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Tol J, Busch O, van Gulik T, Gouma D. Pancreatic Cancer: The Role of Bypass Procedures. PANCREATIC CANCER, CYSTIC NEOPLASMS AND ENDOCRINE TUMORS 2015:83-93. [DOI: 10.1002/9781118307816.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Beenen E, van Roest MHG, Sieders E, Peeters PMJG, Porte RJ, de Boer MT, de Jong KP. Staging laparoscopy in patients scheduled for pancreaticoduodenectomy minimizes hospitalization in the remaining life time when metastatic carcinoma is found. Eur J Surg Oncol 2014; 40:989-94. [PMID: 24582004 DOI: 10.1016/j.ejso.2013.12.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 12/16/2013] [Accepted: 12/19/2013] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To compare the burden of total hospitalization as a ratio of survival of staging laparoscopy versus prophylactic bypass surgery in patients with unresectable periampullary adenocarcinoma. BACKGROUND Periampullary adenocarcinoma is an aggressive cancer with up to 35% of the patients at surgery found to be unresectable. Palliative prophylactic surgical bypass versus endoscopic stenting has been addressed by randomized controlled trials, but none reported on the burden of hospitalization. METHODS From a prospective database all patients with periampullary adenocarcinomas with a preoperative patent biliary stent and absent gastric outlet obstruction, but found unresectable during surgery, were analysed. They underwent a staging laparoscopy only versus prophylactic palliative bypass surgery. In-hospital days of the initial admission as well as all consecutive admission days during the remaining life span were compared both in absolute numbers and as relative impact. RESULTS The inclusion criteria were met by 205 patients. Of these 131 patients underwent a staging laparoscopy detecting metastases in 21 patients. In 184 laparotomies 54 patients underwent prophylactic palliative bypass surgery for unresectable disease. Median total in-hospital-stay in the Laparoscopy Group was 3 days versus 11 days in the Palliative Bypass Group (p = 0.0003). Patients with metastatic disease found during laparoscopy stayed 3.5% of the remaining life time in hospital vs. 10.0% (p = 0.029) in patients with metastatic disease who underwent bypass surgery. CONCLUSIONS Staging laparoscopy and early discharge in patients with metastatic peri-ampullary carcinoma resulted in reduced hospitalization, both in absolute number of days and as a rate of survival time.
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Affiliation(s)
- E Beenen
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - M H G van Roest
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - E Sieders
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - P M J G Peeters
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - R J Porte
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - M T de Boer
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - K P de Jong
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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Assfalg V, Hüser N, Michalski C, Gillen S, Kleeff J, Friess H. Palliative interventional and surgical therapy for unresectable pancreatic cancer. Cancers (Basel) 2011. [PMID: 24212634 DOI: 0.3390/cancers3010652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Palliative treatment concepts are considered in patients with non-curatively resectable and/or metastasized pancreatic cancer. However, patients without metastases, but presented with marginally resectable or locally non-resectable tumors should not be treated by a palliative therapeutic approach. These patients should be enrolled in neoadjuvant radiochemotherapy trials because a potentially curative resection can be achieved in approximately one-third of them after finishing treatment and restaging. Within the scope of best possible palliative care, resection of the primary cancer together with excision of metastases represents a therapeutic option to be contemplated in selected cases. Comprehensive palliative therapy is based on treatment of bile duct or duodenal obstruction for certain locally unresectable or metastasized advanced pancreatic cancer. However, endoscopic or percutaneous stenting procedures and surgical bypass provide safe and highly effective therapeutic alternatives. In case of operative drainage of the biliary tract (biliodigestive anastomosis), the prophylactic creation of a gastro-intestinal bypass (double bypass) is recommended. The decision to perform a surgical versus an endoscopic procedure for palliation depends to a great extent on the tumor stage and the estimated prognosis, and should be determined by an interdisciplinary team for each patient individually.
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Affiliation(s)
- Volker Assfalg
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany.
