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

Abstract

Background As 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. Methods Patients 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. Results Forty-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. Conclusions Although 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.

Outcomes and risks in palliative pancreatic surgery: an analysis of the German StuDoQ|Pancreas registry

“…Patients undergoing explorative laparotomy in curative intention might be otherwise healthier than patients requiring planned bypass surgery. Pencovich et al for instance describe a 30-day mortality of 16.6% in patients who underwent bypass surgery in purely palliative intention [ 22 ]. However, in the current study also in the subgroup of patients with preoperatively normal bilirubin-levels—suggesting that biliary bypass surgery was conducted prophylactically upon intraoperative detection of non-resectability—the morbidity was significantly increased after bypass surgery and comparable to the whole study population.…”

“…Only few studies have investigated morbidity and mortality among patients with PDAC after non-resective surgery [ 17 , 18 ]. Reported morbidity rates range between 28 and 56%, with varying conclusions drawn by the authors [ 15 , 19 – 21 ]: Some recommend a “watch-and-wait”-strategy instead of prophylactic bypass surgery [ 20 ], some conclude that bypass surgery should be avoided in high-risk populations [ 15 ], and others favor a selective approach considering the individual patient or the institution’s prerequisites [ 19 , 21 , 22 ]. Considering the morbidity after bypass surgery, and the improvements of endoscopic palliation, the balance of advantages and disadvantages of bypass procedures during laparoscopy or laparotomy is crucial.…”

Modified hepaticocholecystoenterostomy technique for certain hepatobiliary and pancreatic diseases: case series report by a single surgeon

“…The surgical procedure was targeted only to relieve obstructive biliary symptoms. 3,4,[17][18][19] However, even with benign lesions, the lower bile duct might develop a "sump syndrome", become infected, or accumulate lithiasis. 5 As a result, some minor adjustments were done during the HCE anastomosis.…”

“…Therefore, palliation of symptoms remains an important component in managing this disease. 1,2 Indeed, biliary-enteric anastomosis is indicated not only for relief of symptoms of biliary obstruction caused by an unresectable periampullary tumour of Ampulla of Vater, 2,3 but also following radical surgery such as pancreaticoduodenectomy, 4 choledochal resection 5 or treatment of recurrent intrahepatic lithiasis. 6 Biliary-enteric anastomosis, which mainly includes choledochoduodenostomy (CD) and Roux-en-Y hepaticojejunostomy (RYHJ), is one of the most common procedures.…”

Towards an updated view on the clinical management of pancreatic adenocarcinoma: Current and future perspectives (Review)

“…In recent years, palliative techniques have been developed to limit the duodenal-biliary obstruction that causes locoregional tumor invasion. Possible approaches, including external biliary drainage, surgical biliary diversions or metal stents, are useful in cases where survival time is limited to 3-6 months, and these approaches permit obstructive symptoms such as jaundice or pancreatic insufficiency to be decreased in the final stages of disease for these patients (94)(95)(96). It should also be noted that the invasion of the nerve plexuses generates neuropathic pain of great intensity that may be resistant to drug treatment with analgesics (97).…”