Palliative Surgical Bypass Research Articles

A CLINICAL STUDY ON OBSTRUCTIVE JAUNDICE DUE TO PERIAMPULLARY CARCINOMA WITH SPECIAL REFERENCE TO ITS MANAGEMENT

Background Periampullary carcinoma includes a group of malignant neoplasm arising in the pancreas or in or near the ampulla of vater. Main modalities of treatment in patients with obstructive jaundice due to periampullary carcinoma: resection of the tumor with bilioenteric anastomosis, palliative surgical bypass and stent insertion. Aims and objectives To nd out results, morbidity and mortality to various modalities of treatment to all operable and non operable case of obstructive jaundice due to periampullary carcinoma following proper diagnosis by clinical, radiological and other investigation procedures Materials and methods This is a prospective study on patients presented with obstructive jaundice due to periampullary carcinoma with special reference to its management, admitted in different surgical units of Nootan Medical College & Research Centre, Visnagar from the month of August 2019 to July 2022 suspected due to peri-ampullary carcinoma. Results and discussion Twenty eight cases studied in regard to their incidence of age, sex, religion, occupation, their clinical features, investigations different etiological factors of obstructive jaundice due to periampullary carcinoma and their management. Maximum numbers of obstructive jaundice due to periampullary carcinoma were found to be due to carcinoma head of pancreas, Most of the patients present late and curative resection was not possible in them 24 out of 30 patients were operated out of which 10 had denitive surgery and in 14 palliative surgeries were done. Conclusions Most of the patients' present late and curative resection was not possible in them. Surgical palliation is a better alternative in those patients when nonsurgical palliation is not available

Palliative bypass surgery for patients with advanced pancreatic adenocarcinoma: experience from a tertiary center

BackgroundAs advances in oncological treatment continue to prolong the survival of patients with non-resectable pancreatic ductal adenocarcinoma (PDAC), decision-making regarding palliative surgical bypass in patients with a heavy disease burden turns challenging. Here we present the results of a pancreatic surgery referral center.MethodsPatients that underwent palliative gastrojejunostomy and/or hepaticojejunostomy for advanced, non-resectable PDAC between January 2010 and November 2018 were retrospectively assessed. All patients were taken to a purely palliative surgery with no curative intent. The postoperative course as well as short and long-term outcomes was evaluated in relation to preoperative parameters.ResultsForty-two patients (19 females) underwent palliative bypass. Thirty-one underwent only gastrojejunostomy (22 laparoscopic) and 11 underwent both gastrojejunostomy and hepaticojejunostomy (all by an open approach). Although 34 patients (80.9%) were able to return temporarily to oral intake during the index admission, 15 (35.7%) suffered from a major postoperative complication. Seven patients (16.6%) died from surgery and another seven within the following month. Nine patients (21.4%) never left the hospital following the surgery. Mean length of hospital stay was 18 ± 17 days (range 3–88 days). Mean overall survival was 172.8 ± 179.2 and median survival was 94.5 days. Age, preoperative hypoalbuminemia, sarcopenia, and disseminated disease were associated with palliation failure, defined as inability to regain oral intake, leave the hospital, or early mortality.ConclusionsAlthough palliative gastrojejunostomy and hepaticojejunostomy may be beneficial for specific patients, severe postoperative morbidity and high mortality rates are still common. Patient selection remains crucial for achieving acceptable outcomes.

Surgical management of gastric adenocarcinoma. Official expert recommendations delivered under the aegis of the French Association of Surgery (AFC).

