title: Surgical palliation for pancreatic malignancy: practice patterns and predictors of morbidity and mortality.
abstract: BACKGROUND
  Most patients with pancreatic cancer present with, or develop, biliary or duodenal obstruction. We sought to characterize palliative surgery utilization in a contemporary cohort and identify patients at high risk of morbidity and mortality.
  
  
  METHODS
  The ACS NSQIP database (2005-2011) was queried for patients with a pancreatic malignancy undergoing gastrojejunostomy, biliary bypass, or laparotomy without resection. Univariate analysis and multivariate logistic regression identified factors associated with increased risk of 30-day morbidity or mortality.
  
  
  RESULTS
  Operations for the 1,126 patients undergoing palliative bypass were gastrojejunostomy alone (33%), bile duct bypass alone (27%), both (31%), or cholecystojejunostomy (9%). A major complication occurred in 20% and mortality in 6.5% at 30 days. Risk factors for morbidity and mortality were defined in multivariate models. The number of identified risk factors stratified morbidity from 14.8-50% and mortality from 1.6-50% (p < 0.0001 for each). Laparotomy alone (n = 622) was associated with lower morbidity than bypass (12 vs. 20%, p < 0.0001), but equivalent mortality (5 vs. 6.5%, p = 0.21).
  
  
  CONCLUSIONS
  Palliative bypass for pancreatic cancer is associated with a high rate of morbidity and mortality. In select patients, this risk may be prohibitive. Patient selection reflecting predictors of morbidity and mortality may allow for improved outcomes.
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Edmund K
authors.initials: EK
authors.lastname: Bartlett
authors.forename: Heather
authors.initials: H
authors.lastname: Wachtel
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Fraker
authors.forename: Charles M
authors.initials: CM
authors.lastname: Vollmer
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Drebin
authors.forename: Rachel R
authors.initials: RR
authors.lastname: Kelz
authors.forename: Giorgos C
authors.initials: GC
authors.lastname: Karakousis
authors.forename: Robert E
authors.initials: RE
authors.lastname: Roses
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D002423:Cause of Death; D002768:Choledochostomy / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D015390:Gastric Bypass / Q000379:methods* / Q000401:mortality; D006801:Humans; D007813:Laparotomy / Q000379:methods / Q000401:mortality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D010166:Palliative Care / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D010818:Practice Patterns, Physicians'; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome