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GASTROENTEROLOGY CLINICS
OF NORTH AMERICA
Palliation of Malignant Obstructive
Jaundice
Todd H. Baron, MD
Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, 200 First Street
Southwest, Charlton 8A, Rochester, MN 55905, USA
M
alignant obstructive jaundice in the patient with incurable malignancy
may cause symptoms that reduce quality of life. Palliation of malig-
nant obstructive jaundice leads to improvement in quality of life.
Nonsurgical methods using percutaneous and endoscopic methods have sup-
planted surgical bypass as the primary method for the palliation of malignant
obstructive jaundice. This article reviews management strategies for palliation
of malignant obstructive jaundice.
0889-8553/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.gtc.2006.01.001 gastro.theclinics.com
102 BARON
METHODS OF PALLIATION
There are three methods for palliation of obstructive jaundice: surgical bypass,
percutaneous insertion of stents, and endoscopic insertion of stents. Each of
these approaches has advantages and disadvantages (Table 1). There are
very few comparative studies of outcomes for each of the disciplines, although
nonsurgical palliation of obstructive jaundice is preferred in those with poor
performance status, intra-abdominal ascites, and/or expected survival of less
than 4 to 6 months.
Surgical Palliation
Surgical palliation of malignant obstructive jaundice is achieved by bypassing
the obstructed system through the creation of a choledocho– or hepatico–enter-
ostomy, usually a jejunostomy [5]. Traditionally, biliary bypass was performed
using open techniques, but more recently, it has performed laparoscopically [6].
MALIGNANT OBSTRUCTIVE JAUNDICE 103
Table 1
Approaches to palliation of obstructive jaundice
Advantages Disadvantages
Surgical Life-long palliation usual Most invasive
Simultaneous palliation of Morbidity and mortality
gastric outlet obstruction
Simultaneous palliation of pain
(intraoperative nerve block)
Percutaneous Nonsurgical Pain, bleeding
External drains
Endoscopic Nonsurgical Stents may occlude
Relatively painless Expertise variable
Outpatient treatment possible Complications (perforation,
pancreatitis, bleeding)
Most of the data for surgical bypass are derived from the treatment of distal
biliary obstruction caused by pancreatic cancer.
Palliative surgical bypass may be performed at the time of laparotomy for
attempted curative resection. If the patient is found to be unresectable, a surgical
palliative approach may be undertaken. Alternatively, patients deemed inoper-
able based upon extent of disease, comorbid medical illnesses, or advanced age
are referred for nonsurgical palliation. Since the evolution of better preopera-
tive staging modalities (endoscopic ultrasound, thin section CT, and MRI)
and the improvement in nonoperative palliative strategies, it appears that fewer
patients are undergoing operative palliation. Nonetheless, surgical palliation
has the advantage of allowing simultaneous palliation of biliary and gastric out-
let obstruction and pain control in one setting [5]. Lifelong palliation of biliary
obstruction without the need for further procedures usually is obtained. The
average postoperative length of hospital stay for patients who undergo surgical
palliation is less than 15 days. The average survival of patients who receive
surgical palliation alone for nonmetastatic, unresectable pancreatic cancer is
approximately 8 months [5]. The disadvantage of surgical palliation is the
morbidity, especially in those with advanced disease.
Surgical palliation of distal biliary obstruction
Surgical palliation is performed using a biliary–enteric bypass, most commonly
the bile duct to the jejunum (choledocho–jejunostomy). The use of the gallblad-
der as a conduit (cholecysto–jejunostomy) is utilized rarely, because premature
occlusion of the cystic duct by tumor growth leads to subsequent loss of palli-
ation and need for additional palliative procedures [7]. Successful palliation of
jaundice is achieved in nearly all patients. Complications include wound infec-
tion, pneumonia, and bleeding.
