Biliary and gastric bypass or stenting in nonresectable periampullary cancer: analysis on the basis of controlled trials

Prognosis following surgical bypass compared with laparotomy alone in unresectable pancreatic adenocarcinoma

BACKGROUND

Resection with curative intent has been shown to prolong survival of patients with locoregional pancreatic ductal adenocarcinoma (PDAC). However, up to 33 per cent of patients are deemed unresectable at exploratory laparotomy owing to unanticipated locally advanced or metastatic disease. In these patients, prophylactic double bypass (PDB) procedures have been considered the standard of care. The aim of this study was to compare PDB with exploratory laparotomy alone in terms of impact on postoperative course, chemotherapy and overall survival.

METHODS

This retrospective observational cohort study (2004-2013) was conducted using a prospective institutional database. Patients with histologically confirmed, unresectable PDAC were included. Relationships between PDB procedures, exploratory laparotomy alone, postoperative chemotherapy and best supportive care were investigated by means of Cox regression. Overall survival was compared using Kaplan-Meier estimations and log rank test.

RESULTS

Of 503 patients with PDAC scheduled for resection with curative intent, 104 were deemed unresectable at laparotomy (resection rate 79·3 per cent). Seventy-four patients underwent PDB procedures and 30 had exploratory laparotomy alone. PDB and exploratory laparotomy were similar in terms of perioperative mortality, initiation of chemotherapy and overall survival. Compared with best supportive care, postoperative chemotherapy prolonged survival (8·0 versus 14·4 months in locally advanced PDAC, P = 0·007; 2·3 versus 8·0 months in metastatic PDAC, P < 0·001). Patients undergoing chemotherapy following exploratory laparotomy alone had longer median overall survival than patients undergoing chemotherapy following PDB procedures (16·3 versus 10·3 months; P = 0·040).

CONCLUSION

Patients with pancreatic cancer deemed unresectable at laparotomy may derive survival benefit from subsequent chemotherapy as opposed to supportive care alone. At laparotomy, proceeding with a bypass procedure for prophylactic symptom control may be prognostically unfavourable.

Endoscopic and operative palliation strategies for pancreatic ductal adenocarcinoma

Malignant biliary obstruction, duodenal, and gastric outlet obstruction, and tumor-related pain are the complications of unresectable pancreatic adenocarcinoma that most frequently require palliative intervention. Surgery involving biliary bypass with or without gastrojejunostomy was once the mainstay of treatment in these patients. However, advances in non-operative techniques-most notably the widespread availability of endoscopic biliary and duodenal stents-have shifted the paradigm of treatment away from traditional surgical management. Questions regarding the efficacy and durability of endoscopic stents for biliary and gastric outlet obstruction are reviewed and demonstrate high rates of therapeutic success, low rates of morbidity, and decreased cost. Surgery remains an effective treatment modality, and still produces the most durable relief in appropriately selected patients.

Locally advanced pancreatic head cancer: margin-positive resection or bypass?

Pancreatic cancer is a highly aggressive disease with poor survival. The only effective therapy offering long-term survival is complete surgical resection. In the setting of nonmetastatic disease, locally advanced tumors constitute a technical challenge to the surgeon and may result in margin-positive resection margins. Few studies have evaluated the implications of the latter in depth. The aim of this study was to compare the margin-positive situation to palliative bypass procedures and margin-negative resections in terms of perioperative and long-term outcome. By retrospective analysis of prospectively maintained data from 360 patients operated for pancreatic cancer at our institution, we provide evidence that margin-positive resection still yields a significant survival benefit over palliative bypass procedures. At the same time, perioperative severe morbidity and mortality are not significantly increased. Our observations suggest that pancreatic cancer should be resected whenever technically feasible, including, cases of locally advanced disease.

Role of the laparoscopic approach to biliary bypass for benign and malignant biliary diseases: a systematic review

BACKGROUND

The laparoscopic approach for biliary bypass surgery is a contemporary management option. This article reviews the evidence available for its role and effectiveness.

METHODS

A computerised search was made of the MEDLINE, PubMed, and EMBASE databases for English language publications from the first report of laparoscopic biliary bypass in 1992 to January 2010.