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Palliative interventional and surgical therapy for unresectable pancreatic cancer. Cancers (Basel) 2011; 3:652-61. [PMID: 24212634 PMCID: PMC3756382 DOI: 10.3390/cancers3010652] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 01/14/2011] [Accepted: 02/09/2011] [Indexed: 12/15/2022] Open
Abstract
Palliative treatment concepts are considered in patients with non-curatively resectable and/or metastasized pancreatic cancer. However, patients without metastases, but presented with marginally resectable or locally non-resectable tumors should not be treated by a palliative therapeutic approach. These patients should be enrolled in neoadjuvant radiochemotherapy trials because a potentially curative resection can be achieved in approximately one-third of them after finishing treatment and restaging. Within the scope of best possible palliative care, resection of the primary cancer together with excision of metastases represents a therapeutic option to be contemplated in selected cases. Comprehensive palliative therapy is based on treatment of bile duct or duodenal obstruction for certain locally unresectable or metastasized advanced pancreatic cancer. However, endoscopic or percutaneous stenting procedures and surgical bypass provide safe and highly effective therapeutic alternatives. In case of operative drainage of the biliary tract (biliodigestive anastomosis), the prophylactic creation of a gastro-intestinal bypass (double bypass) is recommended. The decision to perform a surgical versus an endoscopic procedure for palliation depends to a great extent on the tumor stage and the estimated prognosis, and should be determined by an interdisciplinary team for each patient individually.
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Hüser N, Michalski CW, Schuster T, Friess H, Kleeff J. Systematic review and meta-analysis of prophylactic gastroenterostomy for unresectable advanced pancreatic cancer. Br J Surg 2009; 96:711-9. [PMID: 19526616 DOI: 10.1002/bjs.6629] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The value of prophylactic gastroenterostomy (usually combined with a biliary bypass) in patients with unresectable cancer of the pancreatic head is controversial. METHODS A systematic review of retrospective and prospective studies, and a meta-analysis of prospective studies, on the use of prophylactic gastroenterostomy for unresectable pancreatic cancer were performed. RESULTS Analysis of retrospective studies did not reveal any advantage or disadvantage of prophylactic gastroenterostomy. Three prospective studies comparing prophylactic gastroenterostomy plus biliodigestive anastomosis with no bypass or a biliodigestive anastomosis alone were identified (altogether 218 patients). For patients who had prophylactic gastroenterostomy, the chance of gastric outlet obstruction during follow-up was significantly lower (odds ratio (OR) 0.06 (95 per cent confidence interval (c.i.) 0.02 to 0.21); P < 0.001). The rates of postoperative delayed gastric emptying were similar in both groups (OR 1.93 (95 per cent c.i. 0.57 to 6.53); P = 0.290), as were morbidity and mortality. The estimated duration of hospital stay after prophylactic gastroenterostomy was 3 days longer than for patients without bypass (weighted mean difference 3.1 (95 per cent c.i. 0.7 to 5.5); P = 0.010). CONCLUSION Prophylactic gastroenterostomy should be performed during surgical exploration of patients with unresectable pancreatic head tumours because it reduces the incidence of long-term gastroduodenal obstruction without impairing short-term outcome.
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Affiliation(s)
- N Hüser
- Department of Surgery, Technische Universität München, Munich, Germany
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Scott EN, Garcea G, Doucas H, Steward WP, Dennison AR, Berry DP. Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma. HPB (Oxford) 2009; 11:118-24. [PMID: 19590634 PMCID: PMC2697879 DOI: 10.1111/j.1477-2574.2008.00015.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Accepted: 08/07/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass. METHODS This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma. RESULTS We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05). CONCLUSIONS On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.
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Affiliation(s)
- Edwina N Scott
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
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Hosono S, Ohtani H, Arimoto Y, Kanamiya Y. Endoscopic stenting versus surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis. J Gastroenterol 2007; 42:283-90. [PMID: 17464457 DOI: 10.1007/s00535-006-2003-y] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2006] [Accepted: 12/25/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND We attempted to elucidate the current status of endoscopic self-expanding metal stents for palliation of malignant gastroduodenal obstruction in comparison with surgical gastroenterostomy. METHODS Original articles and abstracts published from January 1990 to September 2006 were searched in Medline, EMBASE, and Cochrane Controlled Trials Register databases. Clinical appraisal and data extraction were independently conducted by two reviewers. Statistical analysis was performed by meta-analysis using a random effects model. Weighted mean differences with 95% confidence intervals (CI) were used to analyze continuous variables. Odds ratios with 95% CI were calculated for dichotomous variables. RESULTS The outcomes of 307 procedures from nine studies were analyzed. Endoscopic stenting was found to be associated with higher clinical success (P = 0.007), a shorter time from the procedure to starting oral intake (P < 0.001), less morbidity (P = 0.02), lower incidence of delayed gastric emptying (P = 0.002), and a shorter hospital stay (P < 0.001) than surgical gastroenterostomy. There was no significant difference between the two groups in the analysis of 30-day mortality. CONCLUSIONS Endoscopic stenting may be a feasible alternative to surgery for the palliation of inoperable malignant gastroduodenal obstruction, with a high clinical success and low morbidity rate. Additional well-designed randomized controlled trials with larger sample sizes are expected to further reinforce this conclusion.
