Unresectable pancreatic carcinoma: Correlating length of survival with choice of palliative bypass

The preferred method of biliary bypass and the need for prophylactic gastro enterostomy in unresectable pancreatic carcinoma are dependent on the lengt h of survival of the patient. From 1980 through 1996, 60 patients with biop sy-proven pancreatic cancer were found to be unresectable at exploration. T he reasons for unresectability included major vascular involvement in 21 pa tients (35%), liver metastases in 16 (26.7%), celiac or portal lymph node m etastases in 13 (21.7%), carcinomatosis in 5 (8.3%), and advanced age and/o r comorbid medical condition in 4 patients (6.7%). One patient refused panc reaticoduodenectomy. Nine patients (15%) underwent Roux-en-Y choledochojeju nostomy, and 51 (85%) underwent choledochoduodenostomy. Prophylactic gastro enterostomy was not performed routinely; however, in 9 patients (15%), gast rojejunostomy was performed for impending duodenal obstruction. Late biliar y obstruction did not occur. Late gastric obstruction occurred in 6 of 51 p atients (11.7%), at a median of 13.5 months after initial operation (range, 5-26 months). However, late gastric obstruction primarily occurred in 5 of 31 patients (16%) with locally advanced disease (major vessel involvement or lymph node metastases). The median survival was 12.0 months (range, 3.5- 62 months) for patients with major vessel involvement, 11.5 months (range, 3-42 months) for patients with lymph node metastases, 4.5 months (range 0.5 -24 months) for patients with liver metastases, 5.0 months (range, 4-7 mont hs) for patients with carcinomatosis, and 9.0 months (range 2-27 months) fo r patients with significant comorbid medical illness and/or advanced age. P atients with liver metastases and carcinomatosis do not survive long enough to develop late obstruction. On the other hand, patients with locally adva nced pancreatic carcinoma have a longer median survival and could be consid ered for prophylactic gastroenterostomy to avoid late gastric obstruction. Choledochoduodenostomy offers effective palliation for biliary obstruction.