PALLIATIVE OPERATIVE AND ENDOSCOPIC THERA PY OF MALIGNANT BILIARY OBSTRUCTIVE DISEASE

Cholestatic jaundice is the result of a malignancy of the bile duct it self, of the gallbladder, of the ampulla or (as in most cases) of the pancreas. Patients without evidence of metastases or other signs of ad vanced cancer (e. g. ascites) are candidates for explorative laparotom y. In the vast majority of cases resection of a tumor is not feasible and the surgeon is faced with the objective of providing palliation. T o date there exists not only one palliative procedure, and the surgeon has to take into account the following: In patients with pancreatic c ancer palliation can be given with biliary bypass with or without gast roenterostomy. This carries an operative mortality of almost 20 % and means a survival of only 5-6 months. Nonsurgical procedures as transpa pillary stenting play an increasing role in the management of patients with obstructive jaundice due to pancreatic cancer. In some cases how ever resectable tumors perhaps will be overlooked. The results of cont rolled studies comparing endoscopic stenting and surgical bypass are e ncouraging for stenting techniques (lower morbidity and mortality (<10 %), technical success rates exceeding 90 %). The availability of diff erent palliative treatment modalities for carcinoma of the bile ducts suggests that no approach is definitely superior. Operative biliary-en teric anastomosis gives a tolerable operative mortality rate in younge r patients, less morbidity, than external biliary drainage by better q uality of life of the patients. In retrograde placement of prosthetic stents, in patients with high bile duct obstruction difficulties are f requently. In such cases the percutaneous drainage should be reserved for endoscopic failures, in cases the endoscopic and percutaneous appr oaches can be combined in the,rendezvous' procedure. In recent years s everal reports have advocated extensive surgery for biliary neoplasms. Preoperative staging of these patients remains an issue as none of th e commonly modalities are accurate in predicting resectability.