Unresectable pancreatic carcinoma: correlating length of survival with choice of palliative bypass.

The preferred method of biliary bypass and the need for prophylactic gastroenterostomy in unresectable pancreatic carcinoma are dependent on the length of survival of the patient. From 1980 through 1996, 60 patients with biopsy-proven pancreatic cancer were found to be unresectable at exploration. The reasons for unresectability included major vascular involvement in 21 patients (35%), liver metastases in 16 (26.7%), celiac or portal lymph node metastases in 13 (21.7%), carcinomatosis in 5 (8.3%), and advanced age and/or comorbid medical condition in 4 patients (6.7%). One patient refused pancreaticoduodenectomy. Nine patients (15%) underwent Roux-en-Y choledochojejunostomy, and 51 (85%) underwent choledochoduodenostomy. Prophylactic gastroenterostomy was not performed routinely; however, in 9 patients (15%), gastrojejunostomy was performed for impending duodenal obstruction. Late biliary obstruction did not occur. Late gastric obstruction occurred in 6 of 51 patients (11.7%), at a median of 13.5 months after initial operation (range, 5-26 months). However, late gastric obstruction primarily occurred in 5 of 31 patients (16%) with locally advanced disease (major vessel involvement or lymph node metastases). The median survival was 12.0 months (range, 3.5-62 months) for patients with major vessel involvement, 11.5 months (range, 3-42 months) for patients with lymph node metastases, 4.5 months (range 0.5-24 months) for patients with liver metastases, 5.0 months (range, 4-7 months) for patients with carcinomatosis, and 9.0 months (range 2-27 months) for patients with significant comorbid medical illness and/or advanced age. Patients with liver metastases and carcinomatosis do not survive long enough to develop late obstruction. On the other hand, patients with locally advanced pancreatic carcinoma have a longer median survival and could be considered for prophylactic gastroenterostomy to avoid late gastric obstruction. Choledochoduodenostomy offers effective palliation for biliary obstruction.