Surgical palliation for unresected cancer of the exocrine pancreas

Abstract

Opinions are still divided regarding the optimal palliative procedures in patients with cancer of the pancreas. This retrospective, multicentric study, involving 2493 patients operated on between January 1982 and December 1988 compares the results of various procedures aimed at palliation for pancreatic cancer. Cholecystoenteric bypasses (n = 237) in comparison to choledochoenteric bypasses (n = 1770) were associated with a higher post-operative mortality (20% vs 14%), a lower long-term morbidity (26% vs 35%), and a lower survival rate (means: 3.2 vs 5.2 months). Choledochoduodenostomy (n = 1159) and choledochojejunostomy (n = 611) had similar rates of post-operative mortality (14% vs 13%), morbidity (26% vs 27%), incidence of recurrent jaundice (8% vs 7%), and median survival (5.4 vs 5.0 months). Surgically placed biliary stents (n = 114) were followed by the highest post-operative mortality (27%), morbidity (46%), rate of recurrent jaundice (14%), and the shortest median survival (2.6 months). Post-operative mortality in patients undergoing a choledochoenteric bypass and a gastrojejunostomy (n = 1134) was similar to that observed in patients who had only a biliary bypass (n = 636) (16% and 12%), but among the patients who had a biliary bypass alone, 16% developed a gastric obstruction. For the relief of pancreatic pain, radiotherapy was more effective than other symptomatic treatments (P = 0.02). In conclusion, these results and other previous reports suggest the need (1) in patients with obstructive jaundice to perform a choledochoduodenostomy rather than other biliary bypasses, (2) a routine prophylactic gastrojejunostomy to prevent gastric outlet obstruction, (3) and for the relief of pancreatic pain to perform radiotherapy or splanchnicectomy.