Palliative Surgical Management of Patients with Unresectable Pancreatic Adenocarcinoma

Trends and Lessons Learned from a Large, Single Institution Experience

Peter J. Kneuertz, Steven C. Cunningham, John L. Cameron, Sergio Torrez, Nicholas Tapazoglou, Joseph M. Herman, Martin A. Makary, Frederic Eckhauser, Jingya Wang, Kenzo Hirose, Barish H. Edil, Michael A. Choti, Richard D. Schulick, Christopher L. Wolfgang, Timothy M. Pawlik

Research output: Contribution to journalArticle

49 Citations (Scopus)

Abstract

Introduction: Routine palliative bypass has been advocated for palliation of patients with pancreatic adenocarcinoma who have inoperable disease discovered at the time of surgery. We examined trends in the relative use of palliative bypass over time with an emphasis on identifying changes in surgical indications, type of bypass performed, as well as perioperative outcomes associated with surgical palliation. Methods: Between 1996 and 2010, 1,913 patients with pancreatic adenocarcinoma in the head of the pancreas were surgically explored. Data regarding preoperative symptoms, intraoperative findings, type of surgical procedure performed, as well as perioperative and long-term outcomes were collected and analyzed. Results: Of the 1,913 patients, 583 (30. 5%) underwent a palliative procedure. Most patients presented with jaundice (72. 2%). The majority of patients were evaluated by CT scan (97. 4%), which revealed a median tumor size of 3. 2 cm. Most patients who underwent surgical palliation (64. 5%) had a double bypass, while a minority had either gastrojejunostomy (28. 2%) or hepaticojejunostomy (7. 2%) alone. While the number of pancreaticoduodenectomies remained relatively stable over time, there was a temporal decrease in the utilization of palliative bypass (P<0. 001). Unanticipated locally advanced disease vs. liver/peritoneal metastasis as the indication for palliative surgery also changed over time (1996-2001: 47. 8% vs. 52. 2%; 2002-2007: 49. 2% vs. 50. 8%; 2008-2010: 17. 2% vs. 82. 7%) (P = 0. 005). Palliative failure rates were 2. 3% after hepaticojejunostomy and 3. 1% after grastrojejunostomy. Patients with unsuspected metastatic disease had a worse survival compared with patients who had locally unresectable disease (median survival: 5 vs. 8 months, respectively; HR = 1. 43, P = 0. 001). Conclusion: Palliative bypass procedures were less frequently performed over time, probably due to a significant decrease in the rate of unanticipated advanced locoregional disease at the time of exploration. While palliative bypass was effective, survival in the setting of metastatic disease was extremely short.

Original languageEnglish (US)
Pages (from-to)1917-1927
Number of pages11
JournalJournal of Gastrointestinal Surgery
Volume15
Issue number11
DOIs
StatePublished - Nov 2011

Fingerprint

Adenocarcinoma
Survival
Pancreaticoduodenectomy
Gastric Bypass
Jaundice
Palliative Care
Pancreas
Neoplasm Metastasis
Liver
Neoplasms

Keywords

  • Biliary bypass
  • Double bypass
  • Gastric bypass
  • Outcomes
  • Palliation
  • Pancreatic cancer
  • Survival

ASJC Scopus subject areas

  • Surgery
  • Gastroenterology

Cite this

Palliative Surgical Management of Patients with Unresectable Pancreatic Adenocarcinoma : Trends and Lessons Learned from a Large, Single Institution Experience. / Kneuertz, Peter J.; Cunningham, Steven C.; Cameron, John L.; Torrez, Sergio; Tapazoglou, Nicholas; Herman, Joseph M.; Makary, Martin A.; Eckhauser, Frederic; Wang, Jingya; Hirose, Kenzo; Edil, Barish H.; Choti, Michael A.; Schulick, Richard D.; Wolfgang, Christopher L.; Pawlik, Timothy M.

In: Journal of Gastrointestinal Surgery, Vol. 15, No. 11, 11.2011, p. 1917-1927.