Gastric adenocarcinoma (GA) is the 5th most common cancer in the world; in France, however, its incidence has been steadily decreasing. Twenty-five experts brought together under the aegis of the French Association of Surgery collaborated in the drafting of a series of recommendations for surgical management of GA. As concerns preoperative evaluation and work-up, echo-endoscopy aimed at clarifying lymph node status should be performed in all candidates for surgical resection and exploratory laparoscopy in cases of GA cT3/T4 and/or N+ for peritoneal carcinomatosis. On the other hand, PET-scan should not be performed systematically, but only when the other modalities for diagnosis prove insufficient. Laparotomy remains the route of choice to achieve total or partial gastrectomy with D2 lymph node lymphadenectomy for advanced lesions (>T2N0). To limit the risk of dumping syndrome and esophageal reflux and as a way of reestablishing continuity, construction of a jejunal pouch on Roux-en-Y following total gastrectomy is recommended. In cases of peritoneal carcinosis in GA with a low peritoneal cancer index (PCI) (<7) in a patient in good general condition whose disease is controlled by chemotherapy, macroscopically complete cytoreduction with intraperitoneal hyperthermal chemotherapy will probably be required, and it will have to take place in an expert center. Only in the event of Child A cirrhosis may gastrectomy with D2 lymphadenectomy be considered. Palliative gastrectomy or surgical bypass for distal stomach obstruction in a patient in good general condition may also be envisioned.

Metallic biliary stenting versus surgery for palliation of inoperable distal malignant obstructive jaundice

Background Pancreatic and biliary malignancies are rarely operable. The role of intervention is to palliate jaundice. Biliary drainage can be done by surgical bypass or biliary stenting either percutaneously or by endoscopic retrograde cholangiopancreatography. Plastic and expandable metal stents (EMS) are available.Aim To compare metallic biliary stenting versus surgery for palliation of inoperable malignant obstructive jaundice due to unresectable pancreatobiliary cancer.Patients and methods This retrospective, cohort study included 43 patients, presented by malignant obstructive jaundice due to unresectable pancreatobiliary cancer. They were divided into two groups: group I (20 patients) underwent palliative biliary-enteric surgical bypass; group II (23 patients) underwent endoscopic retrograde cholangiopancreatography and metal stent drainage.Results This study showed that both surgical bypass and EMS insertion have similar short-term satisfactory results in the control of jaundice. Surgical bypass had low incidence rate as regards late complications, although gastric outlet obstruction may occur for patients without gastric bypass. Despite EMS resulted in a shorter hospital stay, the higher late complications rate raised the cost, especially stent occlusion.Conclusion Endoscopic EMS and surgical bypass had similar results according to the efficacy of biliary drainage and mean survival period. EMS had a shorter hospital stay and fewer early complications. But, in the long run, surgical bypass results in less recurrent jaundice than the EMS but higher morbidity and mortality.

Natural history and cost analysis of surgical bypass versus endoscopic stenting for the palliative management of malignant gastric outlet obstruction

BackgroundMalignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes. MethodsPatients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure—defined as repeat surgery, stenting, or gastrostomy tube—was measured. ResultsA total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1–3.8], p 0.028). ConclusionIn patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention.

Palliative surgical bypass is superior to palliative endoscopic stenting in patients with malignant gastric outlet obstruction: systematic review and meta-analysis.

Gastrojejunostomy (GJ) and self-expanding metal stents (SEMS) are the two most common palliative treatment options for patients with malignant gastric outlet obstruction (GOO). Randomised trials and retrospective studies have shown discrepant results, so that there is still a controversy regarding the optimal treatment of GOO. Medline, Web of Science and Cochrane Library were systematically searched for studies comparing GJ to SEMS in patients with malignant GOO. Primary outcomes were survival and postoperative mortality. Secondary outcomes were frequency of re-interventions, major complications, time to oral intake and length of hospital stay. Twenty-seven studies, with a total of 2.354 patients, 1.306 (55.5%) patients in the SEMS and 1.048 (44.5%) patients in the GJ group, were considered suitable for inclusion. GJ was associated with significantly longer survival than SEMS (mean difference 43days, CI 12.00, 73.70, p = 0.006). Postoperative mortality (OR 0.55, CI 0.27, 1.16, p = 0.12) and major complications (OR 0.73, CI 0.5, 1.06, p = 0.10) were similar in both groups. The frequency of re-interventions, however, was almost three times higher in the SEMS group (OR 2.95, CI: 1.70, 5.14, p < 0.001), whereas the mean time to oral intake and length of hospital stay were shorter in the SEMS group (mean differences - 5days, CI - 6.75, - 3.05days, p < 0.001 and - 10days, CI - 11.6, - 7.9days, p < 0.001, respectively). Patients with malignant GOO and acceptable performance status should be primarily considered for a palliative GJ rather than SEMS.

