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

Age comorbidity scores as risk factors for 90-day mortality in patients with a pancreatic head adenocarcinoma receiving a pancreaticoduodenectomy: A National Population-Based Study

Background

To estimate easily assessed preoperative factors for predicting 90‐day mortality in patients with a pancreatic head adenocarcinoma (PHA) receiving a pancreaticoduodenectomy.

Methods

We analyzed data from the Taiwan Cancer Registry Database of patients with a PHA who received a pancreaticoduodenectomy. Basic demographic characteristics, including gender and age, were categorized. The selection of preoperative comorbidities was based on the preoperative American Society of Anesthesiologists score and Charlson comorbidity index.

Results

We enrolled 8490 patients with a PHA who received a pancreaticoduodenectomy without distant metastasis. Currently, a pancreaticoduodenectomy for a PHA achieves an overall 90‐day mortality rate of 8.39%. Univariate and multivariate Cox regression analyses indicated that an older age (65‐74 and ≥75 years) and specific comorbidities (chronic obstructive pulmonary disease, chronic kidney disease, dementia, and sepsis) were significant independent prognostic factors for predicting 90‐day mortality after a pancreaticoduodenectomy. After adjustment, the adjusted hazard ratios (aHRs) (95% confidence intervals [CIs]) of subjects with middle and high comorbidity scores for 90‐day mortality in 65 to 74‐year‐old patients were 1.36 (1.05‐1.75) and 2.25 (1.03‐4.90), respectively, compared to subjects with low comorbidity scores. The aHRs (95% CIs) of subjects with middle and high comorbidity scores for 90‐day mortality in ≥75‐year‐old patients were 1.35 (1.07‐1.78) and 2.07 (1.19‐3.62), respectively, compared to those with low comorbidity scores.

Conclusions

Elderly patients with a PHA and moderate or high comorbidity scores have an increased risk of 90‐day mortality after a pancreaticoduodenectomy.

Safety of radiofrequency ablation in patients with locally advanced, unresectable pancreatic cancer: A phase II study

INTRODUCTION

Radiofrequency ablation (RFA) has been proposed as a new treatment option for locally advanced, unresectable pancreatic cancer (LAPC). In preparation of a randomized controlled trial (RCT), the aim of this phase II study was to assess the safety of RFA for patients with LAPC.

MATERIALS AND METHODS

Patients diagnosed with LAPC confirmed during surgical exploration between November 2012 and April 2014 were eligible for inclusion. RFA probes were placed under ultrasound guidance with a safety margin of at least 10 mm from the duodenum and 15 mm from the portomesenteric vessels. During RFA, the duodenum was continuously perfused with cold saline to reduce risk for thermal damage. Primary outcome was defined as the amount of major complications (Clavien-Dindo grade ≥III). RFA-related complications were predefined as: pancreatic fistula, pancreatitis, thermal damage to the portomesenteric vessels and duodenal perforation.

RESULTS

In total, 17 patients underwent RFA. Delayed gastric emptying (DGE) requiring endoscopic feeding tube placement occurred in 4 patients (24%) as only major complication. Five patients (29%) had a major complication other than DGE. One (6%) RFA-related major complications occurred. One patient (6%) died due to complications from a biliary leak following hepaticojejunostomy. After evaluation of the first 5 patients, gastrojejunostomy was no longer performed routinely. Since then severe DGE seemed to occur less (3/5 vs. 3/12 grade C DGE).

CONCLUSION

RFA is a major, but safe procedure for patients with LAPC if performed with strict predefined safety criteria. A RCT is currently investigating the true effectiveness of RFA in patients with LAPC.

Palliation of malignant gastroduodenal obstruction with self-expandable metal stent using side- and forward-viewing endoscope: Feasibility and outcome

Background

The endoscopic placement of a self‐expandable metal stent (SEMS), an alternative to surgical bypass for the palliation of malignant gastric outlet obstruction (GOO), is commonly performed using a forward‐viewing endoscope with a wide therapeutic channel; however, due to limited availability, most Indian centers use a side‐viewing duodenoscope. We studied the feasibility and outcome of SEMS placement using side‐ and forward‐viewing endoscopes.

Method

Data of patients undergoing SEMS placement using side‐ and forward‐viewing endoscopes with a therapeutic channel for the palliation of malignant GOO presenting during a 5‐year period were analyzed retrospectively. Follow‐up data were obtained from records and telephonic interviews, and technical and clinical success, complications, and survival were evaluated.

Results

Of 114 patients (age 56.5 ± 11.6 years, 59 [52%] female), 90 (79%) and 24 (21%) underwent SEMS placement using side‐ and forward‐viewing endoscopes, respectively. Technical (89, 98.9% vs. 24, 100%, P = ns) and clinical success (84, 93.3% vs. 23, 95.8%, P = ns) and complication rate (3, 3.3% vs. 0, P = ns) between side‐ and forward‐viewing endoscopes were comparable. However, SEMS could be placed in a shorter time using a forward‐ rather than side‐viewing endoscope (21 min [inter‐quartile range 19.5–35] vs. 34 min [25–45], P = < 0.001). SEMS could be deployed successfully with a forward‐viewing endoscope in two patients in whom an initial attempt using side‐viewing endoscope failed. Gastric outlet obstruction scoring system (GOOSS) improved following stent placement (median 0, range 0–2 vs. 2, 0–3, P = 0.0001). The survival of patients undergoing SEMS placement using side‐ and forward‐viewing endoscopes was comparable.

Conclusion

Although side‐ and forward‐viewing endoscopes are equally effective for antroduodenal SEMS placement, the procedure can be performed faster using the latter.

Is routine hepaticojejunostomy at the time of unplanned surgical bypass required in the era of self-expanding metal stents?

BACKGROUND

Hepaticojejunostomy is routinely performed in patients when inoperable disease is found at planned pancreatoduodenectomy; however, in the presence of self-expanding metal stent (SEMS) hepaticojejunostomy may not be required. The aim of this study was to assess biliary complications and outcomes in patients with unresectable disease at time of planned pancreaticoduodenectomy stratified by the management of the biliary tract.

