惡性阻塞性黃疸減黃手術預後之分析

Prognostic Analysis of Malignant Obstructive Jaundice after Biliary Decompression

柯成國(Chen-Guo Ker) ； 侯明鋒(Ming-Feng Hou) ； 李金德(King-Teh Lee) ； 沈柏青(Pai-Ching Sheen)

《The Kaohsiung Journal of Medical Sciences》 3卷4期 (1987/04) Pp. 258-266

https://doi.org/10.6452/KJMS.198704.0258

摘要

阻塞性黃疸之膽道引流術後，影響預後因素是複雜的，本文將討論阻塞部位引流方法等各種因素與膽管引流後之結果，加以研究分析。共125位惡性阻塞性黃疸病例經手術證實且經施手術膽管膽汁引流術者為研究對象，這些病例分成三組：A組為恢復組，B組為遲延恢復組及C組為死亡組。其阻塞性黃疸之原發症狀有皮膚癢，灰色糞便及發燒，但灰色糞便在C組較高，續發症狀包括疼痛、腹部種瘤、體重減輕及血便。其預後如依據其阻塞部位分成肝外膽管上段及下段二種、上段之比率在C組較高占43.24%，而A組為15.91%，兩者相差為有意義的〈p＜0.005〉，全部上段阻塞者42例其中16.67%獲得恢復，而下段阻塞者中44.58%可使黃疸恢復，兩者相差仍為有意義〈p＜0.005〉。在預後不良之B組與C組之上段阻塞者，施總膽管T型管引流者占31.82%及35.14%，比A組為多〈p＜0.005〉，可見上段阻塞只施總膽管引流術可能不夠的。在各組之中施總膽管引流外再附加膽管小腸吻合者，在A組占21.62%，B組占32%，在C組為23.81%，其相差是沒有意義〈p＜0.05〉，所示附加膽汁體內引流之吻合術不會影響預後。再選擇一百位膽紅素高於15mg%者，施PTCD引流術者24位最後引流不良引流後四週內死亡者29.61%，手術施總膽管引流術者76位，死亡率36.84%，兩者相差為無意義〈p＜0.05〉，可見非手術及手術引流術其引流結果是沒有差異的。
術後之合併症包括傷口感染，胃腸出血、肝衰竭、腎衰竭、敗血症、胸積水等，A組占18.18%，B組占34.09%，兩組相差是有意義的〈p＜0.05〉，而C組死亡原因以肝衰竭占45.04%，胃腸出血占32.43%，腎衰竭占16.21%，肺水腫者5.41%，死亡率占全體黃疸例之29.60%。俄性阻塞性黃疸病例如何防止因黃疸本身造成死亡之直接原因是將來研究的課題。

並列摘要

Biliary tract surgery in the presence of jaundice is associated with a high mortality and significant mobidity rate. When the diagnosis of mechanical obstruction is made, the need for biliary drainage is clear. One hundred and twenty-five patients with obstructive jaundice caused by extrahepatic malignancy were studied for clinical analysis and those patients were classied into three groups; recovery, delay recovery and fatal groups. If the obstructive lesion occurred in the lower common bile duct it was found that after biliary decompression 44.58%of such patients were found to have returned to normal, but only 16.67% returned to normal of those with lesions in the upper common bile duct. Another one hundred patients with high serum bilirubin level (more than 15mg%) were treated by non-surgical or surgical drainage. Percutaneous transhepatic cholangiography and drainage (PTCD) was performed on 24 patients. Within one month mortality operative T-tube drainage resulting in a one month mortality rate of 36.84% with no-significant difference. Operative biliary drainage was also available for bilioenterostomy for permanent internal biliary drainage but did not increase the one month mortality rate in this study.
The average daily bile amount was 485±197(M±SD)ml for the recovery group, 410±157ml for the delay recovery group and 228±135ml for the fatal group. A daily bile amount of more than 1,000 ml was noted in 12 cases; 4 in the recovery group, 6 group. The bacterial infection rate was also studied, 31.58% occurred in the recovery group, 36.11% in the delay recovery group and 41.38% in the fatal group. The morbidity rate for the recovery group was 18.08%, 34.09% for the delay recovery group, and overall mortality was 29.6% for obstructive jaundice. The causes of death n the fatal group were hepatic failure (45.04%), gastrointestinal hemorrhage (32.34%), renal failure (16.21%) and lung edema (5.41%).
The management of deeply jaundiced patients with bile duct obstruction remains a significant surgical problem. Recognition of the factors related to post-operative morbidity and mortality in such patients, should encourage the selection of appropriate drainage procedures of diagnosis is established. And such procedures will enable reduction in operative complication and improve the overall surgical outcome.

並列關鍵字

obstructive jaundice ； biliary malignancy ； biliary decompression