The management of obstructive jaundice in pancreatic cancer

Patients with pancreatic cancer often present with advanced disease; so, curative surgical resection is possible in a small number of patients. Palliation in these patients focuses particularly on relief of biliary obstruction. Palliative treatment modalities include both surgical and nonsurgical approaches. Biliary obstruction is initially treated with endoscopic biliary stenting, plastic or metallic stents. Both of these provide similar initial relief of biliary obstruction; however, plastic stents have a greater risk of occlusion and should be used in patients with short survival duration. Metallic stents have a greater initial cost, but provide an overall cost-saving in patients with expected survival more than 6 months. There is no evidence of benefit from routine stenting of jaundiced patients before resection. Surgical palliation for biliary obstruction should be primarily considered in patients who fail endoscopic or percutaneous biliary decompression or who develop gastroduodenal obstruction, It is also indicated for patients with good performance status and expected survival of over 6 months. Surgical decompression of biliary tree should be made with a choledochojejunostomy whenever feasible, associated to a gastroduodenal bypass.