MATERIAL AND METHODS

Retrospective analysis of patients undergoing surgery in January 2010-December 2015. Complications were measured using the Clavien-Dindo scale.

RESULTS

Of 149 patients, 111 (75%) received gastrojejunostomy and hepaticojejunostomy (double bypass group) and 38 (26%) received a single bypass in the presence of SEMS (single bypass group). Post-operative non-biliary [7 (18%) vs 43 (38%), (p = 0.028)] and biliary [0% vs 12 (11%), (p = 0.037)] complications were lower in the single bypass group. Hospital readmissions were significantly higher in the double bypass group (p = 0.021). Overall survival and the time to start chemotherapy were equivalent (p = n.s.).

CONCLUSIONS

Complications are more common following double bypass compared to single bypass with SEMS suggesting that gastric bypass is adequate surgical palliation in presence of SEMS. This study adds further evidence that preoperative SEMS should be used in preference to plastic stents for suspected periampullary malignancy.

Endoscopic management of combined malignant biliary and gastric outlet obstruction

Patients with periampullary cancer or gastric cancer often develop malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), and combined MBO and GOO is not rare in these patients. Combined MBO and GOO is classified by its location and sequence, and treatment strategy can be affected by this classification. Historically, palliative surgery, hepaticojejunostomy and gastrojejunostomy were carried out, but the current standard treatment is combined transpapillary stent and duodenal stent placement. Although a high technical success rate is reported, the procedure can be technically difficult and duodenobiliary reflux with subsequent cholangitis is common after double stenting. Recent development of endoscopic ultrasound (EUS)-guided procedures enables the management of MBO as well as GOO under EUS guidance. EUS-guided biliary drainage is now increasingly reported as an alternative to percutaneous transhepatic biliary drainage in failed endoscopic retrograde cholangiopancreatography (ERCP), and GOO is one of the major reasons for failed ERCP. In addition to EUS-guided biliary drainage, the feasibility of EUS-guided double-balloon-occluded gastrojejunostomy bypass for MBO was recently reported, and EUS-guided double stenting can potentially become the treatment of choice in the future. However, as each procedure has its advantages and disadvantages, treatment strategy should be selected based on the type of obstruction and the prognosis and performance status of the patient.

A newly designed stent for management of malignant distal duodenal stenosis

PURPOSE

To evaluate the clinical effectiveness of a newly designed stent for the treatment of malignant distal duodenal stenosis.

METHODS

From March 2011 to May 2013, six patients with malignant duodenal stenosis underwent fluoroscopically guided placement of the new duodenal stent consisting of braided, nested stent wires, and a delivery system with a metallic mesh inner layer. Primary diseases were pancreatic cancer in three patients, gastric cancer in two patients, and endometrial stromal sarcoma in one patient. Duodenal obstructions were located in the horizontal part in two patients, the ascending part in two patients, and the duodenojejunal flexure in two patients. Technical success, defined as the successful stent deployment, clinical symptoms before and after the procedure, and complications were evaluated.

RESULTS

Technical success was achieved in all patients. No major complications were observed. Before treatment, two patients could not take any food and the gastric outlet obstruction scoring system (GOOSS) score was 0; the other four patients could take only liquids orally (GOOSS score = 1). After treatment, five patients could take soft food (GOOSS score = 2) and one patient could take a full diet (GOOSS score = 3). The mean duration of primary stent patency was 115.7 days.

CONCLUSIONS

The newly designed stent is associated with a high degree of technical success and good clinical outcome and may be clinically effective in the management of malignant distal duodenal obstruction.

Gastroduodenal outlet obstruction and palliative self-expandable metal stenting: a dual-centre experience

Background. Self-expandable metal stents (SEMs) are increasingly being utilised instead of invasive surgery for the palliation of patients with malignant gastroduodenal outlet obstruction. Aim. To review two tertiary centres' experience with placement of SEMs and clinical outcomes. Methods. Retrospective analysis of prospectively collected data over 12 years. Results. Ninety-four patients (mean age, 68; range 28–93 years) underwent enteral stenting during this period. The primary tumour was gastric adenocarcinoma in 27 (29%) patients, pancreatic adenocarcinoma in 45 (48%), primary duodenal adenocarcinoma in 8 (9%), and cholangiocarcinoma and other metastatic cancers in 14 (16%). A stent was successfully deployed in 95% of cases. There was an improvement in gastric outlet obstruction score (GOOS) in 84 (90%) of patients with the ability to tolerate an enteral diet. Median survival was 4.25 months (range 0–49) without any significant differences between types of primary malignancy. Mean hospital stay was 3 days (range 1–20). Reintervention rate for stent related complications was 5%. Conclusion. The successful deployment of enteral stents achieves excellent palliation often resulting in the prompt reintroduction of enteral diet and early hospital discharge with minimal complications and reintervention.

Elevated preoperative neutrophil-to-lymphocyte ratio as a predictor of survival after gastroenterostomy in patients with advanced pancreatic adenocarcinoma

BACKGROUND

There is increasing evidence that the presence of an ongoing systemic inflammatory response, especially a high preoperative neutrophil-to-lymphocyte ratio (NLR), is associated with a poor outcome for a variety of common solid tumors. However, few studies have investigated the clinical value of the NLR in patients undergoing gastroenterostomy for advanced pancreatic cancer.

METHODS

A total of 83 patients who had symptoms of gastric outlet obstruction due to advanced pancreatic cancer and underwent gastroenterostomy were analyzed. The prognostic significance of the NLR was analyzed. The relationship between the NLR value and postoperative outcome was also evaluated.

RESULTS

The median survival time was 9.4 months in patients with an NLR of <4, whereas it was 3.4 months in patients with an NLR of ≥4 (P < 0.001). The multivariate analysis revealed that an NLR of ≥4, the presence of liver metastases, daily pain, and lack of postoperative chemotherapy were significant prognostic factors. A higher NLR was associated with postoperative morbidity; 13 % of patients with an NLR of <4 and 36 % of those with an NLR of ≥4 (P = 0.012) developed morbidities. With regard to quality of life, 96 % of patients with an NLR of <4 and 36 % of patients with an NLR of ≥4 had adequate oral intake of solid food without any support with intravenous nutrition for at least 1 month after surgery (P < 0.001).

