Hospital Pablo Tobón Uribe, Gastroenterología, Universidad de Antioquia, Grupo de Gastrohepatología, Universidad Pontificia Bolivariana, Medellín, Colombia.
Surg Endosc. 2010 Sep;24(9):2092-8. doi: 10.1007/s00464-010-0903-7. Epub 2010 Feb 21.
Curative resection of pancreatic and biliary malignancies is rare. Most tumors are inoperable at presentation, and palliation of jaundice often is the goal. Biliary decompression can be achieved by surgical diversion or endoscopic biliary stents. This study aimed to compare clinical outcomes between surgical bypass and endoscopic uncovered nitinol stents in the palliation of patients with malignant distal common bile duct obstruction.
A multicenter, retrospective, cohort study investigated 86 patients with inoperable malignant distal common bile duct strictures at tertiary referral centers in Medellín, Colombia. These patients had undergone surgery (group 1) or placement of an uncovered 30-Fr self-expandable nitinol stent produced locally in Medellín, Colombia (group 2). The main outcome measurements included cumulative biliary patency, hospital stay, and patient survival.
The study enrolled 86 patients (mean age, 66 years; range, 43-78 years) including 40 patients in group 1 and 46 patients in group 2. Both groups were similar in terms of age, gender, liver metastasis, and diagnosis. Technical success was achieved for 38 patients in group 1 (95%) and 43 patients in group 2 (93%). Functional biliary decompression was obtained in for 35 of the surgical patients (88%) and 42 of the stented patients (91%). Group 2 had lower rates for procedure-related mortality (2 vs. 7.5%; p = 0.01), a lower frequency of early complications (8.7 vs. 45%; p = 0.02), and a shorter hospital stay (median, 6 vs. 12 days; p = 0.01). Recurrent jaundice occurred for three patients in group 1 (7.5%) and eight patients in group 2 (17.3%) (p = 0.198). Late gastric outlet obstruction occurred for 12.5% of the patients in group 1 and 13% of the patients in group 2 (p = 0.73). Despite the early benefits of stenting, no significant difference in the median overall survival between the two groups was found (group 1, 163 days; group 2, 178 days; p = 0.11). The limitations of this study included the small number of patients and the retrospective design.
Endoscopic stenting and surgery are effective palliation. The former is associated with fewer early complications and the latter with fewer late complications. Patients who do not qualify for curative resection may be better managed by stent placement. Surgery should be reserved for patients more likely to survive longer.
胰腺和胆道恶性肿瘤的治愈性切除很少见。大多数肿瘤在就诊时无法手术，黄疸的缓解通常是治疗目标。胆道减压可以通过手术分流或内镜胆道支架实现。本研究旨在比较手术旁路和内镜下未覆膜的镍钛诺支架在缓解恶性远端胆总管梗阻患者中的临床效果。
这项多中心、回顾性队列研究调查了哥伦比亚麦德林三级转诊中心的 86 例不可手术的恶性远端胆总管狭窄患者。这些患者接受了手术（第 1 组）或在哥伦比亚麦德林本地放置了未覆膜的 30Fr 自扩张镍钛诺支架（第 2 组）。主要观察指标包括累积胆道通畅率、住院时间和患者生存率。
该研究纳入了 86 例患者（平均年龄 66 岁；范围 43-78 岁），其中第 1 组 40 例，第 2 组 46 例。两组在年龄、性别、肝转移和诊断方面相似。第 1 组 38 例（95%）和第 2 组 43 例（93%）患者技术成功。35 例手术患者（88%）和 42 例支架患者（91%）获得了功能性胆道减压。第 2 组的手术相关死亡率较低（2%比 7.5%；p=0.01），早期并发症发生率较低（8.7%比 45%；p=0.02），住院时间较短（中位数 6 天比 12 天；p=0.01）。第 1 组有 3 例（7.5%）和第 2 组有 8 例（17.3%）患者出现复发性黄疸（p=0.198）。第 1 组有 12.5%的患者发生晚期胃出口梗阻，第 2 组有 13%的患者发生（p=0.73）。尽管支架置入具有早期优势，但两组的中位总生存期无显著差异（第 1 组 163 天；第 2 组 178 天；p=0.11）。本研究的局限性包括患者数量少和回顾性设计。
内镜下支架置入和手术都是有效的缓解方法。前者与较少的早期并发症相关，后者与较少的晚期并发症相关。不符合治愈性切除条件的患者可能更适合支架置入。手术应保留给可能存活时间更长的患者。