Research output: Contribution to journalArticle

Kneuertz, PJ, Cunningham, SC, Cameron, JL, Torrez, S, Tapazoglou, N, Herman, JM, Makary, MA, Eckhauser, F, Wang, J, Hirose, K, Edil, BH, Choti, MA, Schulick, RD, Wolfgang, CL & Pawlik, TM 2011, 'Palliative Surgical Management of Patients with Unresectable Pancreatic Adenocarcinoma: Trends and Lessons Learned from a Large, Single Institution Experience', Journal of Gastrointestinal Surgery, vol. 15, no. 11, pp. 1917-1927. https://doi.org/10.1007/s11605-011-1665-9
Kneuertz, Peter J. ; Cunningham, Steven C. ; Cameron, John L. ; Torrez, Sergio ; Tapazoglou, Nicholas ; Herman, Joseph M. ; Makary, Martin A. ; Eckhauser, Frederic ; Wang, Jingya ; Hirose, Kenzo ; Edil, Barish H. ; Choti, Michael A. ; Schulick, Richard D. ; Wolfgang, Christopher L. ; Pawlik, Timothy M. / Palliative Surgical Management of Patients with Unresectable Pancreatic Adenocarcinoma : Trends and Lessons Learned from a Large, Single Institution Experience. In: Journal of Gastrointestinal Surgery. 2011 ; Vol. 15, No. 11. pp. 1917-1927.
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AU - Cunningham, Steven C.

AU - Cameron, John L.

AU - Torrez, Sergio

AU - Tapazoglou, Nicholas

AU - Herman, Joseph M.

AU - Makary, Martin A.

AU - Eckhauser, Frederic

AU - Wang, Jingya

AU - Hirose, Kenzo

AU - Edil, Barish H.

AU - Choti, Michael A.

AU - Schulick, Richard D.

AU - Wolfgang, Christopher L.

AU - Pawlik, Timothy M.

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N2 - Introduction: Routine palliative bypass has been advocated for palliation of patients with pancreatic adenocarcinoma who have inoperable disease discovered at the time of surgery. We examined trends in the relative use of palliative bypass over time with an emphasis on identifying changes in surgical indications, type of bypass performed, as well as perioperative outcomes associated with surgical palliation. Methods: Between 1996 and 2010, 1,913 patients with pancreatic adenocarcinoma in the head of the pancreas were surgically explored. Data regarding preoperative symptoms, intraoperative findings, type of surgical procedure performed, as well as perioperative and long-term outcomes were collected and analyzed. Results: Of the 1,913 patients, 583 (30. 5%) underwent a palliative procedure. Most patients presented with jaundice (72. 2%). The majority of patients were evaluated by CT scan (97. 4%), which revealed a median tumor size of 3. 2 cm. Most patients who underwent surgical palliation (64. 5%) had a double bypass, while a minority had either gastrojejunostomy (28. 2%) or hepaticojejunostomy (7. 2%) alone. While the number of pancreaticoduodenectomies remained relatively stable over time, there was a temporal decrease in the utilization of palliative bypass (P<0. 001). Unanticipated locally advanced disease vs. liver/peritoneal metastasis as the indication for palliative surgery also changed over time (1996-2001: 47. 8% vs. 52. 2%; 2002-2007: 49. 2% vs. 50. 8%; 2008-2010: 17. 2% vs. 82. 7%) (P = 0. 005). Palliative failure rates were 2. 3% after hepaticojejunostomy and 3. 1% after grastrojejunostomy. Patients with unsuspected metastatic disease had a worse survival compared with patients who had locally unresectable disease (median survival: 5 vs. 8 months, respectively; HR = 1. 43, P = 0. 001). Conclusion: Palliative bypass procedures were less frequently performed over time, probably due to a significant decrease in the rate of unanticipated advanced locoregional disease at the time of exploration. While palliative bypass was effective, survival in the setting of metastatic disease was extremely short.

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