Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas

Surgical treatment of pancreatic adenocarcinoma; actual survival and prognostic factors in 343 patients

Survival data of patients with pancreatic carcinoma are often overestimated because of incomplete follow-up. Therefore, the aim of this study was to approach complete follow-up and to analyse survival and prognostic factors of patients who underwent surgical treatment for pancreatic adenocarcinoma. Between 1992 and 2002, 343 patients underwent surgical treatment for pancreatic adenocarcinoma. One hundred and sixty patients underwent a resection with a curative intention and 183 patients underwent bypass surgery for palliation. Follow-up was complete for 93% of patients. Median survival after resection and bypass was 17.0 and 7.5 months, and 5-year survival was 8% and 0, respectively. In multivariate analysis, tumour-positive lymph nodes, non-radical surgery, poor tumour differentiation, and tumour size were independent prognostic factors for survival after resection. For patients treated with bypass surgery, metastatic disease and tumour size independently predicted survival. In conclusion, actual survival of patients with pancreatic adenocarcinoma is disappointing compared with the actuarial survival rates reported in the literature. The independent prognostic factors for survival of patients who underwent surgical treatment for pancreatic adenocarcinoma are tumour-related.

[Intrahepatic B3 cholangiojejunostomy in the palliative surgery of high unresectable malignant biliary obstruction]

Palliating the effects of biliary obstruction is a major goal of therapy in patients with unresectable cancer at the hepatic duct confluence. We reviewed our expirience with intrahepatic holangioenteric bypass to the segmental bile duct B3 as a palliative therapy in patients with unresectable malignant diseases involving the ductal confluence or the common hepatic duct. Since March 2001, we have performed intrahepatic segmental bile duct B3 cholangiojejunostomy by Roux-en-Y fashion utilizing a round ligament approach in 13 patients with malignant obstructive jaundice due to unresectable hilar holangiocarcinoma (8 cases) and gallbladder cancer (5 cases). Mean hospital stay was 123 days and mean blood loss was 25060 mL. Postoperative complications occurred in 3 patients (23%), but there was no surgical complications such as postoperative bleeding, bile leakage or abscess formation. 30-day mortality was 7.7% (1 patient). Late complications (37.5%) were observed in 3 of the 8 patients who survived for more than 5 months after the surgery. Median survival after B3 cholangiojejunostomy was 9 months (range, 10 days-22 months). Median survival time was significantly greater in patients with hilar cholangio-carcinoma (11.8 months; range: 2-22 months) compared with those with gallbladder cancer (4.6 months; range: 10 days-11.5 months) (P-0.032 log rank test; P-0.049 Tarone-Ware test). Intrahepatic B3 cholangiojejunostomy when combined with careful patient selection, can provide useful palliation from jaundice, pruritus and cholangitis with acceptable mortality and morbidity rates.

A modification of segment III intrahepatic cholangiojejunostomy

Segment III bypass can achieve excellent palliation in jaundiced patients with unresectable malignancy of the hepatic duct confluence. However, the long-term benefits are often offset by early morbidity and mortality associated with surgery. Bile leakage is a common postoperative complication. Several approaches to the segment III duct have been described. The "round ligament approach" identifies the segment III duct by following the round ligament into the recessus of Rex, in the umbilical fissure. It is the approach adopted by most units, including our own. The liver is often split to a depth of 5 to 6 cm to expose the duct. Fashioning an intrahepatic cholangiojejunostomy within the recess of the umbilical fissure can be technically difficult due to lack of space. We describe a modification of the round ligament approach, creating a long and tension-free cholangiojejunostomy, which we believe reduces the incidence of postoperative bile leakage.

The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life

OBJECTIVE

To evaluate the effect of a prophylactic gastrojejunostomy on the development of gastric outlet obstruction and quality of life in patients with unresectable periampullary cancer found during explorative laparotomy.

SUMMARY BACKGROUND DATA

Several studies, including one randomized trial, propagate to perform a prophylactic gastrojejunostomy routinely in patients with periampullary cancer found to be unresectable during laparotomy. Others suggest an increase of postoperative complications. Controversy still exists in general surgical practice if a double bypass should be performed routinely in these patients.

METHODS

Between December 1998 and March 2002, patients with a periampullary carcinoma who were found to be unresectable during exploration were randomized to receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a single bypass (hepaticojejunostomy). Randomization was stratified for center and presence of metastases. Patients with gastrointestinal obstruction and patients treated endoscopically for more than 3 months were excluded. Primary endpoints were development of clinical gastric outlet obstruction and surgical intervention for gastric outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival, and quality of life, measured prospectively by the EORTC-C30 and Pan26 questionnaires. It was decided to perform an interim analysis after inclusion of 50% of the patients (n = 70).

RESULTS

Five of the 70 patients randomized were lost to follow-up. From the remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There were no differences in patient demographics, preoperative symptoms, and surgical findings between the groups. Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates, including delayed gastric emptying, were 31% in the double versus 28% in the single bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76 days) in the double versus 9 days (range 6-20 days) in the single bypass group (P = 0.06); median survival was 7.2 months in the double versus 8.4 months in the single bypass group (P = 0.15). No differences were found in the quality of life between both groups. After surgery most quality of life scores deteriorated temporarily and were restored to their baseline score (t = -1) within 4 months.

CONCLUSIONS

Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates. There were no differences in quality of life between the two groups. Together with the previous randomized trial from the Hopkins group, this study provides sufficient evidence to state that a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable to a single bypass consisting of only a hepaticojejunostomy in patients undergoing surgical palliation for unresectable periampullary carcinoma. Therefore, the trial was stopped earlier than planned.