CONCLUSIONS

The preoperative NLR offers important prognostic information for patients who have gastric outlet obstruction due to advanced pancreatic adenocarcinoma.

Endoscopic ultrasound-guided choledochoduodenostomy and duodenal stenting in patients with unresectable periampullary cancer: one-step procedure by using linear echoendoscope

OBJECTIVE

Describe a case series of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD) associated with duodenal self-expandable metal stents (SEMS) placement using solely the linear echoendoscope in seven patients with obstructive jaundice and duodenal obstruction due to unresectable periampullary cancer.

MATERIAL AND METHODS

EUS-CD in the first portion of the duodenum, associated with duodenal SEMS placement was performed in seven patients with unresectable periampullary cancer with obstructive jaundice and invasive duodenal obstruction. Laboratory tests and clinical follow-up were performed until patient's death. The procedure was performed by an experienced endoscopist under conscious sedation. The puncture position was chosen based on EUS evaluation, at the common bile duct (CBD) above the tumor, through the distal part of the duodenal bulb. After that, the needle was withdrawn and a wire-guided needle knife was used to enlarge the site puncture in the duodenal wall. Then, a partially covered SEMS was passed over the guide, through the choledochoduodenal fistula. Duodenal SEMS placement was performed during the same endoscopic procedure.

RESULTS

The procedure was performed in seven patients, ranging between 34 and 86 years. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Duodenal SEMS placement was effective in 100% of the cases that remained alive after a follow-up of 7 and 30 days.

CONCLUSION

The results suggest therapeutic EUS one-step procedure drainage as an alternative for these patients, with good clinical success, feasible technique and safety.

Endoscopic self-expandable metallic stent placement in malignant pyloric or duodenal obstruction: does chemotherapy affect stent patency?

AIM

Self-expandable metallic stents (SEMS) have been used for palliation in patients with malignant gastroduodenal obstructions. We evaluated clinical outcomes after SEMS placement and identified prognostic factors of SEMS patency, including chemotherapy.

METHODS

A review of records of 85 patients with unresectable gastric or pancreatic cancer who underwent endoscopic SEMS insertion for gastroduodenal obstructions at Seoul National University Bundang Hospital.

RESULTS

From August 2003 to October 2009, 85 patients with gastroduodenal obstruction were managed with endoscopic SEMS placement. Technical success was achieved in 82 patients (96%) and clinical success in 68 patients (80%). Of 49 patients who had clinical success, 19 underwent chemotherapy (chemoTx group), and 30 patients did not (non-chemoTx group). Cumulative SEMS patency in the 49 patients who achieved clinical success were 84, 54 and 41% at 2, 3 and 6 months, respectively. By univariate and multivariate analysis, there was no statistical difference in the SEMS patency between the two groups (cumulative SEMS patency rate: 95 vs 73% at 2 months, 15 vs 63% at 3 months, 40 vs 42% at 6 months, respectively, P < 0.793).

CONCLUSION

Chemotherapy does not improve SEMS patency in patients with malignant gastroduodenal obstruction caused by unresectable gastric or pancreatic cancer.

Factors influencing survival in patients undergoing palliative bypass for pancreatic adenocarcinoma

PURPOSE

The purpose of this study is to identify factors predictive of early mortality following palliative bypass in patients with previously unsuspected advanced pancreatic adenocarcinoma to provide a basis for the selection of appropriate therapies.

METHODS

All patients with pancreatic adenocarcinoma who underwent a bypass procedure at our institution between 9/30/1994 and 1/31/2006 were reviewed. Patients with peri-operative mortality were excluded from the analysis. Univariate analysis was performed on peri-operative data to identify factors associated with early mortality (death within 6 months of surgery). Patients having multiple risk factors were assigned an overall prognostic score based on the sum of these factors.

RESULTS

Of the 397 patients with pancreatic adenocarcinoma analyzed, four factors were found to predict early mortality following palliative bypass: Presence of distant metastatic disease (HR 2.59, P < 0.0001), poor tumor differentiation (HR 1.71, P = 0.009), severe pre-operative nausea and vomiting (HR 1.48, P = 0.013), and lack of previous placement of a biliary stent (HR 1.36, P = 0.048). Patients with a prognostic score of 0 were significantly more likely to survive past 6 months than patients with a prognostic score of 1 (HR 2.71, P < 0.0001), 2 (HR 3.70, P < 0.0001), or ≥3 (HR 5.63, P < 0.0001).

CONCLUSIONS

In a cohort of patients undergoing a palliative bypass procedure, specific peri-operative factors can be used to identify patients who are at risk of early mortality. These factors may be helpful in selecting appropriate interventions for this group of patients.

Palliative surgical management of patients with unresectable pancreatic adenocarcinoma: trends and lessons learned from a large, single institution experience

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.

Is modified Devine exclusion necessary for gastrojejunostomy in patients with unresectable pancreatobiliary cancer?

PURPOSE

Gastrojejunostomy is often performed as palliative surgery for unresectable pancreatobiliary cancer. Modified Devine exclusion (MDE) is a technical variation of gastrojejunostomy, which partially separates the mid-portion of the stomach. We conducted this study to assess whether MDE is necessary for gastrojejunostomy in patients with unresectable pancreatobiliary cancer.

METHODS

We compared the postoperative results of MDE (n = 26) with those of conventional gastrojejunostomy (CGJ; n = 20) performed palliatively for unresectable pancreatobiliary cancers.

RESULTS

The morbidity rates were 38% after MDE and 50% after CGJ, with 23% and 40% of patients suffering delayed gastric emptying, respectively. Two of the CGJ group patients could never eat again. Modified Devine exclusion slowed the progression of anemia in all of the patients with duodenal bleeding.

CONCLUSION

Modified Devine exclusion may be effective for patients with unresectable pancreatobiliary cancer.

