Background: Exploratory laparotomy has been advocated for patients with pancreatic tumors on the assumption that if found unresectable, a surgical biliary bypass and prophylactic gastric bypass (PGB) are appropriate. However, the use of staging laparoscopy (SL) alone has been associated with a subsequent need for surgical bypass in only 3% of unresectable patients. A randomized trial comparing biliary bypass with PGB to biliary bypass alone has reported a 20% incidence of subsequent bypass in the latter group. We examined our experience with open and laparoscopic management approaches.
Methods: We identified 91 patients having PGB (82 biliary bypass) and 199 patients having SL only from a prospective database of 1400 patients with adenocarcinoma of the pancreas treated between 11/89 and 12/98. Symptomatic gastric outlet obstruction (GOO) was defined as failure to tolerate maintenance level caloric intake, delayed gastric emptying (DGE) was defined as over 10 days to regular diet. Post operative length of stay (LOS) is reported for the first hospitalization. Chi square, Mann Whitney U, and log rank analysis were used for univariate comparisons.
Results: The groups were comparable with regard to sex and median age (66, range 39-87 years). PGB patients had increased perioperative morbidity and mortality. During follow up, 25% of PGB patients and 14% of SL patients had at least one readmission (p<0.05). Both groups had similar rates of readmission for GOO, drainage PEG placement, and reoperation for GOO. There was a higher rate of readmission for cholangitis in the SL group (10% vs 3%, p=NS) with a higher biliary stent placement rate. Median survival was not different (SL 6.9, PGB 5.7 months, p=NS).
Discussion: The performance of PGB is associated with a significant increase in morbidity, peri-operative mortality, and length of stay over SL alone in patients with advanced pancreatic adenocarcinoma. The rate of re-intervention for GOO is the same whether a PGB is performed or not. In light of the apparent equivalent efficacy of the two approaches, a prospective randomized evaluation comparing SL vs. PGB is warranted.
n F/U LOS DGE Morbidity Mortality Readmit GOO Reop GOO Biliary Stent
PGB 91 5.5 m 10(6-75) 22% 35% 7% 4% 4% 3%
SL 199 6.4m 1 (0-30) 1% 1% 0 4% 3% 12%
p NS <0.001 <0.001 <0.001 <0.001 NS NS <0.05