Factors influencing survival in patients undergoing palliative bypass for pancreatic adenocarcinoma
Harvard Radiation Oncology Program, Boston, MA, USA. Journal of Surgical Oncology
(Impact Factor: 3.24).
07/2012; 106(1):66-71. DOI: 10.1002/jso.23047
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.
Available from: Camilo Correa-Gallego
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ABSTRACT: The optimal surgical management of patients found to have unresectable pancreatic cancer at open exploration remains unknown.
Records of patients who underwent non-therapeutic laparotomy for pancreatic cancer during 2000-2009 and were followed until death at Memorial Sloan-Kettering Cancer Center, New York, were reviewed.
Over the 10-year study period, 157 patients underwent non-therapeutic laparotomy. Laparotomy alone was performed in 21% of patients; duodenal bypass, biliary bypass and double bypass were performed in 11%, 30% and 38% of patients, respectively. Complications occurred in 44 (28%) patients. Three (2%) patients died perioperatively. Postoperative interventions were required in 72 (46%) patients following exploration. The median number of inpatient days prior to death was 16 (interquartile range: 8-32 days). Proportions of patients requiring interventions were similar regardless of the procedure performed at the initial operation, as were the total number of inpatient days prior to death. Patients undergoing gastrojejunostomy required fewer postoperative duodenal stents and those undergoing operative biliary drainage required fewer postoperative biliary stents.
In this study, duodenal, biliary and double bypasses in unresectable patients were not associated with fewer invasive procedures following non-therapeutic laparotomy and did not appear to reduce the total number of inpatient hospital days prior to death. Continued effort to identify unresectability prior to operation is justified.
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ABSTRACT: About 80 % of newly diagnosed patients with pancreatic adenocarcinoma cannot benefit from a curative strategy. Palliative approaches of unresectable pancreatic cancer should be adjusted to the expected survival with the aim of preserving the quality of life of these patients. When the diagnosis of unresectable disease is made, nonsurgical endoscopic approaches should be prioritized in order to keep hospital stay as short as possible without delaying systemic chemotherapy. If an unresectable disease is diagnosed at laparotomy, an appropriate palliative surgical treatment should be considered to prevent biliary and enteral obstruction, as well as pain exacerbation due to tumour invasion. Surgical bypass procedures allow significantly more lasting palliation than endoscopic procedures in distinct situations. Since morbidity and mortality of pancreatoduodenectomy have significantly decreased in the last decades, a more aggressive approach towards palliative resection could be justified in specific circumstances. Pain control should not be neglected and is optimized when pharmacotherapy and chemical neurolysis are associated. Since palliative treatment of unresectable pancreatic cancer is not trivial, the choice of the best approach should be discussed by a multidisciplinary team including surgeons, gastroenterologists, radiologists, oncologists and physicians in charge of palliative care.
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ABSTRACT: Malignant biliary obstruction, duodenal, and gastric outlet obstruction, and tumor-related pain are the complications of unresectable pancreatic adenocarcinoma that most frequently require palliative intervention. Surgery involving biliary bypass with or without gastrojejunostomy was once the mainstay of treatment in these patients. However, advances in non-operative techniques-most notably the widespread availability of endoscopic biliary and duodenal stents-have shifted the paradigm of treatment away from traditional surgical management. Questions regarding the efficacy and durability of endoscopic stents for biliary and gastric outlet obstruction are reviewed and demonstrate high rates of therapeutic success, low rates of morbidity, and decreased cost. Surgery remains an effective treatment modality, and still produces the most durable relief in appropriately selected patients.
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