Robot-assisted laparoscopic choledochojejunostomy

BACKGROUND

Endoscopic stenting is the treatment of choice for palliative relief of biliary obstruction by a periampullary tumor. If treated surgically, a choledochojejunostomy and Roux-en-Y diversion is still performed by laparotomy in a large number of cases due to technical challenges of the biliodigestive anastomosis in the laparoscopic approach. Robotic systems may enhance dexterity and vision and might therefore support surgeons in delicate laparoscopic interventions. The purpose of this study is to assess the efficacy and safety of performing a laparoscopic choledochojejunostomy and Roux-en-Y reconstruction with the aid of a robotic system.

METHODS

Ten laparoscopic procedures were performed in pigs with the da Vinci robotic system and compared to 10 procedures performed by laparotomy (controls). Operation room time, anastomoses time, blood loss, and complications were recorded. The effectiveness of the anastomoses was evaluated by postoperative observation for 14 days and by measuring passage, circumference, and number of stitches.

RESULTS

Operating room time was significantly longer for the robot-assisted group than for controls (140 vs 82 min, p < 0.05). The anastomoses times were longer in the robot-assisted cases but not statistically significant (biliodigestive anastomosis, 29 vs 20 min; intestinal anastomosis, 30 vs 15 min), Blood loss was less than 10 cc in all robot-assisted cases and 30 cc (10-50 cc) in the controls. In both groups, there were no intraoperative complications. In the control group, one pig died of gastroparesis on postoperative day 6. In the robot-assisted group, one pig died on postoperative day 7 due to a volvulus of the jejunum. At autopsy, a bilioma was found in one pig in the robot-assisted group. In all pigs, the biliodigestive and intestinal anastomoses were macroscopically patent with an adequate passage. Circumference and number of stitches were similar.

CONCLUSION

The safety and efficacy of robot-assisted laparoscopic choledochojejunostomy was proven in this study. The procedure can be performed within an acceptable time frame.

Metastatic pancreatic cancer: emerging strategies in chemotherapy and palliative care

This update is devoted to discussion of optimal supportive and palliative care of patients with pancreatic cancer. Approximately 33,000 new cases of pancreatic cancer are predicted for the U.S. in 2002. Because diagnosis and intervention occur late in the course of this disease, the vast majority of patients already have metastatic disease at the time of diagnosis. These tumors are relatively resistant to systemic chemotherapy, making pancreatic cancer the fourth leading cause of cancer-related death in the U.S. and the Western world. For these reasons, efforts at identifying and treating disease-related symptomatology are priorities. This update overviews symptom management, supportive care strategies, and both standard and emerging palliative chemotherapy options. The incorporation of molecularly targeted therapies into treatment of metastatic pancreatic cancer is reviewed as well. These strategies are of relevance to internists, gastroenterologists, oncologists, and other specialists who care for patients with pancreatic cancer.

Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study

BACKGROUND

The systematic use of metal stents to treat biliary obstruction is restricted by high cost compared with plastic stents. The aims of this study were to compare cost and efficacy of plastic stents and metal stents in the treatment of patients with malignant common bile duct strictures and to define factors that predict survival of these patients.

METHODS

One hundred eighteen patients (mean age 75 years) with malignant strictures of the common bile duct were randomized to placement of a plastic stent or metal stent. Comparisons were made with the Mann-Whitney or chi-square test as indicated; survival rates were compared with a Cox proportional hazards model.

RESULTS

There was no significant difference in survival between the two groups. Time to first obstruction was longer for patients in the metal stent group (metal stent, median not reached vs. plastic stent, 5 months; p = 0.007). The number of additional days of hospitalization, days of antibiotic therapy, and the numbers of ERCPs and transabdominal US procedures was significantly higher in the plastic stent group. After multivariate analysis, only the presence of liver metastases was independently related to survival (p < 0.0005; OR = 2.25). This variable defined a group with a shorter survival. Median survival of patients with hepatic metastasis at diagnosis was 2.7 months compared with 5.3 months for patients without liver metastasis; in the latter group, the overall cost associated with metal stents was lower than for plastic stents.

CONCLUSIONS

Metal stent placement is the most effective treatment of inoperable malignant common bile duct stricture. Placement of a metal stent is cost effective in patients without hepatic metastases, whereas a plastic stent should be placed in patients with spread of the tumor to the liver.

Pain management of patients with unresectable peripancreatic carcinoma

In patients with unresectable peripancreatic carcinoma, pain is generally treated with pain medication or with a celiac plexus blockade. Radiotherapy has also been reported to reduce pain. The efficacy of these treatment modalities is still under discussion. The aim of this study was to analyze the effects of the various types of pain management on patients who underwent palliative bypass surgery for unresectable peripancreatic carcinoma. During the period January 1995 to December 1998 a series of 98 patients underwent palliative bypass surgery, mostly for unresectable disease found during exploration. Patients were divided into three groups: palliative bypass surgery (BP), palliative bypass surgery with an intraoperative celiac plexus blockade (CPB), and palliative bypass surgery with or without celiac plexus blockade followed by high-dose conformal radiotherapy (RT). Radiotherapy was performed only in selected patients with locally advanced disease and without metastases, implying a better prognosis of the last group. The pain medication consumption, pain medication-free survival, hospital-free survival, and overall survival were analyzed. The preoperative consumption of pain medication was significantly higher in the CPB group than in the BP or RT group. The postoperative consumption of pain medication in the CPB, BP, and RT groups increased during follow-up from 15%, 17%, and 13% before surgery to 52%, 57%, and 46%, respectively, at three-fourths of the survival time (NS). This increase in consumption of pain medication was not different in the three groups. In the RT group the median pain medication-free survival was significantly longer than in the BP or CPB group (9.3 vs. 3.1 and 3.3 months; p = 0.02). The median hospital-free survival and median overall survival were significantly longer in the RT group than in the CPB group (10.3 vs. 6.8 months, p = 0.01; and 7.1 vs. 10.8 months, p = 0.01). Celiac plexus blockade as pain management did not result in an increase of the pain medication-free survival or overall survival. Therefore a positive effect of a celiac plexus blockade on pain could not be confirmed in the present study. Radiotherapy resulted in increased pain-medication survival, hospital-free survival, and overall survival compared to celiac plexus blockade. These effects are probably partly related to patient selection.

Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma: a cost-effectiveness analysis

OBJECTIVES

Obstructive jaundice frequently complicates pancreatic carcinoma and is associated with complications such as malabsorption, coagulopathy, progressive hepatocellular dysfunction, and cholangitis in addition to disabling pruritus, which greatly interferes with terminal patients' quality of life. Endoscopic placement of biliary stents decreases the risk of these complications and is considered the procedure of choice for palliation for patients with unresectable tumors. We used decision analysis with Markov modeling to compare the cost-effectivenesses of plastic stents and metal stents in patients with unresectable pancreatic carcinoma.

METHODS

A model of the natural history of unresectable pancreatic carcinoma was constructed using probabilities derived from the literature. Cost estimates were obtained from Medicare reimbursement rates and supplemented by the literature. Two strategies were evaluated: 1) initial endoscopic plastic stent placement and 2) initial endoscopic metal stent placement. We compared total costs and performed cost-effectiveness analysis in these strategies. The outcome measures were quality-adjusted life months. Sensitivity analyses were performed on selected variables.

RESULTS

Our baseline analysis showed that initial plastic stent placement was associated with a total cost of $13,879/patient and 1.799 quality-adjusted life months. Initial placement of a metal stent cost $13,466/patient and conferred 1.832 quality-adjusted life months. Among the variables examined, expected patient survival was demonstrated by sensitivity analyses to have the most influence on the results of the model.

CONCLUSION

Initial endoscopic placement of a metal stent is a cost-saving strategy compared to initial plastic stent placement, particularly in patients expected to survive longer than 6 months.

Expandable metal biliary stenting in patients with recurrent premature polyethylene stent occlusion

OBJECTIVES

Expandable metal stents are currently used to treat biliary tract obstruction. Few data exist on the role of metal stents in patients with recurrent premature plastic biliary stent occlusion. We report our preliminary results using an expandable metal biliary stent with enhanced stent flexibility in this group of patients. Our aim was to assess the efficacy of the Diamond biliary stent in the treatment of recurrent premature biliary plastic stent blockage.

METHODS

From September 1997 to June 1998, six patients with inoperable biliary obstruction and at least one prior episode of plastic stent occlusion were treated with an expandable metal biliary prosthesis. There were four women and six men, with a mean age of 73+/-11 yr. Five patients had malignant biliary obstruction, and one inoperable patient had a biliary stricture secondary to chronic pancreatitis. Patients were followed-up prospectively until either stent occlusion or death. The patency duration of the metal stents was compared to that of the most recently placed plastic stents.

RESULTS

All stents were successfully inserted endoscopically with visualized biliary drainage. No significant immediate postprocedural complications were noted. Median time from initial diagnosis of biliary obstruction to metal stent insertion was 35 wk (range 7-142), during which time patients had occluded a median of 4.5 plastic stents (range 2-5). Median patient survival was 117 days (15-312) and median time to blockage of the last plastic stent was 25.5 days (range 10-90 days). Three cases of metal stent occlusion occurred. One patient had early stent occlusion at 9 days because of debris and sludge clogging the metal stent. Two other patients developed stent occlusion at 120 and 157 days. Two stents remained patent until the patients' deaths at 15 and 87 days. Overall median stent patency was 139 days. The three patients who developed stent occlusion were treated with successful insertion of one or more plastic stents through the existing metal stent. Duration of metal stent patency was significantly longer than that of the last plastic stent (58.8 days longer; 95% CI [6.4, 111]; p = 0.03).

CONCLUSIONS

Metal biliary prostheses represent an effective management strategy for recurrent plastic biliary stent obstruction. Patients in this subgroup may have a shorter duration of metal stent patency than the reported duration of stent patency in patients receiving initial metal stent placement. However the duration of patency still seems to be significantly longer than that of the most recently placed plastic stent.

Endoscopic treatment of pancreatico-biliary malignancies

Biliary obstructions, due to pancreatic cancer and cholangiocarcinoma, have an ominous prognosis. At the time of diagnosis, most patients are beyond any curative treatment. Palliative therapies, such as transhepatic biliary drainage, bypass surgery, and endoscopy, have an established role in the management of such patients. Endoscopic retrograde cholangio-pancreatography (ERCP) plays a key role, allowing diagnosis, collection of cytologic and bioptic specimens, and insertion of large-bore biliary stents. The major drawback of plastic stents is the high rate of clogging, requiring frequent stent exchange. In the 1990s, self-expanding metal stents (SEMS) were developed and randomized studies have shown their superiority over plastic stents. SEMS can be successfully used in patients with hilar tumors. Duodenal obstruction due to biliopancreatic neoplasms can also be managed endoscopically. ERCP can be performed on an outpatient basis in selected patients, reducing costs related to hospitalization. A team approach is mandatory to obtain the best results.

