Palliative Surgical Treatment of Tumors of Pancreas and Periampullary Region

Česká verzia

Authors: F. Čečka ¹; B. Jon ¹; J. Dvořák ² ; R. Repák ³; Z. Šubrt ¹; A. Ferko ¹
Authors place of work: Chirurgická klinika, LF UK a FN Hradec Králové ¹; Klinika onkologie a radioterapie, LF UK a FN Hradec Králové ²; II. interní klinika, LF UK a FN Hradec Králové ³
Published in the journal: Klin Onkol 2012; 25(2): 117-123
Category: Original Articles

Summary

Backgrounds:
Pancreatic cancer is an aggressive malignant disease with increasing incidence. Radical resection, the only potentially curative method, is possible in only 20–30% of patients. The main symptoms of advanced non-resectable pancreatic head tumors include obstructive jaundice, caused by stenosis of distal common bile duct, duodenal obstruction and pain, especially in the epigastric region and back. The aim of palliative treatment is to relieve these complaints.

This paper evaluates our own palliative surgical treatment results in patients with pancreatic head and periampullary region cancer.

Patients and Methods:
This study included all patients with pancreatic head and periampullary region cancer who underwent surgery at the Department of Surgery, University Hospital in Hradec Kralove from 1st January 2006 to 31st December 2010. The aim of the surgery in all patients was to resect the tumor. Palliative surgical procedure was performed in patients witn an inoperable tumor. We performed gastro-entero anastomosis in all the patients. When perioperative situation allowed, hepatico-jejuno anastomosis was performed in patients with obstructive jaundice. Surgical splanchnicectomy was performed in patients with back pain.

Results:
Over five years, we performed a surgery in 94 patients for malignant disease of pancreas and periampullary region. Radical resection was performed in 45 patients. Palliative bypass procedure was performed in 42 patients. Exploration only was performed in 7 patients. Postoperative complications after palliative bypass procedures were noted in 15 patients (30.6%), the majority of these complications were minor.

Conclusion:
The advantage of surgical hepatico-jejuno anastomosis over endoscopically placed stent is particulary in superior long-term patency. Therefore, it is advisable to perform these procedures in patients with longer expected survival. Morbidity associated with palliative surgical procedures was relatively low and there was no mortality.

Key words:
pancreatic cancer – palliative care – palliative surgery – survival – quality of life

This study was supported by the research programme of the Ministry of Health of the Czech Republic MZO 00179906 and by grant of IGA NS 9998-4.

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.

Submitted:
23. 10. 2011

Accepted:
1. 11. 2011

Zdroje

1. Šálek C. Nové poznatky k epidemiologii nádorů pankreatu. Bull HPB 2004; 12(3): 86–90.

2. Distler M, Kersting S, Rückert F et al. Palliative treatment of obstructive jaundice in patients with carcinoma of the pancreatic head or distal biliary tree. Endoscopic stent placement vs. hepaticojejunostomy. JOP 2010; 11(6): 568–574.

3. van Heek NT, van Geenen RC, Busch OR et al. Palliative treatment in „peri“-pancreatic carcinoma: stenting or surgical therapy? Acta Gastroenterol Belg 2002; 65(3): 171–175.

4. van Heek NT, De Castro SM, van Eijck CH et al. The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life. Ann Surg 2003; 238(6): 894–902.

5. Abraham NS, Barkun JS, Barkun AN. Palliation of malignant biliary obstruction: a prospective trial examining impact on quality of life. Gastrointest Endosc 2002; 56(6): 835–841.

6. Köninger J, Wente MN, Müller MW et al. Surgical palliation in patients with pancreatic cancer. Langenbecks Arch Surg 2007; 392(1): 13–21.

7. Shepherd HA, Royle G, Ross AP et al. Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial. Br J Surg 1988; 75(12): 1166–1168.

8. Vobořil Z, Jon B. Splanchnikektomie při onemocněních pankreatu. Rozhl Chir 1994; 73(4): 154–156.

9. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240(2): 205–213.

10. Tessler DA, Catanzaro A, Velanovich V et al. Predictors of cancer in patients with suspected pancreatic malignancy without a tissue diagnosis. Am J Surg 2006; 191(2): 191–197.

