title: Double bypass for inoperable pancreatic malignancy at laparotomy: postoperative complications and long-term outcome.
abstract: BACKGROUND
  Between 4% and 13% of patients with operable pancreatic malignancy are found unresectable at the time of surgery. Double bypass is a good option for fit patients but it is associated with a high risk of postoperative complications. The aim of this study was to identify  pre-operatively which patients undergoing double bypass are at high risk of complications and to assess their long-term outcome.
  
  
  METHODS
  Of the 576 patients undergoing pancreatic resections between 2006 and 2011, 50 patients who underwent a laparotomy for a planned pancreaticoduodenectomy  had a double bypass procedure for inoperable disease. Demographic data, risk factors for postoperative complications and pre-operative anaesthetic assessment data including the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) and  cardiopulmonary exercise testing (CPET) were collected.
  
  
  RESULTS
  Fifty patients (33 men and 17 women) were included in the study. The median patient age was 64 years (range: 39-79 years). The complication rate was 50% and the in-hospital mortality rate was 4%. The P-POSSUM physiology  subscore and low anaerobic threshold at CPET were significantly associated with postoperative complications (p =0.005 and p =0.016 respectively) but they were unable to predict them. Overall long-term survival was significantly shorter in patients with postoperative complications  (9 vs 18 months). Postoperative complications were independently associated with poorer long-term survival (p =0.003, odds ratio: 3.261).
  
  
  CONCLUSIONS
  P-POSSUM and CPET are associated with postoperative complications but the possibility of using them for risk prediction requires  further research. However, postoperative complications following double bypass have a significant impact on long-term survival and this type of surgery should therefore only be performed in specialised centres.
authors.affiliation: HPB Unit, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DN, UK. f.ausania@googlemail.com
authors.forename: F
authors.initials: F
authors.lastname: Ausania
authors.forename: A E
authors.initials: AE
authors.lastname: Vallance
authors.forename: D M
authors.initials: DM
authors.lastname: Manas
authors.forename: J M
authors.initials: JM
authors.lastname: Prentis
authors.forename: C P
authors.initials: CP
authors.lastname: Snowden
authors.forename: S A
authors.initials: SA
authors.lastname: White
authors.forename: R M
authors.initials: RM
authors.lastname: Charnley
authors.forename: J J
authors.initials: JJ
authors.lastname: French
authors.forename: B C
authors.initials: BC
authors.lastname: Jaques
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y / Q000379:methods; D005260:Female; D005763:Gastroenterostomy / Q000379:methods; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology*; D011300:Preoperative Care / Q000379:methods; D011446:Prospective Studies; D018570:Risk Assessment; D015607:Stents; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult