Advanced Pancreatic Cancer Discovered at Operation: The Role of Palliative Bypass

Abstract

For the patient with advanced pancreatic cancer discovered to be unresectable at exploration, treatment revolves around minimizing disease related symptoms. The current chapter considers the patient who is found at operation to be unresectable and compares single/double bypass to expectant management in regards to the outcomes of jaundice, gastric outlet obstruction (GOO), overall survival, morbidity, mortality, and quality of life.

The level I/II data that have evaluated this question are of moderate quality and do recommend bypass over surveillance, and in some cases, over endoscopic stenting, especially for patients who have a predicted survival of over 2–6 months. Recent retrospective series have not recommended palliative surgical bypass as a routine practice, for high-risk patients, or patients with metastatic disease that are not obstructed, but define situations where it may be advantageous. These studies contain a low to moderate quality of level III data with important sources of selection bias.

Review of published studies of all levels of data, and taking into account that cross-sectional imaging, patient selection, and endoscopic techniques, experience, and equipment have all markedly improved since early trials; we conclude that palliative bypass is reasonable, certainly not contraindicated, and may provide prolonged biliary and gastric luminal patency in the patient found to be unresectable at exploration. However, the decision to bypass the patient can be individualized based on the surgeon’s assessment of multiple factors including patient condition, an estimation of the pace and biology of the disease, the endoscopic expertise available locally, assessment of the level of impending GOO pre-operatively and intra-operatively, and cancer stage/expected OS. It is perhaps reasonable, then, to perform a palliative surgical bypass in highly selected patients in good condition, with localized or minimal metastatic disease, symptoms of jaundice not already stented, or for symptomatic GOO.