Combined arterial infusion and stent implantation compared with metal stent alone in treatment of malignant gastroduodenal obstruction

Many patients with malignant gastroduodenal obstruction have an unresectable primary lesion and distant metastases, which may prompt palliative management to allow the patient to eat and to improve the quality of life. Intraluminal metallic stent implantation (MSI) under fluoroscopic guidance has been reported to be an effective option for symptomatic relief in these patients, with a good safety record. An alternative, dual interventional therapy (DIT), has been used during the last decade, in which prosthesis insertion is followed by intra-arterial chemotherapy via the tumor-feeding arteries. The aim of this study was to compare success rates, complication rates, and survival time between MSI and DIT in patients who presented with gastroduodenal obstruction from advanced upper gastrointestinal tract cancer. All consecutive patients with malignant gastroduodenal obstruction seen at our center between October 2002 and August 2007 were retrospectively studied. Patients were treated palliatively by either MSI or DIT by the patient's or the next of kin's decision. Outcomes included technical and clinical success, complication rates, and survival. Of the 164 patients with malignant gastric and duodenal outlet obstructions, 80 (49%) underwent stent insertion as the primary therapy, while the remaining 84 (51%) received DIT. Clinical characteristics were similar between the two groups. In the MSI cohort initial stent implantation was successful in 73 patients (91%), two stents were used in 5 patients, and delayed additional stent insertion for stent obstruction related to tumor overgrowth was required in 3 patients during follow-up. In the DIT cohort the technical success rate was 94%, 3 patients required two stents, and stent obstruction occurred in 2 patients after initial stent placement. Early postprocedural clinical success, indicated by average dysphagia score, improved significantly in both groups: MSI group, from 4.56 to 1.51 (P < 0.01); and DIT group, from 4.38 to 1.48 (p < 0.01). There were no short-term complications. Late complications including hematemesis (n = 3), migration (n = 12), and stent occlusion due to tumor overgrowth (n = 5) were evenly distributed between the groups. In the DIT group chemotherapy-induced neutropenia and transient renal dysfunction were detected in six patients, which improved after symptomatic management. Mean survival time after the procedure was 5.9 and 11.1 months for MSI and DIT, respectively (P < 0.001). In conclusion, both MSI and DIT offer effective palliation for malignant gastroduodenal obstruction, but DIT appears to offer superior survival over MSI alone. Ideally, a prospective randomized trial comparing these two techniques should be carried out to validate this result.

Medical management of pancreatic adenocarcinoma

Pancreatic cancer is the fourth leading cause of cancer death in the United States. In 2008, an estimated 34,290 people died from pancreatic cancer and 37,680 new cases were diagnosed. Despite modern treatment, 90% of patients die within 1 year of diagnosis. Pancreatectomy is still the only potentially curative approach, but most patients have incurable disease by the time they are diagnosed, and fewer than 20% are candidates for surgery. In the present paper the English-language literature addressing the medical management in pancreatic cancer was reviewed. Based on these data we will discuss the role of currently used chemotherapy and target therapy in pancreatic cancer, as well as perspectives of the emerging strategies that are arising in order to improve the outcomes of this complex disease.

Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma

BACKGROUND

The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass.

METHODS

This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma.

RESULTS

We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05).

CONCLUSIONS

On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.

Surgical palliation of unresectable pancreatic head cancer in elderly patients

AIM: To determine if surgical biliary bypass would provide improved quality of residual life and safe palliation in elderly patients with unresectable pancreatic head cancer.

METHODS: Nineteen patients, 65 years of age or older, were managed with surgical biliary bypass (Group A). These patients were compared with 19 patients under 65 years of age who were managed with surgical biliary bypass (Group B). In addition, the results for group A were compared with those obtained from 17 patients, 65 years of age or older (Group C), who received percutaneous transhepatic biliary drainage to evaluate the quality of residual life.

RESULTS: Five patients (26.0%) in Group A had complications, including one intraabdominal abscess, one pulmonary atelectasis, and three wound infections. One death (5.3%) occurred on postoperative day 3. With respect to morbidity, mortality, and postoperative hospitalization, no statistically significant difference was noted between Groups A and B. The number of readmissions and the rate of recurrent jaundice were lower in Group A than in Group C, to a statistically significant degree (P = 0.019, P = 0.029, respectively). The median hospital-free survival period and the median overall survival were also significantly longer in Group A (P = 0.001 and P < 0.001, respectively).

CONCLUSION: Surgical palliation does not increase the morbidity or mortality rates, but it does increase the survival rate and improve the quality of life in elderly patients with unresectable pancreatic head cancer.

Palliative surgical bypass for pancreatic and peri-ampullary cancers

BACKGROUND

The optimal method of palliation for patients with unresectable pancreatic and peri-ampullary cancer (PAC) is controversial with surgical bypass or endoscopic stenting, each having advantages and disadvantages.

AIMS

We analysed short term outcomes and survival for all patients undergoing surgical palliative bypass procedures.

MATERIALS AND METHODS

All patients undergoing palliative surgical bypass for unresectable PAC from Aug 1999 to July 2007 were identified from our database. Outcomes analysed were peri-operative morbidity, mortality, and overall survival with comparisons from contemporaneous literature.

RESULTS

One hundred eight patients (median age 65 (range 36-86) years; male = 61) had palliative surgical bypass procedures for unresectable PAC. Patients underwent combined biliary and gastric bypass (n = 81, 75%), gastric bypass alone (n = 24, 22.2%) or biliary bypass alone (n = 3, 2.8%). Overall mortality was 6.5% and the morbidity was 15.7%. Median hospital stay was 11 (range 4-54) days. Median survival was 6 (95% confidence interval (CI) = 4.3-7.6) months. No re-explorations for recurrent biliary or gastric obstruction were required. Contemporaneous literature review showed similar results.

CONCLUSION

Surgical bypass performed in a specialist pancreatic center can offer effective palliation for unresectable PAC, with satisfactory outcomes.

Covered expandable nitinol stents for malignant gastroduodenal obstructions

BACKGROUND AND AIM

The aim of the present study was to investigate the clinical effectiveness, safety, and outcome associated with the use of covered expandable Nitinol stents (Taewoong Medical, Seoul, Korea) for the treatment of malignant gastroduodenal obstructions.

