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. 1996 Jun;223(6):718–728. doi: 10.1097/00000658-199606000-00010

Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer?

K D Lillemoe 1, J L Cameron 1, C J Yeo 1, T A Sohn 1, A Nakeeb 1, P K Sauter 1, R H Hruban 1, R A Abrams 1, H A Pitt 1
PMCID: PMC1235219  PMID: 8645045

Abstract

OBJECTIVE: The authors define the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma. BACKGROUND: Decreases in perioperative morbidity and mortality and improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma have clearly established a role for this operation when performed with curative intent. However, most surgeons remain hesitant to perform pancreaticoduodenectomy unless surgical margins are widely clear, choosing rather to perform palliative biliary and gastric bypass. METHODS: A single-institution retrospective review was performed comparing the outcome of 64 consecutive patients undergoing pancreaticoduodenectomy for pancreatic carcinoma with gross or microscopic evidence of adenocarcinoma at the surgical resection margins, and 62 consecutive patients found to be unresectable at the time of laparotomy because of local invasion without evidence of metastatic disease (stage III). Combined biliary and gastric bypass were performed in 87% of patients not resected. RESULTS: The two groups were similar with respect to age, gender, race, and presenting symptoms. The hospital mortality rate was identical in both groups (1.6%). Fifty-eight percent of patients undergoing pancreaticoduodenectomy had an uncomplicated postoperative course compared with 68% of patients undergoing palliative bypass (not significant). The length of postoperative hospital stay after pancreaticoduodenectomy was 18.4 days, which was significantly longer (p < 0.05) than for patients undergoing palliative bypass (15.0 days). The overall actuarial survival (Kaplan-Meier) was improved significantly in patients undergoing pancreaticoduodenectomy (p < 0.02). Postoperative chemotherapy and radiation therapy improved survival in both groups. CONCLUSIONS: Pancreaticoduodenectomy can be performed with a similar perioperative morbidity and mortality and only a minimal increase in hospital stay when compared with traditional surgical palliation. Pancreaticoduodenectomy with postoperative chemotherapy and radiation therapy is associated with improved long-term survival when compared with patients treated with surgical bypass. These data support the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma and with local residual disease.

