Will U, Thieme A, Fueldner F, Gerlach R, Wanzar I, Meyer F
Department of Internal Medicine III, Municipal Hospital, Gera, Germany.
Endoscopy. 2007 Apr;39(4):292-5. doi: 10.1055/s-2007-966215. Epub 2007 Mar 15.
Endoscopic retrograde cholangiopancreatography (ERCP)-guided implantation of a biliary endoprosthesis or stent is the gold standard treatment for biliary obstructions. When the papilla cannot be traversed because there is pyloric or duodenal stenosis, or the catheter cannot be introduced, or because of previous gastrointestinal surgery (Billroth II gastric resection, Whipple procedure, gastrectomy with Roux-en-Y reconstruction), the alternative treatment is considered to be percutaneous transhepatic cholangiography and drainage (PTCD). The aim of the study was to investigate the further alternative of endoscopic ultrasound (EUS)-guided transgastric or transjejunal biliary drainage where PTCD failed or was declined, and particularly, the feasibility and outcome of this option.
Over 3 years all appropriate consecutive patients (as defined above) were enrolled in this prospective, observational, single-center, case series study, and patient and intervention data were recorded. Feasibility was characterized by success rate (regression of cholestasis), and outcomes by complication rate, mortality, and follow-up findings.
Between November 2002 and December 2005, eight patients (in 10 interventions) underwent this new biliary drainage procedure. The routes were transesophageal (n = 1), transgastric (n = 4), and transjejunal (n = 3, including a rendezvous technique with ERCP [n = 1]). The indications were cholestasis, arising from recurrent tumor growth (n = 5, 62.5%), that included gastric carcinoma after previous gastrectomy (n = 4) and a periampullary carcinoma after previous Whipple procedure (n = 1); arising from Klatskin tumor (n = 2, 25%); and from benign stenosis of a hepaticojejunostomy (n = 1, 12.5%). Five patients (62.5%) received a metal stent, and three (37.5%) had a plastic prosthesis (8.5-Fr double-pigtail). The technical success rate was 90% (9/10) and the clinical success rate was 88.9% (8/9). There was only one case of cholangitis (12.5%) and slight postinterventional pain, but no severe complications such as bleeding or perforation, and no mortality. During follow-up (range 4 weeks to 3 years) re-interventions were needed in two patients (20%) because of increasing cholestasis; these resulted in technical success and clinical improvement.
EUS-guided transgastric or transjejunal biliary drainage is a reasonable, feasible and encouraging treatment option in selected patients as indicated, with a low peri-interventional risk. It broadens the therapeutic spectrum but still needs further evaluation and follow-up investigation.
内镜逆行胰胆管造影术（ERCP）引导下植入胆道内支架是治疗胆道梗阻的金标准。当因幽门或十二指肠狭窄无法通过乳头，或无法插入导管，或因既往胃肠道手术（毕罗Ⅱ式胃切除术、惠普尔手术、Roux-en-Y重建胃切除术）而无法进行ERCP时，替代治疗方法被认为是经皮肝穿刺胆管造影及引流术（PTCD）。本研究的目的是探讨在内镜超声（EUS）引导下经胃或经空肠进行胆道引流这一替代方法，该方法适用于PTCD失败或患者拒绝接受PTCD的情况，尤其要探讨其可行性及治疗效果。
在3年时间里，所有符合条件的连续患者（定义如上）均纳入了这项前瞻性、观察性、单中心病例系列研究，并记录患者及干预措施的数据。可行性通过成功率（胆汁淤积消退情况）来衡量，治疗效果则通过并发症发生率、死亡率及随访结果来评估。
2002年11月至2005年12月期间，8例患者（共进行了10次干预操作）接受了这种新的胆道引流手术。手术途径包括经食管（n = 1）、经胃（n = 4）和经空肠（n = 3，其中1例采用了与ERCP联合的会师技术）。手术指征包括复发性肿瘤生长导致的胆汁淤积（n = 5，62.5%），其中包括既往胃切除术后的胃癌（n = 4）和既往惠普尔手术后的壶腹周围癌（n = 1）；肝门部胆管癌导致的胆汁淤积（n = 2，25%）；以及肝空肠吻合口良性狭窄导致的胆汁淤积（n = 1，12.5%）。5例患者（62.5%）植入了金属支架，3例患者（37.5%）植入了塑料支架（8.5F双猪尾支架）。技术成功率为90%（9/10），临床成功率为88.9%（8/9）。仅发生1例胆管炎（12.5%），术后有轻微疼痛，但无出血或穿孔等严重并发症，也无死亡病例。在随访期间（4周至3年），2例患者（20%）因胆汁淤积加重需要再次干预；再次干预取得了技术成功并使临床症状改善。
EUS引导下经胃或经空肠进行胆道引流对于特定适应证的患者是一种合理、可行且令人鼓舞的治疗选择，围手术期风险较低。它拓宽了治疗范围，但仍需进一步评估和随访研究。
