BACKGROUND: Pancreatic adenocarcinoma is an aggressive disease. Surgical therapy with negative margins of resection (R0) offers the only opportunity for cure. Patients who have advanced disease that precludes R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvent chemoradiation. OBJECTIVE: To determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for the treatment of advanced stage pancreatic adenocarcinoma.METHODS: We reviewed our pancreatic surgery database (11/28/2005-12/1/2007) to identify patients undergoing R0 and MP PD, PB, and PX for the treatment of pancreatic adenocarcinoma. RESULTS: We identified 127 patients who underwent PD, PB, or PX. 57 patients underwent RO PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and 9 patients underwent PX. In the PB group 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients 25% underwent the procedure for locally advanced disease and 75% for metastatic disease. All 9 patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP group the distribution of positive margins on permanent section was 57% uncinate/posterior, 11% pancreatic neck, 8% bile duct, 5% circumferential, and 19% with more than one positive margin. The median follow-up for the entire cohort was 25.7 months. Estimated blood loss, complications, median length of postoperative stay, readmission rates, median survival, and one year survival rates for the R0/MP/PB/PX groups are shown in the accompanying table. The 30 day perioperative mortality for the entire cohort was 1.6%. Both deaths were in the RO group (3.5%). CONCLUSIONS: Palliative surgery for advanced stage pancreatic adenocarcinoma in highly selected patients can be performed safely with low perioperative morbidity and mortality. Further work to determine the role of adjuvant treatment and longer term follow-up are required to assess the durability of survival outcomes for patients undergoing MP resection.
Table 1.

VARIABLES	R0 (57)	MP (37)	PB (24)	PX (9)	pvalue MP/PB
EBL (ml)	678.0	701.4	215.2	138.8	p<0.05
MEDIAN POSTOPERATIVE LENGTH OF STAY (days)	7	7	5	5	p<0.05
COMPLICATIONS	31(54.3%)	18(48.6%)	5 (20.8%)	1 (11.1%)	p<0.05
READMISSIONS	14(24.5%)	9 (24.3%)	2 (8.0%)	0 (0.0%)	NS
MEDIAN SURVIVAL (months)	21.3	21.8	11.8	12.7	p<0.05
ONE-YEAR SURVIVAL	81%	84%	38%	44%	p<0.05