Palliation of malignant obstructive jaundice--surgery or stent?

The revolution in therapeutic endoscopy in the last decade has changed the accepted management ofmalignant obstructive jaundice. Non-operative biliary intervention for obstructive jaundice was first developed via the transhepatic route, although that approach was associated with all the problems of puncturing the obstructed liver, particularly bile leakage and bleeding.' With development of bigger channel endo-scopes it became possible to position biliary stents via: the endoscopic route and this provided good decompression with a much lower level of complications.2 Endoscopic biliary stenting is now widely available, although not in all hospitals, and the procedure can be performed easily on a day case basis at a near by referral centre. Clinicians must now decide whether to refer a patient with suspected malignant biliary obstruction to an endoscopist or a surgeon for treatment. High biliary strictures High bile duct lesions or bifurcation lesions, whether due to primary cholangiocarcinoma or secondary growth from colo-nic or gastric carcinoma, are extremely difficult for the surgeon to deal with effectively and there is little doubt that endoscopic stenting is the treatment of choice. Among endoscopists there is debate as to whether one or two sides of the liver should be stented when a bifurcation lesion obstructs both lobes. In some centres it is usual to place stents into both the right and left intrahepatic ducts.3 While this may be satisfying for the endoscopist, it may be clinically unnecessary. Other studies have shown that 80% of hilar lesions can be satisfactorily palliated with a single prosthesis into one lobe of the liver and only 5% of patients needed a second stent, because of either inadequate relief of jaundice or sepsis.4 Low bile duct obstruction Obstruction to the lower part of the bile duct by pancreatic or biliary tumours can be palliated surgically, by either a choledochoduodenostomy or a cholecystenterostomy. The latter procedure is associated with a significant rate of recurrent jaundice from tumour growth obstructing the cystic duct origin. Endoscopic stenting is more straightforward in low bile duct lesions and will reliably palliate jaundice and itching without the need for general anaesthetic or surgery. Patients recover quickly after stenting and are able to return to their normal activities much more rapidly than after surgery. The problem for the clinician is to decide which of these two alternatives to choose for the individual patient. There are few reliable comparative data to aid that decision. The surgical reports are bedevilled …