Abstract
Endoscopic management of biliary obstruction is feasible in most patients and has emerged as standard treatment. Aside from the removal of bile duct stones, placement of a biliary stent is the most commonly employed modality of management. In experienced hands, this is successful in over 90% of patients. Lower procedure-related complications and the relative non-invasive nature of endoscopic treatment has relegated surgical manement to a subsidiary role. Hospitalization time rarely exceeds 1–2 days. In most patients with advanced malignant disease and short life expectancy, stenting affords effective palliation. For the majority of patients endoscopic management is preferable to the percutaneous transphepatic approach due to lower overall mortality and morbidity. Stent occlusion necessitating replacement remains a problem, but improvements in this area can be expected. New plastic stent designs are undergoing investigation. Expandable metallic stents are promising but controlled comparative trials with conventional plastic prostheses are needed. Use of expandable stents should be judicious since these cannot be removed. In the future we can look forward to advances in peroral cholangioscopic technology which may permit targeted treatment of intraductal biliary malignancies.
Résumé
Le traitement endoscopique de l'obstruction de la voie biliaire principale est faisable dans la plupart des cas et est devenu, par conséquent, la méthode de choix. En plus de la possibilité d'enlever des calculs, l'emplacement des endoprothèses est devenu un des actes des plus courants. Dans des mains expérimentées, cette technique réussit dans plus de 90% des cas. En raison d'un taux de complication inférieure et de la nature rélativement non-invasive du traitement endoscopique dans ces indications, la chirurgie n'a plus qu'un rôle secondaire. La durée de l'hospitalisation ne dépasse que rarement un ou deux jours, et dans la plupart des cas, procure un confort dans la survie chez des patients ayant une maladie maligne incurable avec une espérance de vie raccourcie. Dans la majorité des cas, l'approche endoscopique de la voie biliaire principale est préférable à la voie transhépatique en raison d'une morbidité et mortalité réduites. L'occlusion de l'endoprothèse est une complication problématique, mais des solution de rechange sont actuellement à l'étude. Les endoprothèses métalliques à expansion sont pleines de promesse mais, pour le moment, il faut attendre les résultats des études contrôlées les comparant aux endoprothèses en matière plastique traditionnelle. L'utilisation des endoprothèses à expansion serait une solution judicieuse car on ne peut les enlever. A l'avenir, on peut s'attendre à des progrès techniques dans la réalisation de la cholangiographie par voie orale, ce qui permettrait de traiter des lésions biliaires malignes des voies biliaires.
Resumen
El tratamiento endoscópico de la obstrucción biliar es factible en la mayoría de los casos y ha surgido como tratamiento estándar; aparte de la extracción de cálculos, la colocación de una férula de drenaje biliar representa la modalidad más común de manejo. En manos expertas este método es exitoso en más de 90% de los casos. La naturaleza relativamente no invasiva del método endoscópico, y la menor tasa de complicaciones, han relegado el tratamiento quirúrgico a un papel subsidiario. La hospitalización muy rara vez excede 1–2 días; en la mayoría de los pacientes con enfermedad neoplásica maligna y una corta expectativa de vida la colocación de una férula constituye una forma eficaz de paliación. Para la mayoría de los pacientes el manejo endoscópico es preferible al abordaje percutáneo transhepático por sus menores tasas de mortalidad y morbilidad. La obstrucción de la férula y la necesidad de cambiarla sigue siendo un problema real, pero es de esperarse que habrán avances en este campo, y ya están en investigaciones nuevas férulas de diversos materiales plásticos. Las férulas metálicas expansibles aparecen promisorias, pero se requiere realizar estudios comparativos con las prótesis plásticas convencionales. El uso de las férulas expandibles debe ser cuidadosamente meditado, puesto que éstas no pueden ser removidas. Podemos preveer avances en la tecnología colanguioscópica peroral que permita el tratamiento eficaz de neoplasias malignas intraductales.
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Soehendra, N., Binmoeller, K.F. & Grimm, H. Endoscopic therapy for biliary obstruction. World J. Surg. 16, 1066–1073 (1992). https://doi.org/10.1007/BF02067063
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DOI: https://doi.org/10.1007/BF02067063