Surgical palliation of unresectable pancreatic head cancer in elderly patients

Quality of life in patients with pancreatic ductal adenocarcinoma undergoing pancreaticoduodenectomy

INTRODUCTION

Survival for pancreatic ductal adenocarcinoma (PDAC) is relatively short even after complete resection. Pancreaticoduodenectomy (PD) carries a high risk for postoperative morbidity, and the effect on quality of life (QoL) is unclear. We aimed to study QoL in PDAC patients undergoing PD.

PATIENTS AND METHODS

Sixty patients with suspected PDAC and planned PD were asked to complete EORTC QoL questionnaires QLQ-C30 and QLQ-PAN26 preoperatively and at 3-6-12-18-24 months postoperatively.

RESULTS

47 PDAC patients who underwent PD (66 (21-84) years, 53% men) were included. Follow-up was completed by 81% (6 months) and 45% (24 months) post-PD. Compared to preoperative level, QoL tended to improve or remained the same in 63% during the follow-up. At three months after PD patients had less hepatic symptoms (decreased by 100%; p < 0.001), pancreatic pain and sexuality symptoms tended to decrease by 33% and global and functional QoL tended to slightly improve. These parameters remained at the achieved level during the longer follow-up. A temporary rising tendency was seen in digestive symptoms at three months but this later reverted to the preoperative level. More altered bowel movements and sexuality symptoms tended to arise during the longer follow-up. A negative correlation was found between reported financial difficulties and length of survival.

CONCLUSIONS

PD does not worsen the QoL in most of the patients with PDAC. The potentially beneficial effect on QoL is apparent already at three months after surgery. This information may be helpful for the clinician and patient, when deciding on the treatment for PDAC.

Gastrojejunostomy in patients with unresectable pancreatic head cancer - the use of Roux loop significantly shortens the hospital length of stay

AIM: To evaluate the use of the Roux loop on the postoperative course in patients submitted for gastroenteroanastomosis (GE).

METHODS: Non-jaundiced patients (n = 41) operated on in the Department of General and Transplant Surgery in Lodz, between January 2010 and December 2011 were enrolled. The tumor was considered unresectable when liver metastases or major vascular involvement were confirmed. Patients were randomized to receive Roux (n = 21) or conventional GE (n = 20) on a prophylactic basis.

RESULTS: The mean time to nasogastric tube withdrawal in Roux GE group was shorter (1.4 ± 0.75 vs 2.8 ± 1.1, P < 0.001). Time to starting oral liquids, soft diet and regular diet were decreased (2.3 ± 0.86 vs 3.45 ± 1.19; P < 0.001; 3.3 ± 0.73 vs 4.4 ± 1.23, P < 0.001 and 4.5 ± 0.76 vs 5.6 ± 1.42, P = 0.002; respectively). The Roux GE group had a lower use of prokinetics (10 mg thrice daily for 2.2 ± 1.8 d vs 3.7 ± 2.6 d, P = 0.044; total 62 ± 49 mg vs 111 ± 79 mg, P = 0.025). The mean hospitalization time following Roux GE was shorter (7.7 d vs 9.6 d, P = 0.006). Delayed gastric emptying (DGE) was confirmed in 20% after conventional GE but in none of the patients following Roux GE.

CONCLUSION: Roux gastrojejunostomy during open abdomen exploration in patients with unresectable pancreatic cancer is easy to perform, decreases the incidence of DGE and lowers hospitalization time.

Intensity of follow-up after pancreatic cancer resection

The prognosis of patients diagnosed with pancreatic adenocarcinoma remains dismal. Of the 15-20 % of patients who are candidates for potentially curative resection, 66-92 % will develop recurrent disease. Although guidelines for surveillance in the postoperative setting exist, they are not evidence based, and there is wide variability of strategies utilized. Current surveillance guidelines as suggested by the National Comprehensive Cancer Network (NCCN) include routine history and physical, measurement of serum cancer-associated antigen 19-9 (CA19-9) levels, and computed tomographic imaging at 3- to 6-month intervals for the first 2 years, and annually thereafter. However, the lack of prospective clinical data examining the efficacy of different surveillance strategies has led to a variability of the intensity of follow-up and a lack of consensus on its necessity and efficacy. Recent therapeutic advances may have the potential to significantly alter survival after recurrence, but a careful consideration of current surveillance strategies should be undertaken to optimize existing approaches in the face of high recurrence and low survival rates.

Continuous transarterial infusion chemotherapy with gemcitabine and 5-Fluorouracil for advanced pancreatic carcinoma

PURPOSE

Pancreatic carcinoma is one of the most malignant tumors of the alimentary system, with relatively high incidence rates. The purpose of this study was to assess the efficacy and safety of two regimens for advanced pancreatic carcinoma: continuous transarterial infusion versus systemic venous chemotherapy with gemcitabine and 5-fluorouracil.

