Unresectable pancreatic carcinoma: correlating length of survival with choice of palliative bypass.

The preferred method of biliary bypass and the need for prophylactic gastroenterostomy in unresectable pancreatic carcinoma are dependent on the length of survival of the patient. From 1980 through 1996, 60 patients with biopsy-proven pancreatic cancer were found to be unresectable at exploration. The reasons for unresectability included major vascular involvement in 21 patients (35%), liver metastases in 16 (26.7%), celiac or portal lymph node metastases in 13 (21.7%), carcinomatosis in 5 (8.3%), and advanced age and/or comorbid medical condition in 4 patients (6.7%). One patient refused pancreaticoduodenectomy. Nine patients (15%) underwent Roux-en-Y choledochojejunostomy, and 51 (85%) underwent choledochoduodenostomy. Prophylactic gastroenterostomy was not performed routinely; however, in 9 patients (15%), gastrojejunostomy was performed for impending duodenal obstruction. Late biliary obstruction did not occur. Late gastric obstruction occurred in 6 of 51 patients (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 months) for patients with carcinomatosis, and 9.0 months (range 2-27 months) for patients with significant comorbid medical illness and/or advanced age. Patients with liver metastases and carcinomatosis do not survive long enough to develop late obstruction. On the other hand, patients with locally advanced pancreatic carcinoma have a longer median survival and could be considered for prophylactic gastroenterostomy to avoid late gastric obstruction. Choledochoduodenostomy offers effective palliation for biliary obstruction.

Safety and durability of single-layer, stentless, biliary-enteric anastomosis.

Biliary-enteric anastomosis has long been associated with significant complications of early bile leak, cholangitis, and late stricture formation, and controversy exists regarding which operative technique best prevents these problems. Biliary-enteric anastomosis was performed using a single-layer running 4-0 polyglactin (Vicryl) suture, without a transanastomotic stent, in 97 patients by a single surgeon over a 17-year period. Indications for operation included malignant obstruction (84.5%), benign stricture, choledocholithiasis, and choledochal cyst. The most common operation performed was a choledochoduodenostomy; the remaining operations were either Roux-en-Y choledochojejunostomy, hepaticoduodenostomy, or Roux-en-Y hepaticojejunostomy. Complications occurred in 14.1 per cent of patients; there was one perioperative death. There was only one case of anastomotic leak (1%), which resolved spontaneously within 1 week. Mean hospital stay was 8.7 days. The mean follow-up was 13.1 months in all patients. Among patients with benign disorders of the biliary tract, the mean follow-up was 21 months, during which time no patient developed an anastomotic stricture. One patient experienced postoperative cholangitis, although not as a result of anastomotic stricture. Biliary-enteric anastomosis for both benign and malignant disorders can be safely performed using a running, absorbable suture without a stent.

Choledochoduodenostomy for palliation in unresectable pancreatic cancer.

OBJECTIVE: To determine whether choledochoduodenostomy provides adequate long-term palliation of obstructive jaundice in unresectable pancreatic cancer. DESIGN: Consecutive case series. SETTING: Tertiary referral center. PATIENTS: From 1980 to 1997, 79 consecutive patients (45 men, 34 women; mean age, 67.8 years) with biopsy-proved pancreatic cancer found to be unresectable at operation. INTERVENTION: All patients had resectable disease by preoperative criteria. At exploratory laparotomy, unresectability was determined by the presence of liver or peritoneal metastases, encasement of major vascular structures by tumor, and/or celiac lymph node involvement. Choledochoduodenostomy for biliary bypass was performed in 71 (90%) of 79 patients; Roux-en-Y choledochojejunostomy was performed in the remaining 8 patients. MAIN OUTCOME MEASURES: Resolution of jaundice, duration of hospital stay, mean survival, postoperative complications, and evidence of recurrent biliary obstruction. RESULTS: All patients experienced rapid resolution of jaundice. Average hospital stay was 8.3 days. Mean survival after operation was 13.1 months (range, 2 weeks to 62 months). Postoperative mortality was 3%. There were no biliary or duodenal leaks. Four patients (6%) required hospitalization for gastrointestinal hemorrhage; however, only 1 (1%) was from peptic ulceration. No patient developed recurrent biliary obstruction. CONCLUSIONS: Choledochoduodenostomy provides rapid, long-lasting relief of jaundice, with little morbidity and a low rate of duodenal ulceration, and is the palliative operation of choice when patients are found to have unresectable disease at operation or when stenting procedures fail.

Congenital bronchobiliary fistula: diagnosis and postoperative surveillance with HIDA scan.

Congenital bronchobiliary fistula (CBBF) is an extremely rare anomaly with myriad presentations that often include common bile duct abnormalities. Traditionally, bronchoscopy and bronchography have been used to establish the diagnosis. A full-term neonate with pneumonia and bilious secretions was diagnosed as having CBBF by means of a HIDA scan. Successful repair consisted of a right thoracotomy, high ligation of the fistula via an extrapleural approach, and cholecystography to confirm biliary drainage into the duodenum. The HIDA scan is a safe and efficient means to diagnose CBBF. When used in combination with surgical contrast studies, it provides clear delineation of all variations of this abnormality, enabling one-stage correction.

Role of prophylactic gastroenterostomy for unresectable pancreatic carcinoma.

Methods of palliation and the use of prophylactic gastroenterostomy in the treatment of unresectable pancreatic carcinoma remain controversial. Gastroenterostomy has been linked with various complications. We conducted a 10-year (1982-1992) retrospective review of patients who had unresectable pancreatic carcinoma and underwent biliary decompression without prophylactic gastroenterostomy. 50 patients were studied. Only four patients (8%) developed duodenal obstruction and required reoperation for therapeutic gastroenterostomy. The mean time to obstruction was 15.75 months, whereas the mean overall survival was 12.99 months. The mean survival of patients who underwent therapeutic gastroenterostomy was 32.25 months, with an average palliation of 16.5 months after the second operation. We conclude that pancreatic carcinoma has a rapid natural progression, and most patients do not survive long enough to obstruct. The ones who do obstruct are unique in that they survive for a long period of time. We recommend that routine prophylactic gastroenterostomy is unnecessary, and selective use of gastroenterostomy should be exercised in case of present or impending duodenal obstruction.