编者按：肝脏疾病，尤其是慢性肝病，是导致患者患病和死亡的重要原因之一。然而，一些特殊临床治疗，如对合并某些肝脏和胆道系统相关疾病的治疗，会影响慢性肝病患者的治疗效果和安全性。为此，大会从内镜治疗角度出发，设置了“AASLD/ASGE Endoscopy Course: Clinical Challenges and Decision-Making in the Endoscopic Care of Hepatobiliary Patients”，分享最新研究数据，以期为肝脏和肝胆管疾病治疗提供更好的方案。

 

　　专题主持、美国梅奥医学中心 胃肠肝病科Bret T. Petersen教授是内镜诊疗方面的专家，本刊特邀请他为我们分享胆管癌相关诊疗经验。

 

　　如何在术前确诊胆管癌？

 

　　Bret T. Petersen教授：我们需要应用多种方式对胆管癌进行诊断，仅凭单项检查结果，往往难以对胆管癌作出诊断。应用多种影像学手段和其他实验室检测方法，如果怀疑诊断为胆管癌，则需要从胆管内获取组织，或者对病变广泛扩散的患者，经皮或经超声内镜活检获取组织，通过病理学检查对胆管癌进行诊断。

 

　　需要与胆管癌进行鉴别诊断的胆管狭窄包括自身免疫性胆管疾病、自身免疫性胰腺疾病压迫远端胆管以及结石疾病或之前损伤相关的慢性良性狭窄。

 

　　Prof. Peterson: Diagnosis is multimodal. We generally can’t diagnose cholangiocarcinoma with a single test. There are multiple imaging modalities and other laboratory studies that lead to the suspicion of a diagnosis, which then needs acquisition of tissue from within the duct, or in patients with more widely spread disease, acquisition of tissue through external biopsy or endoscopic ultrasound. The differentials for biliary stricture that could be biliary cholangiocarcinoma include autoimmune bile duct disease, autoimmune pancreatic disease putting pressure on the distal duct, and chronic benign strictures related to stone disease or prior injury.

 

　　如何把握胆管癌的手术时机？

 

　　Bret T. Petersen教授：胆管癌患者往往进展至胆管狭窄时才来就诊，所以，确诊时已经为晚期。如果胆管梗阻确实是癌症所致，那么，恶性肿瘤的生长问题较继发性胆汁性肝硬化的发生风险问题更为重要。我们常常并不知道患者在诊断胆管癌之前胆管梗阻的持续时间，但是，我们目前了解，在临床黄疸之前的实验室异常与持续黄疸的时间间隔并不很长。胆管良性狭窄患者与癌症患者相比，继发性胆汁性肝硬化才是更重要的问题。

 

　　Prof. Peterson: These patients often present relatively late. We don’t see them until they have biliary obstruction. If indeed that obstruction is due to a cancer, the issue of the growth and malignancy is more important than the risk of developing secondary biliary cirrhosis. The duration and longevity of the obstruction is often unknown to us but we understand now that the duration of jaundice is not far separated from the time to laboratory abnormalities prior to the appearance of clinical jaundice. Secondary biliary cirrhosis is a much greater issue in patients who have benign strictures than it is in those with cancer.

 

　　解除胆道狭窄，金属支架还是塑料支架？

 

　　Bret T. Petersen教授：内镜下放置支架对于缓解胆管狭窄患者的黄疸非常重要，金属支架和塑料支架都很常用。相比而言，金属支架的花费更高，但是，对许多患者可以提供更长时间的缓解黄疸作用，对位于分叉以下、较直的胆管病变，金属支架往往更为可取，特别是覆膜支架用于良性疾病的情况，并且常常用于恶性疾病。处理分叉处的狭窄时，应用金属支架可能造成非常复杂的解剖学情况，所以，塑料支架往往更为可取，除非患者显然处于生命的末期。

 

　　Prof. Peterson: Both are important and both are commonly used. Metal stents carry a significant cost disadvantage but in many patients provide longer-term palliation. For lesions below the bifurcation where the duct is straight, metal stents are often preferable, particularly covered stents in the setting of benign disease and often in malignant disease. When dealing with strictures of the bifurcation, using the metal stents leads to a very complicated anatomical scenario, so plastic stents are often preferable, unless the patient is clearly in the terminal phases of life.

 

　　如何管理晚期胆管癌和术后复发患者？

 

　　Bret T. Petersen教授：失去外科治疗机会的晚期胆管癌以及胆管癌术后复发均为终末期疾病，我们不能治愈这些患者，只能应用姑息性手段，通常包括用于缓解黄疸及其相关瘙痒的放置机械支架等手段。这种情况下，治疗手段主要是采用化疗和放疗，内镜下治疗手段的姑息性很强，仅能短期缓解黄疸，尽管确实能够提高患者的近期生活质量，实际上并不能为患者提供长期益处。

 

　　Prof. Peterson: Both advanced disease (beyond surgical remedy) and disease that is recurrent are end stage diseases. We can’t cure them and can only use palliative modalities that usually include mechanical stenting, and relief from jaundice and the potential itching related to it. Primarily, therapy in this situation employs chemotherapeutic and radiation approaches. The endoscopic approaches to palliation are very temporizing and short term only. They don’t really offer long-term benefit to the patient, although they do improve the short-term quality of life.

 

　　专家简介：

 

　　Bret T. Petersen博士，美国梅奥医学中心胃肠肝病科医学教授，主要兴趣为内镜治疗胰腺和胆道疾病，主攻内胆胰疾病的经内镜逆行胰胆管造影（ERCP）的操作和管理。