Palliation for nonpancreatic malignant obstruction of the biliary tract

To determine the best palliation for nonpancreatic malignant obstruction of the biliary tract, we analyzed 36 patients with unresectable tumors who were treated from 1970 to 1986. Eleven men and 25 women were treated for 12 cholangiocarcinomas, ten carcinomas of the gallbladder, two advanced ampullary tumors and 12 metastatic tumors. Ten of the patients underwent biliary-enteric bypasses; 18 had stents placed, 11 operatively and nine percutaneously. The remaining eight patients received chemotherapy, radiation therapy or no treatment. Median survival time for patients was 209 days after discharge. Survival was not significantly prolonged for patients with bypass versus those with stents. Achieving and maintaining a bilirubin level of less than or equal to 4 were correlated with survival time (p less than 0.01, p less than 0.001). All ten patients with a bypass versus nine of 18 patients with a stent achieved a bilirubin level of less than or equal to 4 milligrams per deciliter (p less than or equal to 0.01). A multivariate analysis was done using 18 of 27 variables identified by univariate analysis. Albumin was found to be the primary predictor of over-all and hospital-free survival time and was a co-predictor of prolonged maintenance of low bilirubin levels along with biliary-enteric bypass. Placement of a stent was the only predictor of the number of episodes of sepsis and bypass was among the few predictors of length of hospitalization and of over-all morbidity (it was negatively correlated). We concluded that biliary-enteric bypass is the only effective means of palliation in that it improves the quality of life by maintaining low bilirubin levels and minimizing septic complications. Albumin is a strong predictor of survival and maintenance of low bilirubin values and should be a major factor in deciding which patient should undergo a bypass procedure.