METHODS

Between March 2001 and October 2004, covered expandable Nitinol stents were placed in 68 consecutive patients under endoscopic and fluoroscopic guidance for the following reasons: gastric carcinoma (n = 49), recurrent carcinoma after partial gastrectomy (n = 7), or another malignant neoplasm involving the duodenum (n = 12).

RESULTS

Technical success was achieved in 60 of the 68 patients (88.2%). After stent placement, mean dysphagia score improved from a mean of 3.5 to 1.2 (P < 0.001). The mean period of primary stent patency was 107.2 days. During follow up (mean 4.4 months; range, 1-15 months), major complications (migration [6], bleeding [3], perforation [1], ingrowth [1], overgrowth [7], fistula [1]) occurred in 19 patients (27.9%), and stent migration occurred in six (8.8%) (proximal migration into the stomach [n = 3], or distal migration [n = 3]). Recurrent dysphagia (mainly due to tumor ingrowth/overgrowth) occurred in eight patients (11.8%).

CONCLUSION

Covered expandable Nitinol stents appear to offer an effective and feasible palliative therapy in patients with a malignant gastroduodenal obstruction.

Palliative pancreatectomy with postoperative gemcitabine for patients with advanced pancreatic cancer

BACKGROUND

The prognosis of patients with advanced pancreatic cancer remains very poor. This study was designed to evaluate palliative pancreatic resection with postoperative gemcitabine chemotherapy.

METHODS

A total of 127 patients underwent palliative pancreatectomy or palliative nonresectable treatment with gemcitabine at Kobe University Hospital and were analyzed.

RESULTS

The median survival of patients receiving palliative pancreatectomy with gemcitabine was 15 months, and the 1- and 3-year survival rates were 60% and 13%, respectively, while that of patients receiving gemcitabine alone was only 8 months, and their 1- and 3-year survival rates were 26% and 0%. Multivariate analysis showed that gemcitabine was the strongest factor in survival, and no distant metastasis and pancreatectomy were also significant factors. In addition, the median survival of patients undergoing microscopically incomplete resection with gemcitabine was 22 months, and the 1- and 3-year survival rates were 60% and 40%. Pancreatectomy with gemcitabine improved the performance status 3 months after surgery, with longer survival compared with the gemcitabine alone group.

CONCLUSIONS

Microscopically incomplete pancreatectomy with postoperative gemcitabine chemotherapy has a possible role in advanced pancreatic cancer.

Factors influencing survival after bypass procedures in patients with advanced pancreatic adenocarcinomas

BACKGROUND

Patients with occult metastasis or locally nonresectable pancreatic cancer found during surgical exploration have a limited life expectancy. We sought to define markers in these patients that could predict survival and thus aid decision making for selection of the most appropriate therapeutic palliative option.

METHODS

In a prospective 4-year single-center study, 136 consecutive patients with obstructive pancreatic cancer and intraoperative diagnosis of nonresectable or disseminated pancreatic cancer underwent a palliative surgical bypass procedure. Potential factors predicting survival were evaluated.

RESULTS

Ninety-eight patients had metastatic disease and 38 locally advanced disease. Surgical morbidity rate was 16 %, re-operation rate 1%, and overall in-hospital mortality 4%. Univariate analysis showed American Society of Anesthesiologists (ASA) score, pain, operation time, presence of metastasis, and levels of leukocytes, albumin, C-reactive protein (CRP), carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19-9 were associated significantly with survival. The multivariate analysis identified ASA score, presence of liver metastasis, pain, CA 19-9, and CEA levels as independent indicators for poor survival. Patients with none or 1 of these risk factors had a median survival of 13.5 months, whereas patients with 4 or 5 risk factors had a median survival of 3.5 months.

CONCLUSIONS

The clinical markers identified predict poor outcome for patients with palliative bypass surgery and therefore aid the appropriate selection of either surgical bypass or endoscopic stenting in these patients.

Percutaneous drainage and stenting for palliation of malignant bile duct obstruction

Percutaneous biliary drainage and stenting (PTBD) for palliation of malignant obstructive jaundice has evolved to a safe and effective technique. PTBD is equally effective for treatment of distal and proximal bile obstruction. Metal self-expandable stents have proved superior to plastic stents and should therefore be used. Technical success is >90% en clinical success is >75% in all major series. There are a considerable number of complications, but most can be treated conservatively and procedure-related mortality is <2% in most series. Thirty-day mortality after PTBD is >10% in many series, but this is largely due to the underlying disease. About 10-30% of patients will have recurrent jaundice at some point in their disease after PTBD and require re-intervention.

Initial and long-term outcome after palliative surgical drainage of 269 patients with malignant biliary obstruction

AIMS

This study aimed to analyse the current outcome after palliative surgical drainage of malignant biliary obstruction.

METHOD

From 1992 to 2003, perioperative parameters and the incidence and indications of readmissions were analysed in 269 patients who underwent a palliative biliary bypass for periampullary carcinoma.

RESULTS

Hospital mortality occurred in seven patients and median postoperative stay was 10 days. Anastomotic leakage occurred in three patients and intraabdominal haemorrhage in eight patients. Overall 75 patients experienced a complication. Nine patients underwent a relaparotomy during initial hospital admission. Overall, 142 patients were readmitted, 13 for indications related to the biliary bypass, 11 for surgery-related indications. Twenty-five patients were readmitted for radiochemotherapy, 112 for progressive disease and 23 for indications not related to the disease. Median survival was 7.5 months and the 3-year survival 3%. Survival was significantly lower in patients with metastases and in those who underwent elective bypass for gastric outlet obstruction.

CONCLUSION

Current hospital mortality after palliative biliary bypass as well as readmission rates for complications related to the biliary bypass or surgical procedure are low. Surgical biliary bypass is a safe and effective palliative treatment for patients with malignant biliary obstruction.

Self-expandable metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre

AIM

To assess the technical success rate, and evaluate the clinical outcome, length of hospital stay, and cost of palliative gastro-duodenal stenting in a single-centre.

