| At present, percutaneous biliary drainage or bile duct stent in the treatment of obstructive jaundice has been accepted for the majority of doctors and patients. But for some specific place to choose what kind of treatment method is controversial, such as the treatment for hilar bile duct obstruction. And despite the clinical effect of percutaneous biliary stenting for obstructive jaundice has been affirmed, but stent can only play role of drainage, can not afford the treatment effect of tumor, many patients will appear different degrees of stenosis or obstruction after operation,then affect the treatment effect.125 I radioactive stent can achieve better effect than the common stent because it can not only relieve the obstruction,at the same time have the anti-tumor effect by brachytherapy. But due to the lack of research about the bile duct implantation of125 I seeds for the treatment of malignant obstruction jaundice, this fact limits the125 I stents in clinical application.For the above problems and controversies, some cases of clinical and experimental study were choosed to solve the existing problems and provide the basis for rational selection of clinical treatment.Part I Experimental study on the radioactive damage of bile duct in rabbits by 125 I implantationObjective: To observe the extent of radiation injury of implanted 125 I seed on normal common bile duct of the rabbit and explore the relationship between original radioactivity and degree of radioactive injury. Methods: 12 rabbits were randomly divided into six groups, one of which was the control group, the other five groups as the experimental group. The rabbits of the experimental group were implanted 125 I seed on common bileduct. The radioactivity of the125 I seed was 0.2m Ci、0.4m Ci、0.6m Ci、0.7m Ci and 0.8m Ci respectively. The control group was implanted with no radioactive particle. The rabbits were killed at 60 days after surgery, and The pathological changes of the common bile duct were observed after 60 days after surgery by light microscope.In addition, the preoperative and postoperative blood white blood cell and immunoglobulin levels were detected and compared. Results: The survival rate of rabbits is 100%, and the seeds did not fall off. The organ and tissue arounding the implaned bile duct have no radiation damage.There were not fistula, perforation,hemorrhage, and other serious complications of bile duct. Schmidt pathological score was used, the control group was 0, the average score of 0.2m Ci group was 1.2, 0.4m Ci group 2.5, 0.6m Ci group 3.4, 0.7m Ci group 5.2 and 0.8m Ci group was6.1.The damage of the bile duct is related to the initial radiationactivity. The greater the radiationactivity, the heavier the damage. Statistic analysis of white blood cell and immunoglobino cunting showed no significant different between before and after operation（P>0.05）. Conclusions: The125 I seeds implanted into the common bile duct wall of normal rabbits could cause radiation-induced damage, and the damage degree increased with the increase of radioactivity. There were no serious complications such as biliary fistula, perforation, immune abnormality and so on, and the damage could be tolerated in clinic. The results of the experiment can provide reference for further experimental study and clinical application of125 I radioactive biliary stent for malignant bile duct obstruction.PartⅡ Preliminary experience of biliary stent loaded with 125 I seeds in treatment of malignant lower bile duct obstructionObjective: To observe the efficacy of biliary stent implantation loaded with125 I seeds in treatment of malignant lower bile duct obstruction.Methods: We analyzed the datas of 32 patients with malignant lower bile duct obstruction undergoing percutaneous transhepatic bile stenting（PTBS）. Patients were divided into two groups,13 received125 I biliary stent insertion(group125I stent),19 treated by conventional biliary stent（group conventional stent）.Postoperative liver function index, white blood cell（WBC） count, Ig G, stent patencytime, survival time and complications were recorded. Results:32 patients were included in our study.19 were treated by conventional stent,including 12 men and 7 women, 48 to86-year-old, with mean age 68 years. The diagnosis was pancreatic head carcinoma in 11 patienis, cholangiocarcinoma in 5 patient, gallbladder cancer in 2 patients and ampull cancer in 1 patient.13 were treated by125 I stent, including 8 men and 5 women,49 to88-year-old,with mean age 66 years. The diagnosis was 7 pancreatic head carcinoma, 4gallbladder cancer and 2 cholangiocarcinoma.The patients’ operation success rate is 100%.In group conventional stent, preoperative serum total bilirubin（TBIL）, serum direct bilirubin（DBIL）, alanine aminotransferase（ALT）, alkaline phosphatase（ALP）,WBC and Ig G was 302.8±101.5μmol/L,229.7±41.6μmol/L,147.3±25.8 U/L, 435.4±312.4U/L,（8.87±4.76）×109/L,12.23±4.21g/L respectively.30 days after the operation TBIL,DBIL,ALT,ALP,WBC,Ig G was 36.1±31.7μmol/L,29.3±34.5μmol/L,36.7±9.8U/L,109.4±52.7 U/L,（7.65±3.23）×109/L,12.87±3.91g/L. For TBIL, DBIL,ALT,ALP, there were significant differences between preoperative and postoperative index（ P <0.05）, no significant differences abrout WBC,Ig G（P > 0.05）. In group125 I stent, preoperative TBIL,DBIL,ALT,ALP,WBC,Ig G was 298.8±112.3μmol/L,239.8±47.9μmol/L152.3±28.2 U/L,448.4±298.8 U/L,（7.96±5.37）×109/L,11.40±3.62g/L respectively. 