title: Biliary stenting versus surgical bypass for palliation of periampullary malignancy.
abstract: BACKGROUND
  Patients with periampullary cancers may not be suitable for curative resection due to locally advanced disease, metastases, or poor health. Biliary stenting and surgical bypass are utilized for symptom control, but the true benefit of one technique over the other is not clear.
  
  
  METHODS
  A retrospective analysis of case records was undertaken of patients with periampullary (pancreatic head/uncinate process, distal bile duct, and ampulla of Vater and surrounding duodenum) malignancy treated between June 2004 and June 2010 in a tertiary center by palliative biliary stenting or palliative surgical bypass.
  
  
  RESULTS
  Of the 69 patients included in the analysis, combined biliary and gastric bypass was performed on 28, while 41 underwent biliary stent (metallic, n = 39) insertion. Patients undergoing stenting were significantly older and less likely to be offered chemotherapy than those from the surgical bypass group. Overall, there were significantly more complications in the stent insertion group (85 %) than the surgical bypass group (36 %) (p = 0.003). The stent group required significantly more subsequent procedures than the surgical bypass group. Metal stent obstruction occurred in 16 of 39 (41 %) patients, with a median stent patency of 224 days. The overall median survival of patients in this study was 7 months with no significant difference between the groups (p = 0.992). The presence of metastases at presentation was the only independent factor associated with decreased survival.
  
  
  CONCLUSIONS
  There was no survival difference between stenting vs. surgical bypass for palliation of periampullary cancer. There was, however, a high rate of stent occlusion and need for repeat procedures in patients treated by metal stenting, suggesting that stenting may be best suited to patients predicted as having the shortest survival.
authors.affiliation: University of Melbourne, Department of Surgery, Austin Health, LTB 8, Studley Road, Heidelberg, Melbourne, Victoria 3084, Australia. mehrdad.nikfarjam@gmail.com
authors.forename: Mehrdad
authors.initials: M
authors.lastname: Nikfarjam
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Hadj
authors.forename: Vijayaragavan
authors.initials: V
authors.lastname: Muralidharan
authors.forename: Niall
authors.initials: N
authors.lastname: Tebbutt
authors.forename: Michael A
authors.initials: MA
authors.lastname: Fink
authors.forename: Robert M
authors.initials: RM
authors.lastname: Jones
authors.forename: Graham
authors.initials: G
authors.lastname: Starkey
authors.forename: Rhys B
authors.initials: RB
authors.lastname: Vaughan
authors.forename: Alexander W
authors.initials: AW
authors.lastname: Marshall
authors.forename: Christopher
authors.initials: C
authors.lastname: Christophi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects*; D003138:Common Bile Duct Neoplasms / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D007582:Jejunostomy; D053208:Kaplan-Meier Estimate; D008099:Liver / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D010166:Palliative Care / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000473:pathology* / Q000601:surgery*; D011475:Prosthesis Failure / Q000009:adverse effects; D012189:Retrospective Studies; D015607:Stents / Q000009:adverse effects*