MATERIALS AND METHODS

Eight-seven patients referred for insertion of a gastroduodenal stent between April 1999 and April 2004 were recruited to a non-randomized, before and after intervention study performed in a single centre. Demographic data, diagnosis and symptoms along with clinical and technical outcomes were recorded.

RESULTS

The technical success rate was 84/87 (96.6%), with inability to traverse the stricture in three patients. No immediate complications were demonstrated. There was marked improvement after stent placement with resolution of symptoms and commencement of dietary intake in 76 patients (87%). Stenting resulted in improved quality of life as reflected by an increase in Karnofsky score from 44/100, to 63/100 post-procedure. Late complications included perforation (n=1), migration (n=1) and stent occlusions due to tumour ingrowth/overgrowth (n=7; mean 165 days). Mean survival was 107 days (range 0-411 days). Median hospital stay post-stent placement was 5.5 days, (range 1-55 days) with a majority of patients (75%) discharged home. The mean cost of each treatment episode was 4146 pounds ($7132 $US, 6,028 EUROS).

CONCLUSION

The present series confirms that combined endoscopic and radiological gastroduodenal stenting is a highly favourable treatment for patients with inoperable malignant gastric outlet obstruction. The results suggest that this minimally invasive procedure has a very high technical success rate, whilst at the same time providing excellent palliation of symptoms with improved quality of life in the majority of patients.

Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; DRainage vs. (direct) OPeration (DROP-trial)

Background

Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life.

Methods/design

Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8).

Discussion

The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor.

Surgical palliation in patients with pancreatic cancer

BACKGROUND

The aim of palliative strategies in patients with pancreatic cancer is the relief of tumor-associated symptoms such as biliary and duodenal obstruction and tumor growth. Due to high mortality and morbidity rates of surgery, treatment of patients with advanced pancreatic cancer is mainly in the hand of gastroenterologists.

RATIONALE

In recent years, surgery of pancreatic cancer in specialized centres developed strongly, which makes it a viable option even in the treatment of advanced disease.

CONCLUSION

We advocate for an aggressive strategy in the treatment of pancreatic cancer with surgical exploration and tumor resection whenever possible.

Post-metallic stent placement bleeding caused by stent-induced ulcers

Placement of self-expandable metal stents (SEMS) is an effective mode of palliative treatment for patients with malignant gastrointestinal obstruction. Gastrointestinal mucosal bleeding complicates about 5% of placement of SEMS but is not well described. We report three cases of gastrointestinal bleeding post-SEMS placement and suggest that bleeding is caused by direct mucosal infringement by the sharp edges of the ends of the stents.

An evidence-based approach to the diagnosis and staging of pancreatic cancer

Technology has revolutionized the diagnosis and staging of pancreatic malignancy. Previously, staging of disease was accomplished by exploratory laparotomy. Now, however, tumor size, lymph node and vascular involvement and the presence of metastases can be reliably assessed prior to operation using a widely available series of diagnostic tests, facilitating a preoperative assessment of tumor resectability. Appropriate use of these tests often spares patients with unresectable disease the need for operative intervention. As part of our staging algorithm we routinely employ a combination of clinical suspicion, a high-resolution helical CT scan and a serum CA 19-9 level. Endoscopic ultrasonography is useful in the patient in whom CT findings are equivocal, or in whom a tissue diagnosis is desired. Laparoscopy is reserved for patients with suspected advanced disease despite imaging findings to the contrary. Using this strategy, pancreatic malignancy may be diagnosed as expeditiously and as cost-effectively as is possible given current technology.

Therapeutic, prophylactic, and preresection applications of laparoscopic gastric and biliary bypass for patients with periampullary malignancy

BACKGROUND

Laparoscopic bypass surgery for the palliation of gastric and biliary obstruction is associated with a rapid recovery. This study aimed to extend its application to other aspects in the management of patients with periampullary cancer.

METHODS

Between 2001 and 2004, 21 patients (median age, 68 years) underwent laparoscopic gastric (n = 8), biliary (n = 5), and combined gastric and biliary (n = 8) bypass. In addition to its therapeutic role (n = 12), indications included a concomitant prophylactic gastric (n = 3) and biliary (n = 2) bypass as well as pre- 1 Whipple's relief of deep jaundice at the time of staging laparoscopy (n = 3). Construction of the biliary bypass to the gallbladder (n = 11) or bile duct (n = 2) was based on preoperative imaging.

RESULTS

All procedures were completed laparoscopically. The median operating times for gastric, biliary, and combined bypass were 75, 60, and 130 min, respectively. The addition of a prophylactic bypass did not significantly prolong the operating time, as compared with a single therapeutic bypass. One patient died postoperatively of aspiration pneumonia. The postoperative hospital stay (median, 4 days) was not significantly influenced by the type of bypass. No recurrence of or new obstructive symptoms developed during the follow-up period after a therapeutic or prophylactic bypass.

CONCLUSIONS

Applications of laparoscopic gastric and biliary bypass can safely be expanded to include a prophylactic role and preresection relief of obstructive jaundice. Prophylactic bypass surgery does not prolong operating time or hospital stay significantly and prevents future onset of obstructive symptoms.

Cancer in the elderly: pancreatic cancer

Pancreatic cancer remains a devastating and difficult disease to diagnose and successfully treat. Its incidence increases with age, with 60% of patients being over the age of 65 at presentation. Due to the insidious nature and asymptomatic onset of pancreatic cancer approximately 85% of patients present with disseminated or locally advanced disease resulting in a very poor prognosis. In the past the elderly patient, who may be felt to be too frail for operative procedures or further therapy, may have missed out on optimal treatment. In this article we review the investigation and treatment of pancreatic cancer and examine current evidence with regard to pancreatic cancer in the elderly. The evidence suggests that surgical resection can be performed safely in patients who are fit for surgery in specialist centres but may require more intensive post-operative rehabilitation.

Self-expanding metal stents for the palliation of malignant gastroduodenal obstruction in patients unsuitable for surgical bypass

BACKGROUND

The primary therapeutic goals in patients with gastroduodenal obstruction secondary to advanced malignancy are the re-introduction of an enteral diet and early discharge. The endoscopic placement of expandable metal stents has been proposed as an alternative technique for palliation in patients not suitable for surgery.