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Selected References

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  1. Allison D. C., Bose K. K., Hruban R. H., Piantadosi S., Dooley W. C., Boitnott J. K., Cameron J. L. Pancreatic cancer cell DNA content correlates with long-term survival after pancreatoduodenectomy. Ann Surg. 1991 Dec;214(6):648–656. doi: 10.1097/00000658-199112000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bakkevold K. E., Kambestad B. Morbidity and mortality after radical and palliative pancreatic cancer surgery. Risk factors influencing the short-term results. Ann Surg. 1993 Apr;217(4):356–368. doi: 10.1097/00000658-199304000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Barens S. A., Lillemoe K. D., Kaufman H. S., Sauter P. K., Yeo C. J., Talamini M. A., Pitt H. A., Cameron J. L. Pancreaticoduodenectomy for benign disease. Am J Surg. 1996 Jan;171(1):131–135. doi: 10.1016/s0002-9610(99)80087-7. [DOI] [PubMed] [Google Scholar]
  4. Baumel H., Huguier M., Manderscheid J. C., Fabre J. M., Houry S., Fagot H. Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery. Br J Surg. 1994 Jan;81(1):102–107. doi: 10.1002/bjs.1800810138. [DOI] [PubMed] [Google Scholar]
  5. Braasch J. W., Deziel D. J., Rossi R. L., Watkins E., Jr, Winter P. F. Pyloric and gastric preserving pancreatic resection. Experience with 87 patients. Ann Surg. 1986 Oct;204(4):411–418. doi: 10.1097/00000658-198610000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Cameron J. L., Crist D. W., Sitzmann J. V., Hruban R. H., Boitnott J. K., Seidler A. J., Coleman J. Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer. Am J Surg. 1991 Jan;161(1):120–125. doi: 10.1016/0002-9610(91)90371-j. [DOI] [PubMed] [Google Scholar]
  7. Cameron J. L., Pitt H. A., Yeo C. J., Lillemoe K. D., Kaufman H. S., Coleman J. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg. 1993 May;217(5):430–438. doi: 10.1097/00000658-199305010-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Crile G., Jr The advantages of bypass operations over radical pancreatoduodenectomy in the treatment of pancreatic carcinoma. Surg Gynecol Obstet. 1970 Jun;130(6):1049–1053. [PubMed] [Google Scholar]
  9. Crist D. W., Sitzmann J. V., Cameron J. L. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg. 1987 Sep;206(3):358–365. doi: 10.1097/00000658-198709000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Edge S. B., Schmieg R. E., Jr, Rosenlof L. K., Wilhelm M. C. Pancreas cancer resection outcome in American University centers in 1989-1990. Cancer. 1993 Jun 1;71(11):3502–3508. doi: 10.1002/1097-0142(19930601)71:11<3502::aid-cncr2820711107>3.0.co;2-n. [DOI] [PubMed] [Google Scholar]
  11. Fernández-del Castillo C., Rattner D. W., Warshaw A. L. Standards for pancreatic resection in the 1990s. Arch Surg. 1995 Mar;130(3):295–300. doi: 10.1001/archsurg.1995.01430030065013. [DOI] [PubMed] [Google Scholar]
  12. Geer R. J., Brennan M. F. Prognostic indicators for survival after resection of pancreatic adenocarcinoma. Am J Surg. 1993 Jan;165(1):68–73. doi: 10.1016/s0002-9610(05)80406-4. [DOI] [PubMed] [Google Scholar]
  13. Gordon T. A., Burleyson G. P., Tielsch J. M., Cameron J. L. The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg. 1995 Jan;221(1):43–49. doi: 10.1097/00000658-199501000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Grace P. A., Pitt H. A., Tompkins R. K., DenBesten L., Longmire W. P., Jr Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg. 1986 Jan;151(1):141–149. doi: 10.1016/0002-9610(86)90024-3. [DOI] [PubMed] [Google Scholar]
  15. Lieberman M. D., Kilburn H., Lindsey M., Brennan M. F. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg. 1995 Nov;222(5):638–645. doi: 10.1097/00000658-199511000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Lillemoe K. D., Cameron J. L., Kaufman H. S., Yeo C. J., Pitt H. A., Sauter P. K. Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial. Ann Surg. 1993 May;217(5):447–457. doi: 10.1097/00000658-199305010-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Lillemoe K. D., Sauter P. K., Pitt H. A., Yeo C. J., Cameron J. L. Current status of surgical palliation of periampullary carcinoma. Surg Gynecol Obstet. 1993 Jan;176(1):1–10. [PubMed] [Google Scholar]
  18. Nakeeb A., Lillemoe K. D., Cameron J. L. The role of pancreaticoduodenectomy for locally recurrent or metastatic carcinoma to the periampullary region. J Am Coll Surg. 1995 Feb;180(2):188–192. [PubMed] [Google Scholar]
  19. Potts J. R., 3rd, Broughan T. A., Hermann R. E. Palliative operations for pancreatic carcinoma. Am J Surg. 1990 Jan;159(1):72–78. doi: 10.1016/s0002-9610(05)80609-9. [DOI] [PubMed] [Google Scholar]
  20. Shapiro T. M. Adenocarcinoma of the pancreas: a statistical analysis of biliary bypass vs Whipple resection in good risk patients. Ann Surg. 1975 Dec;182(6):715–721. doi: 10.1097/00000658-197512000-00010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Steele G. D., Jr, Osteen R. T., Winchester D. P., Murphy G. P., Menck H. R. Clinical highlights from the National Cancer Data Base: 1994. CA Cancer J Clin. 1994 Mar-Apr;44(2):71–80. doi: 10.3322/canjclin.44.2.71. [DOI] [PubMed] [Google Scholar]
  22. Trede M., Schwall G., Saeger H. D. Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality. Ann Surg. 1990 Apr;211(4):447–458. doi: 10.1097/00000658-199004000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Trede M. The surgical treatment of pancreatic carcinoma. Surgery. 1985 Jan;97(1):28–35. [PubMed] [Google Scholar]
  24. Udelsman R., Yeo C. J., Hruban R. H., Pitt H. A., Niederhuber J. E., Coleman J., Cameron J. L. Pancreaticoduodenectomy for selected pancreatic endocrine tumors. Surg Gynecol Obstet. 1993 Sep;177(3):269–278. [PubMed] [Google Scholar]
  25. Wade T. P., el-Ghazzawy A. G., Virgo K. S., Johnson F. E. The Whipple resection for cancer in U.S. Department of Veterans Affairs Hospitals. Ann Surg. 1995 Mar;221(3):241–248. doi: 10.1097/00000658-199503000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Watanapa P., Williamson R. C. Surgical palliation for pancreatic cancer: developments during the past two decades. Br J Surg. 1992 Jan;79(1):8–20. doi: 10.1002/bjs.1800790105. [DOI] [PubMed] [Google Scholar]
  27. Whipple A. O., Parsons W. B., Mullins C. R. TREATMENT OF CARCINOMA OF THE AMPULLA OF VATER. Ann Surg. 1935 Oct;102(4):763–779. doi: 10.1097/00000658-193510000-00023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Yeo C. J., Cameron J. L., Lillemoe K. D., Sitzmann J. V., Hruban R. H., Goodman S. N., Dooley W. C., Coleman J., Pitt H. A. Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients. Ann Surg. 1995 Jun;221(6):721–733. doi: 10.1097/00000658-199506000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. de Rooij P. D., Rogatko A., Brennan M. F. Evaluation of palliative surgical procedures in unresectable pancreatic cancer. Br J Surg. 1991 Sep;78(9):1053–1058. doi: 10.1002/bjs.1800780909. [DOI] [PubMed] [Google Scholar]

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