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Affiliation(s)
- Shunsuke Hosono
- Department of Surgery, Osaka City Sumiyoshi Hospital, 1-2-16 Higashi-Kagaya, Osaka 559-0012, Japan
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Köninger J, Wente MN, Müller MW, Gutt CN, Friess H, Büchler MW. Surgical palliation in patients with pancreatic cancer. Langenbecks Arch Surg 2006; 392:13-21. [PMID: 17103000 DOI: 10.1007/s00423-006-0100-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Accepted: 08/11/2006] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of palliative strategies in patients with pancreatic cancer is the relief of tumor-associated symptoms such as biliary and duodenal obstruction and tumor growth. Due to high mortality and morbidity rates of surgery, treatment of patients with advanced pancreatic cancer is mainly in the hand of gastroenterologists. RATIONALE In recent years, surgery of pancreatic cancer in specialized centres developed strongly, which makes it a viable option even in the treatment of advanced disease. CONCLUSION We advocate for an aggressive strategy in the treatment of pancreatic cancer with surgical exploration and tumor resection whenever possible.
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Affiliation(s)
- Jörg Köninger
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Wojtyczka A, Moesta T, Kuntz C, Lehnert T. [Palliative bypass surgery]. Chirurg 2006; 77:210-8. [PMID: 16518620 DOI: 10.1007/s00104-006-1165-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Impaired intestinal passage considerably reduces quality of life irrespective of the underlying condition. Limited life expectancy and increased operative risk of advanced malignant disease add particular weight to this issue. The indication for operative therapy results from carefully weighing individual incapacity and potential gain vs operative risk and life expectancy. Exactly because life expectancy is quite limited, selection of an effective, low-risk procedure is of utmost importance to benefit the patient.
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Affiliation(s)
- A Wojtyczka
- Kliniken für Allgemeine, Viscerale, Onkologische und Gefässchirurgie, Klinikum Bremen Mitte, Bremen
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Al-Rashedy M, Dadibhai M, Shareif A, Khandelwal MI, Ballester P, Abid G, McCloy RF, Ammori BJ. Laparoscopic gastric bypass for gastric outlet obstruction is associated with smoother, faster recovery and shorter hospital stay compared with open surgery. ACTA ACUST UNITED AC 2006; 12:474-8. [PMID: 16365822 DOI: 10.1007/s00534-005-1013-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2004] [Accepted: 07/11/2005] [Indexed: 12/18/2022]
Abstract
BACKGROUND/PURPOSE Laparoscopic gastric bypass for relief of gastric outlet obstruction (GOO) is feasible and safe. However, comparative data to confirm the benefits of the laparoscopic approach remain scarce. METHODS Between 1998 and 2003, 26 patients underwent 15 laparoscopic (surgeon A) and 12 open (surgeon B) gastrojejunostomies (GJs) for GOO. The indications for surgery included malignant (n = 17) and benign (n = 10) diseases. RESULTS There were no conversions to open surgery in the laparoscopic group, and no operative mortality occurred in either group. The groups were comparable for age, sex, American Society of Anesthesiology (ASA) score, frequencies of previous abdominal surgery and of malignant or benign disease, and type of GJ fashioned. There were no differences between the laparoscopic and open groups with regard to the operating time (median, 90 vs 111 min; P = 0.113), and patients receiving intraoperative blood transfusion. However, laparoscopic surgery was associated with significantly shorter durations of postoperative intravenous hydration (60 vs 234 h; P = 0.001), opiate analgesia (49 vs 128 h; P = 0.025), and hospital stay (3 vs 15 days; P = 0.005). Operative morbidity occurred more frequently following open surgery (33% vs 13%; P = 0.219). CONCLUSIONS Laparoscopic GJ for the relief of GOO is associated with a smoother and more rapid postoperative recovery and shorter hospital stay compared with open surgery. In experienced hands, the laparoscopic approach to GJ should become the new gold standard.
