Clinical surgery—International
Factors influencing survival after bypass procedures in patients with advanced pancreatic adenocarcinomas

https://doi.org/10.1016/j.amjsurg.2007.02.026Get rights and content

Abstract

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.

Section snippets

Patient characteristics

Between October 2001 and September 2005, all patients which suspected pancreatic cancer were prospectively entered into a standardized electronic database. Imaging positive unresectable local advancement or metastatic disease was preoperatively excluded with contrast-enhanced thin-slice CT or MRI, with many patients undergoing additional endoscopic ultrasound. In all patients laparotomy was performed with the intention of curative tumor resection. If intraoperative findings of local advancement

Perioperative data

Of 627 patients diagnosed with pancreatic adenocarcinoma between October 2001 and September 2005, 136 (22%) patients (56 women, 80 men) received a bypass procedure due to intraoperative findings of local non-resectability or occult distant metastasis. Median age for patients undergoing a bypass was 63 years (range 31–83 years). Seventy-one patients (52%) had preoperative bile duct stenting.

In all patients diagnosis of pancreatic adenocarcinoma was histologically verified. Ninety-eight patients

Comments

Most patients with pancreatic cancer are still diagnosed in advanced tumor stages when therapeutic options are limited [1], [4]. They often present with extra-pancreatic disease, such as diffuse liver metastasis or peritoneal tumor spread, or with complex vascular infiltration (eg, infiltration of mesenteric artery, celiac trunk, etc) [1], [2]. Radical tumor resection might not be beneficial for these patients and is thus not indicated [1], [2], with palliative care becoming the imperative

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