Palliative Bypass Procedures Research Articles

THE ROLE OF CA 19.9 IN PREDICTING THE OPERABILITY OF CARCINOMA PANCREAS

Objectives: Adenocarcinoma of the pancreas remains a relatively incurable disease despite advances in surgical care. Approximately 25% of patients will be found to have unresectable tumors during surgery even though computed tomography (CT) has demonstrated that they are resectable. There is a controversy regarding the use of cancer antigen 19-9 (CA 19-9) to decide the resectability of pancreatic adenocarcinoma [1]. Our aim is to study the use of CA 19-9 in determining the operability of carcinoma pancreas [2]. Methods: This was a prospective study which included 69 patients and the study period was from December 2021 to December 2022. Data were collected from all patients with carcinoma of the pancreas who underwent surgical management. CA 19-9 levels were measured and recorded [3]. During surgery, the operative findings on resectability were documented and tabulated against corresponding CA 19-9 levels and contrast-enhanced CT (CECT) findings. Results: Of the 69 patients who were operated on, 38 patients had resectable tumors and underwent the Whipples procedure and 31 of them had non-resectable tumors and had to undergo palliative bypass procedures. Among the 31 patients whose tumors were non-resectable, only four were diagnosed non-resectable preoperatively with CECT, and the other 27 were found to be non-resectable only during surgery. That shows the relevance of this study. Of the 31 non-resectable cases, 14 (45.2%) patients had elevated CA 19-9 values of more than 501, and the rest 17 (54.8%) patients had low CA 19-9 values. Among the 38 resectable cases, 12 patients (31.6%) had elevated CA 19-9 more than 501, and 26 patients (68.4%) had low values. In conclusion, among non-resectable cases, 45.2% had raised CA 19-9, and among operable cases, 31.6% showed raised CA 19-9. Hence, CA 19-9 seems to be an insignificant predictor of tumor resectability [4]. Conclusion: It was found that the need for a pre-operative predictor for resectability of carcinoma pancreas is relevant while considering mortality and morbidity in operating carcinoma pancreas cases. On evaluating CA 19-9 as a pre-operative predictor, we found that CA 19-9 has no significant role as an indicator of local advancement or metastasis. Hence, we cannot consider CA 19-9 as a predictor of resectability of carcinoma pancreas preoperatively [5].

Impact of Different Surgical Approaches on Morbidity and Mortality in Patients with Borderline Resectable Pancreatic Head Carcinoma.

Radical surgical resection for pancreatic head carcinoma offers a chance for cure but unfortunately is only available to a limited number of patients. For a significant number of patients, palliative surgery remains the only option. The question of the most effective approach for patients with borderline resectable pancreatic head carcinoma (BRPHC) remains unresolved. Objective: The aim of the study was to compare the morbidity and mortality following R1 duodenocephalic pancreatectomy and double palliative bypass to explore the most optimal surgical treatment for patients with BRPHC. Our retrospective cohort study included 64 patients with BRPHC who underwent surgery from 2012 to 2019, with postoperative follow-up for three years. Morbidity and mortality parameters were examined based on the type of surgical treatment: R1 duodenocephalic pancreatectomy or palliative double bypass. Chi-square test, univariate regression, and Kaplan-Meier analysis were used as basic statistical methods in the analysis of the results. Patients undergoing R1 duodenocephalic pancreatectomy had a 3.69 times higher risk of developing biliary leak (p=0.039; 95%CI:1.066, 1.181) and shorter survival compared to those undergoing palliative double bypass (p=0.022). No statistically significant association was found between the type of surgical procedure and other postoperative complications. Our study suggests that the double palliative bypass procedure may be a better option than R1 resection for patients with BRPHC.

Laparoscopic ultrasonography along with staging laparoscopy as a tool for staging in patients with hepatopancreaticobiliary malignancy - A prospective cohort study from a tertiary care centre.