A polymorphism of the interleukin-1 beta gene influences survival in pancreatic cancer

Pro-inflammatory cytokines contribute to the cachexia associated with pancreatic cancer and stimulate the acute phase response which has been associated with shortened survival in such patients. Polymorphisms of cytokine genes may influence their production. The present study examined the effect of a polymorphism of the interleukin (IL)-1b gene upon the inflammatory state and survival in pancreatic cancer. Genomic DNA was obtained from 64 patients with pancreatic cancer and 101 healthy controls. Using the polymerase chain reaction and subsequent TaqI restriction enzyme digestion the subject's genotype for a diallelic polymorphism of the interleukin-1b gene was established. IL-1b production by peripheral blood mononuclear cells and serum C-reactive protein (CRP) levels from patients were also examined and survival noted. Patients homozygous for allele 2 of the IL-1b gene had significantly shorter survival than other groups (P = 0.0001). These patients also exhibited higher IL-1b production (P = 0.022). Possession of allele 2 was also associated with significantly shorter survival (median 144 vs 256 days, P = 0.034) and significantly higher CRP level (P = 0.0003). The possession of a genotype resulting in increased IL-1b production was associated with shortened survival and increased serum CRP level. This may reflect the role of IL-1b in inducing an acute phase protein response and cachexia in cancer or may be related to changes in tumour phenotype.

Pancreatic cancer

Optimal therapy for pancreatic adenocarcinoma requires surgical removal with tumor-free margins. Superior outcomes have been reported for high-volume centers incorporating a multidisciplinary approach. Postoperative ("adjuvant") chemotherapy and radiation should be considered in patients with successfully resected primary tumors. Combined modality treatment with chemotherapy and radiation should be considered for locally advanced, unresectable tumors. Gemcitabine can provide symptom relief and a modest improvement in survival for patients with metastatic disease. Strict attention to relief of symptoms such as pain, depression, anorexia/cachexia, and jaundice is essential in all patients with pancreatic cancer. All patients with pancreatic cancer should be encouraged to enter clinical trials of new therapies, given that long-term survival for all stages remains poor.

Cholangiocarcinoma of the extrahepatic bile ducts

Malignancies of the biliary tree, particularly the extrahepatic bile ducts, remain difficult clinical problems. Because experience with these uncommon tumors has been limited to a small number of centers, meaningful clinical trials have been difficult to perform. Complete resection remains the most effective therapy, but is usually possible in the minority of patients. Palliating the effects of biliary obstruction is thus often the primary therapeutic goal. Chemotherapy and radiation therapy have not been proven to reduce the incidence of recurrence after resection nor to improve survival in patients with unresectable disease. This review focuses on cholangiocarcinoma of the extrahepatic bile ducts.

Treatment of resectable and locally advanced pancreatic cancer

BACKGROUND

Pancreatic cancer is the fifth leading cause of cancer death in the United States, with an overall 5-year survival rate of less than 5%. A minority of patients are candidates for surgical resection, but most treatment strategies focus on palliative care.

METHODS

We discuss strategies in the diagnosis and treatment of resectable and locally advanced pancreatic cancer by reviewing available phase II and phase III trials, as well as large retrospective studies.

RESULTS

Surgical resection for pancreatic cancer is done today with an operative mortality rate below 5% and a 5-year survival rate of approximately 25%. There is evidence that chemoradiation may improve survival and quality of life in both the adjuvant setting and for locally advanced disease. Operative, minimally invasive, and endoscopic techniques are successful in palliating pain and jaundice.

CONCLUSIONS

The diagnosis and treatment of pancreatic cancer continue to improve although most patients will succumb to their disease. Novel methods of earlier detection and more effective systemic therapies are needed to significantly improve outcomes.

Current surgical therapy for carcinoma of the pancreas

Despite progress in treating many solid tumors, pancreatic cancer continues to be a grave illness. Each year, >29,000 new cases of adenocarcinoma of the pancreas are diagnosed in the United States. Of these patients, only 10-20% have resectable tumors and 25,000 patients (83%) die within 12 months of diagnosis. Until recently, surgery has been the only "effective" therapy available for select patients. Historically, the operative mortality after radical pancreatic resection has been variable, ranging 1-30%, and is both operator- and institution-dependent. Even with a safe and complete surgical resection, the actual 5-year survival after surgery alone is essentially zero, although rates up to 5% have been reported. Despite what would appear to be a dismal outlook, slow progress has occurred in the operative and postoperative care of patients with pancreatic cancer. Advanced imaging techniques and laparoscopy have limited the number of unnecessary laparotomies, and novel adjuvant and neoadjuvant chemotherapy approaches have yielded promising results. This review will summarize the recent literature concerning the surgical therapy and trends in the treatment of carcinoma of the pancreas from 1990 to 1999.

Cholangiocarcinoma of the extrahepatic bile ducts

Malignancies of the biliary tree, particularly the extrahepatic bile ducts, remain difficult clinical problems. Because experience with these uncommon tumors has been limited to a small number of centers, meaningful clinical trials have been difficult to perform. Complete resection remains the most effective therapy, but is usually possible in the minority of patients. Palliating the effects of biliary obstruction is thus often the primary therapeutic goal. Chemotherapy and radiation therapy have not been proven to reduce the incidence of recurrence after resection nor to improve survival in patients with unresectable disease. This review focuses on cholangiocarcinoma of the extrahepatic bile ducts.

Staging laparoscopy and laparoscopic ultrasonography in more than 400 patients with upper gastrointestinal carcinoma

BACKGROUND

Resection offers the only chance of cure to patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. Staging is essential to select patients who will benefit from operation because palliation can also be performed nonoperatively. Several studies, including limited numbers of patients, have shown that laparoscopic staging prevents unnecessary laparotomies, but it is doubtful whether general application of this staging method can be advised. The aim of this study was to assess the benefit of diagnostic laparoscopy for staging patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors.

STUDY DESIGN

Between June 1992 and December 1996, 420 patients with a resectable tumor after conventional staging underwent diagnostic laparoscopy combined with laparoscopic ultrasonography. Histologic proof of metastases or ingrowth was used to cancel laparotomy.

