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d i s c u s s i o n
Pancreatic Cancer
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Related narrative: Double Bypass for Pancreatic Cancer Pancreatic cancer is the fifth leading cause of cancer death in the United States. The majority (90%) arise from ductal epithelium and the majority (75%) arise in the head. The tumors in the region of the ampulla of Vater include pancreatic (43%), ampullary (11%), bile duct (10%), and duodenal (4%) lesions, and are classified together as periampullary for diagnostic, therapeutic and prognostic purposes. Periampullary pancreatic cancer has a resectability rate of about 40%. Ampullary and duodenal lesions have a higher resectability rate (60-80%) than pancreatic lesions (15-20%). Reasons for unresectability include local factors (vascular invasion and regional lymphadenopathy), and metastatic disease (liver, peritoneal seeding etc.). Local factors account for 1/3 of unresectable tumors and metastatic disease for 2/3. Survival for unresectable lesions is 6-8 months, slightly longer for locally advanced than for metastatic disease. Most patients with periampullary cancer present with biliary obstruction and jaundice. Few patients have duodenal obstruction at initial presentation and only 15-20% go on to obstruct before dying of the disease. Palliative resection has greater morbidity and offers no benefit over bypass for patients with unresectable disease. The management of pancreatic cancer has changed dramatically in the last several years. Surgery for resectable lesions at high volume institutions has improved survival (21 months median) with low morbidity and mortality. Assessment of resectability by laparoscopy is proving effective in avoiding unnecessary laparotomy for 25% of patients. Endoscopic biliary stenting, particularly with the newer expandable metal stents (vs. the older plastic stents that tended to clog up), is replacing the need for the more morbid operative bypass in many cases. Laparosocpic bypass is supplementing operative bypass as well. References: Sabiston: Textbook of Surgery, 15th ed., Copyright © 1997 W. B. Saunders Company: 1171-1174. Lillemoe KD, Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. - Ann Surg - 1999 Sep; 230(3): 322-8; discussion 328-30 Lillemoe KD, Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer? - Ann Surg - 1996 Jun; 223(6): 718-25; discussion 725-8 Lefor AT, The role of laparoscopy in the treatment of intra-abdominal malignancies. - Cancer J Sci Am - 2000 Apr; 6 Suppl 2: S159-68 Schmassmann A, Wallstents versus plastic stents in malignant biliary obstruction: effects of stent patency of the first and second stent on patient compliance and survival [see comments] - Am J Gastroenterol - 1996 Apr; 91(4): 654-9 Reddy KR, Experience with staging laparoscopy in pancreatic malignancy. Gastrointest Endosc - 1999 Apr; 49(4 Pt 1): 498-503 Yeo CJ , Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. - Ann Surg - 1997 Sep; 226(3): 248-57; discussion 257-60 Pereira-Lima JC , Endoscopic biliary stenting for the palliation of pancreatic cancer: results, survival predictive factors, and comparison of 10-French with 11.5-French gauge stents. - Am J Gastroenterol - 1996 Oct; 91(10): 2179-84 Gouma DJ, Are there indications for palliative resection in pancreatic cancer? - World J Surg - 1999 Sep; 23(9): 954-9 Schwarz A , Biliary and gastric bypass or stenting in nonresectable periampullary cancer: analysis on the basis of controlled trials. - Int J Pancreatol - 2000 Feb; 27(1): 51-8 Kuriansky J , Simultaneous laparoscopic biliary and retrocolic gastric bypass in patients with unresectable carcinoma of the pancreas. - Surg Endosc - 2000 Feb; 14(2): 179-81 Isla AM , A continuing role for surgical bypass in the palliative treatment of pancreatic carcinoma. Dig Surg - 2000; 17(2): 143-6 Takada T, Simultaneous hepatic resection with pancreato-duodenectomy for metastatic pancreatic head carcinoma: does it improve survival? Hepatogastroenterology - 1997 Mar-Apr; 44(14): 567-73 Di Fronzo LA, Unresectable pancreatic carcinoma: correlating length of survival with choice of palliative bypass. - Am Surg - 1999 Oct; 65(10): 955-8 Sohn TA, Surgical palliation of unresectable periampullary adenocarcinoma in the 1990s. - J Am Coll Surg - 1999 Jun; 188(6): 658-66; discussion 666-9 Luque-de Leon E , Staging laparoscopy for pancreatic cancer should be used to select the best means of palliation and not only to maximize the resectability rate. - J Gastrointest Surg - 1999 Mar-Apr; 3(2): 111-7; discussion 117-8 Taylor MC, Biliary stenting versus bypass surgery for the palliation of malignant distal bile duct obstruction: a meta-analysis. - Liver Transpl - 2000 May; 6(3): 302-8 Espat NJ, Patients with laparoscopically staged unresectable pancreatic adenocarcinoma do not require subsequent surgical biliary or gastric bypass. - J Am Coll Surg - 1999 Jun; 188(6): 649-55; discussion 655-7
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