Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction

• Published in: The Lancet (British edition) Vol. 344; no. 8938; pp. 1655 - 1660
• Main Authors: SMITH, A. C, DOWSETT, J. F, RUSSELL, R. C. G, HATFIELD, A. R. W, COTTON, P. B
• Format: Journal Article
• Language: English
• Published: London Lancet 17.12.1994; Elsevier Limited
• Subjects: Adult; Aged; Aged, 80 and over; Bile Duct Neoplasms - mortality; Bile Duct Neoplasms - surgery; Bile Duct Neoplasms - therapy; Biological and medical sciences; Cancer; Cholangiopancreatography, Endoscopic Retrograde; Cholestasis - mortality; Cholestasis - surgery; Cholestasis - therapy; Endoscopy; Female; Humans; Jaundice - etiology; Length of Stay; Life expectancy; Liver, biliary tract, pancreas, portal circulation, spleen; Male; Medical research; Medical sciences; Middle Aged; Pancreas; Postoperative Complications; Prospective Studies; Recurrence; Stents; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Human; Endoprosthesis; Extrahepathic bile duct; Malignant tumor; Obstruction; Result; Resection anastomosis; Treatment; Surgery; Digestive diseases; Endoscopy; Pancreas; Comparative study
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(94)90455-3

The development of non-surgical techniques for the relief of malignant low bileduct obstruction has cast doubt on the best way of relieving jaundice, particularly in patients fit for surgery whose life expectancy is more than a few weeks. We did a randomised prospective controlled trial comparing endoscopic stent insertion and surgical biliary bypass in patients with malignant low bileduct obstruction. 204 patients were randomised (surgery 103, stent 101); 3 subsequently proved to have benign disease and were excluded, leaving 101 surgical and 100 stented patients for assessment. Technical success was achieved in 94 surgical and 95 stented patients, with functional biliary decompression obtained in 92 patients in both groups. In stented patients, there was a lower procedure-related mortality (3% vs 14%, p = 0.01), major complication rate (11% vs 29%, p = 0.02), and median total hospital stay (20 vs 26 days, p = 0.001). Recurrent jaundice occurred in 36 stented patients and 2 surgical patients. Late gastric outlet obstruction occurred in 17% of stented patients and 7% of the surgical group. Despite the early benefits of stenting there was no significant difference in overall survival between the two groups (median survival: surgical 26 weeks; stented 21 weeks; p = 0.065). Endoscopic stenting and surgery are effective palliative treatments with the former having fewer early treatment-related complications and the latter fewer late complications.