遠位悪性胆道狭窄に対する術前内視鏡的胆管ステント留置術の効果と諸問題
遠位悪性胆道狭窄に対する膵頭十二指腸切除（PD）術前の胆道ドレナージが必要か否か議論となっている．プラスチックステント（PS）を用いた内視鏡的胆管ステント留置術（EBS）後にPDを施行した115例を対象に，EBSの効果，偶発症，留置後の胆管炎発生の有無とその要因について後方視的に検討した．EBSにより総ビリルビン値（平均）は6.8mg/dLから2.16mg/dLと低下し，胆管炎例は全例軽快した．偶発症の6例（5.2%）はいずれも軽症膵炎であった．EBS後胆管炎の発生は24例（20.9%）に認め，内視鏡的経鼻胆管ドレナージへの交換あるいはPSの入れ替えを要した．EBS後胆管炎の因子について多変量...
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| Published in | Tando Vol. 29; no. 4; pp. 738 - 744 |
|---|---|
| Main Authors | , , , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
日本胆道学会
2015
Japan Biliary Association |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0914-0077 1883-6879 |
| DOI | 10.11210/tando.29.738 |
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| Abstract | 遠位悪性胆道狭窄に対する膵頭十二指腸切除（PD）術前の胆道ドレナージが必要か否か議論となっている．プラスチックステント（PS）を用いた内視鏡的胆管ステント留置術（EBS）後にPDを施行した115例を対象に，EBSの効果，偶発症，留置後の胆管炎発生の有無とその要因について後方視的に検討した．EBSにより総ビリルビン値（平均）は6.8mg/dLから2.16mg/dLと低下し，胆管炎例は全例軽快した．偶発症の6例（5.2%）はいずれも軽症膵炎であった．EBS後胆管炎の発生は24例（20.9%）に認め，内視鏡的経鼻胆管ドレナージへの交換あるいはPSの入れ替えを要した．EBS後胆管炎の因子について多変量解析で検討した項目はいずれも有意ではなく，原因は主としてPS留置後の逆行性感染と考えられた．遠位悪性胆道狭窄に対する術前EBSは，高度黄疸や胆管炎例のほか，術前化学療法前の減黄必要例，手術待機期間が長くなる例には必要な処置と考える．但し，逆流防止機能を有した新たなPSの開発が課題である． |
|---|---|
| AbstractList | Preoperative biliary drainage by endoscopic biliary stenting (EBS) for distal bile duct stricture due to malignant tumor is controversial. The effect and complication, possibility of post-EBS cholangitis, and factors associated with post-EBS cholangitis were retrospectively analyzed in 115 patients with subsequent pancreaticoduodenectomy after EBS. The mean T-bili before drainage was 6.8mg/dL, but after EBS, the mean T-Bili level decreased to 2.16mg/dL. Complication related to EBS, all of which were pancreatitis, occurred in 6 patients (5.2%). 24 cases (20.9%) developed post-EBS cholangitis. Any factors associated with post-EBS cholangitis were not significant in multi-variant analysis. Preoperative EBS should be performed especially in the cases of which preoperative period is lengthy and in the cases of neo-adjuvant chemotherapy which need jaundice decreased. A new designed PS that can reduce retrograde back flow is awaited.
遠位悪性胆道狭窄に対する膵頭十二指腸切除（PD）術前の胆道ドレナージが必要か否か議論となっている．プラスチックステント（PS）を用いた内視鏡的胆管ステント留置術（EBS）後にPDを施行した115例を対象に，EBSの効果，偶発症，留置後の胆管炎発生の有無とその要因について後方視的に検討した．EBSにより総ビリルビン値（平均）は6.8mg/dLから2.16mg/dLと低下し，胆管炎例は全例軽快した．偶発症の6例（5.2%）はいずれも軽症膵炎であった．EBS後胆管炎の発生は24例（20.9%）に認め，内視鏡的経鼻胆管ドレナージへの交換あるいはPSの入れ替えを要した．EBS後胆管炎の因子について多変量解析で検討した項目はいずれも有意ではなく，原因は主としてPS留置後の逆行性感染と考えられた．遠位悪性胆道狭窄に対する術前EBSは，高度黄疸や胆管炎例のほか，術前化学療法前の減黄必要例，手術待機期間が長くなる例には必要な処置と考える．但し，逆流防止機能を有した新たなPSの開発が課題である． 遠位悪性胆道狭窄に対する膵頭十二指腸切除（PD）術前の胆道ドレナージが必要か否か議論となっている．プラスチックステント（PS）を用いた内視鏡的胆管ステント留置術（EBS）後にPDを施行した115例を対象に，EBSの効果，偶発症，留置後の胆管炎発生の有無とその要因について後方視的に検討した．EBSにより総ビリルビン値（平均）は6.8mg/dLから2.16mg/dLと低下し，胆管炎例は全例軽快した．偶発症の6例（5.2%）はいずれも軽症膵炎であった．EBS後胆管炎の発生は24例（20.9%）に認め，内視鏡的経鼻胆管ドレナージへの交換あるいはPSの入れ替えを要した．EBS後胆管炎の因子について多変量解析で検討した項目はいずれも有意ではなく，原因は主としてPS留置後の逆行性感染と考えられた．遠位悪性胆道狭窄に対する術前EBSは，高度黄疸や胆管炎例のほか，術前化学療法前の減黄必要例，手術待機期間が長くなる例には必要な処置と考える．但し，逆流防止機能を有した新たなPSの開発が課題である． 「要旨」:遠位悪性胆道狭窄に対する膵頭十二指腸切除(PD)術前の胆道ドレナージが必要か否か議論となっている. プラスチックステント(PS)を用いた内視鏡的胆管ステント留置術(EBS)後にPDを施行した115例を対象に, EBSの効果, 偶発症, 留置後の胆管炎発生の有無とその要因について後方視的に検討した. EBSにより総ビリルビン値(平均)は6.8mg/dLから2.16mg/dLと低下し, 胆管炎例は全例軽快した. 偶発症の6例(5.2%)はいずれも軽症膵炎であった. EBS後胆管炎の発生は24例(20.9%)に認め, 内視鏡的経鼻胆管ドレナージへの交換あるいはPSの入れ替えを要した. EBS後胆管炎の因子について多変量解析で検討した項目はいずれも有意ではなく, 原因は主としてPS留置後の逆行性感染と考えられた. 遠位悪性胆道狭窄に対する術前EBSは, 高度黄疸や胆管炎例のほか, 術前化学療法前の減黄必要例, 手術待機期間が長くなる例には必要な処置と考える. 但し, 逆流防止機能を有した新たなPSの開発が課題である. |
| Author | 高橋, 邦幸 真口, 宏介 小山内, 学 潟沼, 朗生 安保, 義恭 加藤, 新 矢根, 圭 金, 俊文 高田, 実 |
| Author_FL | Kin Toshifumi Osanai Manabu Ambo Yoshiyasu 真口 宏介 Yane Kei Takahashi Kuniyuki Katanuma Akio Kato Shin Takada Minoru |
