title: Role of preoperative palliation of jaundice in pancreatic cancer.
abstract: OBJECTIVE
  Recent studies suggest that there is no significant benefit and that there may be significantly higher morbidity rates in pancreatic cancer patients who undergo preoperative plastic stent placement for obstructive jaundice. This review attempts to define the role of stenting in patients with pancreatic cancer and malignant obstructive jaundice. The latter includes patients unresectable for cure, those who are too frail to withstand an operation, the occasional patient who presents with cholangitis, and those patients who will have a significant delay in surgery because of preoperative neoadjuvant therapy.
  
  
  METHODS
  Literature review. A therapeutic endoscopy team member of a multidisciplinary team which evaluates and treats >250 pancreatic cancer patients yearly.
  
  
  RESULTS
  There are 5 historical randomized controlled trials (RCTs) and 1 current RCT demonstrating no significant benefit in preoperatively decompressing jaundiced patients with pancreatic malignancy with percutaneously placed tubes or endoscopically inserted plastic stents. There are 5 RCTs defining a longer patency rate with self-expandable metal stents (SEMS) compared to plastic prostheses suggesting that in the setting of palliation as well as the use of neoadjuvant therapy for resectable or borderline resectable patients, SEMS placement is preferable.
  
  
  CONCLUSIONS
  Despite data demonstrating lack of efficacy and potential harm in decompressing the biliary tree as opposed to early surgery in jaundiced patients with pancreatic malignancy, endoscopic retrograde cholangiopancreatography with SEMS insertion remains an invaluable palliative modality in non-resectable patients as well as those in whom contemplated resection is delayed in order to give neoadjuvant therapy.
authors.affiliation: Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA. gasrak@vmmc.org.
authors.forename: Richard
authors.initials: R
authors.lastname: Kozarek
mesh_terms: D006801:Humans; D041781:Jaundice, Obstructive / Q000209:etiology / Q000628:therapy*; D010166:Palliative Care / Q000379:methods*; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000150:complications / Q000628:therapy*; D011300:Preoperative Care / Q000379:methods*
keywords: ERCP; jaundice; pancreatic cancer