Особенности организации медицинской помощи больным с обструктивными заболеваниями поджелудочной железы в Республике Коми

The efficiency of 3 level medical care system is shown. The level of hospital is determined by the diagnostic possibilities and human resources. The task of I level is the diagnosis of biliary and duodenal obstruction of any origin. At II level perform palliative surgical bypass for malignant obstruction. Radical surgical resection for cancer, procedures for chronic pancreatitis carry out only at III level. Cases of obstructive pancreatic diseases in the Komi Republic from 2007 to 2014 were analysed. According to the accepted routing scheme for overwyelming majority of patients (92,9%) medical care was provided at III level. After analysis of minimally invasive intervention long-term results at III level indications for palliative treatment were revised in favor of surgical decompression. Thus patients judged eligible for surgical bypass may undergo this procedure at II level without being referred to III level. However, the proportion of patients at II level was insignificaqnt and accounted for only 3.9%. Hospital of II level solved its local task. However, in the region meanwhile is no real load redistribution from II level to III level. There are two hospitals in the region with high diagnostic opportunities, but currently lack of qualified surgeons does not allow rank them as II level. Accepted in the republic medical care system for patients with obstructive pancreatic diseases provides effective use of health care resources and brings nearer specialized surgical aid to the population of remote territories.

Preoperative evaluation of pancreatic ductal adenocarcinoma with synchronous liver metastasis: Diagnosis and assessment of unresectability.

AIMTo identify predictors for synchronous liver metastasis from resectable pancreatic ductal adenocarcinoma (PDAC) and assess unresectability of synchronous liver metastasis.METHODSRetrospective records of PDAC patients with synchronous liver metastasis who underwent simultaneous resections of primary PDAC and synchronous liver metastasis, or palliative surgical bypass, were collected from 2007 to 2015. A series of pre-operative clinical parameters, including tumor markers and inflammation-based indices, were analyzed by logistic regression to figure out predictive factors and assess unresectability of synchronous liver metastasis. Cox regression was used to identify prognostic factors in liver-metastasized PDAC patients after surgery, with intention to validate their conformance to the indications of simultaneous resections and palliative surgical bypass. Survival of patients from different groups were analyzed by the Kaplan-Meier method. Intra- and post-operative courses were compared, including complications. PDAC patients with no distant metastases who underwent curative resection served as the control group.RESULTSCA125 > 38 U/mL (OR = 12.397, 95%CI: 5.468-28.105, P < 0.001) and diabetes mellitus (OR = 3.343, 95%CI: 1.539-7.262, P = 0.002) independently predicted synchronous liver metastasis from resectable PDAC. CA125 > 62 U/mL (OR = 5.181, 95%CI: 1.612-16.665, P = 0.006) and age > 62 years (OR = 3.921, 95%CI: 1.217-12.632, P = 0.022) correlated with unresectability of synchronous liver metastasis, both of which also indicated a worse long-term outcome of liver-metastasized PDAC patients after surgery. After the simultaneous resections, patients with post-operatively elevated serum CA125 levels had shorter survival than those with post-operatively reduced serum CA125 levels (7.7 mo vs 16.3 mo, P = 0.013). The survival of liver-metastasized PDAC patients who underwent the simultaneous resections was similar to that of non-metastasized PDAC patients who underwent curative pancreatectomy alone (7.0 mo vs 16.9 mo, P < 0.001), with no higher rates of either pancreatic fistula (P = 0.072) or other complications (P = 0.230) and no greater impacts on length of hospital stay (P = 0.602) or post-operative diabetic control (P = 0.479).CONCLUSIONThe criterion set up by CA125 levels could facilitate careful diagnosis of synchronous liver metastases from PDAC, and prudent selection of appropriate patients for the simultaneous resections.