RESULTS

Some 89 patients featured in 19 reports underwent 89 laparoscopic biliary bypass procedures for benign (n=17) and malignant (n=72) indications. Of those, 52 patients underwent biliary bypass alone, while 37 patients underwent biliary bypass combined with gastric bypass. The procedures included cholecystojejunostomy (n=64), hepaticojejunostomy (n=14), and choledochoduodenostomy (n=11). The overall success rate in achieving resolution of jaundice was 98.9%, with a morbidity rate of 12.3% and a mortality rate of 5.6%. More than one procedure was required in 1.1% of patients to achieve resolution of obstructive jaundice. During a reported median follow-up period of 13 months, obstructive jaundice recurred in none of the patients.

CONCLUSION

The laparoscopic approach to biliary bypass surgery is safe and has a high initial success rate, low reintervention rate, and low morbidity and mortality rates. Longer follow-up data and comparative studies with open surgery and endoscopic stenting are needed.

Radical surgery for pancreatic malignancy in the elderly

BACKGROUND

Improving life expectancy is associated with increasing incidence of pancreatic cancer. We reviewed morbidity and mortality in patients aged 65 years and older undergoing curative intent surgery in two centers in the Czech Republic.

METHODS

Data were retrieved by retrospective analysis of the medical records over the period 2000-2007. In total, 60 patients were included. The mean age was 71 years (median 70 years; range 65-85 years). Most patients (43, 72%) underwent hemipancreatoduodenectomy, combined in 4 with portomesenterial vessel resection. Twelve patients (20%) had distal pancreatectomy and 5 patients (8%) total pancreatectomy.

RESULTS

Overall morbidity was 28%. Only 10 patients (18%) developed serious surgical complications in terms of pancreatic leak (5, 8%), biliary leak (2, 3%), and intra-abdominal inflammatory collection (4, 7%). Four patients (6.6%) died within 30 days. The 1-year survival was 62.8%.

CONCLUSION

We can conclude that age per se is not a contraindication to surgery. Patient's overall general condition, co-existing co-morbidities, and ability to get over with any potential complications are more important. and IAP.

Nitinol biliary stent versus surgery for palliation of distal malignant biliary obstruction

BACKGROUND

Curative resection of pancreatic and biliary malignancies is rare. Most tumors are inoperable at presentation, and palliation of jaundice often is the goal. Biliary decompression can be achieved by surgical diversion or endoscopic biliary stents. This study aimed to compare clinical outcomes between surgical bypass and endoscopic uncovered nitinol stents in the palliation of patients with malignant distal common bile duct obstruction.

METHODS

A multicenter, retrospective, cohort study investigated 86 patients with inoperable malignant distal common bile duct strictures at tertiary referral centers in Medellín, Colombia. These patients had undergone surgery (group 1) or placement of an uncovered 30-Fr self-expandable nitinol stent produced locally in Medellín, Colombia (group 2). The main outcome measurements included cumulative biliary patency, hospital stay, and patient survival.

RESULTS

The study enrolled 86 patients (mean age, 66 years; range, 43-78 years) including 40 patients in group 1 and 46 patients in group 2. Both groups were similar in terms of age, gender, liver metastasis, and diagnosis. Technical success was achieved for 38 patients in group 1 (95%) and 43 patients in group 2 (93%). Functional biliary decompression was obtained in for 35 of the surgical patients (88%) and 42 of the stented patients (91%). Group 2 had lower rates for procedure-related mortality (2 vs. 7.5%; p = 0.01), a lower frequency of early complications (8.7 vs. 45%; p = 0.02), and a shorter hospital stay (median, 6 vs. 12 days; p = 0.01). Recurrent jaundice occurred for three patients in group 1 (7.5%) and eight patients in group 2 (17.3%) (p = 0.198). Late gastric outlet obstruction occurred for 12.5% of the patients in group 1 and 13% of the patients in group 2 (p = 0.73). Despite the early benefits of stenting, no significant difference in the median overall survival between the two groups was found (group 1, 163 days; group 2, 178 days; p = 0.11). The limitations of this study included the small number of patients and the retrospective design.

CONCLUSIONS

Endoscopic stenting and surgery are effective palliation. The former is associated with fewer early complications and the latter with fewer late complications. Patients who do not qualify for curative resection may be better managed by stent placement. Surgery should be reserved for patients more likely to survive longer.

Combined biliary and gastric bypass procedures as effective palliation for unresectable malignant disease

BACKGROUND

Although endoscopic treatment of jaundice is increasingly used in the palliation of unresectable malignant disease, surgical bypass still has a role to play in this setting. This study aimed to reappraise the short-term and long-term results of combined biliary/gastric bypass (hepaticojejunostomy and gastrojejunostomy) as palliation for unresectable malignant disease.

METHODS

All patients undergoing simultaneous biliary and gastric bypass procedures for unresectable malignant disease between August 2000 and January 2006 were identified and outcomes reviewed.

RESULTS

One hundred and two patients underwent open surgical biliary drainage procedures for palliation of malignant disease. Underlying malignant disease included pancreatic carcinoma (n = 88), duodenal adenocarcinoma (n = 6) and distal cholangiocarcinoma (n = 3). Thirty-one of the patients underwent a planned palliative bypass procedure, the remainder being carried out after unresectable disease was identified at laparotomy. Postoperative mortality and morbidity rates were higher in the group undergoing planned bypass. During follow up, two patients developed recurrent jaundice that required transhepatic stenting and two patients developed late gastric outlet obstruction requiring refashioning of the gastrojejunostomy.

CONCLUSION

Combined surgical biliary and gastric bypass achieved effective palliation of jaundice and gastric outlet obstruction until death in >95% of patients in this series. It remains first-line therapy in patients identified as having unresectable disease at laparotomy.

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.

Bypass Surgery Versus Palliative Pancreaticoduodenectomy in Patients with Advanced Ductal Adenocarcinoma of the Pancreatic Head, with an Emphasis on Quality of Life Analyses

BACKGROUND

In some centers, palliative resection (PR; partial pancreaticoduodenectomy) is, in selected cases, promoted in preference to double loop bypass (DLB) surgery for advanced pancreatic cancer. This prospective study compares PR with DLB, placing particular focus on patients' quality of life (QoL).

METHODS

From 01/1993 to 09/2004, 167 patients were analyzed in a prospective single center study of palliative surgical treatment of advanced ductal adenocarcinoma of the pancreatic head. Thirty-eight underwent PR and 129 underwent palliative DLB. Patients undergoing DLB were divided into: (1) locally advanced disease (LAD-subgroup; n = 61; 47%) and (2) metastasized disease (MD-subgroup; n = 68; 53%). QoL was assessed using the EORTC QLQ-C30 questionnaire supplemented by a pancreatic cancer specific module. QoL data were collected pre-operatively and for up to 12 months after surgery.

RESULTS

Median survival was 7.0 months (95% CI 4.09; 9.91) in PR patients and 6.0 months (95% CI 5.39; 6.61) in patients who received DLB. Mortality and morbidity were, respectively, 7.8 and 58% for PR, and 2.6 and 42% for DLB. QoL decreased more after PR than after DLB. The DLB-group recovered quicker, reaching pre-operative QoL levels after 3 months, and were less impaired when discharged. The LAD-subgroup and the MD-subgroup presented with equal levels of QoL.

CONCLUSIONS

QoL analysis revealed favorable QoL data after DLB. Additionally, the survival rates of the two groups did not differ significantly, but morbidity and mortality rates in the PR group were elevated. Therefore, the use of PR for advanced pancreatic cancer needs to be carefully evaluated.

Surgery or endoscopy for palliation of biliary obstruction due to metastatic pancreatic cancer

BACKGROUND AND AIMS

Both endoscopic and surgical drainage procedures are effective palliative methods for malignant biliary obstruction. Surgical drainage is still preferred in developing countries due to the high cost of procuring metal biliary stents. The aim of this study was to evaluate the quality of life and the cost of care in patients with metastatic pancreatic cancer after endoscopic biliary drainage and surgical drainage.

PATIENTS AND METHODS

This is a prospective, randomized controlled trial conducted in a tertiary referral center in Brazil. Patients with biliary obstruction due to metastatic pancreatic cancer and liver metastasis, but without gastric outlet obstruction, were included in the study. Endoscopic biliary drainage with the insertion of a metal stent into the bile duct was compared with the surgical drainage procedure (choledochojejunostomy and gastrojejunostomy). Quality of life was assessed before, and 30 days, 60 days, and 120 days after the drainage procedure. The cost of drainage procedure, cost during the first 30 days and the total cost from drainage procedure to death were calculated.

RESULTS

Of the 273 patients with pancreatic malignancy seen at our hospital between July 2001 and October 2004, 35 patients were eligible for the study, and 30 agreed to participate in the study. Both surgical and endoscopic drainage procedures were successful, without any mortality in the first 30 days. The cost of biliary drainage procedure (US dollars 2,832 +/- 519 vs 3,821 +/- 1,181, p= 0.031), the cost of care during the first 30 days after drainage (US dollars 3,122 +/- 877 vs 6,591 +/- 711, p= 0.001), and the overall total cost of care that included initial care and subsequent interventions and hospitalizations until death (US dollars 4,271+/- 2,411 vs 8,321 +/- 1,821, p= 0.0013) were lower in the endoscopy group compared with the surgical group. In addition, the quality of life scores were better in the endoscopy group at 30 days (p= 0.042) and 60 days (p= 0.05). There was no difference between the two groups in complication rate, readmissions for complications, and duration of survival.

CONCLUSIONS

Endoscopic biliary drainage is cheaper and provides better quality of life in patients with biliary obstruction and metastatic pancreatic cancer.

Innovations in Treating the Elderly Who Have Biliary and Pancreatic Disease

Many diseases of the biliary tract and pancreas preferentially effect the elderly. Recent innovations in the evaluation and management of these disorders have directly impacted the lives of many seniors. Improved outcomes of pancreatic surgery is a good example of a positive impact in quality of life, especially when these surgeries are performed in centers of excellence. Evaluation and treatment strategies are presented for complicated calculous biliary disease, pancreatic carcinoma, and pancreatic cystic neoplasms.

Palliative surgery for unresectable pancreatic and periampullary cancer: a reappraisal

This study aimed to reappraise short-term and long-term results of palliative biliary and gastric bypass surgery in patients with unresectable pancreatic head carcinoma found at explorative laparotomy. We retrospectively analyzed 83 consecutive patients whose pancreatic head carcinoma appeared unresectable at laparotomy (vascular involvement [57%], liver metastases [24%], distant metastatic lymph nodes [11%], peritoneal implants [8%]) and who underwent palliative surgical concomitant biliary and gastric bypass. Postoperative mortality and morbidity rates were 4.8% and 26.5%, respectively. Postoperative-delayed gastric emptying occurred in 9 patients (10%). Antecolic (46%) and retrocolic (54%) gastrojejunostomies did not differ for the duration of nasogastric suction, the delay of oral intake, and the incidence of delayed gastric emptying. Mean hospital stay was 16 +/- 8 days. Median survival was 9 months (range 1-44). Late cholangitis occurred in 2 patients (2.4%) treated medically. One recurrent jaundice required transhepatic stenting 9 months from surgery. Four late gastric outlet obstructions occurred (4.8%) with a mean delay of 8 months from surgery. These data demonstrate that, in patients with unresectable pancreatic head carcinoma at laparotomy, palliative concomitant biliary and gastric bypass in a single procedure is safe and long-term efficient. This strategy remains to be compared to endoscopic palliation in this setting.

Palliative biliary stents for obstructing pancreatic carcinoma

BACKGROUND

Palliative endoscopic stents or surgical by-pass are often required for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the distal biliary tree. The optimal method of intervention remains unknown.

OBJECTIVES

To compare surgery, metal endoscopic stents and plastic endoscopic stents in the relief of distal biliary obstruction in patients with inoperable pancreatic carcinoma.