METHODS

Of the 48 patients with advanced pancreatic carcinoma receiving chemotherapy with gemcitabine and 5-fluorouracil, 24 received the selective transarterial infusion, and 24 the systemic chemotherapy. For the continuous transarterial infusion group (experimental group), all patients received gemcitabine 1000 mg/m2,given by 30-minute transarterial infusion, on day 1 of a 4-week cycle for 2 cycles, and a dose of 600 mg/ m2 5-fluorouracil was infused on days 1~5 of a 4-week cycle for 2 cycles. For the systemic venous group (control group), gemcitabine and 5-fluorouracil were infused through a peripheral vein, a dose of 1000 mg/m2 gemcitabine being administrated over 30 min on days 1 and 8 of a 4-week cycle for 2 cycles, and a dose of 600 mg/m2 5-fluorouracil was infused on days 1~5 of a 4-week cycle for 2 cycles. The effectiveness and safety were evaluated after 2 cycles according to WHO criteria.

RESULTS

The objective effective rate in transarterial group was 33.3% versus 25% in the systemic group, the difference not being significant (P=0.626). Clinical benefit rates(CBR) in the transarterial and systemic groups were 83.3% and 58.3%, respectively (P=0.014). The means and medians for survival time in transarterial group were higher than those of the systemic group (P<0.005). at the same time, the adverse effects did not significantly differ between the two groups (P>0.05).

CONCLUSION

Continuous transarterial infusion chemotherapy with gemcitabine and 5-fluorouracil could improve clinical benefit rate and survival time of patients with advanced pancreatic carcinoma, compared with systemic venous chemotherapy. Since adverse effects were limited in the transarterial group, the regimen of continuous transarterial infusion chemotherapy can be used more extensively in clinical practice. A CT and MRI conventional sequence can be used for efficacy evaluation after chemotherapy in pancreatic carcinoma.

Endoscopic biliary drainage by stent placement for carcinoma of the head of the pancreas with hepatic metastasis: a report of 16 cases

AIM: To evaluate the clinical significance of endoscopic biliary drainage by stent placement in the treatment of carcinoma of the head of the pancreas with hepatic metastasis.

METHODS: Sixteen patients with obstructive jaundice, who were diagnosed as carcinoma of the head of the pancreas with hepatic metastasis by imaging between May 2006 and December 2008, were included in the study. All patients underwent stent placement for endoscopic biliary drainage to cure obstructive jaundice.

RESULTS: Retroperitoneal lymph node metastasis was found in 5 patients. Of all patients, 12 underwent biliary drainage with expandable metallic biliary stents, 4 with plastic biliary stents, and 6 with pancreatic duct stents. Complete resolution of obstructive jaundice was achieved in all patients. Mental state, appetite and sleep were improved obviously in 75.0%, 25.0% and 37.5% of patients. The survival time was extended from 9 d to 134 d, with an average value of 81.4 d ± 50.2 d. The follow-up data showed that appreciable outcome and satisfactory outcome were achieved in 97% and 69% of patients, respectively.

CONCLUSION: Endoscopic biliary drainage by stent placement can not only cure completely obstructive jaundice but also improve survival quality in patients with carcinoma of the head of the pancreas with hepatic metastasis.

Nitinol biliary stent versus surgery for palliation of distal malignant biliary obstruction

BACKGROUND

Curative resection of pancreatic and biliary malignancies is rare. Most tumors are inoperable at presentation, and palliation of jaundice often is the goal. Biliary decompression can be achieved by surgical diversion or endoscopic biliary stents. This study aimed to compare clinical outcomes between surgical bypass and endoscopic uncovered nitinol stents in the palliation of patients with malignant distal common bile duct obstruction.

METHODS

A multicenter, retrospective, cohort study investigated 86 patients with inoperable malignant distal common bile duct strictures at tertiary referral centers in Medellín, Colombia. These patients had undergone surgery (group 1) or placement of an uncovered 30-Fr self-expandable nitinol stent produced locally in Medellín, Colombia (group 2). The main outcome measurements included cumulative biliary patency, hospital stay, and patient survival.

RESULTS

The study enrolled 86 patients (mean age, 66 years; range, 43-78 years) including 40 patients in group 1 and 46 patients in group 2. Both groups were similar in terms of age, gender, liver metastasis, and diagnosis. Technical success was achieved for 38 patients in group 1 (95%) and 43 patients in group 2 (93%). Functional biliary decompression was obtained in for 35 of the surgical patients (88%) and 42 of the stented patients (91%). Group 2 had lower rates for procedure-related mortality (2 vs. 7.5%; p = 0.01), a lower frequency of early complications (8.7 vs. 45%; p = 0.02), and a shorter hospital stay (median, 6 vs. 12 days; p = 0.01). Recurrent jaundice occurred for three patients in group 1 (7.5%) and eight patients in group 2 (17.3%) (p = 0.198). Late gastric outlet obstruction occurred for 12.5% of the patients in group 1 and 13% of the patients in group 2 (p = 0.73). Despite the early benefits of stenting, no significant difference in the median overall survival between the two groups was found (group 1, 163 days; group 2, 178 days; p = 0.11). The limitations of this study included the small number of patients and the retrospective design.

CONCLUSIONS

Endoscopic stenting and surgery are effective palliation. The former is associated with fewer early complications and the latter with fewer late complications. Patients who do not qualify for curative resection may be better managed by stent placement. Surgery should be reserved for patients more likely to survive longer.