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Lesurtel M, Dehni N, Tiret E, Parc R, Paye F. Palliative surgery for unresectable pancreatic and periampullary cancer: a reappraisal. J Gastrointest Surg 2006; 10:286-91. [PMID: 16455463 DOI: 10.1016/j.gassur.2005.05.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Accepted: 05/19/2005] [Indexed: 01/31/2023]
Abstract
This study aimed to reappraise short-term and long-term results of palliative biliary and gastric bypass surgery in patients with unresectable pancreatic head carcinoma found at explorative laparotomy. We retrospectively analyzed 83 consecutive patients whose pancreatic head carcinoma appeared unresectable at laparotomy (vascular involvement [57%], liver metastases [24%], distant metastatic lymph nodes [11%], peritoneal implants [8%]) and who underwent palliative surgical concomitant biliary and gastric bypass. Postoperative mortality and morbidity rates were 4.8% and 26.5%, respectively. Postoperative-delayed gastric emptying occurred in 9 patients (10%). Antecolic (46%) and retrocolic (54%) gastrojejunostomies did not differ for the duration of nasogastric suction, the delay of oral intake, and the incidence of delayed gastric emptying. Mean hospital stay was 16 +/- 8 days. Median survival was 9 months (range 1-44). Late cholangitis occurred in 2 patients (2.4%) treated medically. One recurrent jaundice required transhepatic stenting 9 months from surgery. Four late gastric outlet obstructions occurred (4.8%) with a mean delay of 8 months from surgery. These data demonstrate that, in patients with unresectable pancreatic head carcinoma at laparotomy, palliative concomitant biliary and gastric bypass in a single procedure is safe and long-term efficient. This strategy remains to be compared to endoscopic palliation in this setting.
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Affiliation(s)
- Mickael Lesurtel
- Department of Digestive Surgery, Saint Antoine University-Hospital, 184 Rue du Faubourg Saint Antoine, 75012 Paris, France
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Ghanem AM, Hamade AM, Sheen AJ, Owera A, Al-Bahrani AZ, Ammori BJ. Laparoscopic Gastric and Biliary Bypass: A Single-Center Cohort Prospective Study. J Laparoendosc Adv Surg Tech A 2006; 16:21-6. [PMID: 16494542 DOI: 10.1089/lap.2006.16.21] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Relief of gastric outlet and distal biliary obstruction may be accomplished by open surgery or by minimally invasive techniques including endoscopic and laparoscopic approaches. We examined the feasibility and safety of laparoscopic gastric and biliary bypass in all patients with malignant and benign disease requiring surgical relief of obstructive symptoms. MATERIALS AND METHODS Patients with benign duodenal stricture or inoperable malignancy underwent therapeutic laparoscopic bypass surgery. Prophylactic gastric or biliary bypass was added in selected patients with nonmetastatic malignancy. RESULTS Twenty-eight patients (17 of them female) with a median age of 67 years (range, 26-81 years) underwent 29 laparoscopic bypass procedures for malignant (n = 23) or benign (n = 6) disease. One patient who underwent a Roux-en-Y gastrojejunostomy for non-steroidal anti-inflammatory drug induced ulcer disease developed stenosis of the stoma that required laparoscopic refashioning 2 months later, accounting for the 29th procedure reported herein in 28 patients. Surgery included the construction of a single gastric (n = 16) or biliary (n = 5) bypass or a double bypass (n = 8), and an additional prophylactic bypass in 5 of 23 cancer patients (21.8%). All procedures were completed laparoscopically. The median operative time was 90 minutes (range, 60-153 minutes) and mean postoperative hospital stay was 4 days (range, 3-6 days). Complications developed following 4 procedures (13.8%) and 1 patient died (3.4%). No complications occurred in patients with prophylactic bypass. One patient required laparoscopic revision of the gastroenterostomy 2 months postoperatively, for benign disease. No recurrence of obstructive symptoms was observed in cancer patients during follow-up. CONCLUSION Laparoscopic bypass surgery for distal biliary and gastric obstruction in patients with benign or malignant disease results in low morbidity and mortality and short postoperative hospital stay. The addition of prophylactic bypass in patients with nonmetastatic unresectable malignancy appears safe and effective.
