Klempa I, Arnold W
Klinik für Allgemein- und Gefässchirurgie, Zentralkrankenhauses St.-Jürgen-Strasse Bremen.
Chirurg. 1994 Oct;65(10):836-48.
Cholestatic jaundice is the result of a malignancy of the bile duct itself, of the gallbladder, of the ampulla or (as in most cases) of the pancreas. Patients without evidence of metastases or other signs of advanced cancer (e.g. ascites) are candidates for explorative laparotomy. In the vast majority of cases resection of a tumor is not feasible and the surgeon is faced with the objective of providing palliation. To date there exists not only one palliative procedure, and the surgeon has to take into account the following: In patients with pancreatic cancer palliation can be given with biliary bypass with or without gastroenterostomy. This carries an operative mortality of almost 20% and means a survival of only 5-6 months. Nonsurgical procedures as transpapillary stenting play an increasing role in the management of patients with obstructive jaundice due to pancreatic cancer. In some cases however resectable tumors perhaps will be overlooked. The results of controlled studies comparing endoscopic stenting and surgical bypass are encouraging for stenting techniques (lower morbidity and mortality (< 10%), technical success rates exceeding 90%). The availability of different palliative treatment modalities for carcinoma of the bile ducts suggests that no approach is definitely superior. Operative biliary-enteric anastomosis gives a tolerable operative mortality rate in younger patients, less morbidity, than external biliary drainage by better quality of life of the patients. In retrograde placement of prosthetic stents, in patients with high bile duct obstruction difficulties are frequently. In such cases the percutaneous drainage should be reserved for endoscopic failures, in cases the endoscopic and percutaneous approaches can be combined in the 'rendezvous' procedure. In recent years several reports have advocated extensive surgery for biliary neoplasms. Preoperative staging of these patients remains an issue as none of the commonly modalities are accurate in predicting resectability.
胆汁淤积性黄疸是胆管本身、胆囊、壶腹或（在大多数情况下）胰腺恶性肿瘤的结果。没有转移证据或其他晚期癌症迹象（如腹水）的患者适合进行剖腹探查术。在绝大多数情况下，切除肿瘤是不可行的，外科医生面临着提供姑息治疗的目标。迄今为止，不止有一种姑息治疗方法，外科医生必须考虑以下几点：对于胰腺癌患者，可以通过有或没有胃肠吻合术的胆肠吻合术进行姑息治疗。这一手术的死亡率几乎为20%，意味着患者仅能存活5至6个月。非手术方法如经乳头支架置入术在胰腺癌所致梗阻性黄疸患者的治疗中发挥着越来越重要的作用。然而，在某些情况下，可能会忽略可切除的肿瘤。比较内镜支架置入术和手术旁路术的对照研究结果对支架置入技术是令人鼓舞的（发病率和死亡率较低（<10%），技术成功率超过90%）。胆管癌有多种不同的姑息治疗方式，这表明没有一种方法绝对更优越。手术胆肠吻合术在年轻患者中的手术死亡率可接受，发病率较低，与外引流相比，患者的生活质量更高。在逆行放置假体支架时，高位胆管梗阻患者经常会遇到困难。在这种情况下，经皮引流应留作内镜治疗失败时使用，在某些情况下，内镜和经皮方法可在“会师”手术中联合使用。近年来，有几份报告主张对胆管肿瘤进行广泛手术。这些患者的术前分期仍然是一个问题，因为常用的方法都无法准确预测可切除性。
