Surgical palliation in pancreatic cancer

The prognosis of patients with pancreatic carcinoma is poor. At the time of diagnosis, approximately 80% of patients are found to have an unresectable tumour, because of local spread or metastatic disease. Therefore, most patients will undergo palliative treatment, which is aimed at the improvement of the quality of life and the prevention of symptoms. The most important symptoms which are associated with advanced pancreatic cancer are pain, obstructive jaundice and gastric outlet obstruction. Controversy remains on the question whether these symptoms should be treated surgically or non-surgically. This review describes the best evidence (if possible randomised controlled trials) in recent literature on the palliation of most important symptoms and focuses on surgical palliative treatment options.     

Endoscopic palliation of pancreatic cancer

There are many approaches to palliation of jaundice in patients with pancreatic cancer. Each stenting technique has merit. Regrettably, an insufficient number of randomized comparative trials using the latest technology have been performed. Moreover, economic analyses of techniques to aid in clinical decision making are few. Currently data support endoscopic stenting as the standard for most patients with obstructive jaundice from pancreatic cancer. Patients with an expected survival of more than 6 months should undergo placement of an expandable metal stent, whereas patients with a limited life expectancy (<3 months) are best served with a plastic stent. Randomized comparative studies are needed between laparoscopic techniques and endoscopically placed expandable metal stents. Percutaneous techniques may prove safer and more effective when metal expandable stents are used.     

Surgical palliation for pancreatic cancer

The effectiveness of surgical palliation for pancreatic cancer has been reviewed. Jaundice should be relieved early as this eliminates distressing pruritus, improves the quality of life, and avoids the sequelae of prolonged extrahepatic obstruction. The procedure may prolong survival, but this has not been proved. Biliary obstruction is managed best by a simple loop cholecystojejunostomy. If the gallbladder is unavailable, a choledochojejunostomy is equally effective. Nonsurgical techniques such as percutaneous or endoscopically placed biliary stents may be appropriate in patients who are not candidates for surgery. A gastrojejunostomy should be done in all patients who have gastroduodenal obstruction by tumor. Most patients who undergo surgical biliary bypass also should have a gastrojejunostomy, even if gastroduodenal obstruction has not yet developed. Otherwise, more than 20 per cent of patients may need a second operation if gastroduodenal obstruction develops later. Pain, a problem in more than half of patients, is best relieved by an intraoperative celiac ganglion block with 50 per cent ethanol. Laparotomy is desirable in most of these patients with pancreatic cancer, because it provides tissue for diagnosis, allows a definite assessment of resectability, and produces effective palliation.     

Nonsurgical palliation of jaundice in pancreatic cancer

The endoscopic approach to biliary drainage came late on the scene; some of the published results reflect early experience with inadequate techniques. Now it is clear that the endoscopic approach is preferable to the percutaneous method. When palliation of jaundice is required (in a patient without impending duodenal obstruction), there is a simple choice between surgical bypass or endoscopic stenting. Stenting is substantially cheaper than surgery--at least for the initial admission. Recovery from stenting is almost immediate, which cannot be said for surgical intervention. Time will tell how far the need for readmission (stent blockage, duodenal obstruction) will erode these advantages. The main factor influencing our decision (stent or surgery), apart from the hope of resection, is the patient's general status, or "operative risk." Unfortunately, there is no accepted risk factor scale or template against which our experiences can be compared. There are no absolutes, only a spectrum of patients who differ according to the tumor load and their general medical condition. A fit patient with a relatively small tumor is best served by surgical intervention. The diagnosis and its unresectable nature can be established beyond doubt, and anastomoses (biliary and gastroduodenal) can be established of such a size that subsequent obstruction is unlikely. The operative mortality rate will be low. Patients with a large tumor load and poor general condition are best served by an endoscopic stent. Between these positions lies a spectrum of patients and plenty of room for discussion and personal opinions. Drainage procedures are unwarranted in patients who are truly terminal. Specialist vested interests have seriously jaundiced the view of many people in this field--and obstructed attempts at consensus. As in the management of patients with gallstone disease, it is important that surgeons, endoscopists, and radiologists work together as teams in the best interests of our patients, present and future.     