SEARCH STRATEGY

We searched the databases of the Cochrane Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane Central Register of Controlled Trials , MEDLINE, EMBASE, CancerLit, Current Concepts Database and BIDS (September 2002 to September 2004). Reference lists of articles and published abstracts from UEGW and DDW were hand-searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgery to endoscopic stenting, endoscopic metal stents to plastic stents, and different types of endoscopic plastic and metal stents, used to relieve obstruction of the distal bile duct in patients with inoperable pancreatic carcinoma.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Adverse effects information was collected from the trials.

MAIN RESULTS

Twenty-one trials involving 1,454 people were included. Based on meta-analysis, endoscopic stenting with plastic stents appears to be associated with a reduced risk of complications (RR 0.60, 95% CI 0.45 - 0.81), but with higher risk of recurrent biliary obstruction prior to death (RR 18.59, 95% CI 5.33 - 64.86) when compared with surgery. There was a trend towards higher 30-day mortality in the surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04). There was no evidence of a difference in technical or therapeutic success. Other outcomes were not suitable for meta-analysis. No trials comparing endoscopic metal stents to surgery were identified. In endoscopic stent comparisons, metal biliary stents appear to have a lower risk of recurrent biliary obstruction than plastic stents (RR 0.52, 95% CI 0.39 - 0.69). There was no significant statistical difference in technical success, therapeutic success, complications or 30-day mortality using meta-analysis. A narrative review of studies of the cost-effectiveness of metal stents drew conflicting conclusions, but results may be dependent on the patients' length of survival. Neither Teflon, hydrourethane, or hydrophilic coating appear to improve the patency of plastic stents above polyethylene in the trials reviewed. Only perflouro alkoxy plastic stents had superior outcome to polyethylene stents in one trial. The single eligible trial comparing types of metal stents reported higher patency with covered stents, but also a higher risk of complications. These results are based on review of the trials individual results only.

AUTHORS' CONCLUSIONS

Endoscopic metal stents are the intervention of choice at present in patients with malignant distal obstructive jaundice due to pancreatic carcinoma. In patients with short predicted survival, their patency benefits over plastic stents may not be realised. Further RCTs are needed to determine the optimal stent type for these patients.

An analysis of cost and clinical outcome in palliation for advanced pancreatic cancer

BACKGROUND

The optimal palliative method for patients with unresectable pancreatic cancer remains controversial.

METHODS

A retrospective chart review evaluated patients who underwent exploration for presumed resectable pancreatic cancer. Cost-based analysis was performed using relative value units (RVUs) that included the initial surgical procedure and any additional procedure required to achieve satisfactory palliation.

RESULTS

Of 96 patients (1993--2002), 6% had biliary bypass, 42% had duodenal bypass, 40% had double bypass, and 13% had no procedure with equivalent clinical outcomes. If biliary bypass was not initially performed, there was a significant incidence of biliary complications before definitive endoscopic stenting (P=.01). If duodenal bypass was not initially performed, 11% developed duodenal obstruction (P=.04). Total RVUs was highest for a double bypass and lowest for no initial surgical palliative procedure.

CONCLUSIONS

Although surgical bypass procedures at initial exploration provide durable palliation, these procedures are associated with greater costs.

Stomach-interposed cholecystogastrojejunostomy: A palliative approach for periampullary carcinoma

AIM: For patients of periampullary carcinoma found to be unresectable at the time of laparotomy, surgical palliation is the primary choice of treatment. Satisfactory palliation to maximize the quality of life with low morbidity and mortality is the gold standard for a good procedure. Our aim is to explore such a procedure as an alternative to the traditional ones.

METHODS: A modified double-bypass procedure is performed by, in addition to the usual gastrojejunostomy, implanting a mushroom catheter from the gall bladder into the jejunum through the interposed stomach as an internal drainage. A retrospective review was performed including 22 patients with incurable periampullary carcinomas who underwent this surgery.