RESULTS

Laparoscopic staging avoided laparotomy in 20% of patients (sensitivity 0.70): 5% with an esophageal tumor, 20% with a gastroesophageal junction tumor, 15% with a periampullary tumor, 40% with a proximal bile duct tumor, 35% with a liver tumor, and 40% with a pancreatic body or tail tumor. Complications and port-site metastases were seen in 4% and 2% of patients, respectively.

CONCLUSIONS

Laparoscopic staging is a safe procedure with low morbidity and without mortality in this series. It has shown no benefit in esophageal cancer, but seems beneficial for staging tumors located at the gastroesophageal junction, proximal bile duct tumors, liver tumors, and pancreatic body and tail tumors. The value of laparoscopic staging for patients with periampullary tumors is not as great as stated in previous studies and is still the subject of investigation.

Comparative costs of metal versus plastic biliary stent strategies for malignant obstructive jaundice by decision analysis

BACKGROUND

For palliation of patients with malignant obstructive jaundice, expansile metal stents provide longer patency than plastic stents but are more expensive. The optimal cost-effective strategy has not been established. Our aim was to compare the relative costs of 3 strategies: (1) plastic stent, with exchange on occlusion; (2) metal stent initially, with coaxial plastic stent insertion in the event of occlusion; or (3) plastic stent initially, with metal stent exchange in the event of occlusion.

METHODS

A decision analysis model was created using DATA 2.6 software to assess the relative costs of the three strategies. Values for variables including the probabilities of reintervention and patient survival were obtained from published data. Costs were based on Medicare reimbursements of hospital charges, and the model was evaluated from the perspective of a third-party payer. One-way and two-way sensitivity analysis of the variables was performed over a wide range.

RESULTS

The outcome is highly sensitive to the ratio of metal stent cost relative to endoscopic retrograde cholangiopancreatography cost (cost ratio M:ERCP) and to the length of survival of the patient. The most economical strategies were (2), (3) and (1) for M:ERCP cost ratios of <0.5, 0.5 to 0.7, and >0.7, respectively.

CONCLUSIONS

The choice of stent should be guided by the relative local costs of ERCP and metal stents and by the prognosis of the patient. At current metal stent costs and Medicare reimbursement rates, initial placement of a plastic stent, followed by metal stent placement at first occlusion in longer survivors, is an economical option. If metal stent cost is less than half of ERCP cost, then initial insertion of a metal stent would be most economical. Use of plastic stents is preferable for patients surviving less than 4 months, whereas metal stents are more economical for patients with longer survival.

Staging laparoscopy for pancreatic cancer should be used to select the best means of palliation and not only to maximize the resectability rate

Staging laparoscopy, based on the assumption that endobiliary stenting is the best palliation, allegedly saves an "unnecessary" laparotomy for incurable pancreatic cancer. Our aim was to determine survival of patients with clinically resectable pancreatic cancer that is found to be unresectable intraoperatively and thereby infer appropriate utilization of staging laparoscopy. A retrospective analysis was undertaken of 148 patients with ductal adenocarcinoma (1985 to 1992) with a clinically resectable lesion based on current imaging techniques. All were considered candidates for resection but were deemed unresectable at operation because of metastases to the liver (group I; 29 patients), the peritoneum (group II; 22 patients), or distant lymph nodes (group III; 44 patients) or because of vascular invasion (group IV; 53 patients). Overall median survival was 9 months (range 1 to 53 months), but by group was as follows: group I, 6 months; group II, 7 months; group III, 11 months; and group IV, 11 months. Individual comparisons showed shorter survival for patients with distant nodal, liver, or peritoneal metastases than with nodal or vascular involvement (P<0.03). Staging laparoscopy should be performed to identify patients with liver or peritoneal metastases who have an expected survival of approximately 6 months, in whom short-term endoscopic palliation is satisfactory. Extended laparoscopy to identify lymph node or vascular involvement is contingent upon which palliation (operative vs. endoscopic) is considered most appropriate. Because we believe operative bypass provides better, more durable palliation in this latter group, we have not adopted extended laparoscopy.

Treatment of cancer of the exocrine pancreas

BACKGROUND

The incidence of cancer of the exocrine pancreas varies among populations, being the fourth or fifth cause of cancer death in the West. Outcome remains poor and opinions remain divided over the optimal management of the condition.

METHOD

A computer literature search was made of the MEDLINE database from January 1990 to December 1997 and selected other studies.

RESULTS

Indications and contraindications for surgery, indications for stenting, indications for resection, the technique of palliative procedures and of resection, chemotherapy, radiotherapy, and combined treatments and other treatments are discussed and recommendations made.

CONCLUSIONS

Irrespective of tumor size or spread, resection if feasible gives the best survival rates. Careful patient selection is required, however, to exclude those patients for whom surgical resection has no benefit. Nonsurgical procedures including endoscopic stenting in patients with high operative risk or short survival expectancy can significantly improve quality of life. The place of adjuvant therapies remains controversial and further controlled trials are required to demonstrate their efficacy.

Laparoscopic pancreatic surgery

BACKGROUND

Potential applications for laparoscopic surgery in pancreatic disease include (1) staging of pancreatic malignancies; (2) palliation of pancreatic malignancies; (3) pancreatic resections for benign and malignant disease; and (4) pancreatic drainage procedures.

METHODS

A review of the literature is presented. In addition, original data on a series of 5 laparoscopic pancreatic distal resections and 10 laparoscopic cystogastrostomies are presented.