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| References | 11) van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 2010; 362: 129-137 18) Baron TH, Kozarek RA. Preoperative biliary stents in pancreatic cancer -proceed with caution. N Engl J Med 2010; 362: 170-172 10) Qiu YD, Bai JL, Xu FG, et al. Effect of preoperative biliary drainage on malignant obstructive jaundice: a meta-analysis. World J Gastroenterol 2011; 17: 391-396 24) de Bellis M, Palaia R, Sandomenico C, et al. Is preoperative endoscopic biliary drainage indicated for jaundiced patients with resectable pancreatic cancer? Curr Drug Targets 2012; 13: 753-763 20) Christensen M, Matzen P, Schulze S, et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60: 721-731 12) Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393 21) Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007; 39: 793-801 8) Wang Q, Gurusamy KS, Lin H, et al. Preoperative biliary drainage for obstructive jaundice. Cochrane Database Syst Rev 2008; Cd005444 25) 外川 修, 伊佐山浩, 中井陽介, ほか. 中下部悪性胆管閉塞bridge to surgeryに対するcovered metallic stentの有用性. 胆と膵 2012; 33: 823-826 6) Sewnath ME, Birjmohun RS, Rauws EA, et al. The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy. J Am Coll Surg 2001; 192: 726-734 13) Takada T, Strasberg SM, Solomkin JS, et al. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20: 1-7 23) Hui CK, Lai KC, Yuen MF, et al. Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis? Gastrointest Endosc 2003; 58: 500-504 15) Katz MH, Pisters PW, Evans DB, et al. Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am Coll Surg 2008; 206: 833-846; discussion 46-48 2) Klinkenbijl JH, Jeekel J, Schmitz PI, et al. Carcinoma of the pancreas and periampullary region: palliation versus cure. Br J Surg 1993; 80: 1575-1578 19) Freeman ML. Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography. Curr Gastroenterol Rep 2003; 5: 145-153 14) 日本膵臓学会. 科学的根拠に基づく膵癌診療ガイドライン 2013年度版. 2013: 83-86 9) Sewnath ME, Karsten TM, Prins MH, et al. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002; 236: 17-27 3) Trede M, Schwall G. The complications of pancreatectomy. Ann Surg 1988; 207: 39-47 17) Varadhachary GR, Wolff RA, Crane CH, et al. Preoperative gemcitabine and cisplatin followed by gemcitabine-based chemoradiation for resectable adenocarcinoma of the pancreatic head. J Clin Oncol 2008; 26: 3487-3495 1) van der Gaag NA, Kloek JJ, de Castro SM, et al. Preoperative biliary drainage in patients with obstructive jaundice: history and current status. J Gastrointest Surg 2009; 13: 814-820 5) Lillemoe KD. Preoperative biliary drainage and surgical outcome. Ann Surg 1999; 230: 143-144 22) Sugiyama M, Atomi Y. The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis. Am J Gastroenterol 1998; 93: 2065-2068 4) Kimmings AN, van Deventer SJ, Obertop H, et al. Endotoxin, cytokines, and endotoxin binding proteins in obstructive jaundice and after preoperative biliary drainage. Gut 2000; 46: 725-731 7) Pisters PW, Hudec WA, Hess KR, et al. Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients. Ann Surg 2001; 234: 47-55 16) Evans DB, Varadhachary GR, Crane CH, et al. Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol 2008; 26: 3496-3502 |