AIM

To review our experience with gastroduodenal metal stent insertion for the palliation of malignant gastric and duodenal obstruction.

METHODS

A retrospective review was conducted of the notes of all patients who underwent gastroduodenal stent insertion in our unit.

RESULTS

Forty patients (mean age, 64.5 years; range, 34-93 years) underwent insertion of an enteral stent for malignant gastroduodenal obstruction. The primary tumour was gastric in 20 patients, pancreatico-biliary in 15 and metastatic in five. A stent was successfully placed in all cases. Thirty-two patients have subsequently died, the median (range) survival being 7 weeks (1 week to 10 months). Thirty-three patients (82.5%) were discharged from hospital. During follow-up, 12 patients (30%) returned to a solid diet, 20 (50%) required a soft diet, six (15%) tolerated liquids and two (5%) were unable to tolerate any enteral nutrition.

CONCLUSION

The use of enteral stents achieves good palliation, allowing discharge from hospital and re-introduction of an enteral diet.

[Endoscopic palliation of malignant gastric outlet obstruction by self-expanding metal stents]

INTRODUCTION

Malignant gastric outlet stenosis is caused by tumour obstruction and restricts the oral intake of food, resulting in a seriously reduced quality of life. Endoscopic implantation of self expanding metal stents (SEMS) can clear stenosis in the GI-tract and reestablish and preserve the passage in the GI-tract.

PATIENTS AND METHODS

Between October 2001 and April 2003 seven patients with malignant gastric outlet stenosis have been treated by the implantation of SEMS. Four patients had malignant stenosis in the upper duodenum or gastric antrum, two patients had stenosis because of tumour recurrence in the efferent loop of the jejunum after gastric resection because of gastric carcinoma and one patient had an obstruction 20 cm distal of the oesophagus after gastrectomy because of gastric cancer.

RESULTS

In all patients obstruction was cleared by the implantation of SEMS, and oral intake of food was possible in all patients after two days. No serious complications occurred during or after stent implantation.

CONCLUSION

Stent implantation for the treatment of malignant gastric outlet stenosis is a cost effective procedure, associated with low risk and low stress for the patient, and provides excellent palliation of symptoms in patients with malignant gastric outlet stenosis.

The utility of gastrojejunostomy in secondary cytoreduction and palliation of proximal intestinal obstruction in recurrent ovarian cancer

BACKGROUND

Gastrointestinal obstruction is a common complication of recurrent ovarian cancer. Proximal intestinal obstruction, at the level of the duodenum or proximal jejunum, can result from bulky intraperitoneal or retroperitoneal disease. Classic management has been palliation of symptoms with a gastrostomy or jejunostomy tube.

CASE

We describe a series of four patients with recurrent ovarian carcinoma and proximal intestinal obstructions treated with a bypass stapled side-to-side gastrojejunostomy at the time of secondary cytoreduction or surgical palliation. The clinical history, preoperative evaluation, surgical technique, and outcomes of each patient are reviewed.

CONCLUSIONS

Gastrojejunostomy may offer patients with ovarian cancer and a proximal intestinal obstruction symptomatic relief and an opportunity for resumption of enteral feedings.

Self-expandable metallic stents for malignant duodenal obstruction caused by biliary tract cancer

BACKGROUND

Malignant duodenal obstruction is a common event in patients with advanced biliary tract cancer. Because bypass surgery is accompanied by significant morbidity, self-expandable metallic stents have emerged as a possible alternative for palliation.

METHODS

Twenty patients with biliary tract cancer (7 gallbladder, 13 Klatskin tumors) and duodenal obstruction were treated with metallic stents at a single institution between 1999 and 2001. Survival, morbidity, and stent function were studied prospectively. The ability to eat was assessed by using a scoring system.

RESULTS

Stent placement was technically successful in all patients. An additional stent was required in 6 cases (4 occlusions, 2 dislocations). Median survival was 20.5 weeks; there was no treatment-related death. Twenty-eight biliary stent exchanges were performed in 13 (65%) patients. Erosive reflux esophagitis improved in 11 of 12 (92%) cases. After 4 weeks, all 17 surviving patients tolerated soft or solid food, whereas 13 of 17 (77%) tolerated a more solid diet (p < 0.001, gastric outlet obstruction scoring system). Twelve of 17 (71%) patients gained a median of 1.5 kg of body weight (p = 0.001). The median Karnofsky scale increased from 50% to 60% in 13 of 17 (77%) patients.

CONCLUSIONS

Self-expandable metallic stents are a safe, efficacious, and minimally invasive treatment option for palliation of patients with duodenal obstruction from biliary tract cancer. Technical complications can be managed endoscopically and the bile duct remains accessible for endoluminal treatment.

Prognostic factors in the palliation of pancreatic cancer

AIM

Few patients with pancreatic cancer are eligible for resection. In the remainder, estimation of prognosis is important to optimise various aspects of care, including palliation of biliary obstruction and trial of chemotherapy. The aim is to evaluate the prognostic significance of clinical and laboratory variables in patients with unresectable pancreatic cancer.

METHODS

Information was gathered retrospectively for 325 patients with unresectable pancreatic cancer who underwent palliative interventions, including surgical bypass, endoscopic or percutaneous stenting or who received supportive care only.

RESULTS

Histological proof was obtained in 182 patients (56%). Median survival was 5.7 months. Absence of therapeutic intervention, leukocytosis (WCC> or =11 x 10(9)/l), gamma glutamyl transferase (gamma GT)>165U/L, prothrombin time ratio > or =1.1, and C-reactive protein (CRP) > or = 5mg/dL were associated with shorter survival on univariate analysis. Only absence of therapeutic intervention, leukocytosis, and gamma GT>165 U/L reached significance on multivariate analysis. In the 51 patients in whom serum CRP was available, CRP was the only significant predictor of survival on multivariate analysis.

