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为胆道“铺路架桥”:记一种新型胆道支架的研发与转化

2019-03-28 16:51:24     来源:中新网     责任编辑:刘欣

当被诊断为胰头癌时,60岁徐明(化名)的生活彻底改变了。而令其家人最接受不了的现实是:因伴有腹腔淋巴结转移及血管受侵,胰头癌浸润胆总管造成梗阻性黄疸,肝功受损……已经失去了手术机会。

 

“目前,最需要解决的就是患者胆道梗阻(黄疸)问题。”北京大学第三医院消化科副主任、消化内镜中心主任黄永辉在接诊时了解到,患者已经出现因胆道梗阻导致的食欲不振、体重下降、发烧盗汗、皮肤瘙痒等症状。

 

通常胆道梗阻治疗是经内镜下逆行胰胆管造影术(ERCP),在胆管内放置塑料支架或者金属支架。“但塑料支架通畅时间短,3个月左右就会堵塞,需要再次行ERCP手术更换。而金属支架价格昂贵,单纯一根支架就要两万元左右,通畅时间虽然较塑料支架长,但多数会在1年内出现堵塞,有的甚至数月就会出现胆道反流所致的胆管炎。”黄永辉告诉《中国科学报》,他带领团队研发的一种新型的胆道支架——肝内胆管高位悬挂式超长塑料支架(以下简称新型支架)很好地解决了临床上胆道梗阻问题。

 

“并且,新型支架的通畅程度不仅可以达到甚至超过金属支架,花费也比塑料支架还要少,一根支架在一千元左右。”黄永辉说。

 

新型支架,科学证实

 

其实,临床上很多疾病都能引发肝内外胆道梗阻。如肝门部胆管癌、肝内转移瘤压迫、肝外胆管肿瘤、肝外胆管良性狭窄、壶腹部恶性肿瘤、胰腺癌、胆管多发巨大结石的临时支架引流等。

 

“这就需要为胆道梗阻患者‘铺路搭桥’。”黄永辉说,传统支架的开口在十二指肠乳头处,很容易导致十二指肠内容物胆管反流,堵塞胆管。

 

而新型支架长约为25cm~30cm,头端悬挂于肝内胆管下行支,避免支架移位,尾端置于十二指肠水平部远端,有效延长了十二指肠内容物反流路径,使十二指肠胆管反流明显减少。并且,材质与普通胆管塑料支架相同,均为聚氯乙烯,可以在胆管内长期留置。此外,支架具有多侧孔,能有效增加胆汁排出速度。

 

北京三院消化内科副主任医师闫秀娥向《中国科学报》提供这样一组研究数据:一项18例自身前后对照患者应用新支架疗效评估结果显示,除1例失访,17例患者超长胆管塑料支架平均通畅时间为210天,相比普通塑料支架139天明显延长。

 

获批专利,瞄准市场

 

回想起这项新技术研发的过程,黄永辉颇为感慨。“临床上,我们经常遇到很多患者反复多次更换支架,不仅费用昂贵,而且还要冒着ERCP术后并发症的风险。我们就在想,能不能开发一种能够延长通畅时间的支架呢?”

 

不过,再美好愿望映射到现实都必须经历“脱胎换骨”。

 

“研发前期的最大困难就是对支架置入过程的摸索。”黄永辉表示,在ERCP结束时,将此支架在X线透视监测下用支架推送导管将其头端置于肝内胆管下行支,放置过程与鼻胆管放置相似。当支架头端置入肝内胆管合适位置后,调整透视视野以保证整个支架在X线监控之下。之后继续推送导管,同时需要保证导丝保留在支架之内,整个过程需在内镜和X线透视监测之下进行。当支架尾端以顺畅状态到达十二指肠腔后,再缓慢收回导丝,同时需保证支架尾端不打折弯曲。

 

经过几次摸索,研究团队已经能较好地掌握放置新型支架。“但当时,我们都是将鼻胆引流管改制成新型支架,还没有厂家生产。”闫秀娥说,这就要求助手在无菌条件下熟练进行支架的改制,以达到尽量减少患者在术中的等待时间,但如果无菌条件做不好,后期患者可能容易出现医源性的胆道感染。

 

不过,目前经过专利转化,国内已经有厂家开始生产这种新型支架。

 

便于掌握,费用降低

 

黄永辉告诉记者,该项技术已经在国内多个单位实施,也得到了很多国内的ERCP专家的高度认可。

 

不过,新技术的实施需要熟练掌握ERCP操作的内镜医师,因此在一些没有开展ERCP技术的单位,如县级医院或某些市级单位可能无法进行推广。

 

“对于有熟练ERCP基础的内镜医师,培训基本在3天即可基本掌握。”黄永辉说,ERCP为消化科四级内镜手术,操作难度大,手术风险高,并发症发生后处理棘手,器械费用昂贵,每次ERCP的费用在1~2万元不等,甚至操作难度较大者,费用可增加到3万元。

 

而新支架不仅能够明显减少肝外胆管狭窄患者ERCP更换支架次数,还能进一步降低了医疗风险,明显减少了医疗费用,经济社会效益显著。

 

谈到是否存在新技术到来的其他并发症?黄永辉表示,置入此支架的并发症基本与ERCP的并发症相同。目前仅有1例患者发生了由于支架在蠕动过程中抵住十二指肠肠壁,发生了后腹膜包裹性穿孔,但也经过保守治疗好转。

 

黄永辉透露,在未来技术优化方面,团队还要在支架的胆道部和肠道部之间的连接处预设一定角度,以更加顺应肠道走形,从而进一步减少防止支架与肠黏膜的接触。另外,在支架的肠道部计划预设侧翼,减少十二指肠内容物的逆流,还可以增加胆汁流出量。

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