| References_xml | – reference: 6) Sewnath ME, Birjmohun RS, Rauws EA, et al. The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy. J Am Coll Surg 2001; 192: 726-734 – reference: 9) Sewnath ME, Karsten TM, Prins MH, et al. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002; 236: 17-27 – reference: 11) van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 2010; 362: 129-137 – reference: 21) Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007; 39: 793-801 – reference: 19) Freeman ML. Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography. Curr Gastroenterol Rep 2003; 5: 145-153 – reference: 15) Katz MH, Pisters PW, Evans DB, et al. Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am Coll Surg 2008; 206: 833-846; discussion 46-48 – reference: 17) Varadhachary GR, Wolff RA, Crane CH, et al. Preoperative gemcitabine and cisplatin followed by gemcitabine-based chemoradiation for resectable adenocarcinoma of the pancreatic head. J Clin Oncol 2008; 26: 3487-3495 – reference: 5) Lillemoe KD. Preoperative biliary drainage and surgical outcome. Ann Surg 1999; 230: 143-144 – reference: 20) Christensen M, Matzen P, Schulze S, et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60: 721-731 – reference: 2) Klinkenbijl JH, Jeekel J, Schmitz PI, et al. Carcinoma of the pancreas and periampullary region: palliation versus cure. Br J Surg 1993; 80: 1575-1578 – reference: 25) 外川 修, 伊佐山浩, 中井陽介, ほか. 中下部悪性胆管閉塞bridge to surgeryに対するcovered metallic stentの有用性. 胆と膵 2012; 33: 823-826 – reference: 10) Qiu YD, Bai JL, Xu FG, et al. Effect of preoperative biliary drainage on malignant obstructive jaundice: a meta-analysis. World J Gastroenterol 2011; 17: 391-396 – reference: 12) Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393 – reference: 22) Sugiyama M, Atomi Y. The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis. Am J Gastroenterol 1998; 93: 2065-2068 – reference: 24) de Bellis M, Palaia R, Sandomenico C, et al. Is preoperative endoscopic biliary drainage indicated for jaundiced patients with resectable pancreatic cancer? Curr Drug Targets 2012; 13: 753-763 – reference: 18) Baron TH, Kozarek RA. Preoperative biliary stents in pancreatic cancer -proceed with caution. N Engl J Med 2010; 362: 170-172 – reference: 7) Pisters PW, Hudec WA, Hess KR, et al. Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients. Ann Surg 2001; 234: 47-55 – reference: 13) Takada T, Strasberg SM, Solomkin JS, et al. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20: 1-7 – reference: 3) Trede M, Schwall G. The complications of pancreatectomy. Ann Surg 1988; 207: 39-47 – reference: 23) Hui CK, Lai KC, Yuen MF, et al. Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis? Gastrointest Endosc 2003; 58: 500-504 – reference: 4) Kimmings AN, van Deventer SJ, Obertop H, et al. Endotoxin, cytokines, and endotoxin binding proteins in obstructive jaundice and after preoperative biliary drainage. Gut 2000; 46: 725-731 – reference: 8) Wang Q, Gurusamy KS, Lin H, et al. Preoperative biliary drainage for obstructive jaundice. Cochrane Database Syst Rev 2008; Cd005444 – reference: 1) van der Gaag NA, Kloek JJ, de Castro SM, et al. Preoperative biliary drainage in patients with obstructive jaundice: history and current status. J Gastrointest Surg 2009; 13: 814-820 – reference: 14) 日本膵臓学会. 科学的根拠に基づく膵癌診療ガイドライン 2013年度版. 2013: 83-86 – reference: 16) Evans DB, Varadhachary GR, Crane CH, et al. Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol 2008; 26: 3496-3502 |
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| Snippet | 遠位悪性胆道狭窄に対する膵頭十二指腸切除（PD）術前の胆道ドレナージが必要か否か議論となっている．プラスチックステント（PS）を用いた内視鏡的胆管ステント留置... 「要旨」:遠位悪性胆道狭窄に対する膵頭十二指腸切除(PD)術前の胆道ドレナージが必要か否か議論となっている. プラスチックステント(PS)を用いた内視鏡的胆管ステント留置... Preoperative biliary drainage by endoscopic biliary stenting (EBS) for distal bile duct stricture due to malignant tumor is controversial. The effect and... |
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| SubjectTerms | endoscopic biliary stenting pancreaticoduodenectomy preoperative biliary drainage 内視鏡的胆管ステント留置術 膵頭十二指腸切除術 術前胆道ドレナージ |
| Title | 遠位悪性胆道狭窄に対する術前内視鏡的胆管ステント留置術の効果と諸問題 |
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