A wait-and-see strategy with subsequent self-expanding metal stent on demand is superior to prophylactic bypass surgery for unresectable periampullary cancer

Caroline Williamsson; Johanna Wennerblom; Bobby Tingstedt; Claes Jönsson

doi:10.1111/hpb.12513

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). 2015 Oct 16. doi: 10.1111/hpb.12513. Online ahead of print.

Authors

Caroline Williamsson¹, Johanna Wennerblom², Bobby Tingstedt¹, Claes Jönsson²

Affiliations

¹ Department of Surgery, Skåne University Hospital at Lund, Lund University, Lund, Sweden.
² Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Gothenburg University, Gothenburg, Sweden.

PMID: 26473999
DOI: 10.1111/hpb.12513

Abstract

Background: A patient with unresectable periampullary malignancy found at laparotomy has traditionally received a prophylactic double bypass (biliary and duodenal), associated with considerable morbidity. With modern endoscopic treatments, a surgical bypass has become questionable. This study aims to compare the two strategies. Sahlgrenska University Hospital (SU) performs a double bypass (DoB) routinely, and Skåne University Hospital Lund (SUL) secures biliary drainage endoscopically and treats only symptomatic duodenal obstruction (Wait and See, WaS).

Method: Between 2004 and 2013, 73 patients from SU and 70 from SUL were retrospectively identified. Demographics, tumour-related factors and post-operative outcomes during the remaining lifetime of the patients were noted.

Results: The DoB group had significantly more complications (67% versus 31%, P = 0.00002) and a longer hospital stay (14 versus 8 days, P = 0.001) than the WaS group. The two groups had a similar proportion of patients in need of readmission. The DoB patients and the WaS patients with metallic biliary stents were comparable regarding their need of re-interventions and hospitalization as a result of biliary obstruction. A surgical duodenal bypass did not prevent future duodenal obstructions.

Conclusion: Patients with unresectable periampullary malignancies can safely be managed with endoscopic drainage on demand and with a lower morbidity and a shorter hospital stay than with a surgical prophylactic bypass.