Short Communication
Palliation of Extra-Hepatic Biliary Malignancies: Diminishing Role for Surgery
Savio G Barreto1 and John A Windsor2*
1Department of Surgery, Perioperative Medicine Flinders Medical Centre, Bedford Park, Adelaide, Australia
2Department of General Surgery, University of Auckland, New Zealand
*Corresponding author: John A Windsor, Department of Surgery, University of Auckland, New Zealand
Published: 20 Mar, 2017
Cite this article as: Barreto SG, Windsor JA. Palliation of
Extra-Hepatic Biliary Malignancies:
Diminishing Role for Surgery. Clin
Oncol. 2017; 2: 1229.
Short Communication
In a recently published manuscript, Buettner and colleagues [1] provides an analysis of outcomes
following palliative surgery for extra hepatic biliary malignancies over a period of 15 years from ten
of the best cancer centres in the United States. Their findings suggest that palliative bypass surgery
is associated with increased morbidity and no survival benefit compared with ‘open and close’
laparotomies. It has been shown that palliative bypass surgery is not associated with a reduction in
the number of invasive procedures or to overall hospital stay [2].
Justifying palliative bypass surgery is difficult when gains in quality of life can be discounted by
a reduced quantity of life and reduced survival [3]. And it is even more difficult to justify when nonsurgical
alternatives to surgical bypass are effective and safe [4-6].
The intention of surgery often changes during the course of the operation. Whilst a curative
resection might be intended at the outset there are situations where resection is completed with the
full knowledge that cancer has been left behind. This is different from the less common situation
when resectional surgery is known to be palliative from the outset. Different again is the situation
where a trial dissection indicates that resection is not possible and the decision has to be made
about the best approach to palliating obstructive jaundice and incipient duodenal obstruction.
These three different situations should be distinguished. The finding of unresectable disease with an
open abdomen does not automatically justify traditional ‘double bypass’ given the apparent superior
palliation from endoscopic stenting for malignant biliary [6] and/or gastric outlet obstruction [7,8].
Pancreatic ductal adenocarcinoma is incurable in the vast majority of patients and the avoidance
of unnecessary surgery in these patients is an important goal. And now with the availability of nonsurgical
alternatives for palliation it is even more important to exclude patients and avoid palliative
resection or palliative bypass. It is time to conduct prospective randomised clinical trials to better
define the relative benefits of different palliative strategies (including surgical resection, surgical
bypass, endoscopic and radiological stenting, ablation techniques, chemotherapy and radiotherapy)
for patients with advanced extrahepatic biliary malignancies in regards symptom control and quality
of life. Pending a revolution in the biologic treatment of pancreatic ductal adenocarcinoma more
effort should be expended on improving the palliative management of the vast majority of patients
for whom surgery is never going to be the answer.
References
- Buettner S, Wilson A, Margonis GA, Gani F, Ethun CG, Poultsides GA, et al. Assessing Trends in Palliative Surgery for Extrahepatic Biliary Malignancies: A 15-Year Multicenter Study. J Gastrointest Surg. 2016; 20: 1444-1452.
- Lyons JM, Karkar A, Correa-Gallego CC. Operative procedures for unresectable pancreatic cancer: does operative bypass decrease requirements for postoperative procedures and in-hospital days? HPB (Oxford). 2012; 14: 469-475.
- Ausania F, Vallance AE, Manas DM. Double bypass for inoperable pancreatic malignancy at laparotomy: postoperative complications and long-term outcome. Ann R Coll Surg Engl. 2012; 94: 563-568.
- Williamsson C, Wennerblom J, Tingstedt B, Jonsson C. A wait-and-see strategy with subsequent self-expanding metal stent on demand is superior to prophylactic bypass surgery for unresectable periampullary cancer. HPB (Oxford). 2016; 18: 107-112.
- Nagaraja V, Eslick GD, Cox MR. Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials. J Gastrointest Oncol. 2014; 5: 92-98.
- Lima SAd, Bustamante F, Moura EHd. Endoscopic palliative treatment versus surgical bypass in malignant low bile duct obstruction: A systematic review and meta-analysis. Int J Hepatobiliary Pancreat Dis. 2015; 5: 35-46.
- Ly J, O'Grady G, Mittal A, Plank L, Windsor J. A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc. 2010; 24: 290-297.
- Mittal A, Windsor J, Woodfield J, Casey P, Lane M. Matched study of three methods for palliation of malignant pyloroduodenal obstruction. Br J Surg. 2004; 91: 205-209.