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Affiliation(s)
- Ali M Ghanem
- Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, United Kingdom
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Hamade AM, Al-Bahrani AZ, Owera AMA, Hamoodi AA, Abid GH, Bani Hani OI, O'Shea S, Lee SH, Ammori BJ. Therapeutic, prophylactic, and preresection applications of laparoscopic gastric and biliary bypass for patients with periampullary malignancy. Surg Endosc 2005; 19:1333-40. [PMID: 16021372 DOI: 10.1007/s00464-004-2282-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Accepted: 05/10/2005] [Indexed: 12/27/2022]
Abstract
BACKGROUND Laparoscopic bypass surgery for the palliation of gastric and biliary obstruction is associated with a rapid recovery. This study aimed to extend its application to other aspects in the management of patients with periampullary cancer. METHODS Between 2001 and 2004, 21 patients (median age, 68 years) underwent laparoscopic gastric (n = 8), biliary (n = 5), and combined gastric and biliary (n = 8) bypass. In addition to its therapeutic role (n = 12), indications included a concomitant prophylactic gastric (n = 3) and biliary (n = 2) bypass as well as pre- 1 Whipple's relief of deep jaundice at the time of staging laparoscopy (n = 3). Construction of the biliary bypass to the gallbladder (n = 11) or bile duct (n = 2) was based on preoperative imaging. RESULTS All procedures were completed laparoscopically. The median operating times for gastric, biliary, and combined bypass were 75, 60, and 130 min, respectively. The addition of a prophylactic bypass did not significantly prolong the operating time, as compared with a single therapeutic bypass. One patient died postoperatively of aspiration pneumonia. The postoperative hospital stay (median, 4 days) was not significantly influenced by the type of bypass. No recurrence of or new obstructive symptoms developed during the follow-up period after a therapeutic or prophylactic bypass. CONCLUSIONS Applications of laparoscopic gastric and biliary bypass can safely be expanded to include a prophylactic role and preresection relief of obstructive jaundice. Prophylactic bypass surgery does not prolong operating time or hospital stay significantly and prevents future onset of obstructive symptoms.
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Affiliation(s)
- A M Hamade
- Department of Surgery, Manchester Royal Infirmary, M13 9WL, Manchester, UK
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Hao CY, Su XQ, Ji JF, Huang XF, Xing BC. Stomach-interposed cholecystogastrojejunostomy: A palliative approach for periampullary carcinoma. World J Gastroenterol 2005; 11:2009-12. [PMID: 15800996 PMCID: PMC4305727 DOI: 10.3748/wjg.v11.i13.2009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: For patients of periampullary carcinoma found to be unresectable at the time of laparotomy, surgical palliation is the primary choice of treatment. Satisfactory palliation to maximize the quality of life with low morbidity and mortality is the gold standard for a good procedure. Our aim is to explore such a procedure as an alternative to the traditional ones.
METHODS: A modified double-bypass procedure is performed by, in addition to the usual gastrojejunostomy, implanting a mushroom catheter from the gall bladder into the jejunum through the interposed stomach as an internal drainage. A retrospective review was performed including 22 patients with incurable periampullary carcinomas who underwent this surgery.
RESULTS: Both jaundice and impaired liver function improved significantly after surgery. No postoperative deaths, cholangitis, gastrojejunal, biliary anastomotic leaks, recurrent jaundice or late gastric outlet obstruction occurred. Delayed gastric emptying occurred in two patients. The total surgical time was 150±26 min. The estimated blood loss was 160±25 mL. The mean length of hospital stay after surgery was 22±6 d. The mean survival was 8 mo (range 1.5-18 mo).
CONCLUSION: In patients of unresectable periampullary malignancies, stomach-interposed cholecystogastr-ojejunostomy is a safe, simple and efficient technique for palliation.
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Affiliation(s)
- Chun-Yi Hao
- Department of Surgery, Peking University School of Oncology, 52 Fu-Cheng-Lu Street, Beijing 100036, China.
