[Palliative surgical and endoscopic therapy of malignant bile duct occlusion]

Cholestatic jaundice is the result of a malignancy of the bile duct itself, of the gallbladder, of the ampulla or (as in most cases) of the pancreas. Patients without evidence of metastases or other signs of advanced cancer (e.g. ascites) are candidates for explorative laparotomy. In the vast majority of cases resection of a tumor is not feasible and the surgeon is faced with the objective of providing palliation. To date there exists not only one palliative procedure, and the surgeon has to take into account the following: In patients with pancreatic cancer palliation can be given with biliary bypass with or without gastroenterostomy. This carries an operative mortality of almost 20% and means a survival of only 5-6 months. Nonsurgical procedures as transpapillary stenting play an increasing role in the management of patients with obstructive jaundice due to pancreatic cancer. In some cases however resectable tumors perhaps will be overlooked. The results of controlled studies comparing endoscopic stenting and surgical bypass are encouraging for stenting techniques (lower morbidity and mortality (< 10%), technical success rates exceeding 90%). The availability of different palliative treatment modalities for carcinoma of the bile ducts suggests that no approach is definitely superior. Operative biliary-enteric anastomosis gives a tolerable operative mortality rate in younger patients, less morbidity, than external biliary drainage by better quality of life of the patients. In retrograde placement of prosthetic stents, in patients with high bile duct obstruction difficulties are frequently. In such cases the percutaneous drainage should be reserved for endoscopic failures, in cases the endoscopic and percutaneous approaches can be combined in the 'rendezvous' procedure. In recent years several reports have advocated extensive surgery for biliary neoplasms. Preoperative staging of these patients remains an issue as none of the commonly modalities are accurate in predicting resectability.