Staging laparoscopy (SL) plays an important role in avoiding unnecessary non-therapeutic laparotomy in radiologically resectable hepatopancreaticobiliary (HPB) malignancy patients. The limitation of SL is to detect deep-seated malignancy. The addition of laparoscopic ultrasonography for identifying metastatic lesions or locally unresectable disease improves the diagnostic yield of SL. This prospective, observational study was conducted in a single unit of the tertiary care centre between 2017 and 2019. All the patients of HPB malignancy who were radiologically resectable underwent SL and laparoscopic intraoperative ultrasonography. Metastatic disease patients were either underwent palliative bypass procedures or abandoned depending on the condition of the patient. Patients who had resectable disease underwent standard surgical procedures. Forty patients of HPB malignancy with potentially resectable on radiological imaging underwent SL and diagnostic ultrasonography. Out of 40, 21 patients had periampullary, 14 had carcinoma gallbladder and 5 patients had distal cholangiocarcinoma. Metastatic lesions were identified on laparoscopy in eight patients and the diagnostic yield of SL is 20%. Addition of laparoscopic ultrasonography identified one haemangioma which was false positive on laparoscopy and underwent the radical standard procedure. Four patients were unresectable so the procedure was abandoned and another three patients underwent a bypass procedure. Laparoscopic ultrasonography during SL can detect deep-seated metastatic lesions and decide the management in resectable disease.

The aborted Whipple: Why, and what happens next?

For patients with periampullary adenocarcinoma (PAC), pancreatoduodenectomy (PD) provides the best survival. Surgery on a subset of patients is aborted during PD. We analyzed these patients. Patients who underwent laparotomy for planned PD for PAC were identified (2006-2019). From operative notes, we identified the subset with intraoperative decision to abort. Patient, treatment, and outcome data were analyzed. The subset with pancreatic ductal adenocarcinoma (PDAC) was analyzed for survival. Only 6.7% (n = 55/819) of cases were aborted. Majority 78% (n = 43) had pathologically-confirmed diagnoses at time of surgery, and 18.2% (n = 10) received preoperative chemotherapy. Reasons for aborted PD included: distant metastases (65.5%, n = 36) and local invasion (34.5%, n = 19). Of patients with metastatic disease, 75% (n = 27) had liver metastases. Eighty-nine percent (n = 49) of patients underwent at least one palliative bypass procedure and 81.8% (n = 45) had both gastric and biliary bypass. Patients with computed tomography (CT) scans before surgery more commonly had missed metastatic disease (79.2% CT compared to 54.8% magnetic resonance imaging [MRI], χ2 = 3.54, p = 0.059). In PDAC, 61.4% (n = 27/44) were aborted for metastatic disease and 38.7% (n = 17/44) for local invasion. Median overall survival for all PDAC patients after aborted PD was 334 days. Majority of pancreatoduodenectomies for periampullary adenocarcinoma are done to completion. Liver metastases is the most common reason for aborting. Preoperative MRI may help identify hepatic metastases.

THE ROLE OF CA 19-9 IN PREDICTING TUMOR RESECTABILITY AND PROGNOSIS IN CARCINOMA HEAD OF THE PANCREAS.

Background: Pancreatic cancer is the fth leading cause of cancer death.. Pancreatic cancer is diicult to diagnose in its early stages. at the time presentation nearly 50% cases have distant metastsis. CA 19-9 is tumor associated mucin glycoprotein present in epithelial tissues of pancreas, biliary ductularcells, stomach, gall bladder. Blood levels may be elevated in benign as well as malignant conditions. Aims And Objectives: To study the relation between levels of CA 19-19 and tumor respectability in cases of carcinoma head of pancreas. To study the relation between levels of CA 19-9 and prognosis of the cases. Materials And Methods: A Retrospective analysis of all the cases of carcinoma head of pancreas admiited over a period of 2 years, June 2019 to may 2021 at king George Hospital Visakhapatnam and in them the data was collected from all the patients of ca head of pancrteas on basis of CECT, MRCP. CA 19-9 levels were measured and recorded. During surgery the operative ndings on operability and prognosis were documented and tabulated aganist correspoding CA 19-9 levels. Results: A total of 45 cases Carcinoma head of pancreas of which 30 were operated; of which 21 cases were operable and underwent whipples procedure and 9 under went palliative bypass procedure. CA 19-9 was elevated in all the cases. In operable cases (21) CA 19-9 levels were elevated but not more than 1000IU/ml. Among inoperable cases (24) 85% cases have high levels of CA !9-9 (greater than 1000 IU/ml) Conclusion: Rasie in CA 19-9 levels are seen in many bengin conditions and CA 19-9 is tumor marker for various GI malignancies. Very high levels of CA 19-9 denotes high chances of inooperability and distant metastasis and poor prognosis.

