GUIDELINES FOR THE APPLICATION OF SURGERY AND ENDOPROSTHESES IN THE PALLIATION OF OBSTRUCTIVE-JAUNDICE IN ADVANCED CANCER OF THE PANCREAS

Objective This study was set up to identify patient-related factors fa voring the application of either surgery or endoprostheses in the pall iation of obstructive jaundice in subsets of patients with cancer of t he head of the pancreas or periampullary region. Summary Background Da ta In the palliation of obstructive jaundice, surgical biliodigestive anastomosis has traditionally been performed. Surgical biliary bypass is associated with high mortality(15% to 30%) and morbidity rates (20% to 60%) but little recurrent obstructive jaundice (0% to 15%). Biliar y drainage with endoscopically placed endoprostheses has a lower compl ication rate, but recurrent obstructive jaundice is seen in up to 20% to 50% of patients. Methods Patients with advanced cancer of the head of the pancreas or periampullary region treated at the University Hosp ital Dijkzigt, Rotterdam, The Netherlands, between 1980 and 1990 were reviewed. In 148 patients, data were compared concerning the morbidity and hospital stay after the palliation of obstructive jaundice with e ndoscopic endoprostheses or surgical biliary bypasses. These patients were stratified for long (> 6 months) and short (< 6 months) survival times. Results In short-term survivors, the higher late morbidity rate s after endoprostheses were offset by higher early morbidity rates and longer hospital stays after the surgical bypass. In long-term survivo rs, there was no difference in the hospital stay between the two group s, but the late morbidity rate was significantly higher in the endopro sthesis group. Conclusions These data suggest that endoscopic endopros thesis is the optimal palliation for patients surviving less than 6 mo nths and surgical biliary bypass for those surviving more than 6 month s. This policy necessitates the development of prognostic criteria, wh ich were obtained by Cox proportional-hazards survival analysis. Advan ced age, male sex, liver metastases, and large diameters of tumors wer e unfavorable prognostic factors. With these factors, the risk of shor t- or long-term survival can be predicted. It is hoped that the applic ation of these data may allow a rational approach toward optimal palli ative treatment of this form of malignant obstructive jaundice.