Schoeman M N, Huibregtse K
Department of Gastroenterology and Hepatology, University of Amsterdam, The Netherlands.
Gastrointest Endosc Clin N Am. 1995 Jan;5(1):217-36.
Surgery should be the first therapeutic modality considered in patients with pancreatic and ampullary carcinoma. Surgery is the only potentially curative therapy and offers the best form of palliation in patients with impending or overt duodenal obstruction. Patients with clearly unresectable tumors or those considered unfit for surgery should be offered palliative therapy, preferably endoscopically. The difficulty, however, arises in patients who undergo laparotomy and who subsequently are found to have unresectable tumors. The problem of stent occlusion and frequent associated hospital visits has been an argument to proceed to palliative double bypass surgery. Against this is the low mortality and shorter hospital stay of nonsurgical endoscopic palliative therapy. Direct comparisons of surgery versus endoscopic therapy have shown that both are equally effective in the initial relief of jaundice (Table 6). Surgery has a higher initial mortality and complication rate, but more long-term complications and hospital visits were seen in the endoscopic group, suggesting that it offered a poorer long-term palliation. There was no significant difference in the survival of the patients in the two groups. Patient choice is a major factor in the final decision, but current recommendations probably should be that patients with a poor short-term survival outlook should be offered nonsurgical palliative therapy and those with a longer life expectancy may best be handled with surgery. Predicting patient survival, of course, remains a major difficulty. A recent publication of the laparoscopic formation of a cholecystojejunostomy for palliation of malignant biliary obstruction also offers a promising approach that requires further evaluation.
对于胰腺癌和壶腹癌患者，手术应是首先考虑的治疗方式。手术是唯一具有潜在治愈可能的疗法，对于即将发生或已出现十二指肠梗阻的患者，也是最佳的姑息治疗方式。对于肿瘤明显无法切除或被认为不适合手术的患者，应给予姑息治疗，最好是内镜治疗。然而，困难在于那些接受剖腹手术但随后被发现肿瘤无法切除的患者。支架阻塞问题以及频繁的相关住院就诊一直是进行姑息性双旁路手术的一个理由。与之相对的是，非手术内镜姑息治疗的死亡率低且住院时间短。手术与内镜治疗的直接比较表明，两者在初始缓解黄疸方面同样有效（表6）。手术的初始死亡率和并发症发生率较高，但内镜治疗组出现了更多的长期并发症和住院就诊情况，这表明内镜治疗提供的长期姑息效果较差。两组患者的生存率没有显著差异。患者的选择是最终决策的一个主要因素，但目前的建议可能是，短期生存前景不佳的患者应接受非手术姑息治疗，而预期寿命较长的患者可能最好通过手术治疗。当然，预测患者的生存情况仍然是一个主要难题。最近一篇关于腹腔镜下胆囊空肠吻合术治疗恶性胆管梗阻的姑息治疗的报道也提供了一种有前景的方法，需要进一步评估。