A contemporary analysis of palliative procedures in aborted pancreatoduodenectomy: Morbidity, mortality, and impact on future therapy

BackgroundPeriampullary malignancies are often unresectable tumors that frequently cause biliary or duodenal obstruction. Advances in endoscopic and percutaneous options have lessened the need for operative palliation. Nevertheless, many patients are still found to be unresectable at the time of exploration, making palliative bypass a consideration. Several prior studies have examined the morbidity of operative palliation, but many were conducted over lengthy time periods, and few have examined the impact of these procedures on future therapy. This study is a contemporary analysis of the short- and long-term outcomes of palliative bypass procedures for unresectable periampullary malignancies at a single high-volume institution. MethodsWe identified a contemporary cohort of patients in whom a pancreatoduodenectomy was planned for periampullary malignancy but instead underwent an aborted procedure. Patients were divided into 5 procedure groups: laparoscopy only, laparotomy with or without cholecystectomy, gastrointestinal bypass, biliary bypass, and double bypass (gastrointestinal and biliary). Data regarding the patient cohort, procedures, morbidity/mortality, and the interval to initiation of systemic therapy were collected prospectively and reviewed retrospectively. ResultsBetween July 2011 and November 2018, 128 out of 615 (17%) patients had an aborted pancreatoduodenectomy; 113 out of 128 patients had pancreatic adenocarcinoma, and 86 (67.1%) had duodenal or biliary obstruction at the time of operation. Patients who underwent laparoscopy only (n = 34) had no operative complications and a 90-day mortality of 6%; 88% of these patients went on to receive systemic therapy (median 21 days postprocedure). Double bypass was associated with a far lesser complication rate than in prior studies; 17% of patients had some complication(s), but only 9% had a severe complication. The 90-day all-cause mortality was 13%, and only 71% of these patients went on to receive systemic therapy (median 47 days postprocedure). Notably, 27 out of 34 (79%) of patients who underwent laparoscopy alone needed additional procedures for local obstruction, whereas only 5 out of 42 (12%) double bypass patients needed additional interventions. Median survival for the entire cohort was 10.3 months. ConclusionPalliative procedures in this cohort had a far lesser complication rate than that of historical series. Palliative procedures, however, delayed systemic therapy, and a fair number of patients never received additional treatments. Palliative procedures markedly decreased the need for future interventions. Intraoperative decisions regarding palliative procedures must incorporate the functional status and motivations of the patient; these procedures are increasingly safe but may still affect survival.

The "aborted" Whipple: why, and what happens next?