RESULTS AND CONCLUSIONS

Laparoscopy may have a role in the staging of patients with pancreatic malignancies; however, with high-quality preoperative imaging, the percentage of patients who will benefit from laparoscopy may be as low as 5%. For palliation, both cholecystoenterostomy and choledochoenterostomy can be performed laparoscopically. The former is technically straightforward but has a higher failure rate; the latter is technically difficult and currently not suitable for widespread adoption. Laparoscopic gastroenterostomy is a straightforward means of palliating gastrointestinal obstruction. Patients appear to benefit from laparoscopic distal pancreatic resection but not from laparoscopic pancreaticoduodenectomy. Patients appear to benefit from laparoscopic pseudocyst decompression.

Laparoscopic gastrojejunostomy in the palliation of pancreatic cancer: reflections on the preliminary results

The aim of this study was to assess the feasibility of laparoscopic gastroenteric and cholecystenteric bypass procedures for palliation of inoperable cancer of the pancreas. Between July 1994 and January 1996, five patients underwent laparoscopic gastroenterostomy for duodenal obstruction due to pancreatic cancer. There were four men and one woman, ranging in age from 53 to 72 years (median 63). Four patients already had endoscopic biliary decompression. One patient underwent laparoscopic cholecystojejunostomy for biliary obstruction at the time of the laparoscopic gastroenterostomy. The procedure was completed laparoscopically in all patients. There was no perioperative mortality, and the morbidity was low. The median post-operative stay was 4 days (range, 4-6). Laparoscopic gastroenterostomy associated with cholecystojejunostomy in selected cases offers a less invasive alternative than open surgery, with a shorter hospital stay and more rapid return to normal activity.

Intrahepatic biliary enteric bypass provides effective palliation in selected patients with malignant obstruction at the hepatic duct confluence

BACKGROUND

Palliating the effects of biliary obstruction is a major goal of therapy in patients with cancer at the hepatic duct confluence. This study was undertaken to evaluate the effectiveness of intrahepatic biliary-enteric bypass to either the segment III duct or the right sectoral hepatic ducts in patients with unresectable hilar cholangiocarcinoma or gallbladder carcinoma.

METHODS

From December 1991 to October 1996, 55 consecutive bypass procedures were prospectively evaluated in patients with unresectable hilar cholangiocarcinoma or gallbladder cancer. Patients were divided into three groups based on the primary tumor and the type of bypass performed: group 1A, cholangiocarcinoma/segment III bypass (n = 20); group 1B, cholangiocarcinoma/right sectoral hepatic duct bypass (n = 14); group 2, gallbladder cancer/segment III bypass (n = 21).

RESULTS

Mean hospital stay (14+/-2 days) and mean blood loss (629+/-84 mL) were similar among the three groups. Perioperative death occurred in 6 patients (11%): 0 in group 1A, 3 each in groups 1B and 2. All survivors had relief of jaundice and pruritus after bypass. Complications occurred in 25 patients (45%). Preoperative transhepatic biliary drainage, performed in 14 patients prior to referral, was associated with a higher incidence of contaminated bile, greater operative blood loss, and postoperative biliary leak that was less likely to resolve spontaneously. Median survival in patients with cholangiocarcinoma (groups 1A and 1B) was 52 weeks and was unaffected by the type of bypass performed. By contrast, median survival in patients with gallbladder cancer (group 3) was 20 weeks; all but 3 died within 32 weeks of surgery. In patients with cholangiocarcinoma, the 1-year bypass patency was 80% in group 1A (segment III bypass) and 60% in group 1B (right sectoral hepatic duct bypass). Overall, there were 9 late bypass failures (18%) requiring reintervention.

CONCLUSIONS

Intrahepatic biliary-enteric bypass effectively relieves symptoms due to malignant hilar obstruction. In patients with cholangiocarcinoma, segment III bypass provides excellent palliation with relatively few late complications and can be performed with minimal morbidity and mortality. Bypass to the right sectoral hepatic ducts, on the other hand, is associated with significant procedure-related morbidity and mortality and more late complications. Patients with gallbladder cancer, because of their poor survival, are probably better palliated by percutaneous biliary stenting.

Predictive factors for survival of patients with inoperable malignant distal biliary strictures: a practical management guideline

BACKGROUND

Stenting is the treatment of choice for inoperable malignant strictures of the common bile duct. Criteria for the choice of stents (plastic versus metallic) remain controversial because predicting survival is difficult.

AIMS

To define prognostic factors in order to improve the cost effectiveness of endoscopic palliation.

PATIENTS

One hundred and one patients were included in a prospective trial. Seven prognostic variables for survival were analysed (age, sex, bilirubinaemia, weight loss, presence of liver metastases, and tumour histology and size). All patients were followed until death or at least one year after inclusion. By the end of the study, 81 (80.2%) patients had died.

RESULTS

In univariate analysis, the variables associated with survival were weight loss (p < 0.05) and tumour size (p < 0.01). By multivariate analysis, tumour size was the only independent prognostic factor (p < 0.05). A threshold of 30 mm at diagnosis distinguished two survival profiles: the median survival of patients with a tumour greater than 30 mm was 3.2 months, whereas it was 6.6 months for patients with a tumour less than 30 mm (p < 0.001).

CONCLUSIONS

A practical strategy could be based on tumour size at diagnosis: a metal stent should be systematically chosen for patients with an inoperable tumour smaller than 30 mm, while larger tumours are efficiently palliated by a plastic stent.

Outcome of palliative biliary and gastric bypass surgery for pancreatic head carcinoma in 126 patients

BACKGROUND

Recent reports of decreased morbidity and mortality following palliative surgery for patients with irresectable pancreatic head carcinoma prompted a review of the results in 126 patients (median age 64 (range 39-90) years) who had undergone palliative biliary and gastric bypass surgery.