Surgical palliation of hilar biliary obstruction
Surgical palliation is performed infrequently for palliation of hilar biliary ob-
struction. The bypass is created by sewing intrahepatic ducts to the jejunum
104 BARON
Nonsurgical Palliation
Nonsurgical palliation of malignant obstructive jaundice is achieved with stent
placement by means of the percutaneous, endoscopic, or rarely combined per-
cutaneous–endoscopic approaches. For nonsurgical techniques, biliary stents
used are composed of plastic (Fig. 1) or metal materials. Plastic stents occlude,
because the formation of bacterial biofilm and plant materials [11] results in re-
current jaundice, frequently with cholangitis, and necessitates repeat proce-
dures with stent replacement. Self-expandable metal stents (SEMS) have
combined the advantage of a small predeployment delivery system with a large
postdeployment stent diameter (Fig. 2). Additionally, they are less likely to oc-
clude than plastic stents. Metal stents still may occlude because of tumor in-
growth through the mesh, tumor overgrowth (tumor growing beyond the
ends of the stent), or tissue hyperplasia (excessive normal tissue growth in
response to the stent). SEMS may be uncovered or covered. Covered SEMS
resist occlusion from tumor ingrowth or tissue hyperplasia, although they are
Fig. 2. Examples of deployed self-expanding metal biliary stents. Note the third stent from the
left is covered.
more likely to migrate. They cannot be used across the bifurcation, because
the covering prevents drainage of intrahepatic bile ducts.
Percutaneous Palliation
Percutaneous therapy is performed by interventional radiologists by means of
a transhepatic approach (percutaneous transhepatic cholangiography, PTC).
The intrahepatic bile ducts initially are accessed with a skinny needle under
fluoroscopic guidance and an anterograde approach. Three possible outcomes
may occur following attempted percutaneous drainage. The least desirable is
termed external drainage. This occurs when the bile ducts are entered, but
there is a failure to traverse the stricture to place catheters and guide wires
into the duodenum. Thus, the only route for bile drainage is externally,
through the percutaneous tube (Fig. 3). The second possible scenario is called
internal–external drainage. This occurs when the stricture is traversed, and
a catheter is passed into the duodenum; the external portion exits the skin
(Fig. 4). Bile can drain internally and externally, and eventually the external
tube can be capped or completely internalized. Usually, the most desirable out-
come is internal drainage, whereby the entire drainage is within the patient by
means of an internal stent. Some patients may have internalization on the first
attempt, or rarely, stages of advancement may occur from external to internal.
For example, one procedure may be required for initial external tube placement
and another for internalization to a stent. Uncommonly, internalization is not
technically possible, and the patient is left with an external drain.
Prior to the advent of SEMS, the percutaneous tract through the liver re-
quired dilation to accommodate large-bore plastic stents. This was associated
with a higher incidence of postprocedural pain and bleeding. Because SEMS
have a small predeployment delivery system, the tract through the liver requires
less dilation. The main disadvantage of percutaneous therapy is the pain felt as
a result of the catheter placement procedure through body wall and the liver
106 BARON
Fig. 3. Radiograph of external biliary drain (arrowheads). The stricture below the catheter
was not traversable at the time of percutaneous transhepatic cholangiography.
Fig. 4. Radiograph of patient with internal–external biliary drain. Note the external portion
(arrowheads) leads to the skin. Bile flows through the drain into the duodenum, where the distal
end is coiled (arrow).
MALIGNANT OBSTRUCTIVE JAUNDICE 107
Endoscopic
Endoscopic palliation of distal biliary obstruction
ERCP and biliary stent placement (Fig. 5) has been shown in randomized trials
to be an acceptable alternative to palliative surgical bypass [22]. Biliary stents
108 BARON
Fig. 5. Illustration of endoscopic placement of plastic biliary stent for relief of jaundice from
malignant biliary obstruction. (Courtesy of Wilson-Cook Medical, Winston-Salem, NC; with
permission.)
Fig. 6. (A) Endoscopic photo of occluded metal stent caused by tissue hyperplasia and/or
tumor. (B) Same patient. Plastic stent (blue) has been inserted through the metal stent.
SUMMARY
Palliation of obstructive jaundice can be achieved in most patients using various
approaches. The method chosen should be individualized to the patient and
based upon performance status, patient preferences, and available expertise.
The best approach ideally should be determined by a multi-discipline approach
with endoscopists, interventional radiologists, oncologists, and surgeons.
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