van Heek N T, van Geenen R C I, Busch O R C, Gouma D J
Department of Surgery, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands.
Acta Gastroenterol Belg. 2002 Jul-Sep;65(3):171-5.
Mostly, patients with peri-pancreatic cancer (including pancreatic, ampullary and distal bile duct tumors) are diagnosed in a stage in which curative resection is not possible. The median survival rate of patients with non resectable peri-pancreatic cancer varies between 6 and 12 months. During this period palliative treatment is necessary, which should focus on major symptoms as obstructive jaundice, duodenal obstruction and pain. Controversy exists about how to provide optimal palliative treatment. Both surgical and non surgical palliative procedures relief obstructive jaundice. From early retrospective and prospective randomized studies it is known that in the early phase after treatment, more complications are found after surgical palliation, whereas in the late phase more complications are seen after endoscopic palliation. Because more recent studies clearly showed improved results after surgical palliation, current recommendations probably should be that patients with a suspected poor short-term survival (< 6 months) should be offered non surgical palliative therapy and those with a longer life expectancy may best be treated with bypass surgery. Unfortunately, valid criteria for estimating the remaining survival time are not available, except for the presence of metastases. The use of a prognostic score chart might assist in estimating the prognosis. Literature does not give sufficient information to make a well deliberated (evidence based) selection between the different types of surgical bypasses, but a choledochojejunostomy is generally preferred. After stenting, a correlation is found between survival and the development of duodenal obstruction, and between 9% and 21% of the patients who underwent a surgical biliary bypass without a prophylactic gastric bypass, will develop gastric outlet obstruction. Therefore, in patients with a relatively good prognosis it is recommended to perform routinely a double--biliary and gastric--bypass. Pain is a frequent symptom and is related with poor survival. Pain management aside from pain medication can be performed by means of a celiac plexus blockade or a thorascopic splanchnicectomy, and also radiotherapy seems to have a positive result on pain.
大多数胰周癌（包括胰腺癌、壶腹癌和远端胆管肿瘤）患者确诊时已处于无法进行根治性切除的阶段。不可切除的胰周癌患者的中位生存期在6至12个月之间。在此期间，姑息治疗是必要的，应着重于主要症状，如梗阻性黄疸、十二指肠梗阻和疼痛。关于如何提供最佳姑息治疗存在争议。手术和非手术姑息治疗方法均可缓解梗阻性黄疸。从早期的回顾性和前瞻性随机研究可知，在治疗后的早期阶段，手术姑息治疗后发现的并发症更多，而在后期阶段，内镜姑息治疗后出现的并发症更多。由于最近的研究清楚地表明手术姑息治疗后效果有所改善，目前的建议可能是，对于疑似短期生存期较差（<6个月）的患者，应提供非手术姑息治疗，而预期寿命较长的患者最好接受旁路手术治疗。不幸的是，除了存在转移外，尚无有效的标准来估计剩余生存时间。使用预后评分表可能有助于估计预后。文献没有提供足够的信息来在不同类型的手术旁路之间进行深思熟虑的（基于证据的）选择，但一般首选胆总管空肠吻合术。支架置入后，生存期与十二指肠梗阻的发生之间存在相关性，并且在未进行预防性胃旁路手术的情况下接受手术性胆道旁路手术的患者中，有9%至21%会发生胃出口梗阻。因此，对于预后相对较好的患者，建议常规进行双胆道和胃旁路手术。疼痛是常见症状，且与生存期较差有关。除了使用止痛药物外，疼痛管理可通过腹腔神经丛阻滞或胸腔镜内脏神经切除术来进行，放疗似乎对疼痛也有积极效果。
