Bypass procedures in the treatment of nonresectable carcinoma of the head of the pancreas

M. G. House, K. D. Lillemoe

Research output: Chapter in Book/Report/Conference proceedingChapter


Adenocarcinoma of the pancreas, with an annual incidence of approximately 28,000, is the fourth leading cause of cancer-related mortality in men and women in the United States [1]. While complete surgical extirpation can improve the outlook for some patients, the 5-year survival for all patients with pancreatic adenocarcinoma ranges from 0.4 to 4% [2]. Patients who undergo complete surgical resection for localized adenocarcinoma of the head of the pancreas in addition to adjunctive chemotherapy experience a 5-year survival of only 20%, with a median survival of 18 months [3, 4]. Unfortunately, at the time of initial diagnosis, only 50% of patients with pancreatic cancer will be free of distant metastases, and less than 20% of these patients will have localized disease amenable to curative resection [3, 4]. Among patients who are felt to be candidates for curative resection on preoperative imaging, approximately 15-25% will be found to have occult metastases or locoregional vascular invasion at the time of exploration [5]. Even though the majority of patients with pancreatic cancer are not candidates for curative resection due to early metastatic spread or extensive locoregional tumor involvement, palliation of obstruction of the biliary tree and/or duodenum remains a key consideration in the surgical management of this disease. During the course of their disease, approximately 80% of patients with cancer involving the head of the pancreas will experience obstructive jaundice, and 20% will develop symptoms related to duodenal obstruction [6-10]. Depending on performance status and medical comorbidities, survival for patients with metastatic disease is approximately 3-6 months, while patients with nonmetastatic, locally advanced pancreatic cancer experience a median survival of approximately 6-12 months [6-8, 10]. Adequate palliation of biliary and duodenal obstruction has been shown to improve quality of life; therefore, every attempt, whether nonoperative or operative, should be made to palliate obstruction in virtually all patients with unresectable pancreatic cancer [9-12]. Surgical treatment has served as the traditional modality for palliating the symptoms associated with locally advanced pancreatic cancer; however, improved nonoperative strategies have proved to be reliable and durable in select patients with either biliary or duodenal obstruction [10, 13]. For patients with unequivocal evidence of unresectable disease during preoperative evaluation, or those at prohibitive operative risk, endoluminal methods for biliary and duodenal stenting should be attempted first, and open surgical bypass procedures should be reserved for treatment failures of nonsurgical (i.e., endoscopic or percutaneous) methods. Despite improvements in nonsurgical methods, open palliative bypass procedures for biliary and duodenal obstruction continue to be more durable long-term and require less reintervention [14]. For patients undergoing open exploration for equivocal radiographic signs of unresectable pancreatic cancer, surgical palliation is often indicated for those found to have nonmetastatic (or lowvolume metastatic), unresectable disease intraoperatively.

Original languageEnglish (US)
Title of host publicationDiseases of the Pancreas
Subtitle of host publicationCurrent Surgical Therapy
PublisherSpringer Berlin Heidelberg
Number of pages10
ISBN (Print)9783540286554
StatePublished - Dec 1 2008
Externally publishedYes

ASJC Scopus subject areas

  • Medicine(all)

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