METHODS

The indication for surgical palliation was the finding of an irresectable tumour at laparotomy (n = 44), failure of endoscopic treatment (n = 43), clinical symptoms of gastric outlet obstruction (n = 28) and miscellaneous (n = 11). Biliary and gastric bypass was performed in 118 patients, biliary bypass alone in six and gastrojejunostomy alone in two. The indication for gastrojejunostomy was symptoms in 28 patients (23 per cent) and prophylaxis in 92 patients (77 per cent).

RESULTS

Postoperative local complications occurred in 17 per cent of patients, general complications in 10 per cent and delayed gastric emptying in 14 per cent of patients. The 30-day mortality rate was 1 per cent and overall hospital mortality rate 2 per cent. Median hospital stay was 17 (range 5-80) days. Median overall postoperative survival was 190 (range 14-830) days. Late obstructive gastrointestinal symptoms occurred in 14 patients (11 per cent) after a median of 141 (range 21-356) days.

CONCLUSION

Roux-en-Y hepaticojejunostomy combined with gastrojejunostomy offers effective palliation for irresectable pancreatic head cancer and can be performed with low mortality and acceptable morbidity rates.

Cost-effective analysis of surgical palliation versus endoscopic stenting in the management of unresectable pancreatic cancer

BACKGROUND

Ductal carcinoma of the pancreas is unresectable for cure in the majority of patients. We reviewed our results and cost effectiveness of surgical and endoscopic biliary bypass for unresectable pancreatic cancer to evaluate the comparable outcomes.

METHODS

Between 1990 and 1992, 136 patients were managed operatively or endoscopically for pancreatic carcinoma. Excluding potentially curative resections and patients without follow-up, 34 patients endoscopically stented and 32 patients surgically bypassed were evaluated.

RESULTS

Mean patient age was older (72.1 vs. 69.3 years) but average performance status was comparable (0.8 vs. 0.9 Eastern Cooperative Oncology Group grading) in the medical treatment group. The initial hospital stay was significantly longer for surgical patients (mean 14 vs. 7 days, p < 0.001), with higher average charges ($18,325 vs. $9,663). Twelve stented patients required rehospitalization (average charge of $4,029), and eight surgical patients were readmitted (average charge of $6,776). An average of 1.7 stent changes (average charge $1,190) were required. Mean survival was longer for the stented group (9.7 vs. 7.3 months, p = 0.13).

CONCLUSIONS

Endoscopic stenting for unresectable pancreatic cancer provides equivalent duration of survival at reduced cost and shorter hospital stay, although subsequent stent changes are necessary. When curative resection is not possible, endoscopic biliary drainage should be considered a good first choice for palliative management.

Biliary decompression promotes Kupffer cell recovery in obstructive jaundice

BACKGROUND

Jaundiced patients undergoing surgical procedures have an increased risk of Gram negative sepsis with potential morbidity and mortality. Depressed Kupffer cell clearance capacity (KCCC) predisposes jaundiced patients to endotoxaemia and its sequelae. Biliary decompression remains the main therapeutic strategy in obstructive jaundice.

AIMS

This study investigates the efficacy of internal (ID) and external biliary drainage (ED) on KCCC in an experimental model of extrahepatic biliary obstruction.

METHODS

Adult male Wistar rats (250-300 g) were assigned to one of six groups: sham operated, where the bile duct was mobilised but not divided; bile duct ligation (BDL) for three weeks, and sham operated or BDL for three weeks followed by a second laparotomy and further 21 days of ID or ED, by way of choledochoduodenostomy or choledochovesical fistula respectively. KCCC was measured using an isolated hepatic perfusion technique with FITC labelled latex particles (0.75 mu) as the test probe. Plasma was assayed for bilirubin, endotoxin, and anticore glycolipid antibody (ACGA) concentrations.

RESULTS

Jaundiced rats had reduced KCCC (p < 0.001), increased concentrations of ACGA (p < 0.001), and endotoxin (p < 0.001) compared with controls. Biliary drainage for three weeks produced a recovery in KCCC and normalisation of endotoxin and ACGA concentrations, however, external drainage was less effective than ID (p < 0.01).

CONCLUSIONS

These data support the hypothesis that endotoxaemia and its mediated effects are integral in the pathophysiology of jaundice. Furthermore, a short period of internal biliary drainage is a useful therapeutic strategy in restoring Kupffer cell function and negating systemic endotoxaemia and consequent complications in biliary obstruction.

AN EXPERIENCE IN MANAGEMENT OF SURGICAL OBSTRUCTIVE JAUNDICE

One hundred and five patients of surgical obstructive jaundice were admitted to Army Hospital, Delhi from July 1991 to June 1994. Patients were investigated as per the diagnostic protocol. The causes of obstruction were choledocholithiasis (24 patients), periampullary carcinoma and carcinoma head of pancreas (32 patients), carcinoma gall bladder and cholangiocarcinoma (11 patients each). The procedures performed to relieve obstructive jaundice in 89 cases included choledochojejunostomy (17), pancreato-duodenectomy (15), hepaticojejunostomy (15), choledocholithotomy (12) and choledochoduodenostomy (12). Mortality was 7 per cent in pancreatoduodenectomy and 8 per cent in palliative procedures.

Malignant obstructive jaundice. Evaluation and management

A large number of laboratory tests, radiologic studies, and endoscopic techniques are available for the evaluation of the jaundiced patient. Similarly, the therapeutic options have increased with the development and improvement of endoscopic, percutaneous, and laparoscopic procedures, and the morbidity and mortality rates associated with open surgery have decreased. The challenge is to select, on an individual basis, the most efficient and cost-effective evaluation as well as the management with the lowest morbidity and mortality rates and the best short- and long-term goals.

