Have Expandable Metallic stents Replaced Operation for Malignant Biliary Obstruction?

Abstract

A consecutive series of 50 patients with malignant biliary obstruction were treated by means of palliative drownage with a metallic expandable stent. Stent placement was successful in all patients. The patients were followed up prospectively at 2-month intervals over a period of 9-22 months. Forty-one patients (82%) died; nine (18%) are still living. The overall patency and survival rates for the 50 patients were 5.8 months and 7.5 months, respectively. The 30-day mortality rate was 8% (n = 4), the minor complication rate was 18% (n = 9), and the major complication rate was 8% (n = 4). One patient (2%) had intrahepatic arterial bleeding that required embolization, one (2%) had a right subphrenic abscess, and two patients (4%) had transient septic events. Stent occlusion requiring a second intervention occurred in 24% of patients (n = 12). Excellent palliation was achieved in most patients. No stent migration occurred. No great clinical advantages in prolonged patency compared with those of other published series involving the use of plastic stents were demonstrated. Ease of placement and versatility may oifset the high cost of the stent. In recent years, the use of nonoperative palliation for unresectable periampullary carcinoma has increased markedly, in part, because of the high morbidity and mortality rates after surgical palliation. The current analysis was undertaken to determine whether or not decreases in morbidity and mortality rates, recently observed after resection of periampullary carcinoma, are now being seen in the surgical palliation of unresectable periampullary carcinoma. During a 54 month period, 118 consecutive patients underwent surgical exploration with the finding of unresectable periampullary adenocarcinoma. Jaundice was the most common complaint at admission, being present in 73 per cent of the patients. Abdominal or back pain, or both, was present in 71 per cent of the patients and weight loss was observed in 61 per cent of the patients. The most commonly performed procedure was combined biliary bypass and gastrojejunostomy, being performed upon 75 per cent of the patients. A gastroje-junostomy was performed upon 107 of 118 patients (91 per cent). The hospital mortality rate was 2.5 per cent. Postoperative complications occurred in 37 per cent of the patients but were seldom life-threatening. Wound infection was the most frequent postoperative complication (10 per cent), followed by cholangitis (8 per cent) and delayed gastric emptying (8 per cent). During the late follow-up period, only 4 per cent of the patients had gastric outlet obstruction, and only 2 per cent had recurrent jaundice. The mean survival time postoperatively was 7.7 months. These results demonstrate that patients with unresectable periampullary carcinoma can undergo surgical palliation with minimal perioperative mortality, acceptable morbidity and good long term palliation. We conclude that surgical palliation is the treatment of choice for carefully selected patients with unresectable periampullary carcinoma. Surg. Gynecol. Obstet., 1993, 176:1-10. © 1994, Harwood Academic Publishers GmbH.