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.
Sabiston: Textbook of Surgery, 15th ed., Copyright © 1997 W. B. Saunders Company: 1171-1174.
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