Surgical palliative treatment in bilio-pancreatic malignancy

Most patients with bilio-pancreatic malignancy are no candidate for curativ e resection and will need palliative treatment. Palliation in these patient s is focussed on relief symptoms such as obstructive jaundice, duodenal obs truction and pain. It has been suggested that non surgical treatment (stent ing) is the optimal palliation for patients with short survival and surgica l bypass for those surviving more than 6 months. Unfortunately valid criter ia for estimating survival are not available except for metastases. A progn ostic score chart to predict survival probabilities for 3,6 and 9 months af ter diagnosis has been developed. The use of this prognostic score chart ma y help clinicians to select optimal palliative treatment for individual pat ients. Surgical biliary drainage can be performed by a simple cholecystoent erostomy; a choledochoduodenostomy or a choledocho/hepaticojejunostomy with Roux-Y jejunal limb reconstruction. The present data available in the literature do not give sufficient guidanc e to make a well deliberated selection between the different types of bypas s surgery but choledochojejunostomy is generally preferred. Gastroentero-st omy is performed routinely during the biliary bypass procedure in our insti tution because gastric outlet obstruction has been described between 9-21% of the patients who underwent only a surgical biliary bypass but there is s till controversy. Recently it was also suggested that there is an indicatio n to perform palliative resections. No results are available to justify res ections as a debulking procedure.