Biliary and gastric bypass or stenting in nonresectable periampullary cancer: analysis on the basis of controlled trials.
BACKGROUND
The median survival rate of patients with nonresectable periampullary cancer is not much longer than 6-12 mo. Nevertheless, in most incurable patients palliative treatment is necessary, which has to focus on jaundice, pain, and prevention of gastric outlet obstruction. Up to now, debate remains about how to best provide palliative treatment.


METHODS
The results of controlled clinical trials and large multicenter studies comparing operative biliary bypass and biliary stent insertion in nonresectable pancreatic tumors are discussed in this review.


RESULTS
The initial success rate in palliation of jaundice is similar after endoscopic stent insertion and biliary bypass operation (range: 90-95 %). Morbidity (range: 1 1-36% vs 26-40%) and 30-d mortality (range: 8-20% vs 15-31%) is higher after bypass operation, whereas stent insertion is accompanied by a higher rate of hospital readmission and reintervention because of recurrent jaundice (range: 28-43%) and a later gastric outlet obstruction (up to 17%).


CONCLUSIONS
Endoscopic biliary stent insertion should be performed if there is evidence of hepatic, peritoneal, or pulmonary metastasis formation, in old patients with a high comorbidity, or if the patient has had several laparotomies. Combined biliary and gastric operative bypass procedures should be performed in nonresectable periampullary carcinomas with accompanying gastric outlet obstruction, in the absence of metastatic spread, if a locally advanced tumor is the only reason for incurability, if exploratory laparotomy demonstrates an unresectable tumor, or if endoscopic treatment fails.
Schwarz
A
A
Department of General Surgery, University of Ulm, Germany.
Beger
H G
HG
D014670:Ampulla of Vater; D001662:Biliary Tract Surgical Procedures; D018849:Controlled Clinical Trials as Topic; D003362:Cost-Benefit Analysis; D016145:Endoscopy, Digestive System; D015390:Gastric Bypass; D017219:Gastric Outlet Obstruction / Q000517:prevention & control / Q000601:surgery; D006801:Humans; D007565:Jaundice / Q000601:surgery; D010166:Palliative Care / Q000191:economics; D010190:Pancreatic Neoplasms / Q000601:surgery*; D015607:Stents