Sutured or fibrin-glued laparoscopic choledochojejunostomy

Minimally invasive techniques for choledochojejunostomy offer theoretical advantages for palliating unresectable periampullary neoplasms. Fibrin glue, a biologic adhesive containing concentrated fibrinogen, may obviate suturing and promote healing without stricture formation. We examined the technical ability to perform laparoscopic choledochojejunostomy (LCJ) and the applicability of thrombin-activated fibrin glue in an animal model of biliary obstruction. Domestic pigs underwent laparoscopic cholecystectomy and ligation of the distal bile duct. Three days later, a side-to-side LCJ was performed by intracorporeal sutured anastomosis (n = 7) or using four stay sutures and homologous fibrin glue (n = 7). Control animals underwent a similar bypass via open laparotomy (n = 7). The postoperative interval to ambulation and oral intake was recorded, and serial serum liver enzymes were measured. The animals were sacrificed at 6 weeks, and tensile strength of the anastomoses was assessed by tensometry. Liver function tests returned to normal values within 7 days following all methods of choledochojejunostomy. In the fibrin glue group, three anastomotic leaks (43%) occurred in the 1st postoperative week. At 6 weeks, all other anastomoses were intact and patent by cholangiogram, but there was moderate stenosis of two open and one fibrin-glue anastomosis. The sutured LCJ, while taking approximately 1 h longer to perform (P < 0.05), resulted in similar efficacy and more rapid recovery (P < 0.05) than open biliary-enteric bypass. Fibrin-glued LCJ was performed rapidly, but had less tensile strength (P < 0.05) and often leaked in the early post-operative interval. We conclude that while there may be a role for laser-activated solders for primary anastomosis, thrombin-activated fibrinogen cannot be advocated as the primary means of creating biliary anastomoses. Using intracorporeal suturing techniques, laparoscopic choledochojejunostomy may be performed safely.

Controversial issues in the management of pancreatic cancer: Part one. A debate held at St Mary's Hospital, London on 18 November 1993

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Cystic duct patency in malignant obstructive jaundice. An ERCP-based study relevant to the role of laparoscopic cholecystojejunostomy

OBJECTIVE

This endoscopic retrograde cholangiopancreatography-(ERCP)based study estimates the potential role of laparoscopic cholecystojejunostomy for palliation of patients with malignant obstructive jaundice.

SUMMARY BACKGROUND DATA

Traditional treatment of malignant obstructive jaundice has used a standard bilioenteric anastomosis. Laparoscopic biliary bypass via a gallbladder conduit currently is an established technique; it provides a low initial morbidity alternative to open procedures, similar to endoscopic stenting. No study has specifically addressed anatomic factors relevant to cholecystojejunostomy, such as prior cholecystectomy, stricture location in reference to the hepatocystic junction, and cystic duct patency in patients with malignant obstructive jaundice.

METHODS

Retrograde cholangiograms were reviewed from consecutive patients with malignant obstructive jaundice and a control group without biliary disease who underwent ERCP during a 2-year period. Patients with either prior biliary surgery or hilar tumors were excluded. The presence of gallbladder or cystic duct filling was assessed. In patients with patent cystic ducts, the distance from obstruction to the cystic duct takeoff was classified as either greater or less than 1 cm.

RESULTS

Nearly half the patients with malignant obstructive jaundice were ineligible for cholecystojejunostomies because of prior biliary surgery (29%) or hilar tumors (17%). Half (50 of 101) of the remaining potential candidates had patent hepatocystic junctions. Patients with ampullary carcinoma and patent hepatocystic junctions (5 of 9) were all ideal candidates for cholecystojejunostomies, having biliary obstruction more than 1 cm from the cystic duct takeoff. Two thirds of the remaining eligible patients (28 of 45) had obstructions less than 1 cm from patent hepatocystic junctions.

CONCLUSIONS

Palliation of malignant obstructive jaundice by laparoscopic cholecystojejunostomy should only be attempted after direct cholangiography demonstrates a patent hepatocystic junction that is well separated from the malignant stricture. The majority of patients with malignant obstructive jaundice are ineligible for cholecystojejunostomies because of prior cholecystectomies, hilar obstructions, or tumor involvement of the hepatocystic junction. Nonoperative treatments will continue to be indicated for the majority of patients with malignant obstructive jaundice.

Current management of pancreatic carcinoma

OBJECTIVE

The author seeks to provide an update on the current management of pancreatic carcinoma, including diagnosis and staging, surgical resection and adjuvant therapy for curative intent, and palliation.

SUMMARY BACKGROUND DATA

During the 1960s and 1970s, the operative mortality and long-term survival after pancreaticoduodenectomy for pancreatic carcinoma was so poor that some authors advocated abandoning the procedure. Several recent series have reported a marked improvement in perioperative results with 5-year survival in excess of 20%. Significant advances also have been made in areas of preoperative evaluation and palliation for advanced disease.

CONCLUSION

Although carcinoma of the pancreas remains a disease with a poor prognosis, advances in the last decade have led to improvements in the overall management of this disease. Resection for curative intent currently should be accomplished with minimal perioperative mortality. Surgical palliation also may provide the optimal management of selected patients.

Pancreatic carcinoma

The management of patients with pancreatic carcinoma poses many problems. The diagnosis is usually made late, generally because the patients present late, but it is not unusual to find patients who have had many negative investigations for vague upper abdominal symptoms only to be diagnosed as having pancreatic carcinoma many months later. Staging the disease is equally difficult and often inaccurate. The results of treatment are to date discouraging even in those patients diagnosed early. But the outlook is not totally dismal; in recent years the results for surgical resection of pancreatic lesions have improved; adjuvant treatment may finally be having an effect, although small, on this relentless disease. The most notable inroad made in the management of pancreatic cancer in the last 10 years is the improvement in palliation due to the use of the endoprosthesis. In spite of the poor results we must continue to search actively for more accurate methods of diagnosis and better methods of treatment.