Palliative interventional and surgical therapy for unresectable pancreatic cancer

Towards an updated view on the clinical management of pancreatic adenocarcinoma: Current and future perspectives

Pancreatic cancer has a dire prognosis and will represent the second leading cause of cancer death in the next 10 years. The multifactorial approach represents one of the main issues in controlling the extension of this neoplasm. In recent years, the characteristics of the tumor microenvironment, metastasis mechanisms and the relationship between immune system and neoplastic cells have been described, which has made it possible to understand the pathophysiology of pancreatic adenocarcinoma. Currently, there is a failure to provide an effective preventive method or early detection, so patients present with an advanced stage at the time of diagnosis. Despite numerous efforts, little progress has been made in clinical outcome and in improving survival in long term. Therefore, in the recent years, diverse diagnostic tests, treatments and possible approaches have been developed in the fields of radiotherapy, chemotherapy and surgery to find a combination of them that improves life expectancy in patients diagnosed with pancreatic cancer. At the moment, numerous clinical trials are being conducted to evaluate preventive diagnostic procedures such as serological markers or perfecting available imaging tests. On the other hand, implementation of immunotherapy is being studied in a neoplasm that has lagged in the application of this procedure since present possible treatments do not substantially improve quality of life. Therefore, the purpose of our study is to summarize the main progresses that have been made in the diagnosis, treatment and screening of this disease, explaining the limitations that have been observed and analyzing future prospects in the management of this illness.

Cholecyst-jejunostomy for palliative surgery

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Many cases of unresectable cancer that cause obstructive jaundice require treatment.

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Biliary reconstruction can be difficult to perform safely and quickly due to many factors.

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Cholecyst-jejunostomy may be completed within 10 min.

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Cholecyst-jejunostomy is an appropriate palliative surgery.

Introduction and importance

Many cases of unresectable cancer that cause obstructive jaundice require treatment. Depending on the patient's condition in these cases, surgery may be performed to treat jaundice. The main goal of palliative surgery is to improve the quality of life. Therefore, palliative surgery for obstructive jaundice must be performed safely and quickly.

Case presentation

This case presents a 45-year-old man with fever and back pain who was diagnosed with pancreatic head cancer and multiple liver metastases. Chemotherapy was initiated; however, during the course of treatment, the patient developed hemorrhage from pancreatic cancer that had invaded the duodenum caused hematemesis and melena. Therefore, the chemotherapy could not be continued. Because the patient also developed obstructive jaundice and cholangitis, a gastrojejunostomy and cholecyst-jejunostomy was performed. The surgery was successful; however, the cancer continued to progress, and patient died 31 days after surgery.

Clinical discussion

Biliary reconstruction can be difficult to perform safely and quickly due to many factors.

This study shows that cholecyst-jejunostomy is effective for patients with end-stage cancer. In the long term, cholecyst-jejunostomy is not suitable for biliary reconstruction due to the possibility of bile congestion and cholecystitis. However, this easy and quick procedure is well indicated for emergency patients with a short life expectancy.

Conclusion

As an easy and quick procedure for emergency patients with a short life expectancy, jejunal anastomosis of the gallbladder is an appropriate palliative surgery that is indicated for jaundice treatment.

Is routine hepaticojejunostomy at the time of unplanned surgical bypass required in the era of self-expanding metal stents?

BACKGROUND

Hepaticojejunostomy is routinely performed in patients when inoperable disease is found at planned pancreatoduodenectomy; however, in the presence of self-expanding metal stent (SEMS) hepaticojejunostomy may not be required. The aim of this study was to assess biliary complications and outcomes in patients with unresectable disease at time of planned pancreaticoduodenectomy stratified by the management of the biliary tract.

MATERIAL AND METHODS

Retrospective analysis of patients undergoing surgery in January 2010-December 2015. Complications were measured using the Clavien-Dindo scale.

RESULTS

Of 149 patients, 111 (75%) received gastrojejunostomy and hepaticojejunostomy (double bypass group) and 38 (26%) received a single bypass in the presence of SEMS (single bypass group). Post-operative non-biliary [7 (18%) vs 43 (38%), (p = 0.028)] and biliary [0% vs 12 (11%), (p = 0.037)] complications were lower in the single bypass group. Hospital readmissions were significantly higher in the double bypass group (p = 0.021). Overall survival and the time to start chemotherapy were equivalent (p = n.s.).

CONCLUSIONS

Complications are more common following double bypass compared to single bypass with SEMS suggesting that gastric bypass is adequate surgical palliation in presence of SEMS. This study adds further evidence that preoperative SEMS should be used in preference to plastic stents for suspected periampullary malignancy.

The Choice of Palliative Treatment for Biliary and Duodenal Obstruction in Patients With Unresectable Pancreatic Cancer: Is Surgery Bypass Better?

This study aimed to investigate the clinical significance of palliative operation for carcinoma of pancreas between bypass surgery and interventional therapy. Most patients with locally advanced pancreatic cancer cannot undergo resection and show obstructive jaundice at presentation. Methods of palliation in these patients comprise biliary stent or surgical bypass. We retrospectively analyzed the clinical data of 53 patients who underwent palliative treatment with incurable locally advanced pancreatic ductal adenocarcinoma. This retrospective study compared morbidity, mortality, hospital stay, readmission rate, and survival in these patients. A total of 31 patients underwent biliary bypass surgery, and 22 had interventional therapy. There was no significant difference in the patients' basic condition before operation and in the 30-day mortality between surgical palliation and intervention. However, there were some differences in the early complications, survival time, successful biliary drainage, and recurrent jaundice. Through analysis of these clinical data and the published studies, we conclude that surgical bypass is a better effective palliative method for patients than biliary and duodenum stent with locally advanced pancreatic cancer. Patients need to be carefully selected in consideration of operative risk and perceived overall survival.