Presenter: Rebecca Meltzer BA | Emory University Background: For patients with periampullary adenocarcinoma (PAC), pancreatoduodenectomy (PD) provides the best chance of cure. A subset of patients is taken to the operating room for planned PD that is subsequently aborted. We reviewed these cases to determine reasoning for aborted PD, subsequent operative management, and patient outcome. Methods: Data from all patients between 2006-2019 who underwent exploratory laparotomy for planned PD for suspected or pathologically confirmed PAC were identified. From the operative notes, we identified the subset who were scheduled for PD with an intraoperative decision to abort and the reason why. Patient, treatment, and outcome data were analyzed. The subset with pancreatic ductal adenocarcinoma (PDAC) was analyzed for survival. Results: 819 patients with PAC were taken to the operating room for PD in the specified interval, and 6.7% (n=55) of cases were aborted. Median age at diagnosis was 68 years in this cohort (range 43-85 years). 78% (n=43) had pathologically-confirmed diagnoses at time of surgery, and 18.2% (n=10) received preoperative chemotherapy. Reasons for aborted PD included: distant metastases (65.5%, n=36) and local invasion (34.5%, n=19). Of patients with metastatic disease, 75% (n=27) had liver metastases. 89% of patients underwent at least one palliative bypass procedure, including gastrojejunostomy (85.5%, n=47) or biliary bypass (87.0%, n=47), and 81.8% (n=45) had both gastric and biliary bypass. Patients who had only CT scans prior to surgery more commonly had missed metastatic disease (79.2% CT compared to 54.8% MRI, chi-squared = 3.54, p=0.059). The rate of postoperative complications was low, with surgical site infection being the most common (9.1%, n=5). The median length of stay was 7 days. Of 44 patients with a final diagnosis of PDAC, 62.8% (n=27) were aborted for metastatic disease and 37.2% (n=17) for local invasion. Median overall survival for all PDAC patients after aborted PD was 334 days, 212 days for patients with distant metastases, and 540 days for patients with local invasion. Conclusion: With current imaging as a preoperative guide, the majority of pancreatoduodenectomies for periampullary adenocarcinoma are done to completion, with a 6.7% rate of aborted operations. Intraoperative discovery of liver metastases is the most common reason for aborting PD, and the majority of these patients undergo successful gastric and biliary bypass with low rates of postoperative complications and acceptable survival. MRI prior to PD for PAC may improve the yield of identifying hepatic metastases.

Clinicopathological Characteristics, Surgical Treatments, and Survival Outcomes of Patients with Duodenal Gastrointestinal Stromal Tumor

Background: Duodenal gastrointestinal stromal tumors (GISTs) are rare and their clinicopathological features have not been completely described. In this retrospective study, we examined the characteristics and long-term outcomes of patients who underwent surgical treatment for duodenal GISTs. Methods: We examined patients surgically treated for duodenal GISTs from 1999 to 2016 at the China National Cancer Center. We analyzed patient characteristics, treatments, histological examinations, and survival outcomes. Results: The 52 surgeries performed included 14 pancreaticoduodenectomies (26.9%), 37 limited resections (71.2%), and one palliative bypass procedure (1.9%). No surgery-related death occurred. The complication rate in patients who underwent pancreaticoduodenectomy was slightly higher than that in patients who underwent limited resection. The 5-year overall survival and progression-free survival rates for patients with duodenal adenocarcinoma were 89.1 and 72.9%, respectively. The overall survival and progression-free survival rates were not significantly related to surgical methods. Large tumor size and high mitotic rate were associated with poor overall survival outcomes. However, no independent factor was associated with prognosis, which may be due to the small sample size. Conclusion: The prognosis of duodenal gastrointestinal stromal tumors was good. Limited resection seems to be oncologically feasible, with outcomes being less worse than those of pancreaticoduodenectomy.

Radiofrequency Ablation of Pancreatic Ductal Adenocarcinoma: An Evolving Comrade?

Background: Pancreatic ductal adenocarcinoma (PDAC) presents a challenge for the surgeon due to its aggressiveness and to the stagnation of the management options in cases where complete resection is not feasible. Radiofrequency ablation (RFA) in PDAC is described by a few studies as a promising technique. Methods: We present our 12 years’ experience in locally advanced unresectable PDAC with a series of 19 patients. The mean age was 66.8 years. The mean tumour diameter was 8.1 cm. In all patients, RFA was performed during laparotomy using Cooltip&copy, in some with IOUS monitoring, followed by palliative bypass procedures. Results: The postoperative period was relatively uneventful. A repeat CT showed remarkable changes in the size and morphology of the tumour. We observed significant improvement in pain relief. The mean survival with the RFA was 19.3 months (6 - 30 months). Conclusions: Our series suggest that RFA for locally advanced and unresectable PDAC in carefully selected patients (excluding multifocal disease) presents a promising, effective and safe associate for the surgeon. RFA plays a complimentary role to current standard palliative therapy, which may prolong survival and improve quality of life. Whether the laparoscopic approach or other non-invasive methods are feasible, will be a challenge for the following years.

