Frey C F, Suzuki M, Isaji S
Department of Surgery, University of California, Davis, Sacramento 95817.
World J Surg. 1990 Jan-Feb;14(1):59-69. doi: 10.1007/BF01670547.
In patients with chronic pancreatitis, common bile duct obstruction is reported in 3.2-45.6% of patients; however, only 5-10% of all patients with chronic pancreatitis require operative decompression of the bile duct. The cause of the intrapancreatic stricture of the common bile duct may be either a fibrotic inflammatory restriction, or compression by a pseudocyst. Obstruction of the duodenum is much less common than common bile duct obstruction in chronic pancreatitis occurring in less than 1-2% of patients with chronic pancreatitis. Colonic obstruction secondary to pancreatitis is very infrequent. The intrapancreatic strictures of chronic pancreatitis are characteristically smooth and tapering on endoscopic retrograde cholangiopancreatography (ERCP), but in some patients, they may have a sharp cut-off and closely resemble the appearance of carcinoma of the pancreas invading the bile duct. The natural history of these intrapancreatic strictures is variable. They may progress and be associated with cholangitis, biliary cirrhosis, common duct stones, or may remain stable for years or regress. Prior pancreaticojejunostomy is not protective against the development of intrapancreatic biliary strictures which may follow in 5-30% of patients, with most authors reporting an incidence of less than 10%. Evaluation of alkaline phosphatase, bilirubin, the presence of jaundice, or the appearance of an intrapancreatic stricture on ERCP is not predictive of whether cholangitis or biliary cirrhosis may or may not develop. The incidence of cholangitis and biliary cirrhosis in patients with intrapancreatic stricture is 9.4% and 7.3%, respectively. Laennec's cirrhosis occurs in a similar number of patients. Operation is indicated in patients with intrapancreatic strictures of the common bile duct in association with chronic pancreatitis in patients developing cholangitis, biliary cirrhosis, common duct stones, progression of the stricture, persistent high elevations of alkaline phosphatase and/or bilirubin for over a month or inability to rule out cancer of the pancreas or periampullary region. The operation of choice is choledochoduodenostomy or Roux-en-Y choledochojejunostomy to bypass the obstructed intrapancreatic portion of the common bile duct. Persistent duodenal obstruction for over 3 or 4 weeks is an indication for gastrojejunostomy. Pain is not a feature of common bile duct obstruction in the absence of cholangitis. In the presence of pain associated with chronic pancreatitis, longitudinal pancreaticojejunostomy is the operation of choice combined with Roux-en-Y choledochojejunostomy. Some of the newer operations, e.g., the Beger and Frey procedures, may make the necessity of a separate operation for biliary decompression superfluous.
在慢性胰腺炎患者中，3.2% - 45.6%的患者报告有胆总管梗阻；然而，所有慢性胰腺炎患者中只有5% - 10%需要进行胆管手术减压。胆总管胰腺内段狭窄的原因可能是纤维化炎症性狭窄，或被假性囊肿压迫。十二指肠梗阻在慢性胰腺炎中比胆总管梗阻少见得多，发生率不到慢性胰腺炎患者的1% - 2%。胰腺炎继发的结肠梗阻非常罕见。慢性胰腺炎的胰腺内段狭窄在内镜逆行胰胆管造影（ERCP）上的特征是光滑且逐渐变细，但在一些患者中，它们可能有突然截断，与侵犯胆管的胰腺癌外观非常相似。这些胰腺内段狭窄的自然病程是可变的。它们可能进展并伴有胆管炎、胆汁性肝硬化、胆总管结石，或者可能多年保持稳定或消退。既往的胰空肠吻合术并不能预防胰腺内胆管狭窄的发生，5% - 30%的患者可能会出现这种情况，大多数作者报告的发生率低于10%。评估碱性磷酸酶、胆红素、黄疸的存在或ERCP上胰腺内段狭窄的表现，并不能预测是否会发生胆管炎或胆汁性肝硬化。胰腺内段狭窄患者胆管炎和胆汁性肝硬化的发生率分别为9.4%和7.3%。同样数量的患者会发生Laennec肝硬化。对于伴有慢性胰腺炎的胆总管胰腺内段狭窄患者，若出现胆管炎、胆汁性肝硬化、胆总管结石、狭窄进展、碱性磷酸酶和/或胆红素持续高水平超过一个月，或无法排除胰腺癌或壶腹周围癌，则需进行手术。首选的手术方式是胆总管十二指肠吻合术或Roux - en - Y胆总管空肠吻合术，以绕过胆总管胰腺内梗阻段。持续十二指肠梗阻超过3或4周是胃空肠吻合术的指征。在没有胆管炎的情况下，疼痛不是胆总管梗阻的特征。在伴有慢性胰腺炎的疼痛患者中，纵向胰空肠吻合术是首选手术，可联合Roux - en - Y胆总管空肠吻合术。一些新的手术，如Beger手术和Frey手术，可能使单独进行胆管减压手术变得不必要。