Surgical palliation in patients with pancreatic cancer

Background The aim of palliative strategies in patients with pancreatic cancer is the relief of tumor-associated symptoms such as biliary and duodenal obstruction and tumor growth. Due to high mortality and morbidity rates of surgery, treatment of patients with advanced pancreatic cancer is mainly in the hand of gastroenterologists. Rationale In recent years, surgery of pancreatic cancer in specialized centres developed strongly, which makes it a viable option even in the treatment of advanced disease. Conclusion We advocate for an aggressive strategy in the treatment of pancreatic cancer with surgical exploration and tumor resection whenever possible.     

Surgical and endoscopic palliation for pancreatic cancer

Patients with pancreatic cancer often present with locally advanced or metastatic disease and are deemed not to be candidates for a curative resection. Palliation in these patients focuses on relief of biliary obstruction, gastroduodenal obstruction and pain. Palliative treatment modalities include both surgical and nonsurgical approaches. Biliary obstruction is often initially treated with endoscopic biliary stenting. Two major types of biliary stents are used, plastic and metallic stents. Both of these provide similar initial relief of biliary obstruction, however, plastic stents have a greater propensity for occlusion and should primarily be used in patients with anticipated short survival duration. Metallic stents have a greater initial cost, but provide an overall cost-saving in patients with expected survival duration of over 6 months. Surgical palliation for biliary obstruction should be primarily considered in patients who fail endoscopic biliary decompression or who develop clinical evidence of gastroduodenal obstruction. In these patients, surgical palliation should consist of biliary decompression with a choledochojejunostomy when ever feasible, a gastroduodenal bypass and a chemical splanchnicectomy for pain relief. An initial prophylactic gastroenterostomy at the time of endoscopic biliary decompression is rarely indicated. The role of palliative pancreaticoduodenectomy remains controversial and to date there are no prospective randomized data to support its role in palliation of locally advanced pancreatic cancer. This review examines the available data from prospective trials for surgical and nonsurgical palliation of locally advanced and metastatic pancreatic cancer.     

Laparoscopic pancreatic resection of pancreatic cancer

Laparoscopic pancreatic resection of pancreatic cancer is still not universally accepted as an alternative approach to open surgery because of technical difficulties and a lack of consensus regarding the adequacy of this approach for malignancy. Ten patients with pancreatic cancer underwent laparoscopic pancreatic resection, including pancreaticoduodenectomy and distal pancreatectomy in our institution. Eight of the 10 patients recovered without any complications and were discharged on the 10-29th postoperative day. The remaining 2 patients developed pancreatic fistula and were discharged on the 46 and 60th postoperative day, respectively. All lesions were well clear of surgical margins in 6 patients (R0). In the remaining 4 patients, microscopic neoplastic change was found at the surgical margin (R1). Those 4 patients developed tumor recurrence, including liver metastases or peritoneal dissemination, and 3 of the 4 died of the primary disease. Although experience is limited, laparoscopic pancreatic resection of pancreatic cancer can be feasible, safe, and effective in carefully selected patients. However, the benefit of this procedure has yet to be confirmed. Not only adequate experience in pancreatic surgery but also expertise in laparoscopy is mandatory, and careful selection of patients is essential for successful application of this procedure.     

Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer

Background: Most patients presenting with pancreatic cancer are irresectable at the time the diagnosis is made. Therefore, they are in need of palliative treatment that can guarantee minimal morbidity, mortality, and hospital stay. To address this need, we designed a study to test the feasibility of laparoscopic gastroenterostomy and hepaticojejunostomy and to compare their results with those achieved with open techniques. Methods: We performed a case control study of a new concept in laparoscopic palliation based on the findings of preoperative imaging and diagnostic laparoscopy. Laparoscopic side-to-side gastroenterostomy and end-to-side hepaticojejunostomy (Roux-en-Y) were done in irresectable cases. Of 14 patients who underwent laparoscopic palliation, three had a laparoscopic double bypass, seven had a gastroenterostomy, and four underwent staging laparoscopy only. The results were compared with a population of 14 matched patients who had conventional palliative procedures. Results: Postoperative morbidity was 7% vs 43% for laparoscopic and open palliation, respectively (p < 0.05). There were no mortalities in the laparoscopic group, as compared to 29% in the group who had open bypass surgery (p < 0.05). Postoperative hospital stay averaged 9 days in the laparoscopic group and 21 days in the open group (p < 0.06). Operating time tended to be shorter in the laparoscopic group (p < 0.25). Morphine derivatives were necessary for a significantly shorter period after laparoscopic surgery (p < 0.03). Conclusions: Our preliminary experience strongly suggests that laparoscopic palliation can reduce the three major drawbacks of open bypass surgery—i.e., high morbidity, high mortality, and long hospital stay. Received: 24 February 1999/Accepted: 13 May 1999     