The Role of CA19-9 in Predicting Tumour Resectability in Carcinoma Head of Pancreas

Carbohydrate antigen 19-9 (CA 19-9) is a tumour associated antigen. Blood levels may be elevated in benign as well as malignant conditions. Its sensitivity (70-90%) and specificity (68-91%) are inadequate for accurate diagnosis. It can be used to predict the extent of disease and outcome after resection. The aim of the present study was to assess the role of CA 19-9 in predicting the resectability of the tumour in the head of pancreas. This was a prospective study which included 30 patients and study period was from May 2012 to October 2014. Data collected from all patients with carcinoma of the head of pancreas on the basis of contrast enhanced computed tomography/Magnetic resonance cholangiopancreaticography. CA 19-9 levels were measured and recorded. Patients who were medically unfit for surgery or those who didn't warrant palliative surgery were excluded from the study. During surgery the operative findings on operability were documented and tabulated against corresponding CA 19-9 levels. Of the 30 patients who were operated, 13(43.3%) patients had operable tumours and underwent Whipple's procedure and 17(56.7%) underwent palliative bypass procedure. Of the 30, CA 19-9 levels were elevated in 9(30.0%) and were normal in 21(70.0%). Among 13(43.3%) who had operable tumours, CA 19-9 was elevated in 4(13.3) and was normal in 9(30.0%). Of the 17(56.7%) who had inoperable tumours CA 19-9 was elevated in 5(16.7%) and was normal in 12(40.0%). Among the 17 who had inoperable tumours, 8(47.1%) were diagnosed preoperatively and of them CA 19-9 levels were raised in 2(11.8%) and normal in 6(35.3%). In the group of 9(52.9%) who had inoperable tumours diagnosed intraoperatively, CA 19-9 was raised in 3(17.6%) of them and was normal in the remaining 6(35.3%) of them. Based on the study findings, it can be stated that there is no significant correlation with resectability of pancreatic adenocarcinoma and CA 19-9 and it doesn't predict vascular involvement and liver metastasis.

Enhanced recovery after surgery protocols as a management strategy following major pancreatic surgery.

396 Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to have positive effects on lengths of stay (LOHS) and resource utilisation without a rise in readmission and post-operative morbidity rates in colorectal, hepatic and oesophago-gastric surgery. This study aimed to investigate the effects of an ERAS protocol on postoperative morbidity and readmission rates following pancreatic surgery in a tertiary referral centre. Methods: The perioperative care of patients undergoing pancreatic surgery was guided by a locally developed ERAS protocol incorporating pre-operative counselling and carbohydrate loading. Intra-thecal opiate and Patient Controlled Analgesia devices were utilised for postoperative analgesia. Supplemental intravenous fluid prescription was protocolised. Oral intake was restarted from post-operative day (PoD) 1 and escalated on an on-demand basis. Patients were mobilised from PoD 1 and escalated daily. Drain removal and step down care decisions were guided by serum markers and clinical progress. Results: 212 consecutive patients from 2010 to 2014 were included (conventional, N = 108, ERAS protocol, N = 104). 134 (63.2%) patients underwent pancreaticoduodenectomy, 41 (19.3%) patients underwent distal pancreatectomy, 11 (5.2%) patients underwent total pancreatectomy and the rest underwent palliative bypass or other procedures. There was a statistically significant reduction in the volume of supplemental intravenous fluids received with no significant renal impairment noted. Median LOHS was reduced to 10 days (Inter-quartile range [IQR] 7 – 19) from 16 days (IQR 12 – 26) (P < 0.001). Median critical care stay was reduced from 7 days (IQR 5 – 10) to 6 (IQR 4 -7) (P = 0.020). There was a statistically significant reduction in clinically significant wound complications (P = 0.019). There were no statistically significant increases in readmission rates, pancreas-specific or other generic post-operative morbidity rates. Conclusions: ERAS protocols are a viable peri-operative management strategy after major pancreatic surgery, and data suggests that LOHS can be reduced without an associated increase in readmission or post-operative morbidity rates.

Locally Advanced Pancreatic Head Cancer: Margin-Positive Resection or Bypass?

