Pancreatic and ampullary carcinoma.

Surgery should be the first therapeutic modality considered in patients with pancreatic and ampullary carcinoma. Surgery is the only potentially curative therapy and offers the best form of palliation in patients with impending or overt duodenal obstruction. Patients with clearly unresectable tumors or those considered unfit for surgery should be offered palliative therapy, preferably endoscopically. The difficulty, however, arises in patients who undergo laparotomy and who subsequently are found to have unresectable tumors. The problem of stent occlusion and frequent associated hospital visits has been an argument to proceed to palliative double bypass surgery. Against this is the low mortality and shorter hospital stay of nonsurgical endoscopic palliative therapy. Direct comparisons of surgery versus endoscopic therapy have shown that both are equally effective in the initial relief of jaundice (Table 6). Surgery has a higher initial mortality and complication rate, but more long-term complications and hospital visits were seen in the endoscopic group, suggesting that it offered a poorer long-term palliation. There was no significant difference in the survival of the patients in the two groups. Patient choice is a major factor in the final decision, but current recommendations probably should be that patients with a poor short-term survival outlook should be offered nonsurgical palliative therapy and those with a longer life expectancy may best be handled with surgery. Predicting patient survival, of course, remains a major difficulty. A recent publication of the laparoscopic formation of a cholecystojejunostomy for palliation of malignant biliary obstruction also offers a promising approach that requires further evaluation.