NATURAL HISTORY OF DISEASE PROGRESSION AND INTERVENTIONS AFTER ABORTED PANCREATODUODENECTOMY FOR PANCREATIC ADENOCARCINOMA
Timothy J. Vreeland*, Timothy E. Newhook, Laura R. Prakash, Whitney L. Dewhurst, Morgan L. Bruno, Thomas Aloia, Jean-Nicolas Vauthey, Jeffrey E. Lee, Michael P. Kim, Matthew Katz, Ching-Wei Tzeng
Surgical Oncology, University of Texas MD Anderson, Houston, TX
Background:
Planned pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) is sometimes aborted due to intraoperative finding of locally unresectable (UR) or metastatic disease (mets). Some patients subsequently develop biliary or gastric outlet obstruction (GOO), but there is little guidance regarding the need for prophylactic palliative bypasses when a resection is aborted. The aims of this study were to characterize the overall survival and interventional needs of these patients.
Methods:
Patients treated with neoadjuvant therapy (NT) before planned PD (2010-2015) were reviewed to identify those with aborted resection. Data were gathered on OS and symptoms of biliary obstruction or GOO requiring medical or procedural intervention.
Results:
Of 213 intended PDs, 37 (17.4%) were aborted (20 mets, 13 UR, 4 medically inoperable). Median overall survival for aborted PD patients was 11.4mo (IQR 7.5-18.8), with lower overall survival in patients aborted for mets than for other reasons (9.6 vs 14.3mo, p=0.04). Patients with >2mo follow-up (n=28) were analyzed for symptoms. Median follow-up for this group was 11mo (range 2.1-40.9). Five patients (18%) had a biliary bypass (BB) (2 prior to, 3 at time of aborted PD) and 5 (18%) had gastro-jejunostomy (GJ) (all at time of aborted PD). One patient had delayed gastric emptying requiring gastrostomy tube after prophylactic GJ bypass; there were no other complications after palliative bypass. Prior to intended PD, 21/28 had a metal biliary stent, with no duodenal stents. In all, 15/22 (68%) patients with no operative bypass required an intervention at a median of 10.2 mo (range 0.5-27.3 mo), but none required palliative surgery. Of 23 without GJ, 9 (39%) had GOO (3 managed medically, 6 endoscopically). Of 23 without BB, 15 (65%) developed obstruction (3 treated medically, 10 endoscopically, 2 percutaneously). All 5 patients with plastic stents required metal stent replacement.
Conclusions:
When intended PD is aborted, patients frequently develop obstructive symptoms. A metal endobiliary stent is recommended for all of these patients. Preemptive surgical bypass may be avoided as these symptoms can usually be managed with endoscopic/percutaneous interventions, especially given the unfortunately short OS.
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