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Van Heek NT, De Castro SMM, van Eijck CH, van Geenen RCI, Hesselink EJ, Breslau PJ, Tran TCK, Kazemier G, Visser MRM, Busch ORC, Obertop H, Gouma DJ. The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life. Ann Surg 2003; 238:894-902; discussion 902-5. [PMID: 14631226 PMCID: PMC1356171 DOI: 10.1097/01.sla.0000098617.21801.95] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the effect of a prophylactic gastrojejunostomy on the development of gastric outlet obstruction and quality of life in patients with unresectable periampullary cancer found during explorative laparotomy. SUMMARY BACKGROUND DATA Several studies, including one randomized trial, propagate to perform a prophylactic gastrojejunostomy routinely in patients with periampullary cancer found to be unresectable during laparotomy. Others suggest an increase of postoperative complications. Controversy still exists in general surgical practice if a double bypass should be performed routinely in these patients. METHODS Between December 1998 and March 2002, patients with a periampullary carcinoma who were found to be unresectable during exploration were randomized to receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a single bypass (hepaticojejunostomy). Randomization was stratified for center and presence of metastases. Patients with gastrointestinal obstruction and patients treated endoscopically for more than 3 months were excluded. Primary endpoints were development of clinical gastric outlet obstruction and surgical intervention for gastric outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival, and quality of life, measured prospectively by the EORTC-C30 and Pan26 questionnaires. It was decided to perform an interim analysis after inclusion of 50% of the patients (n = 70). RESULTS Five of the 70 patients randomized were lost to follow-up. From the remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There were no differences in patient demographics, preoperative symptoms, and surgical findings between the groups. Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates, including delayed gastric emptying, were 31% in the double versus 28% in the single bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76 days) in the double versus 9 days (range 6-20 days) in the single bypass group (P = 0.06); median survival was 7.2 months in the double versus 8.4 months in the single bypass group (P = 0.15). No differences were found in the quality of life between both groups. After surgery most quality of life scores deteriorated temporarily and were restored to their baseline score (t = -1) within 4 months. CONCLUSIONS Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates. There were no differences in quality of life between the two groups. Together with the previous randomized trial from the Hopkins group, this study provides sufficient evidence to state that a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable to a single bypass consisting of only a hepaticojejunostomy in patients undergoing surgical palliation for unresectable periampullary carcinoma. Therefore, the trial was stopped earlier than planned.
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Affiliation(s)
- N Tjarda Van Heek
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Horstmann O, Kley CW, Post S, Becker H. 'Cross-section gastroenterostomy' in patients with irresectable periampullary carcinoma. HPB (Oxford) 2001; 3:157-63. [PMID: 18332918 PMCID: PMC2020797 DOI: 10.1080/136518201317077170] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The most frequent complication following gastroenterostomy (GE) for gastric outlet obstruction is delayed gastric emptying (DGE), which occurs in roughly 20% of patients. There is evidence that DGE may be linked to the longitudinal incision of the jejunum and that a transverse incision (cross-section GE) may decrease the incidence of DGE following GE. PATIENTS AND METHODS In contrast to the orthodox GE, the jejunum is severed transversely up to a margin of 1.5 cm at the mesenteric border and the anastomosis is created with a single running suture. A Braun anastomosis is added 20-30 cm distally to the GE. Patients were followed prospectively with special regard to the occurrence of DGE. RESULTS Between 1 August 1994 and 1 August 1998, 25 patients underwent cross-section GE, mostly because of an irresectable periampullary carcinoma. Eight patients exhibited clinical signs of gastric outlet obstruction preoperatively, while in 17 the GE was performed on a prophylactic basis. A biliary bypass was added in 15 patients. There was no disruption of the GE, but one patient died in hospital (4%). The nasogastric tube was withdrawn on the first postoperative day (range 0-6 days), a liquid diet was started on the fifth day (range 2-7 days) and a full regular diet was tolerated at a median of 9 days (6-14 days).The incidence of DGE was 4%: only the single patient who died fulfilled the formal criteria for DGE. DISCUSSION In contrast to orthodox GE, DGE seems to be of minor clinical importance following cross-section GE. As the technique is easy to perform, is free of specific complications and leads to a low incidence of DGE, it should be considered as an alternative to conventional GE.
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Affiliation(s)
- O Horstmann
- Department of General Surgery, Georg August UniversityGöttingenGermany
| | - CW Kley
- Department of General Surgery, Georg August UniversityGöttingenGermany
| | - S Post
- Department of Surgery, Mannheim University Hospital, University of HeidelbergGermany
| | - H Becker
- Department of General Surgery, Georg August UniversityGöttingenGermany
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