Panpimanmas Sukij, Ratanachu-ek Thawee
Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand.
J Med Assoc Thai. 2011 Mar;94 Suppl 2:S129-34.
There are many palliative treatments for patients with unresectable malignant biliary obstruction, e.g. endoscopic retrograde cholangiopancreatography (ERCP) with stents, percutaneous transhepatic biliary drainage (PTBD) or surgery. We propose a new technique by using endoscopic ultrasound (EUS) with fluoroscopy to perform hepaticogastrostomy for palliative drainage far from the site of tumor to avoid tumor obstruction.
Between December 2005 and June 2006, two patients with severe jaundice by hilar cholangiocarcinoma were treated with this new procedure. The first case was a 44-year female post partial resection of tumor and Roux en Y hepaticojejunostomy and the second case was a 48-year male post ERCP and right hepatic stent. We used an electronic convex curved linear-array echo-endoscope with fluoroscope guided to drain left dilated intrahepatic duct to the stomach by inserting 8 Fr 60 mm metallic wallstent via lesser curvature. We performed under general anesthesia and followed-up every two weeks.
There were former two patients failed to place the stents. Hepaticogastrotomy of both patients were our first successful trial but stent site of the first case was not good because the insertion was at esophagogastric junction. Total bilirubin of first and second case fell from 38.4 mg/dl to 27.3 mg/dl and 22.0 mg/dl to 3.4 mg/ dl in two weeks, respectively. No immediate complication was found and oral diet was well succeeded on the next day after procedure in both cases. The first case was dead after 32 days of operation from sepsis and hepatic failure. The second case was clinically much improved after 3 months and died from liver failure after 6 months and 10 days.
This new interventional EUS-guided hepaticogastrostomy is safe, feasible and may provide an alternative to surgery or PTBD or failed ERCP. It can improve the palliative treatment in hilar lesions because it's internal drainage and far from tumor site that promote fast recovery. However, long term study is still necessary to evaluate the results and cost-effectiveness of this technique.
对于无法切除的恶性胆管梗阻患者，有多种姑息治疗方法，如内镜逆行胰胆管造影术（ERCP）置入支架、经皮肝穿刺胆道引流术（PTBD）或手术。我们提出一种新技术，即使用内镜超声（EUS）结合荧光透视进行肝胃吻合术，以实现远离肿瘤部位的姑息性引流，避免肿瘤阻塞。
2005年12月至2006年6月期间，对2例因肝门部胆管癌导致严重黄疸的患者采用了这种新方法。第一例是一名44岁女性，曾接受肿瘤部分切除术及Roux-en-Y肝空肠吻合术；第二例是一名48岁男性，曾接受ERCP及右肝支架置入术。我们使用带有荧光透视引导的电子凸阵曲线线性阵列超声内镜，经小弯侧插入8Fr 60mm金属壁支架，将扩张的左肝内胆管引流至胃内。手术在全身麻醉下进行，每两周进行一次随访。
前两名患者支架置入失败。两例患者的肝胃吻合术均为首次成功尝试，但第一例患者的支架位置不佳，因为插入位置在食管胃交界处。第一例和第二例患者的总胆红素在两周内分别从38.4mg/dl降至27.3mg/dl和从22.0mg/dl降至3.4mg/dl。未发现即刻并发症，两例患者术后次日经口进食均顺利。第一例患者术后32天因败血症和肝衰竭死亡。第二例患者术后3个月临床症状明显改善，6个月零10天后死于肝衰竭。
这种新的内镜超声引导下肝胃吻合术是安全、可行的，可能为手术、PTBD或ERCP失败提供一种替代方法。它可以改善肝门部病变的姑息治疗，因为它是内引流且远离肿瘤部位，有助于快速康复。然而，仍需要长期研究来评估该技术的效果和成本效益。
