Palliation of unresectable periampullary neoplasms. "surgical" versus "non-surgical" approach

A series of 84 patients with unresectable periampullary neoplasms, observed during an eight-year period (1992-1999), is reviewed for a critical analysis of modalities of treatment and clinical outcome. Two different approaches, a preference for "non-surgical" palliation and a preference for "surgical" palliation, in two consecutive periods, are compared.

In the first period (1992-1995) endoscopic retrograde cholangiopancreatography with endoprosthesis insertion was performed routinely and, after diagnostic assessment, patients were divided into two groups: those with apparently resectable neoplasms, candidates for surgery, in whom the decision to perform a surgical palliation by biliary bypass was taken intraoperatively, and those with unresectable neoplasms, in whom the endoprosthesis insertion was considered as definitive palliation. Since January 1996, a different approach was started; surgical bypass was considered the palliation of choice and only patients unfit for surgery underwent endoscopic stenting.

Evaluation of the results showed that the first strategy was associated with a high incidence of complications and unsatisfactory long-term results, with frequent hospital readmissions, poor quality of residual life and therefore failure of palliation. On the contrary, the latter approach with preference for surgical palliation was associated with lower morbidity and mortality, with persistent relief of symptoms and better quality of life in a larger percentage of patients.

This study provides evidence that, in patients with unresectable periampullary carcinoma, surgical palliation provides better long-term results than endoscopic palliation. The results were also consistent with the advantage of associating a gastric bypass to the biliary bypass, also in the absence of gastric outlet obstruction.