发现伴有胆囊结石的患者SEMS置入使术 后胆囊炎发生风险增加5.6倍20 而Jang等22 指出即使存在胆 囊结石，支架置入后周围胆汁引流仍可以是正常的，所以应具体评估结石 的大小、数量和位置后判断其是否为独立危险因素。理论上，流经胆囊管 口的胆汁可以通过裸SEMS壁的网孔，减少胆汁淤积的发生，胆囊炎的发 生风险应该小于覆膜SEMS ,然而相关Meta分析显示其风险与SEMS覆 膜与否无关12,231根据之前的报告，轴向力和径向力是SEMS两种重要的力学性能，轴向力 是促使SEMS弯曲后变直的恢复力，径向力是对抗外界压迫的扩张力，两 者共同维持支架的通畅，同时SEMS的长度和轴向力成反比24 ； Nakai 等25 发现置入高轴向力的SEMS和SEMS长度460 mm为术后发