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

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