Endoscopic ultrasound-guided gastroenterostomy using a lumen-apposing self-expanding metal stent for decompression of afferent loop obstruction.

Acute afferent loop syndrome following pancreaticoduodenostomy is generally caused by mechanical occlusion due to pancreatic cancer recurrence. Historically, it has been treated with palliative surgical bypass [1–5]. A retrograde endoscopic approach with placement of an enteral metal stent across the afferent limb stricture is often not possible [2]. We report the first case series of endoscopic ultrasound (EUS)-guided gastrojejunostomy using a lumen-apposing, self-expanding, metal stent (LASEMS) for therapy of acute afferent loop syndrome. Three patients who had previously undergone a pancreaticoduodenostomy for pancreatic cancer presented with acute abdominal pain and vomiting. Computed tomography revealed dilation of the afferent loop caused by bowel obstruction due to cancer recurrence (● Fig.1). All three patients underwent successful EUS-guided gastroenterostomy using LASEMS. The dilated afferent limb was located endosonographically by an echoendoscope in the stomach. The obstructed afferent limb was then punctured using a 19-gauge EUS needle. Contrast was injected through the 19-gauge needle into the dilated afferent limb to confirm the position, and a 0.035-inch guidewire was introduced through the needle and coiled into the obstructed afferent limb. Needle-knife cautery was used to make an incision into the fistula tract, and then a 6-mm balloon was used to dilate the tract (● Fig.2,● Video 1). A 15mm×10mm LASEMS (Axios; Boston Scientific Corp., Marlborough, Massachusetts, USA) was then deployed under fluoroscopic guidance across the tract, resulting in apposition between the dilated afferent limb and the stomach wall. A 15-mm balloon was then used to dilate the tract within the lumen of the LASEMS to create an endoscopic gastrojejunostomy for drainage of the obstructed afferent limb (● Fig.3,● Video 1). All three patients had resolution of clinical symptoms (● Fig.4) and were discharged. This series demonstrates that EUS-guided gastroenterostomy involving LASEMS placement offers a safe, technically feasible, and clinically successful endoscopic method of management for acute afferent loop obstruction.

The Added Value of Partial Stomach-partitioning to a Conventional Gastrojejunostomy in the Treatment of Gastric Outlet Obstruction

IntroductionPoor results have been reported after conventional gastrojejunostomy (CGJ) as palliative surgical bypass treatment of gastric outlet obstruction (GOO). Partial stomach-partitioning gastrojejunostomy (PSPGJ) has been introduced as an alternative surgical treatment of GOO to reduce the risk of postoperative delayed gastric emptying (DGE). AimThe aim was to study PSPGJ as an alternative to CGJ in the treatment of GOO, with respect to DGE. Patients and MethodsA retrospective cohort study was completed in all patients who underwent a bypass of the duodenum via PSPGJ or CGJ due to GOO. Cases where concomitant biliary or bariatric procedures were performed were excluded. ResultsTwenty-four patients met the inclusion criteria for the study; ten cases underwent PSPGJ and 14 CGJ. The incidence of DGE grade B-C was significantly lower in the PSPGJ group (0 %) compared with the CGJ group (42.9 %, p = 0.024). Oral nutrition only was recorded more often at follow-up in the PSPGJ group (9/9, 100 %) than in the CGJ group (4/13, 30.8 %) (p = 0.002). ConclusionPSPGJ seems to be followed by a lower rate of DGE compared to CGJ.

