[Surgery in malignant obstructive jaundice: laparoscopic surgery--the future?].

The systematic staging of pancreatic cancer has facilitated exact evaluation of a patient's prognosis in recent years. Minimally invasive surgery, on the other hand, has produced new procedures which necessitate a distinct dichotomy between open, curative surgery and minimally invasive, palliative procedures. Diagnostic modalities facilitating an accurate assessment of resectability have to be found. Preoperative imaging and endoscopic techniques are only successful in about 50% of cases. Diagnostic laparoscopy is the only method for visualization of peritoneal metastases. The use of diagnostic laparoscopy and laparoscopic sonography raise the accuracy concerning resectability from 20% to between 75% and 100%. 33% up to 67% of patients deemed resectable by preoperative imaging show signs of unresectable cancer at laparoscopy and can be spared an unnecessary laparotomy. For these patients a choice of laparoscopic or endoscopic bypass techniques is available. The laparoscopic hepaticojejunostomy without sutures developed in Zurich has proven to be efficient in animal trials and will soon be implemented in clinical trials. A differentiated indication for laparoscopic bypass techniques and endoscopic stenting is necessary. The laparoscopic procedures should be employed in patients with a risk of duodenal obstruction or a projected mean survival of more than 6 months (stage III), while endoscopic stenting has already been established in the treatment of patients with a survival of less than 6 months (stage IV).