Endoscopic palliation for pancreatic cancer with expandable metal stents

Pancreatic cancer is generally not amenable to curative resection. Consequently, therapeutic efforts for these patients are most commonly directed at palliation of symptoms. Historically, surgery has been considered the most effective method of providing relief for biliary and/or enteric obstruction. However, less invasive methods have become available that can provide effective relief of jaundice and duodenal obstruction. Surgeons should still play an integral role in the management of these patients. We present a case report in which self-expanding metallic stents were used to relieve obstruction of the bile duct and duodenum in a patient with unresectable pancreatic cancer.     

Complications of pancreatic cancer resection

Pancreatic cancer is a common cause of cancer death in the developed world. Currently, resection is the only chance of long-term survival. The post-operative mortality in nonspecialist centres often exceeds 20% but is around 6% or less in specialist centres. The overall complication rate even in specialist centres is 18-54%. An analysis of eleven large series of pancreatic resections shows an incidence of common complications of 10.4% for fistula, 9.9% for delayed gastric emptying, 4.8% for bleeding, 4.8% for wound infection and 3.8% for intra-abdominal abscess. The median hospital stay is 13-18 days in different series. The re-operation rate varies from 4 to 9% with a mortality rate of 23 to 67%. Major complications are a significant factor in post-operative mortality, especially if they require re-operation. The use of octreotide or somatostatin to prevent complications is supported by several multicentre, double-blind, randomized controlled trials. The best way to improve outcome is to concentrate pancreatic cancer care in regional specialist centres.     

Pancreatic resection for pancreatic cancer

In the majority of patients, pancreatic resection is performed for a proved carcinoma or for a mass in the pancreas with clinical features of carcinoma. Preoperative preparation is similar to that for other cancer operations, and good nutritional status and normal clotting factors are important. In many patients with resectable lesions, preoperative histologic diagnosis is not possible.     

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 ±75 mg/dl vs. 231 ±24 mg/dl; P<0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient’s life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 2l–24, 2000.     

Surgical palliation for pancreatic cancer. The UCLA experience.

We reviewed the records of 340 patients with a tissue diagnosis of pancreatic cancer treated at UCLA Medical Center between 1973 and 1988. Sixty-one patients underwent pancreatic resection (group I), 173 had some form of surgical palliation (group II), and 106 had neither (group III). The diagnosis was made 1 to 2 months more quickly in the last 8 years of the review than in the first 8 years, but the effect of early diagnosis on curability was negligible. Biliary obstruction was best treated by cholecystojejunostomy or choledochojejunostomy, which were equally effective. Anastomoses to the jejunum were safer and more effective than were those to the duodenum for the relief of biliary obstruction. Gastrojejunostomy should be performed prophylactically as well as therapeutically. It was effective and safe in both settings. Surgical palliation for pancreatic cancer was generally effective and was associated with an operative mortality rate of less than 10%. However morbidity was high, with significant complications occurring in one third of cases.     

Redefining the R1 resection in pancreatic cancer

BACKGROUND: Resection margin (RM) status in pancreatic head adenocarcinoma is assessed histologically, but pathological examination is not standardized. The aim of this study was to assess the influence of standardized pathological examination on the reporting of RM status. METHODS: A standardized protocol (SP) for pancreaticoduodenectomy specimen examination, involving multicolour margin staining, axial slicing and extensive tissue sampling, was developed. R1 resection was defined as tumour within 1 mm of the RM. A prospective series reported according to this protocol (SP series, n = 54) was compared with a historical matched series in which a non-standardized protocol was used (NSP series, n = 48). RESULTS: Implementation of the SP resulted in a higher R1 rate overall, and for pancreatic (22 of 26 85 per cent) compared with ampullary (four of 15) and bile duct (six of 13) cancer. Sampling of the circumferential RM was more extensive in the SP series and correlated with RM status. RM involvement was often multifocal (14 of 32), affecting the posterior RM most frequently (21 of 32). Survival correlated with RM status for the entire SP series (P < 0.001), but not for the NSP series. There was a trend towards better median and actuarial 5-year survival after R0 resection in the SP pancreatic cancer subgroup. CONCLUSION: Standardized examination influences the reporting of RM status.     

