title: Palliative surgical management of patients with unresectable pancreatic adenocarcinoma: trends and lessons learned from a large, single institution experience.
abstract: BACKGROUND
  Routine palliative bypass has been advocated for palliation of patients with pancreatic adenocarcinoma who have inoperable disease discovered at the time of surgery. We examined trends in the relative use of palliative bypass over time with an emphasis on identifying changes in surgical indications, type of bypass performed, as well as perioperative outcomes associated with surgical palliation.
  
  
  METHODS
  Between 1996 and 2010, 1,913 patients with pancreatic adenocarcinoma in the head of the pancreas were surgically explored. Data regarding preoperative symptoms, intraoperative findings, type of surgical procedure performed, as well as perioperative and long-term outcomes were collected and analyzed.
  
  
  RESULTS
  Of the 1,913 patients, 583 (30.5%) underwent a palliative procedure. Most patients presented with jaundice (72.2%). The majority of patients were evaluated by CT scan (97.4%), which revealed a median tumor size of 3.2 cm. Most patients who underwent surgical palliation (64.5%) had a double bypass, while a minority had either gastrojejunostomy (28.2%) or hepaticojejunostomy (7.2%) alone. While the number of pancreaticoduodenectomies remained relatively stable over time, there was a temporal decrease in the utilization of palliative bypass (P < 0.001). Unanticipated locally advanced disease vs. liver/peritoneal metastasis as the indication for palliative surgery also changed over time (1996-2001: 47.8% vs. 52.2%; 2002-2007: 49.2% vs. 50.8%; 2008-2010: 17.2% vs. 82.7%) (P = 0.005). Palliative failure rates were 2.3% after hepaticojejunostomy and 3.1% after grastrojejunostomy. Patients with unsuspected metastatic disease had a worse survival compared with patients who had locally unresectable disease (median survival: 5 vs. 8 months, respectively; HR = 1.43, P = 0.001).
  
  
  CONCLUSIONS
  Palliative bypass procedures were less frequently performed over time, probably due to a significant decrease in the rate of unanticipated advanced locoregional disease at the time of exploration. While palliative bypass was effective, survival in the setting of metastatic disease was extremely short.
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kneuertz
authors.forename: Steven C
authors.initials: SC
authors.lastname: Cunningham
authors.forename: John L
authors.initials: JL
authors.lastname: Cameron
authors.forename: Sergio
authors.initials: S
authors.lastname: Torrez
authors.forename: Nicholas
authors.initials: N
authors.lastname: Tapazoglou
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Herman
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
authors.forename: Frederic
authors.initials: F
authors.lastname: Eckhauser
authors.forename: Jingya
authors.initials: J
authors.lastname: Wang
authors.forename: Kenzo
authors.initials: K
authors.lastname: Hirose
authors.forename: Barish H
authors.initials: BH
authors.lastname: Edil
authors.forename: Michael A
authors.initials: MA
authors.lastname: Choti
authors.forename: Richard D
authors.initials: RD
authors.lastname: Schulick
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wolfgang
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000230:Adenocarcinoma / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D005260:Female; D015390:Gastric Bypass; D006801:Humans; D007565:Jaundice / Q000209:etiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D010166:Palliative Care / Q000639:trends*; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome