Obstructive jaundice in advanced gastric cancer (AGC): Clinical characteristics and therapeutic approaches

Abstract

Background; AGC is frequently associated with obstructive jaundice and is a more common cause of secondary malignant biliary obstruction in Asia. However, the clinical characteristics and therapeutic approach of biliary obstruction secondary to AGC has not been fully elucidated. Patients and Methods; Between January 1989 and February 1999, 27 patients with obstructive jaundice in histologically confirmed gastric cancer were reviewed retrospectively. The diagnostic work-up of obstructive jaundice was performed with abdominal ultrasound, CT, ERCP or PTC. The percutaneous transhepatic biliary drainage(PTBD) and endoscopic retrograde biliary drainage(ERBD) were performed for palliative management of obstructive jaundice. Results; I) Obstruction sites were distal extrahepatic duct(EHD) in 20 patients(74%), proximal EHD in 5(19%), ampulla in 1(3%), and undetermined in 1(3%). 2) The causes of biliary obstruction were metastatic lymphadenopathy in 13 patients(48%), direct invasion to bile duct in 4(15%), pancreatic invasion in 4(15%), liver metastasis in 2(7%), and undetermined in 1(3%). Three cases showed combined duodenal obstruction. 3) Stages of AGC were III in 8(30%) and IV in 15(56%). In II patients whose histologic type could be reviewed, histologic types of AGC were signet ring cell carcinoma in 2, poorly differentiated adenocarcinoma in 7 and moderately differentiated in 2. 4) In 21 patients who underwent gastrectomy, obstructive jaundice was initially managed by ERBD in 3 and PTBD in 18. Initial ERBD was converted into PTBD in I due to stent clogging, and initial PTBD into ERBD in 12 by conventional ERBD method or percutaneous endoscopic biliary stenting(PEBS) method. 5) In 6 patients who did not undergo gastrectomy, obstructive jaundice was initially managed by ERBD in 4 and PTBD in 2 debilitating patients. Initial ERBD was kept without conversion into PTBD, and initial PTBD was converted into ERBD in I by PEBS method. 6) The mean time between onset of jaundice and initial diagnosis of gastric cancer was 15.1:'::20.2 months. The mean survival time after onset of obstructive jaundice was 4.6:'::5.3 months and 6 month survival rate was 19%. Conclusions; Obstructive jaundice in AGC is associated with relatively short life expactency(mean 4.6 months), preferential site of obstuction is distal EHD, and ERBD is recommendable as initial therapeutic approach, especially in patients who did not undergo gastrectomy.