11. Nieveen van Dijkum EJ, Romijn MG, Terwee CB et al. Laparoscopic staging and subsequent palliation in patients with peripancreatic carcinoma. Ann Surg 2003; 237(1): 66–73.

12. Gürlich R, Oliverius M, Lipár K et al. Výsledky jednoročního přežití u nemocných po resekci hlavy slinivky břišní s resekcí žil portomezenterické oblasti (PMO). Rozhl Chir 2009; 88(8): 417–421.

13. Loyer EM, David CL, Dubrow RA et al. Vascular involvement in pancreatic adenocarcinoma: reassessment by thin-section CT. Abdom Imaging 1996; 21(3): 202–206.

14. Phoa SS, Reeders JW, Stoker J et al. CT criteria for venous invasion in patients with pancreatic head carcinoma. Br J Radiol 2000; 73(875): 1159–1164.

15. Yekebas EF, Bogoevski D, Cataldegirmen G et al. En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients. Ann Surg 2008; 247(2): 300–309.

16. Winter JM, Cameron JL, Campbell KA et al. 1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience. J Gastrointest Surg 2006; 10(9): 1199–1210.

17. Haigh PI, Bilimoria KY, DiFronzo LA. Early postoperative outcomes after pancreaticoduodenectomy in the elderly. Arch Surg 2011; 146(6): 715–723.

18. Lee MK, Dinorcia J, Reavey PL et al. Pancreaticoduodenectomy can be performed safely in patients aged 80 years and older. J Gastrointest Surg 2011; 14(11): 1838–1846.

19. Sener SF, Fremgen A, Menck HR et al. Pancreatic cancer: a report of treatment and survival trends for 100,313 patients diagnosed from 1985–1995, using the National Cancer Database. J Am Coll Surg 1999; 189(1): 1–7.

20. Kuhlmann KF, van Poll D, de Castro SM et al. Initial and long-term outcome after palliative surgical drainage of 269 patients with malignant biliary obstruction. Eur J Surg Oncol 2007; 33(6): 757–762.

21. Andersen JR, Sørensen SM, Kruse A et al. Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut 1989; 30(8): 1132–1135.

22. Bornman PC, Harries-Jones EP, Tobias R et al. Prospective controlled trial of transhepatic biliary endoprosthesis versus bypass surgery for incurable carcinoma of head of pancreas. Lancet 1986; 1(8472): 69–71.

23. Smith AC, Dowsett JF, Russell RC et al. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet 1994; 344(8938): 1655–1660.

24. Schwarz A, Beger HG. Biliary and gastric bypass or stenting in nonresectable periampullary cancer: analysis on the basis of controlled trials. Int J Pancreatol 2000; 27(1): 51–58.

25. Taylor MC, McLeod RS, Langer B. Biliary stenting versus bypass surgery for the palliation of malignant distal bile duct obstruction: a meta-analysis. Liver Transpl 2000; 6(3): 302–308.

26. Maosheng D, Ohtsuka T, Ohuchida J et al. Surgical bypass versus metallic stent for unresectable pancreatic cancer. J Hepatobiliary Pancreat Surg 2001; 8(4): 367–373.

27. Kaassis M, Boyer J, Dumas R et al. Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study. Gastrointest Endosc 2003; 57(2): 178–182.

28. Lillemoe KD, Cameron JL, Hardacre JM et al. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg 1999; 230(3): 322–328.

29. Shaw JM, Bornman PC, Krige JE et al. Self-expanding metal stents as an alternative to surgical bypass for malignant gastric outlet obstruction. Br J Surg 2010; 97(6): 872–876.

30. Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg 1995; 80(2): 290–295.

31. Giovannini M. Ultrasound-guided endoscopic surgery. Best Pract Res Clin Gastroenterol 2004; 18(1): 183–200.

32. Klapman JB, Chang KJ. Endoscopic ultrasound-guided fine-needle injection. Gastrointest Endosc Clin N Am 2005; 15(1): 169–177.

33. Ihse I, Zoucas E, Gyllstedt E et al. Bilateral thoracoscopic splanchnicectomy: effects on pancreatic pain and function. Ann Surg 1999; 230(6): 785–790.