RESULTS: Both jaundice and impaired liver function improved significantly after surgery. No postoperative deaths, cholangitis, gastrojejunal, biliary anastomotic leaks, recurrent jaundice or late gastric outlet obstruction occurred. Delayed gastric emptying occurred in two patients. The total surgical time was 150±26 min. The estimated blood loss was 160±25 mL. The mean length of hospital stay after surgery was 22±6 d. The mean survival was 8 mo (range 1.5-18 mo).

CONCLUSION: In patients of unresectable periampullary malignancies, stomach-interposed cholecystogastr-ojejunostomy is a safe, simple and efficient technique for palliation.

Laparoscopic choledochojejunostomy via PTFE-covered stent successfully achieves internal drainage of common bile duct obstruction

The purpose of this study was to develop a method of laparoscopic biliary bypass utilizing a PTFE-covered biliary stent. An animal model of common bile duct obstruction was developed. Three days before the planned choledochojejunostomy, the common duct in 10 female pigs was ligated using mini-laparoscopy instrumentation (2 mm) to create an obstruction model. A laparoscopic choledochojejunostomy was then performed using intracorporal suturing (n=5) or stented (n=5) techniques. In the sutured group, a side-to-side two-layer anastomosis was performed. In the stented group, a Seldinger technique was used to deliver the stent into the abdomen through the small bowel and into the anterior wall of the common bile duct for deployment across both the duct and bowel to create an anastomosis (under fluoroscopic guidance). After the surgery, the animals were followed for 7 days, and then sacrificed to examine the anastomosis grossly and histologically. Statistical analysis was used to compare the two groups. Although the difference was not statistically significant, the mean anastomosis time in minutes was shorter for the stented group (37.8; range 15-74 minutes) than in the sutured group (52.8; range 28-70 minutes). All animals survived for 7 days after the procedure with no detectable biliary leaks or biliary obstruction at autopsy. These gross findings were confirmed by pathologic examination of the anastomoses. Laparoscopic choledochojejunostomy using a PTFE-covered metallic biliary stent can be performed to relieve common bile duct obstruction. In addition, the stent method was as safe and effective as sutured laparoscopic choledochojejunostomy.

Coledocoduodenostomia laparoscópica

OBJETIVO: Estudar, a curto e médio prazos, o resultado e complicações da coledocoduodenostomia (CDD) realizada por via laparoscópica. MÉTODO: Estudo prospectivo de 20 pacientes com indicação de coledocoduodenostomia vídeo-laparoscópica operados na DIGEST no período de 1991 a 2003. RESULTADOS: Dos 20 pacientes com indicação para CDD laparoscópica, quatro tinham coledocolitíase associada à litíase vesicular, oito litíase residual de colédoco, dois estenose benigna e seis tumor periampolar. Houve duas conversões para ressecção de colédoco. Dentre as 18 CDD, todos tinham via biliar acima de 1,5 cm de diâmetro. Foi observado vazamento biliar pelo dreno cavitário em quatro casos (duração máxima de quatro dias) resolvidos espontaneamente, uma infecção de ferida e uma morte súbita no 2º. dia de pós-operatório. Os seis portadores de tumor periampolar tiveram sobrevida média de 7,2 meses evoluindo sem prurido ou icterícia até o óbito. CONCLUSÕES: Além da demonstração da viabilidade do método laparoscópico na realização da CDD, evidenciou-se que o posicionamento de trocarte adicional facilita a confecção da anastomose. Acredita-se que, a ocorrência de vazamento da anastomose possa diminuir com a experiência e que a CDD seja alternativa interessante na paliação dos tumores periampolares.

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.

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.

Surgical palliation in advanced disease: recent developments

Despite many valuable technical innovations for the relief of suffering in advanced disease over the past few years, only recently have surgical oncologists attempted to more clearly define palliation. Previous definitions have been misleading, creating confusion about the merits of surgery in many situations and difficulty in posing questions for future prospective clinical trials. This report outlines recent progress in identifying and refining a philosophy of palliative surgery that would align it with the consensus of nonsurgical opinion summarized by the 1990 World Health Organization definition of palliative care and the emerging consensus among the medical specialties in the United States concerning principles of care at the end of life. Selected controversies and recent innovations, as well as guidelines for palliative surgery, are discussed.