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中华普通外科学文献(电子版)

中华普通外科学文献(电子版) ›› 2021, Vol. 15 ›› Issue (06) : 412 -417. doi: 10.3877/cma.j.issn.1674-0793.2021.06.003

论著

支架联合125I粒子腔内照射与姑息性手术治疗晚期肝外胆管癌的对比研究
梅治永1, 庞青1, 王勇2, 满忠然1, 金浩2, 刘会春2,†()   
  1. 1. 233004　蚌埠医学院第一附属医院肝胆外科
    2. 233004　蚌埠医学院第一附属医院肝胆外科；233041　合肥，安徽省第二人民医院肝胆胰外科
  • 收稿日期:2021-06-15 出版日期:2021-12-01
  • 通信作者: 刘会春
  • 基金资助:
    安徽省学术和技术带头人及后备人选科研活动经费资助项目(2018D194); 安徽省自然科学基金杰出青年项目(2008085J37)

Comparison of the efficacy between stent combined with 125I seeds intracavitary irradiation and palliative surgery in advanced extrahepatic cholangiocarcinoma

Zhiyong Mei1, Qing Pang1, Yong Wang2, Zhongran Man1, Hao Jin2, Huichun Liu2,†()   

  1. 1. Department of Hepatobiliary Surgery, the First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China
    2. Department of Hepatobiliary Surgery, the First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China; Department of Hepatopancreatobiliary Surgery, Anhui No.2 Provincial People’s Hospital, Hefei 230041, China
  • Received:2021-06-15 Published:2021-12-01
  • Corresponding author: Huichun Liu
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引用本文：

梅治永, 庞青, 王勇, 满忠然, 金浩, 刘会春. 支架联合125I粒子腔内照射与姑息性手术治疗晚期肝外胆管癌的对比研究[J]. 中华普通外科学文献(电子版), 2021, 15(06): 412-417.

Zhiyong Mei, Qing Pang, Yong Wang, Zhongran Man, Hao Jin, Huichun Liu. Comparison of the efficacy between stent combined with 125I seeds intracavitary irradiation and palliative surgery in advanced extrahepatic cholangiocarcinoma[J]. Chinese Archives of General Surgery(Electronic Edition), 2021, 15(06): 412-417.

目的

探讨胆道支架基础上联合腔内125I粒子置入与传统的姑息性手术（PS）在晚期肝外胆管癌（EHCC）患者中的应用和疗效对比。

方法

回顾性分析2014年1月至2019年12月在蚌埠医学院第一附属医院肝胆外科入院并接受治疗的晚期EHCC患者136例。根据治疗方式，将患者分为两组：联合组（接受胆道支架联合腔内125I粒子置入术，91例）和PS组（接受开腹胆管空肠吻合联合胆囊切除术，45例）。观察两组患者术后1、3、6个月血清胆红素、转氨酶及白蛋白（ALB）水平的变化；分析比较两组患者住院时间及费用、术后并发症；Kaplan-Meier曲线分析总体生存率（OS）有无差异，Cox回归分析影响患者术后OS的独立因素。

结果

联合组和PS组患者术后1、3、6个月血清胆红素、转氨酶及ALB水平均较术前有不同程度的改善。两组患者总体并发症发生率差异无统计学意义（P=0.073）。与PS组相比，联合组患者的住院时间显著缩短、住院费用有所降低（均P<0.001），术后OS明显延长（P=0.017）。亚组分析提示，联合治疗在肝门部胆管癌患者中的优势较远端胆管癌更为明显。接受PS治疗（HR=2.665，95% CI：1.544~4.564，P<0.001）、术前血清高CA19-9水平（HR =2.031，95% CI：1.201~3.432，P=0.008）及术前低ALB水平（HR =1.908，95% CI：1.130~3.221，P=0.016）是影响患者术后OS的独立危险因素。

结论

与传统的PS相比，胆道支架联合腔内125I粒子置入可显著减少晚期EHCC患者的住院时间，降低住院费用及延长生存时间，但不增加总体并发症，值得在临床上进一步推广和应用。

关键词: 胆管肿瘤, 近距离放射疗法, 支架, 姑息性手术, 总体生存率
Objective

To explore and compare the clinical application of biliary stent combined with 125I seeds implantation and palliative surgery (PS) in patients with advanced extrahepatic cholangiocarcinoma (EHCC).