Pancreatic cancer is a highly aggressive disease with poor survival. The only effective therapy offering long-term survival is complete surgical resection. In the setting of nonmetastatic disease, locally advanced tumors constitute a technical challenge to the surgeon and may result in margin-positive resection margins. Few studies have evaluated the implications of the latter in depth. The aim of this study was to compare the margin-positive situation to palliative bypass procedures and margin-negative resections in terms of perioperative and long-term outcome. By retrospective analysis of prospectively maintained data from 360 patients operated for pancreatic cancer at our institution, we provide evidence that margin-positive resection still yields a significant survival benefit over palliative bypass procedures. At the same time, perioperative severe morbidity and mortality are not significantly increased. Our observations suggest that pancreatic cancer should be resected whenever technically feasible, including, cases of locally advanced disease.

Factors influencing survival in patients undergoing palliative bypass for pancreatic adenocarcinoma

The purpose of this study is to identify factors predictive of early mortality following palliative bypass in patients with previously unsuspected advanced pancreatic adenocarcinoma to provide a basis for the selection of appropriate therapies. All patients with pancreatic adenocarcinoma who underwent a bypass procedure at our institution between 9/30/1994 and 1/31/2006 were reviewed. Patients with peri-operative mortality were excluded from the analysis. Univariate analysis was performed on peri-operative data to identify factors associated with early mortality (death within 6 months of surgery). Patients having multiple risk factors were assigned an overall prognostic score based on the sum of these factors. Of the 397 patients with pancreatic adenocarcinoma analyzed, four factors were found to predict early mortality following palliative bypass: Presence of distant metastatic disease (HR 2.59, P < 0.0001), poor tumor differentiation (HR 1.71, P = 0.009), severe pre-operative nausea and vomiting (HR 1.48, P = 0.013), and lack of previous placement of a biliary stent (HR 1.36, P = 0.048). Patients with a prognostic score of 0 were significantly more likely to survive past 6 months than patients with a prognostic score of 1 (HR 2.71, P < 0.0001), 2 (HR 3.70, P < 0.0001), or ≥3 (HR 5.63, P < 0.0001). In a cohort of patients undergoing a palliative bypass procedure, specific peri-operative factors can be used to identify patients who are at risk of early mortality. These factors may be helpful in selecting appropriate interventions for this group of patients.

Optimal combination of radiofrequency ablation with chemoradiotherapy for locally advanced pancreatic cancer

Problems have been reported in the treatment of pancreatic cancer with radiofrequency ablation (RFA), such as the friability of the organ itself. This report presents possible solutions to such problems. Although our patient suffered from locally advanced unresectable pancreatic cancer, she remained well at 18 mo after RFA with no evidence of recurrence. To ameliorate the side effects of RFA, after a palliative bypass procedure, the subject was treated with combined radiotherapy and chemotherapy. After this regimen had been administered, a contrast-enhanced computed tomography scan confirmed that RFA is a viable approach to the treatment of pancreatic cancer as the chemoradiotherapy had resulted in marked tumor shrinkage and pancreatic fibrosis; i.e., sufficient tumor ablation was achieved without serious RFA-related complications, such as pancreatitis or pancreatic fistulae. The present case suggests that RFA combined with preceding chemoradiotherapy is safe and effective for the palliative treatment of locally advanced pancreatic cancer.

