Surgical palliation of proximal malignant biliary obstruction.

Proximal malignant biliary obstruction can be cured only by surgery. Such treat ment may involve hepatic resection and is associated with significant morbidity and mortality. Unfortunately up to 90% of patients with this problem are either unfit or unsuitable for a curative procedure.' Conventional surgical decompression for these patients with obstructive jaundice via a cholecystojejunostomy, choledochojejunostomy or hepaticojejunostomy below the confluence of the right and left hepatic ducts may be impossible because of extension of the tumour.2 Normally, these patients receive a stent using a radiological percutaneous transhepatic cholangiography procedure (PTC) or an endoscopic route at ERCP. In a small proportion of cases stenting may not be possible by either route. We believe that an attempt at palliation should be made, as otherwise these patients will die within a few months with a very poor quality of life.3 Such palliation can be achieved by a bilioenteric anastomosis either to the left main hepatic duct or to the segment Ill duct, draining the left lobe of the liver, lateral to the ligamentum teres. These techniques were first described by Hepp and Couinaud in 1956,4 but initially were rarely performed outside France. There has been more interest since 1984 following a report by Blumgart and Kelley on the use of these techniques in benign and malignant disease.5 We describe these procedures and their successful use for palliation in three patients with proximal malignant biliary obstruction.