恶性梗阻性黄疸的治疗策略新进展

Choosing the appropriate strategy in managing malignant biliary obstruction

大多数胰腺癌及壶腹周围癌可以表现出恶性梗阻性黄疸,治疗主要包括缓解症状,改善并发症发病率及死亡率.首选的治疗方案是内镜下胆道支架置入.最近,使用塑料支架和自费的金属支架的研究数据表明金属支架的开放时间更长,是否需要治疗梗阻性黄疸及使用何种方法治疗主要根据临床情况而定.对于肿瘤可切除的患者,术前胆道引流仅仅适用于手术会被推迟和存在黄疸并发症的患者;对于局部浸润化疗后可手术切除的患者,使用自费的金属支架更优于塑料支架;对于不可手术的侵袭性的患者,支架的使用类型根据患者的生存预期而定.当内镜放置支架失败时,超声引导下的胆道引流,经皮肝穿胆道引流或行旁路手术都是合适的治疗方案.

Most patients with pancreatic cancer develop malignant biliary obstruction.Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality.First-line therapy consists of endoscopic biliary stent placement.Recent data comparing plastic stents to self-expanding metallic stents（SEMS）have shown improved patency with SEMS.The decision of whether to treat obstruction and the means for doing so depend on the clinical scenario.For patients with resectable disease,preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist.For patients with locally advanced disease,self-expanding metal stents are superior to plastic stents for long-term patency.For patients with advanced disease,the choice of metallic or plastic stent depends on life expectancy.When endoscopic stent placement fails,EUS guided biliary drainage,percutaneous transhepatic biliary drainage or surgical treatments are appropriate.