Matsumoto Kazuya, Takeda Yohei, Onoyama Takumi, Kawata Soichiro, Kurumi Hiroki, Koda Hiroki, Yamashita Taro, Isomoto Hajime
Department of Gastroenterology, Tottori University Hospital, Yonago, Japan.
Ann Transl Med. 2017 Apr;5(8):190. doi: 10.21037/atm.2017.02.22.
Distal malignant biliary obstruction (MBO) leads to obstructive jaundice as a result of when the bile excretion from the liver is disturbed and induces hepatic failure and sepsis, which when complicated with cholangitis, it becomes necessary to perform drainage for the MBO. For biliary drainage, we can perform a surgical bypass operation, percutaneous transhepatic biliary drainage (PTBD), endoscopic biliary drainage (EBD) via duodenal papilla, or endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD), which is a transgastrointestinal biliary drainage. Although currently we usually perform EBD for distal MBO to begin with, the choice is different for biliary drainage in patients in whom EBD has failed in a preoperative case or an unresectable case. In other words, we choose PTBD for preoperative cases, and PTBD or EUS-BD according to the ability of the institution for their procedures when EBD has failed. It is desirable not to choose a plastic stent (PS) but a self-expandable metallic stent (SEMS), in particular for the unresectable cases of pancreatic cancer it is desirable not to choose an uncovered SEMS but a covered SEMS in EBD. Nevertheless, further examinations are expected to decide which, a covered or uncovered SEMS, we should choose in unresectable biliary tract cancer (BTC) and whether we should select PS, SEMS or ENBD in preoperative cases.
远端恶性胆管梗阻（MBO）由于肝脏胆汁排泄受阻而导致梗阻性黄疸，并诱发肝衰竭和脓毒症，当合并胆管炎时，就有必要对MBO进行引流。对于胆管引流，我们可以进行外科旁路手术、经皮经肝胆道引流（PTBD）、经十二指肠乳头的内镜胆管引流（EBD）或内镜超声（EUS）引导下的胆管引流（EUS-BD，一种经胃肠道的胆管引流）。尽管目前我们通常首先对远端MBO进行EBD，但对于术前或不可切除病例中EBD失败的患者，胆管引流的选择有所不同。换句话说，对于术前病例我们选择PTBD，当EBD失败时，根据机构进行相关操作的能力选择PTBD或EUS-BD。特别是对于不可切除的胰腺癌病例，不建议选择塑料支架（PS），而应选择自膨式金属支架（SEMS）；在EBD中，不建议选择无覆膜SEMS，而应选择覆膜SEMS。然而，仍期待进一步的研究来决定在不可切除的胆管癌（BTC）中应选择覆膜还是无覆膜SEMS，以及在术前病例中应选择PS、SEMS还是内镜鼻胆管引流（ENBD）。