Multivisceral Resections in Pancreatic Cancer: Identification of Risk Factors

There is an assumption that multivisceral resections (MVRs) in patients with a pancreatic malignancy are associated with higher morbidity. The oncologic benefit, however, remains controversial. The aim was to identify risk factors for complications in cases of MVR in patients with pancreatic cancer. Of 1099 patients who underwent major pancreatic resection at our institution between January 1992 and October 2008, a total of 55 were treated with an MVR involving resection of one or more additional organs. This group was compared with 154 patients who had palliative bypass surgery and 303 patients who underwent standard pancreatic head resection. Multivisceral resection patients had an overall higher incidence of major surgical complications (p < 0.001). In-hospital mortality was comparable in all groups. Median survival after MVR was inferior to that after standard resection but was significantly better than that after palliative bypass. Univariate logistic regression analysis identified concomitant colon, kidney, and liver resections and any intraoperative transfusion as predictors of complications; in the multivariate analysis, only kidney resections and any intraoperative transfusion were confirmed predictors. In contrast, T status, kidney resection, resection of four or more organs, any postoperative transfusion, and intensive care unit stay of >2 days were identified as predictors of survival in the univariate Cox regression analysis; in the multivariate analysis, only the T status was confirmed. Median survival after MVR was 16 months, after palliative bypass 6 months, and after standard resection 18 months (p < 0.001). Multivisceral resections are technically feasible procedures with increased survival when compared to palliative bypass procedures. The incidence of postoperative complications was increased with kidney resection and when intraoperative transfusion was required.

Anaplastic pancreatic cancer: Presentation, surgical management, and outcome

Anaplastic pancreatic cancers are rare neoplasms. The available data are focused on pathologic and molecular features, and little is known about the clinical presentation and management. The outcome of operative exploration and resection is unknown. From a prospective database, all consecutive operations for anaplastic pancreatic cancer performed at our institution were identified. The clinicopathologic details were analyzed and the outcome was compared with a matched group of typical pancreatic ductal adenocarcinomas (nested case-control study). Eighteen patients with anaplastic pancreatic cancer were identified. The patients had a median age of 64 years. The tumors were large (median diameter, 4 cm) and showed peripheral contrast enhancement in radiologic imaging. Fifteen (83%) patients underwent resection, a palliative bypass procedure was performed in 1 (6%) patient, and 2 patients underwent exploration with biopsy only. Perioperative morbidity was 39% and mortality was 6%. The median survival rate in patients with anaplastic pancreatic cancer was 5.7 months and was less than in the control group of patients with pancreatic ductal adenocarcinoma (15.7 months). In anaplastic pancreatic cancer, the median duration of survival was significantly greater after R0/R1 resection, as compared with palliative surgery (7.1 vs 2.3 months). The duration of survival was significantly greater in neoplasms with osteoclast-like giant cells. In 3 (17%) patients, long-term survival of 33, 49, and 161 months was observed. Anaplastic pancreatic cancer is an aggressive type of pancreatic cancer with a short median survival; however, because of the observation of prolonged survival after resection, resection should be performed whenever possible. The presence of osteoclast-like giant cells is associated with a favorable prognosis.

Combined biliary and gastric bypass procedures as effective palliation for unresectable malignant disease

Although endoscopic treatment of jaundice is increasingly used in the palliation of unresectable malignant disease, surgical bypass still has a role to play in this setting. This study aimed to reappraise the short-term and long-term results of combined biliary/gastric bypass (hepaticojejunostomy and gastrojejunostomy) as palliation for unresectable malignant disease. All patients undergoing simultaneous biliary and gastric bypass procedures for unresectable malignant disease between August 2000 and January 2006 were identified and outcomes reviewed. One hundred and two patients underwent open surgical biliary drainage procedures for palliation of malignant disease. Underlying malignant disease included pancreatic carcinoma (n = 88), duodenal adenocarcinoma (n = 6) and distal cholangiocarcinoma (n = 3). Thirty-one of the patients underwent a planned palliative bypass procedure, the remainder being carried out after unresectable disease was identified at laparotomy. Postoperative mortality and morbidity rates were higher in the group undergoing planned bypass. During follow up, two patients developed recurrent jaundice that required transhepatic stenting and two patients developed late gastric outlet obstruction requiring refashioning of the gastrojejunostomy. Combined surgical biliary and gastric bypass achieved effective palliation of jaundice and gastric outlet obstruction until death in >95% of patients in this series. It remains first-line therapy in patients identified as having unresectable disease at laparotomy.

Adenosquamous Carcinoma of the Pancreas: A Single-Institution Experience Comparing Resection and Palliative Care

Adenosquamous carcinoma is a rare malignancy of the exocrine pancreas. Previous literature has reported dismal survival for these patients. We examined our single-institution experience with this tumor to compare survival for sugical resection and palliative therapy. Records were reviewed for patients with adenosquamous pancreatic cancer evaluated during the years 1985 to 2003. Pathology specimens were reviewed. Survival was calculated by Kaplan-Meier method and categorical variables were compared with Chi-square analysis. A p value < 0.05 was considered significant. Twenty-three patients were identified with adenosquamous carcinoma of the pancreas. Twelve patients underwent curative resection and 11 patients had either no surgery or a palliative bypass procedure. For the resection group the mean age was 69 years (7 men). In the nonoperative group the mean age was 65 years (6 men). Operative procedures included standard pancreaticoduodenectomy (PD), 4 patients; pyloruspreserving PD, 3 patients; and distal pancreatectomy, 5 patients. Median length of stay was 13.5 days (7-30 d). Morbidity included delayed gastric emptying (4 patients), leak (2 patients), superficial skin infection, abscess, and GI bleed (1 patient each). There was no operative or inhospital mortality in the resection group. For R0 resection median survival was 14.4 months compared to 8 months for R1 and 4.8 months for patients undergoing palliative therapies. The retrospective review of our single-institution experience with resection and palliative care for adenosquamous cancer of the pancreas has demonstrated a longer survival for patients that can undergo an R0 resection. Although this is a small series we continue to recommend resection for these patients.

Factors influencing survival after bypass procedures in patients with advanced pancreatic adenocarcinomas

BackgroundPatients with occult metastasis or locally nonresectable pancreatic cancer found during surgical exploration have a limited life expectancy. We sought to define markers in these patients that could predict survival and thus aid decision making for selection of the most appropriate therapeutic palliative option. MethodsIn a prospective 4-year single-center study, 136 consecutive patients with obstructive pancreatic cancer and intraoperative diagnosis of nonresectable or disseminated pancreatic cancer underwent a palliative surgical bypass procedure. Potential factors predicting survival were evaluated. ResultsNinety-eight patients had metastatic disease and 38 locally advanced disease. Surgical morbidity rate was 16 %, re-operation rate 1%, and overall in-hospital mortality 4%. Univariate analysis showed American Society of Anesthesiologists (ASA) score, pain, operation time, presence of metastasis, and levels of leukocytes, albumin, C-reactive protein (CRP), carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19-9 were associated significantly with survival. The multivariate analysis identified ASA score, presence of liver metastasis, pain, CA 19-9, and CEA levels as independent indicators for poor survival. Patients with none or 1 of these risk factors had a median survival of 13.5 months, whereas patients with 4 or 5 risk factors had a median survival of 3.5 months. ConclusionsThe clinical markers identified predict poor outcome for patients with palliative bypass surgery and therefore aid the appropriate selection of either surgical bypass or endoscopic stenting in these patients.

Palliative Surgical Bypass for Pancreatic and Peri-ampullary Cancers

The optimal method of palliation for patients with unresectable pancreatic and peri-ampullary cancer (PAC) is controversial with surgical bypass or endoscopic stenting, each having advantages and disadvantages. We analysed short term outcomes and survival for all patients undergoing surgical palliative bypass procedures. All patients undergoing palliative surgical bypass for unresectable PAC from Aug 1999 to July 2007 were identified from our database. Outcomes analysed were peri-operative morbidity, mortality, and overall survival with comparisons from contemporaneous literature. One hundred eight patients (median age 65 (range 36-86) years; male = 61) had palliative surgical bypass procedures for unresectable PAC. Patients underwent combined biliary and gastric bypass (n = 81, 75%), gastric bypass alone (n = 24, 22.2%) or biliary bypass alone (n = 3, 2.8%). Overall mortality was 6.5% and the morbidity was 15.7%. Median hospital stay was 11 (range 4-54) days. Median survival was 6 (95% confidence interval (CI) = 4.3-7.6) months. No re-explorations for recurrent biliary or gastric obstruction were required. Contemporaneous literature review showed similar results. Surgical bypass performed in a specialist pancreatic center can offer effective palliation for unresectable PAC, with satisfactory outcomes.