CONCLUSIONS

Leukocytosis, elevated gamma GT and raised CRP predict shorter survival and may help to guide the choice of palliative intervention for patients with unresectable pancreatic cancer.

Laparoscopic staging and subsequent palliation in patients with peripancreatic carcinoma

OBJECTIVE

To test the hypothesis that laparoscopic staging improves outcome in patients with peripancreatic carcinoma compared to standard radiology staging.

SUMMARY BACKGROUND DATA

Diagnostic laparoscopy of peripancreatic malignancies has been reported to improve assessment of tumor stage and to prevent unnecessary exploratory laparotomies in 10% to 76% of patients.

METHODS

Laparoscopy and laparoscopic ultrasound were performed in 297 consecutive patients with peripancreatic carcinoma scheduled for surgery after radiologic staging. Patients with pathology-proven unresectable tumors were randomly allocated to either surgical or endoscopic palliation. All others underwent laparotomy.

RESULTS

Laparoscopic staging detected biopsy-proven unresectable disease in 39 patients (13%). At laparotomy, unresectable disease was found in another 72 patients, leading to a detection rate for laparoscopic staging of 35%. In total, 145 of the 197 patients classified as having "possibly resectable" disease after laparoscopic staging underwent resection (74%). Average survival in the group of 14 patients with biopsy-proven unresectable tumors randomly allocated to endoscopic palliation was 116 days, with a mean hospital-free survival of 94 days. The corresponding figures were 192 days and 164 days in the 13 patients allocated to surgical palliation.

CONCLUSIONS

Because of the limited detection rate for unresectable metastatic disease and the likely absence of a large gain after switching from surgical to endoscopic palliation, laparoscopic staging should not be performed routinely in patients with peripancreatic carcinoma.

Surgical bypass is still relevant in the palliation of malignant obstructive jaundice

Malignant tumours of the biliopancreatic system causing obstructive jaundice are not curable in most of the patients, and palliation plays a very important therapeutic role. The role of surgery in palliation of malignant obstructive jaundice has been questioned in the light of availability of endoscopic techniques. In developing countries, however, exploratory laparotomy and palliative surgery (when possible) is the only option available as sophisticated instruments and the expertise to use them is limited to a very few centres. This was a retrospective study of 83 consecutive cases with malignant obstructive jaundice admitted to the Department of Surgery, NSCB Government Medical College, Jabalpur, MP, India from January 1996 to December 2000.

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.

'Cross-section gastroenterostomy' in patients with irresectable periampullary carcinoma

BACKGROUND

The most frequent complication following gastroenterostomy (GE) for gastric outlet obstruction is delayed gastric emptying (DGE), which occurs in roughly 20% of patients. There is evidence that DGE may be linked to the longitudinal incision of the jejunum and that a transverse incision (cross-section GE) may decrease the incidence of DGE following GE.

PATIENTS AND METHODS

In contrast to the orthodox GE, the jejunum is severed transversely up to a margin of 1.5 cm at the mesenteric border and the anastomosis is created with a single running suture. A Braun anastomosis is added 20-30 cm distally to the GE. Patients were followed prospectively with special regard to the occurrence of DGE.

RESULTS

Between 1 August 1994 and 1 August 1998, 25 patients underwent cross-section GE, mostly because of an irresectable periampullary carcinoma. Eight patients exhibited clinical signs of gastric outlet obstruction preoperatively, while in 17 the GE was performed on a prophylactic basis. A biliary bypass was added in 15 patients. There was no disruption of the GE, but one patient died in hospital (4%). The nasogastric tube was withdrawn on the first postoperative day (range 0-6 days), a liquid diet was started on the fifth day (range 2-7 days) and a full regular diet was tolerated at a median of 9 days (6-14 days).The incidence of DGE was 4%: only the single patient who died fulfilled the formal criteria for DGE.

DISCUSSION

In contrast to orthodox GE, DGE seems to be of minor clinical importance following cross-section GE. As the technique is easy to perform, is free of specific complications and leads to a low incidence of DGE, it should be considered as an alternative to conventional GE.

Feasibility and efficacy of high dose conformal radiotherapy for patients with locally advanced pancreatic carcinoma

BACKGROUND

The feasibility and efficacy of high dose conformal radiotherapy were examined in the treatment of patients with locally advanced, unresectable pancreatic carcinoma.

METHODS

Forty-four patients with pathologically confirmed, unresectable pancreatic adenocarcinoma without distant metastases were treated in a Phase II study. The patients received three-dimensional, planned, high dose conformal radiotherapy (70-72 grays). Toxicity was scored according to the World Health Organization criteria. Follow-up time ranged from 7 months to 25 months (median, 9 months).

RESULTS

The treatment was feasible. Forty-one patients received the intended total dose. Treatment was never stopped because of toxicity. Acute toxicity was mainly Grade 1 and Grade 2 (in 70% and 57% of patients, respectively), whereas Grade 3 toxicity was seen in 9% of patients. One fatal event occurred that was not treatment related. Late Grade 3 and Grade 4 gastrointestinal toxicity was seen in 3 patients and 2 patients, respectively. Late (Grade 5) gastrointestinal bleeding was observed in 3 patients, 2 of whom had local tumor progression. At 3 months, reduction in tumor size was seen in 27% of patients, stable disease was seen in 20% of patients, and local disease progression was seen in 40% of patients. Ultimately, local disease progression was observed in 44% of patients. No true partial or complete responses were documented. The median survival from the time of diagnosis was 11 months (10 months from the start of radiotherapy). Seventeen of 25 patients (68%) experienced pain relief.

CONCLUSIONS

High dose conformal radiotherapy for the treatment of patients with locally advanced pancreatic carcinoma is feasible with acceptable toxicity. In case of pain, it can offer palliation. The efficacy of the treatment in terms of prolongation of life is not proven. Distant metastases remain the major problem.

Diagnostic and therapeutic approach to pancreatic cancer

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all GI-related carcinomas. It usually presents late in its course. The clinical features are discussed, with emphasis on those that allow early detection of the disease, as well as a review of diagnostic methods and pre- and perioperative staging, which will allow the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance our therapeutic approach to this aggressive cancer.