30 days after the operation TBIL, DBIL,ALT,ALP,WBC,Ig G was 33.3±19.2μmol/L,28.3±14.5μmol/L,33.7±8.9 U/L,103.4±49.5 U/L,（6.98±3.79）×109/L,11.65±4.12g/L respectively. For TBIL,DBIL,ALT,ALP, there were significant differences between preoperative and postoperative index（ P < 0.05）, no significant differences abrout WBC,Ig G（P > 0.05）. There was no significant difference between two groups（P > 0.05）.In group conventional stent, the median stent patency time was 3.9 months, the median survival time was 139 days, in group125 I stent, was 8.1 months, 298 days respectively. In group conventional stent, 5cases had short-term complications in 19 patients, the incidence was 26.32% while23.08%（3/13） in125 I stent group. There was no statistically significant difference between two groups（P > 0.05）.Conclusions: For lower malignant obstructive jaundice, metal stent placement in the bile duct has good clinical effect,such as improving liver function andeliminating symptoms.125 I stent implantation can not only effectively alleviate the the symptoms of jaundice, but also can achieve the effect of anti-tumor therapy. Compared with conventional metal stents,125 I radioactive stent could significantly prolong the survival time and stent patency time, besides it also has the advantages of safety, easy operation, small trauma, then it is worth popularizing widespread use.Part Ⅲ Interventional drainage in the treatment of malignant bifurcation obstruction: unilateral or bilateral?Objective: To compare the clinic effect of percutaneous transhepatic bile drainage（PTBD）by unilateral or bilateral drainage in the patients with malignant bifurcation obstruction.Methods: We analyzed the datas of 47 patients with malignant bifurcation obstruction undergoing PTBD. Unilateral puncture drainage（group unilateral drainage） or bilateral puncture drainage（group bilateral drainage）were used for treatment. Postoperative liver function index, drainage time, survival time and complications were recorded. Results:47patients were included in our study.22 were treated by unilateral drainage,including 12 men and10 women, 46 to 89-year-old, with mean age 68 years. The diagnosis was primary hilar cholangiocarcinoma in 13 patienis, hepatocellular careinoma in 5 patient, gallbladder cancer in 2 patients, metastatic liver cancer in 1 patient and pancreatic cancer 1 patient.25 were treated by bilateral drainage, including 13 men and 12 women,49 to 90-year-old,with mean age 69 years, 16 hilar cholangiocarcinoma, 6 hepatocellular carcinoma, 1 gallbladder cancer and 2 metastatic liver cancer. The patient’s operation success rate is 100%.In group unilateral drainage, 10 patients were treated by biliary metal stent, the other 12 patients were implanted 8.5F biliary drainage tube, in which 5 patients were treated with simple external drainage, 7 cases underwent internal-external drainage. In group bilateral drainage,11 cases of patients with right placement of internal-external drainage tube, left external drainage. 5 cases with bilateral stent.3 patients with metal stent placement on the right side,external drainage on the left. 3 patients right placement of external drainage tube, metal stent placement on the left side.3 patients with bilateral external drainage tube. In groupunilateral drainage, preoperative serum total bilirubin（TBIL） was 298.8±117.3μmol/L, 1weeks after the operation 198.4±91.1μmol/L, after 30 days 102.3±32.1μmol/L. Serum direct bilirubin（DBIL） before operation was 237.7±37.6μmol/L, 1 weeks after138.4±87.1μmol/L, 30 days after 74.3±32.7μmol/L. Preoperative and postoperative 1 week,30 days index were compared by t test, p values were less than 0.05. In group bilateral drainage, preoperative TBIL was 306.8±121.3μmol/L, 1 weeks after the operation147.4±92.3μmol/L, after 30 days 36.3±17.1μmol/L. DBIL before operation was243.8±41.6μmol/L, 1 weeks after 97.4±84.2μmol/L, 30 days after31.3±13.6μmol/L.Preoperative and postoperative 1 week, 30 days index were compared by t test, p values were less than 0.05. TBIL, DBIL index of preoperative and postoperative 1 week between groups had significant difference（P < 0.05）, the 30 day after operation had differences（P<0.05）.In group unilateral drainage, the median drainage patency time was 3.1 months, the median survival time was 121 days, in group bilateral drainage, was 7.2 months, 195 days respectively. In group unilateral drainage, 5 cases had short-term complications in 22 patients, the incidence was 22.73%, of which 3 cases of cholangitis, 1 cases of hemobilia, 1cases of mild acute pancreatitis. The incidence was 22.73%（10/25） in group bilateral drainage, hemobilia in 4 patient, 3 cases of pancreatitis, 2 cases of bile leakage and 1 cases of cholangitis. Bilateral drainage group bleeding, pancreatitis. There was no statistically significant difference between two groups（P > 0.05）.Conclusions: PTBD can effectively relieve the malignant bifurcation obstruction, restore bile drainage, improve the liver function of patients and prolong the survival period. The effect of bilateral drainage is better than unilateral drainage, such as survival, drainage patency time. |
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