Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, ST 9, Boston, MA 02215, USA.
J Gastrointest Surg. 2010 Sep;14(9):1414-21. doi: 10.1007/s11605-010-1258-z. Epub 2010 Jun 22.
Obstruction of the pancreatico-biliary (PB) drainage limb following major PB operations creates unique diagnostic and management dilemmas. We describe the etiology and prevalence, as well as diagnostic and therapeutic approaches for this challenging problem.
Individuals with PB limb obstruction were identified from a cohort of 477 patients undergoing major PB resections or bypasses for benign and malignant (N = 265) diseases from September 2000 to January 2010. Their presentation, management, short-term outcomes, and survival were analyzed.
Thirteen patients developed eventual PB limb obstruction with a mean time to presentation of 18.4 months (range 0.5-41.9), representing an overall adjusted incidence of 4%. Presenting symptoms were reflective of limb obstruction (elevated LFTs, jaundice, cholangitis, and pancreatitis). CT scans demonstrated dilation of the PB drainage limb in all 13 patients and evidence of intrahepatic biliary dilation in eight. Endoscopy was not valuable for either diagnostic or therapeutic purposes in the five patients evaluated in this manner. Percutaneous transhepatic biliary drainage (PTC) was pursued in six patients and provided definitive palliation in two, while three were temporized by this modality prior to a definitive operation, and it was employed postoperatively in another. Operative management occurred in 11 of 13 patients. Causative lesions were not accurately predicted by preoperative imaging and included adhesions, limb volvulus, abscess, malignant local recurrence, solitary metastatic disease, and carcinomatosis. Surgical interventions varied (five enteric bypasses, three adhesiolyses, two explorations, and one external limb venting). There were two perioperative mortalities, but limited morbidity otherwise (one myocardial infarction, one wound dehiscence, and one empyema from PTC placement). The median duration of postoperative hospital stay was 9 days, and no patient required readmission for further surgical management. No patients suffered subsequent recurrence of PB obstruction. In follow-up, nine of the remaining 11 patients are deceased with a median survival of 2.3 months (0.6-9.4 months). The other two are alive at a mean follow-up of 48 months.
Although infrequent, PB limb obstruction occurs for a variety of reasons and most commonly in the setting of an original malignancy. Since numerous therapeutic modalities are available, an improved understanding of the condition is important in managing these complex patients. Decisive operative intervention accurately assesses the cause and extent of the problem and, for most presentations, provides definitive palliation with limited morbidity for this near-terminal event.
在进行主要的胰胆管（PB）手术之后，如果 PB 引流支发生阻塞，将会产生独特的诊断和治疗难题。我们描述了这种具有挑战性的问题的病因、流行程度，以及诊断和治疗方法。
从 2000 年 9 月至 2010 年 1 月期间，477 例因良性和恶性疾病接受主要 PB 切除术或旁路术的患者队列中，确定了 PB 支阻塞的患者。分析了他们的表现、治疗、短期结果和生存情况。
13 例患者最终发生 PB 支阻塞，其出现时间的平均时间为 18.4 个月（范围 0.5-41.9），总体调整发生率为 4%。主要表现为支阻塞的症状（升高的 LFTs、黄疸、胆管炎和胰腺炎）。所有 13 例患者的 CT 扫描均显示 PB 引流支扩张，8 例患者显示肝内胆管扩张。对 5 例以这种方式评估的患者，内镜检查对诊断或治疗均无价值。6 例患者行经皮经肝胆道引流（PTC），其中 2 例获得明确缓解，3 例通过该方法暂时缓解，另 1 例在术后采用该方法。13 例患者中有 11 例接受了手术治疗。术前影像学检查不能准确预测病因，包括粘连、支旋转、脓肿、局部恶性复发、孤立性转移疾病和癌性播散。手术干预方式多样（5 例肠内旁路术、3 例粘连松解术、2 例探查术和 1 例外部支通风术）。有 2 例围手术期死亡，但其他方面的发病率有限（1 例心肌梗死、1 例伤口裂开和 1 例 PTC 置管术后脓胸）。术后住院时间中位数为 9 天，无患者因进一步手术治疗而再次住院。无患者出现 PB 支再阻塞。随访时，其余 11 例患者中有 9 例死亡，中位生存期为 2.3 个月（0.6-9.4 个月）。另外 2 例仍存活，平均随访 48 个月。
尽管很少见，但 PB 支阻塞发生的原因多种多样，最常见于原发性恶性肿瘤。由于有多种治疗方法，因此了解这种疾病对于治疗这些复杂的患者非常重要。明确的手术干预可以准确评估病因和问题的严重程度，对于大多数表现，通过有限的发病率提供明确的姑息治疗，从而解决这种接近终末期的问题。