Preoperative prediction of complete resection in pancreatic cancer

BACKGROUND: Accurate preoperative staging is essential in pancreatic cancer to select the 15% of patients who can benefit from surgery and avoid surgery in the 85% with advanced disease. With improvements in computed tomography (CT) scanning, the value of routine laparoscopy for preoperative staging of pancreatic cancer has been questioned because it changes the preoperative plan in less than 20% of unselected cases. METHODS: We retrospectively reviewed our experience with preoperative staging in 88 consecutive patients with pancreatic cancer. All patients had preoperative CT scans, and selective criteria were used to determine which patients would also undergo preoperative staging laparoscopy. Patients were categorized preoperatively as resectable or not resectable (locally advanced or metastatic). Medical records, operative, and pathology reports were reviewed to determine the accuracy of preoperative predictions. RESULTS: Thirty patients were deemed resectable based on CT alone and 27 (90%) were resected (25 R0, 2 R1). Two (7%) had metastatic disease discovered at laparotomy and one (3%) had a R2 resection. Only 19 patients (39%) of 49 patients deemed resectable by CT met our selective criteria for preoperative staging laparoscopy. Laparoscopy changed the treatment plan in 11 (58%) of these patients. Eight were still deemed resectable after staging laparoscopy and 7 (88%) were resected (6 R0, 1 R1). One patient (12%) had metastatic disease diagnosed at laparotomy. If selective staging laparoscopy were eliminated from our algorithm, 49 patients would have been deemed potentially resectable based on CT alone, 34 (69%) would have been found to be resectable at laparotomy (31 R0, 3 R1), and 15 (31%) would have been found to be unresectable at laparotomy (positive predictive value of 69%). The addition of selective staging laparoscopy avoided unnecessary laparotomy in 11 patients and increased the positive predictive value to (34/38) 89%. CONCLUSION: Selective use of laparoscopy increases the positive predictive value of preoperative staging in pancreatic cancer and avoids unnecessary laparoscopy in the majority of patients.     

Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis

OBJECTIVE: To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology. SUMMARY BACKGROUND DATA: Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate. METHODS: Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001. RESULTS: The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. CONCLUSIONS: Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.     

Thoracoscopic splanchnicectomy--a method of pain palliation in non-resectable pancreatic cancer and chronic pancreatitis

Severe upper abdominal pain is a dominant and distressing feature in advanced pancreatic cancer and in chronic pancreatitis. A way of palliation needs to be practiced in the non-resectable pancreatic cancer in order to control the pain. Between the many methods of palliation the thoracoscopic splanchnicectomy seems to be the best due its simplicity, no risk to the patient and the good results. In the Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute we have practiced 50 thoracoscopic splanchnicectomies in a number of 49 patients during a period of 3 years. The morbidity was 2% and the mortality 0. We noticed a significant improvement in the pain score, the quality of sleep and the overall quality of life and consecutively a quick social reintegration of these patients. The quality of life is greatly improved (with a significant reduction of the pain score in 92% of the cases) after this minimally invasive procedure, a fact the qualifies this procedure as the technique of choice in these patients.     

An analysis of cost and clinical outcome in palliation for advanced pancreatic cancer

BACKGROUND: The optimal palliative method for patients with unresectable pancreatic cancer remains controversial. METHODS: A retrospective chart review evaluated patients who underwent exploration for presumed resectable pancreatic cancer. Cost-based analysis was performed using relative value units (RVUs) that included the initial surgical procedure and any additional procedure required to achieve satisfactory palliation. RESULTS: Of 96 patients (1993--2002), 6% had biliary bypass, 42% had duodenal bypass, 40% had double bypass, and 13% had no procedure with equivalent clinical outcomes. If biliary bypass was not initially performed, there was a significant incidence of biliary complications before definitive endoscopic stenting (P=.01). If duodenal bypass was not initially performed, 11% developed duodenal obstruction (P=.04). Total RVUs was highest for a double bypass and lowest for no initial surgical palliative procedure. CONCLUSIONS: Although surgical bypass procedures at initial exploration provide durable palliation, these procedures are associated with greater costs.     

胰腺癌根治术联合血管切除术中血管切除的指征探讨

早在1882年德国Trendelenberg就成功施行了胰体尾联合脾切除治疗胰尾癌,1899年意大利Codivilla为治疗胰头癌作胰头和十二指肠整块切除,1937年Brunschwig成功施行胰十二指肠切除术（pancrea-ticoduodenectomy，PD）．1941年Rocky为1例胰腺癌行全胰切除术．