Takahashi Ei, Fukasawa Mitsuharu, Sato Tadashi, Takano Shinichi, Kadokura Makoto, Shindo Hiroko, Yokota Yudai, Enomoto Nobuyuki
Ei Takahashi, Mitsuharu Fukasawa, Tadashi Sato, Shinichi Takano, Makoto Kadokura, Hiroko Shindo, Yudai Yokota, Nobuyuki Enomoto, First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan.
World J Gastroenterol. 2015 Apr 28;21(16):4946-53. doi: 10.3748/wjg.v21.i16.4946.
To identify criteria for predicting successful drainage of unresectable malignant hilar biliary strictures (UMHBS) because no ideal strategy currently exists.
We examined 78 patients with UMHBS who underwent biliary drainage. Drainage was considered effective when the serum bilirubin level decreased by ≥ 50% from the value before stent placement within 2 wk after drainage, without additional intervention. Complications that occurred within 7 d after stent placement were considered as early complications. Before drainage, the liver volume of each section (lateral and medial sections of the left liver and anterior and posterior sections of the right liver) was measured using computed tomography (CT) volumetry. Drained liver volume was calculated based on the volume of each liver section and the type of bile duct stricture (according to the Bismuth classification). Tumor volume, which was calculated by using CT volumetry, was excluded from the volume of each section. Receiver operating characteristic (ROC) analysis was performed to identify the optimal cutoff values for drained liver volume. In addition, factors associated with the effectiveness of drainage and early complications were evaluated.
Multivariate analysis showed that drained liver volume [odds ratio (OR) = 2.92, 95%CI: 1.648-5.197; P < 0.001] and impaired liver function (with decompensated liver cirrhosis) (OR = 0.06, 95%CI: 0.009-0.426; P = 0.005) were independent factors contributing to the effectiveness of drainage. ROC analysis for effective drainage showed cutoff values of 33% of liver volume for patients with preserved liver function (with normal liver or compensated liver cirrhosis) and 50% for patients with impaired liver function (with decompensated liver cirrhosis). The sensitivity and specificity of these cutoff values were 82% and 80% for preserved liver function, and 100% and 67% for impaired liver function, respectively. Among patients who met these criteria, the rate of effective drainage among those with preserved liver function and impaired liver function was 90% and 80%, respectively. The rates of effective drainage in both groups were significantly higher than in those who did not fulfill these criteria (P < 0.001 and P = 0.02, respectively). Drainage-associated cholangitis occurred in 9 patients (12%). A smaller drained liver volume was associated with drainage-associated cholangitis (P < 0.01).
Liver volume drainage ≥ 33% in patients with preserved liver function and ≥ 50% in patients with impaired liver function correlates with effective biliary drainage in UMHBS.
由于目前尚无理想的策略，旨在确定预测不可切除恶性肝门部胆管狭窄（UMHBS）引流成功的标准。
我们检查了78例接受胆管引流的UMHBS患者。当血清胆红素水平在引流后2周内从支架置入前的值下降≥50%，且无需额外干预时，引流被认为有效。支架置入后7天内发生的并发症被视为早期并发症。在引流前，使用计算机断层扫描（CT）容积测量法测量每个肝段（左肝外侧和内侧段以及右肝前和后段）的肝脏体积。根据每个肝段的体积和胆管狭窄类型（根据Bismuth分类）计算引流肝脏体积。通过CT容积测量法计算的肿瘤体积从每个肝段的体积中排除。进行受试者操作特征（ROC）分析以确定引流肝脏体积的最佳截断值。此外，评估与引流效果和早期并发症相关的因素。
多因素分析显示，引流肝脏体积[比值比（OR）=2.92，95%置信区间：1.648 - 5.197；P < 0.001]和肝功能受损（伴有失代偿期肝硬化）（OR = 0.06，95%置信区间：0.009 - 0.426；P = 0.005）是影响引流效果的独立因素。有效引流的ROC分析显示，肝功能 preserved（肝脏正常或代偿期肝硬化）患者的肝脏体积截断值为33%，肝功能受损（伴有失代偿期肝硬化）患者为50%。这些截断值的敏感性和特异性在肝功能 preserved患者中分别为82%和80%，在肝功能受损患者中分别为100%和67%。在符合这些标准的患者中，肝功能 preserved和肝功能受损患者的有效引流率分别为90%和80%。两组的有效引流率均显著高于未满足这些标准的患者（分别为P < 0.001和P = 0.02）。9例患者（12%）发生了与引流相关的胆管炎。较小的引流肝脏体积与引流相关的胆管炎相关（P < 0.01）。
肝功能 preserved患者的肝脏体积引流≥33%，肝功能受损患者≥50%与UMHBS的有效胆管引流相关。