Endoscopic palliative treatment versus surgical bypass in malignant low bile duct obstruction: A systematic review and meta-analysis

Aims: Despite technological advances, only about 20% of periampullary tumors are found to be resectable at the time of presentation. Biliary tree obstruction and consequent jaundice occur in 70–90% of those patients and has important consequences for a patient’s quality of life. Relief of biliary tree obstruction is the main goal for treatment, and few options for palliative therapy of biliary tree obstruction can be performed, including surgical bypass, percutaneous stenting, and endoscopic stenting. Objective: The aim of the present study was to acquire and analyze data to compare the success of procedures, procedure-related complication, mortality in 30

Staging laparoscopy in patients scheduled for pancreaticoduodenectomy minimizes hospitalization in the remaining life time when metastatic carcinoma is found

ObjectiveTo compare the burden of total hospitalization as a ratio of survival of staging laparoscopy versus prophylactic bypass surgery in patients with unresectable periampullary adenocarcinoma. BackgroundPeriampullary adenocarcinoma is an aggressive cancer with up to 35% of the patients at surgery found to be unresectable. Palliative prophylactic surgical bypass versus endoscopic stenting has been addressed by randomized controlled trials, but none reported on the burden of hospitalization. MethodsFrom a prospective database all patients with periampullary adenocarcinomas with a preoperative patent biliary stent and absent gastric outlet obstruction, but found unresectable during surgery, were analysed. They underwent a staging laparoscopy only versus prophylactic palliative bypass surgery. In-hospital days of the initial admission as well as all consecutive admission days during the remaining life span were compared both in absolute numbers and as relative impact. ResultsThe inclusion criteria were met by 205 patients. Of these 131 patients underwent a staging laparoscopy detecting metastases in 21 patients. In 184 laparotomies 54 patients underwent prophylactic palliative bypass surgery for unresectable disease. Median total in-hospital-stay in the Laparoscopy Group was 3 days versus 11 days in the Palliative Bypass Group (p = 0.0003). Patients with metastatic disease found during laparoscopy stayed 3.5% of the remaining life time in hospital vs. 10.0% (p = 0.029) in patients with metastatic disease who underwent bypass surgery. ConclusionsStaging laparoscopy and early discharge in patients with metastatic peri-ampullary carcinoma resulted in reduced hospitalization, both in absolute number of days and as a rate of survival time.

Prognostic factors associated with long-term survival and recurrence in pancreatic adenocarcinoma.

It is very important to determine the prognostic factors for pancreatic adenocarcinoma when choosing surgical and conservative management strategies. In this study, we identified prognostic factors for survival and recurrence in patients with histologically proven pancreatic adenocarcinoma. Between January 2003 and December 2009, 82 patients with histologically proven pancreatic adenocarcinoma were considered for this study. Follow-up consisted of personal contact with patients or review of electronic medical records at this center and was terminated on December 31, 2011 or upon the patient's death. Overall survival rates of all patients at 1, 3, and 5 years were 51.9, 21.6 and 16.0%. Preoperative jaundice was the only independent prognostic factor for total pancreatic cancer patients, while N stage and perineural invasion in pathological findings was identified as an independent prognostic factor for survival of patients with surgical resection. Chemotherapy was the only independent prognostic factor for survival of patients who underwent palliative surgical bypass. Preoperative jaundice in any patients, lymph node metastasis, perineural invasion in patients with surgical resection, and chemotherapy in patients undergoing palliative surgical bypass are important prognostic factors for survival of pancreatic cancer.

Margin Positive Pancreaticoduodenectomy Is Superior to Palliative Bypass in Locally Advanced Pancreatic Ductal Adenocarcinoma

BackgroundPancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection. ObjectiveThe aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma. MethodsWe reviewed our pancreatic surgery database (January 2005–December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX. ResultsWe identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients, 25% had locally advanced disease and 75% had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57% retroperitoneal soft tissue, 19% with more than one positive margin, 11% pancreatic neck, and 8% bile duct. The perioperative complication rates for the respective groups were R0 36%, MP 49%, PB 33%, and PX 22%. The 30-day perioperative mortality rate for the entire cohort was 2%, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months. ConclusionsMargin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.

