Cotton P B
Duke University Medical Center, Durham, North Carolina.
Surg Clin North Am. 1989 Jun;69(3):613-27. doi: 10.1016/s0039-6109(16)44838-3.
The endoscopic approach to biliary drainage came late on the scene; some of the published results reflect early experience with inadequate techniques. Now it is clear that the endoscopic approach is preferable to the percutaneous method. When palliation of jaundice is required (in a patient without impending duodenal obstruction), there is a simple choice between surgical bypass or endoscopic stenting. Stenting is substantially cheaper than surgery--at least for the initial admission. Recovery from stenting is almost immediate, which cannot be said for surgical intervention. Time will tell how far the need for readmission (stent blockage, duodenal obstruction) will erode these advantages. The main factor influencing our decision (stent or surgery), apart from the hope of resection, is the patient's general status, or "operative risk." Unfortunately, there is no accepted risk factor scale or template against which our experiences can be compared. There are no absolutes, only a spectrum of patients who differ according to the tumor load and their general medical condition. A fit patient with a relatively small tumor is best served by surgical intervention. The diagnosis and its unresectable nature can be established beyond doubt, and anastomoses (biliary and gastroduodenal) can be established of such a size that subsequent obstruction is unlikely. The operative mortality rate will be low. Patients with a large tumor load and poor general condition are best served by an endoscopic stent. Between these positions lies a spectrum of patients and plenty of room for discussion and personal opinions. Drainage procedures are unwarranted in patients who are truly terminal. Specialist vested interests have seriously jaundiced the view of many people in this field--and obstructed attempts at consensus. As in the management of patients with gallstone disease, it is important that surgeons, endoscopists, and radiologists work together as teams in the best interests of our patients, present and future.
内镜下胆道引流术在临床上应用较晚；一些已发表的结果反映了早期技术不完善时的经验。现在很明显，内镜方法优于经皮方法。当需要缓解黄疸时（对于没有即将发生十二指肠梗阻的患者），在手术旁路或内镜支架置入之间有一个简单的选择。支架置入术比手术便宜得多——至少对于初次入院来说是这样。支架置入术后恢复几乎是立竿见影的，而手术干预则并非如此。时间会证明再次入院的必要性（支架堵塞、十二指肠梗阻）会在多大程度上削弱这些优势。除了切除的希望外，影响我们决策（支架还是手术）的主要因素是患者的一般状况，即“手术风险”。不幸的是，没有公认的风险因素量表或模板可供我们比较经验。没有绝对的标准，只有根据肿瘤负荷和一般医疗状况不同的一系列患者。肿瘤相对较小的健康患者最好接受手术干预。可以毫无疑问地确定诊断及其不可切除的性质，并且可以建立大小合适的吻合口（胆管和胃十二指肠吻合口），使随后发生梗阻的可能性不大。手术死亡率会很低。肿瘤负荷大且一般状况差的患者最好接受内镜支架置入。在这两种情况之间存在一系列患者，有很大的讨论空间和个人观点。对于真正处于终末期的患者，引流手术是不必要的。该领域许多人的观点因专家的既得利益而严重受到影响——并阻碍了达成共识的努力。与胆结石疾病患者的管理一样，外科医生、内镜医生和放射科医生作为团队共同努力，以患者当前和未来的最佳利益为重，这一点很重要。