Methods

136 advanced EHCC patients, who were admitted into Department of Hepatobiliary Surgery, the First Affiliated Hospital of Bengbu Medical College and received medical treatment between January 2014 and December 2019, were analyzed retrospectively. According to the treatment method, the patients were divided into two groups: combination group (received biliary stent combined with 125I seeds implantation, 91 cases) and PS group (underwent open choledochojejunostomy and cholecystectomy, 45 cases). The levels of serum bilirubin, aminotransferase and albumin (ALB) were observed at 1, 3 and 6 months postoperatively in the two groups. The length of stay, hospital costs, and postoperative overall complications were compared between the two groups. Kaplan-Meier curves were used to analyze the differences in overall survival (OS).

Results

The serum levels of bilirubin, transaminase, and ALB at 1, 3, and 6 months postoperatively were improved in both groups, compared with preoperative values. There was no statistically significant difference in postoperative overall complications between the two groups (P=0.073). Compared with the PS group, the length of stay was significantly shorter (P<0.001), hospital costs were significantly less (P<0.001), OS was significantly better in the combination group (P=0.017). The subgroup analysis further suggested that the advantage of combined therapy was more obvious in patients with hilar cholangiocarcinoma than that in distal cholangiocarcinoma. PS treatment (HR=2.665, 95% CI: 1.544-4.564, P<0.001), higher preoperative level of carbohydrate antigen 19-9 (HR=2.031, 95% CI: 1.201-3.432, P=0.008) and lower level of ALB (HR=1.908, 95% CI: 1.130-3.221, P=0.016) were independent predictors of worse OS.

Conclusions

Compared with PS, biliary stent combined with 125I seeds implantation may significantly shorten the length of stay, reduce hospital costs, and prolong survival, without increasing the overall complications in advanced EHCC patients, which is worthy of further popularization and application in clinical practice.

Key words: Bile duct neoplasms, Brachytherapy, Stents, Palliative surgery, Overall survival
表1 两组晚期肝外胆管癌患者基线资料比较
项目 总体 联合组 PS组 Z/χ2值 P值
例数 136 91 45    
性别(例,男/女) 102/34 66/25 36/9 0.897a 0.344
年龄(例, ≥70岁/<70岁) 78/58 55/36 23/22 1.071a 0.301
肿瘤部位(例, HCCA/DCCA) 47/89 36/55 11/34 3.042a 0.081
CA19-9(μg/L) 283.6(58.6~855.5) 332.1(72.5~1 006.9) 127.4(31.3~471.3) -0.956 0.339
ALT(U/L) 102.0(68.3~215.5) 113.0(80.0~211.0) 90.0(56.5~256.0) -1.707 0.088
AST(U/L) 116.0(69.3~161.0) 124.0(72.0~162.0) 105.0(60.0~160.0) -0.753 0.452
TBIL(µmol/L) 184.3(117.2~300.3) 230.4(124.7~307.5) 154.6(80.9~271.4) -0.451 0.652
DBIL(µmol/L) 156.4(93.7~253.8) 172.2(107.0~282.6) 135.3(71.1~218.1) -0.675 0.500
ALB(g/L) 34.4(31.5~37.8) 33.8(31.1~37.5) 35.1(31.8~38.0) -1.233 0.217
图1 胆道支架联合125I粒子组患者术后肝功能指标的变化　 **P<0.01；*P<0.01
图2 姑息性手术患者术后肝功能指标的变化　 **P<0.01
图3 胆道支架联合125I粒子及PS组患者总体生存曲线的比较
图4 胆道支架联合125I粒子及PS组患者之间OS的比较　A为HCCA；B为DCCA
表2 影响患者术后总生存率的单因素和多因素分析
变量 单因素分析 多因素分析
HR (95% CI) P值 HR (95% CI) P值
性别(男/女) 1.179(0.722~1.927) 0.510    
年龄(≥70岁/<70岁) 1.195(0.780~1.829) 0.413    
肿瘤部位(HCCA/DCCA) 1.232(0.792~1.918) 0.355    
CA19-9 (≥283.6 /<283.6μg/L) 1.980(1.259~3.115) 0.003 2.031(1.201~3.432) 0.008
ALT (≥102.0 U/L /<102.0 U/L) 1.215(0.791~1.866) 0.374    
AST (≥116.0 U/L /<116.0 U/L) 1.036(0.675~1.590) 0.872    
TBIL (≥184.3µmol/L /<184.3 µmol/L) 1.690(1.105~2.584) 0.015 1.467(0.860~2.504) 0.160
ALB (≤34.4 g/L />34.4 g/L) 1.634(1.066~2.506) 0.024 1.908(1.130~3.221) 0.016
治疗方法(PS/胆道支架联合125I粒子) 1.671(1.074~2.599) 0.023 2.665(1.544~4.564) <0.001
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