目的 探讨不同减黄方式对合并梗阻性黄疸的壶腹周围癌患者术前减黄效能的优劣。探索梗阻性黄疸对壶腹周围癌患者血清糖链抗原19-9（Carbohydrate antigen 19-9, CA19-9）的影响作用和定量关系。

方法 回顾性分析2015年1月至2020年9月北京协和医院基本外科收治的128例胰十二指肠切除术前行减黄治疗的胰头癌、十二指肠壶腹癌和胆总管下段癌患者的临床资料。根据不同的减黄方式分为内镜逆行性胰胆管造影（Endoscopic retrograde cholangiopancreatography, ERCP）放置支胆管架引流组（简称ERCP组）和经皮肝穿刺胆道引流术（Percutaneous transhepatic cholangial drainage, PTCD）组。ERCP组共纳入80例患者，男性47例，女性33例；PTCD组共纳入48例患者，男性24例，女性24例。全部纳入患者分别在减黄前及手术前72小时内检测血清总胆红素（Total bilirubin, TB）、白蛋白、谷氨酸氨基转移酶、血红蛋白浓度、白细胞计数、中性粒细胞百分比和CA19-9等血清学指标。选择手术前的TB（以TB_减黄后表示）、TB下降百分率和减黄充分率（TB_减黄后≤100μmol/L占比）作为评价减黄效能的指标。根据减黄方式分组，比较上述指标在组间的差别，为排除高胆红素水平对减黄效能影响，选取TB_减黄前＞340μmol/L的重度梗阻性黄疸患者进行对照分析；按照不同的肿瘤类型进一步分层，分别进行对照分析。最后选取CA19-9_减黄前≥500U/mL（国际胰腺学会将此作为判断胰腺癌交界可切除性的生物学指标）的患者，根据CA19-9_减黄后能否降至500U/mL以下分组进行对照分析，根据组间差异筛选出CA19-9的影响因素，拟合CA19-9_减黄后与CA19-9_减黄前、TB_减黄前之间的二元线性回归曲线及预测公式。

结果 总体上ERCP组TB_减黄后、TB下降率、减黄充分率均明显优于PTCD组 [分别为(68.0±44.7)μmol/L vs. (114.0±68.8)μmol/L；(73.9±16.9)% vs. (64.2±21.2)%；83.8% vs. 56.3%]，在重度梗阻性黄疸患者中也得到了一致的结果。在十二指肠壶腹癌中，ERCP组TB_减黄后、TB下降率、减黄充分率均明显优于PTCD组 [分别为(50.6±20.2) μmol/L vs. (102.8±48.7)μmol/L；(78.6±10.9)% vs. (67.2±14.8)%；100% vs. 58.3%]；在胆总管下段癌中，ERCP组TB_减黄后、TB下降率、减黄充分率也均优于PTCD组 [分别为(76.1±51.6) μmol/L vs. (161.2±51.1)μmol/L；(70.6±18.5)% vs. (56.5±10.4)%；82.1% vs. 11.1%]；在胰腺癌中，ERCP组和PTCD组上述指标无统计学差异。CA19-9_减黄后、CA19-9下降率、TB_减黄前、TB下降率在能否转化为生化学可切除的两组间存在显著差异，拟合二元线性回归曲线：lgCA19-9_减黄后= 0.822lgCA19-9_减黄前−1.597lgTB_减黄前+3.858。

结论 对于合并梗阻性黄疸的壶腹周围癌患者建议首选ERCP放置胆管支架进行术前减黄，尤其对十二指肠壶腹腺癌和胆总管下段腺癌患者更为适合。梗阻性黄疸可引起CA19-9的假性升高，减黄前胆红素水平与CA19-9偏倚呈显著性正相关。

Objective To investigate the efficacy of different jaundice reduction methods for patients diagnosed of periampullary adenocarcinoma complicated with obstructive jaundice.To explore the impact and quantitative relationship of obstructive jaundice on carbohydrate antigen 19-9 (CA19-9) in patients with periampullary adenocarcinoma.

Methods The clinical data of 128 patients with pancreatic adenocarcinoma, ampullary adenocarcinoma or distal cholangiocarcinoma, who received preoperative biliary decompression followed by pancreaticoduodenectomy in Peking Union Medical College Hospital from January 2015 to September 2020, were retrospectively collected and analyzed. The patients were divided into endoscopic retrograde cholangiopancreatography (ERCP) with stent placement group (referred to as ERCP group) and percutaneous transhepatic cholangial drainage (PTCD) group according to different methods of jaundice reduction. A total of 80 patients were enrolled in ERCP group, while 48 patients were enrolled in PTCD group.Total bilirubin (TB), albumin, alanine aminotransferase, hemoglobin, white blood cell, percentage of neutrophil and CA19-9 were monitored in 72 hours before jaundice reduction and surgery respectively.TB before pancreaticoduodenectomy (referred to as TB_post), rate of TB decline (referred to as RD) and proportion of reduction sufficiency (the percentage of patients with TB_post≤100 μmol/L, referred to as PRS) were selected as indicators for evaluating the efficacy of jaundice reduction. Firstly, we performed a comparative analysis by grouping the method of jaundice reduction, in order to exclude the effect of high bilirubin levels, patients with severe obstructive jaundice TB_pre＞340 μmol/L were compared and analyzed; then comparative analysis was performed according to different tumor pathological types. Finally, patients with CA19-9_pre≥500 U/mL were selected, and comparative analysis was performed in two groups according to the occasion that whether CA19-9 could be reduced lower than 500U/mL after jaundice reduction, the influencing factors of CA19-9 are screened out according to the difference between groups, and the binary linearity between CA19-9_post, CA19-9_pre and TB_pre.

Results The TB_post, RD and PRS in ERCP group were significantly better than those indicators in PTCD group [(68.0±44.7)μmol/L vs. (114.0±68.8)μmol/L; (73.9±16.9)% vs. (64.2±21.2)%; 83.8% vs. 56.3%], while the severe obstructive jaundice patients share the consistent outcomes. In patients with ampullary carcinoma，TB_post, RD and PRS in ERCP group was significantly better than those in PTCD group [(50.6±20.2)μmol/L vs. (102.8±48.7)μmol/L; (78.6±10.9)% vs. (67.2±14.8)%; 100% vs. 58.3%]. In patients with distal cholangiocarcinoma, TB_post, RD and PRS of ERCP group were better than those of PTCD group [(76.1±51.6)μmol/L vs. (161.2±51.1)μmol/L; (70.6±18.5)% vs. (56.5±10.4)%; 82.1% vs. 11.1%]. There was no statistical difference in the above indicators of jaundice reduction between ERCP group and PTCD group in pancreatic cancer patients.There are significant differences in CA19-9post, rate of CA19-9 decline, TBpre and RD between the two groups. A binary linear regression curve was fitted: lgCA19-9_post= 0.822lgCA19-9_pre−1.597lgTB_pre+ 3.858

Conclusions For patients diagnosed of periampullary adenocarcinoma complicated with obstructive jaundice, stent placement by ERCP is recommended as the first choice for preoperative jaundice reduction, especially for those with ampullary carcinoma or distal cholangiocarcinoma.Obstructive jaundice can cause an over increase of CA19-9. There is a significant positive correlation between the total bilirubin level before jaundice reduction and the CA19-9 bias.