Tratamiento paliativo de la obstrucción tumoral del vaciamiento gástrico con prótesis metálicas autoexpandibles insertadas endoscópicamente

the insertion of self-expanding metal stents to palliate malignant gastric outlet obstruction is a minimally invasive procedure that is being increasingly used. We discuss experience with this technique in a level-II hospital in the Spanish National Health System. a retrospective five-year study (2003-2007) was conducted in 23 patients who underwent 27 procedures aimed at resolving malignant gastric outlet obstruction (mean, 0.45 procedures per month) using endoscopically inserted noncovered stents (Wallstent and Wallflex). insertion was technically feasible in all 27 (100%) attempts, with satisfactory clinical results in 25 cases (92.5%). Endoscopy alone was used 10 times (37%), and both endoscopy and fluoroscopy on 17 (63%) occasions. After stent insertion, one patient was intervened for treatment, and a patient with an unsuccessful prosthesis received a palliative surgical bypass. Four stents became obstructed by tumoral ingrowth, and patency was reestablished by inserting a new stent. Obstructive jaundice caused by stents covering the papilla of Vater occurred in three cases. There were no other complications or mortality due to the procedure. Mean survival was 104 days (range 28-400, SD +/- 94). in our experience endoscopic insertion of self-expanding metal stents appears to be a safe and efficient palliative method for malignant gastric outlet obstruction, and can be performed successfully in a center with our characteristics.

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.

Pancreatic cancer — Palliative therapy: surgery (bypass/resection)

Objective We compare the outcome of palliative pancreaticoduodenectomy and palliative surgical bypass in patients with advanced pancreatic carcinoma in our hospital. Recent published related articles are also reviewed.

Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice?

Gastroduodenal obstruction is a common preterminal event for patients with gastric and pancreatic cancer who often undergo palliative surgical bypass. Endoscopic palliation with self-expanding metallic stents has emerged as a safe and an effective alternative to surgery, but experience with the technique remains limited. Twenty-eight patients hospitalized with GI obstruction because of incurable gastric or pancreatic cancer were recruited for a prospective study of palliation with self-expanding metallic stents. Complications and clinical outcomes were assessed. Stent insertion was technically successful in 26 patients. Thereafter, 24 patients resumed an adequate liquid or semisolid diet. Stent insertion facilitated hospital discharge for 20 patients. Occlusion of the stent because of tumor ingrowth occurred in 3 patients, but there was no complication related to stent insertion or the stent itself. Endoscopic placement of a self-expanding metallic stent is a simple, effective means of palliation for patients with malignant gastroduodenal obstruction.

Biliopancreatic tumors: patient survival and quality of life after palliative treatment.

to analyse survival and quality of life of patients with malignant obstructive jaundice after palliative treatment, comparing endoscopic stent insertion and palliative surgical (palliative resection and bypass surgical). eighty and seven patients were included in a trial. They were distributed to endoscopic stent (50) and palliative surgical (37). It analysed survival, quality of life and comfort index of jaundiced patients. The good quality of life was defined by absence of jaundice, pruritus and cholangitis after the initial treatment. the median survival of the patients treated to endoscopic stent was 9,6 months whereas the patients to surgical treatment survived a median of 17 months. The time free of disease was 4 months in stented patients and 10,5 months in surgical patients. There was no significant difference in comfort index between the two groups (stented 34%, surgical 42,5%) Neither was there significant difference in survival and quality of life between palliative resection and bypass surgery. despite the survival and time free of disease being better in surgical patients, there was no significant difference in overall quality of life between the two groups. The survival and quality of life are the same after palliative resection as after bypass surgery, for this should not be performed routinely or to justify resection as a debulking procedure.